Challenging Behaviors In Children Research Articles

Membangun karakter anak sejak dini melalui program Tetirah Bimasakti

Elementary school children have the potential to develop positively with the support of their social environment. The more positive experiences presented in a child's daily life, the more likely they are to grow into well-adjusted individuals. The aim of this research is to evaluate the effectiveness of the Program Tetirah Bimasakti in reducing challenging behaviors in elementary school children. This study utilized a quasi-experimental, one-group pretest-posttest design. Participants included six children enrolled in the Program Tetirah Bimasakti, selected through purposive sampling. The research instrument employed was the Indonesian version of the Strengths and Difficulties Questionnaire (SDQ) for children. Data analysis was conducted using the paired sample t-test. The results indicated a decrease in the participants' difficulty scores; however, there was no significant change in their prosocial scores. This suggests that while the Program Tetirah Bimasakti was effective in reducing difficult behaviors, it was insufficient for fostering prosocial behavior. Consequently, this study implies that relevant institutions should develop structured modules for activity programs that can be tailored to specific and targeted competencies.

Cultural Adaptation of RUBI Intervention with Korean Families(K-RUBI): A Mixed Method Study.

Challenging behaviors of young autistic children remain a major parenting challenge for many of their family members, including caregivers. Caregivers from underrepresented cultural or linguistic backgrounds may experience exacerbated difficulties related to challenging behaviors due to limited access to culturally sustaining and responsive interventions. Evidence-based behavior parent training programs, such as RUBI, are highly effective in increasing caregivers' capacity in preventing and responding to these behaviors in naturalistic settings using behavior analytic principles. Therefore, the purpose of this study was to examine the effectiveness, acceptability, and feasibility of the culturally adapted RUBI program with underserved families. We conduct a convergent mixed-methods study using a pilot randomized controlled trial with a waitlist control group and focus group interviews with 31 Korean families of young children with or suspected of autism. The Korean RUBI underwent rigorous cultural adaptation using the Cultural Adaptation Checklist, including the use of multiple community advisory boards to inform cultural adaptation. Both quantitative and qualitative findings revealed significant improvements in parents' confidence and knowledge in behavioral principles and decrease in severity of challenging behaviors, which suggest clinical utility of RUBI in an underrepresented, low-resourced community. A culturally adapted intervention for a different population can be perceived as a newly constructed intervention. This study provides insight on the systematic process of cultural adaptation of an established autism intervention and effectiveness, feasibility, and acceptability of RUBI.

Implementing a Positive Behavior Support Program for Young Children with Autism in Public Agencies: A Social Validity Evaluation from Parents, Practitioners, and Administrators.

Challenging behaviors in young children with autism and intellectual disabilities pose significant barriers to learning and inclusion. The Prevent-Teach-Reinforce for Young Children (PTR-YC) program is an evidence-based intervention that addresses these behaviors according to Positive Behavior Intervention Support principles. It is essential to assess the social validity of an intervention, when implemented into a public service system, to ensure sustainability and relevance to stakeholders. The present study aimed to document the social validity of PTR-YC from the point of view of three key informants: parents, practitioners, and administrators. Sixty-one participants were interviewed about their experience with PTR-YC (9 administrators, 31 practitioners, and 20 families). Semi-structured interviews assessed three fundamental components of social validity (Wolf, 1978): (a) social relevance of intervention goals, (b) social appropriateness of intervention procedures, and (c) social importance of intervention effects. Participants' responses were subjected to thematic analysis. Intervention goals, namely family participation in the clinical process, strategies that focuses on prevention, and teaching alternative adaptive behaviors, were identified as relevant. Participants appreciated the program's clear, structured, and turnkey clinical process, its parent-practitioner collaboration, and its consistency with practices already in place in the field. Positive instrumental outcomes (e.g., knowledge, competencies, self-efficacy) and ultimate outcomes (e.g., decrease in challenging behavior) of the intervention were reported on children, families, and practitioners. This study represents the first in-depth evaluation of the social validity of PTR-YC in specialized public services for autism and demonstrates its appropriateness for universal implementation in this sector.

Child gender and challenging behavior influences early childhood teachers' use of behavior specific praise

AbstractThis study used data from 435 teacher‐child dyads in early childhood classrooms to examine the extent to which teachers' use of behavior specific praise (BSP) with children screened for elevated rates of externalizing behaviors was influenced by the intensity of child challenging behavior and gender. Observational assessments indicated that teachers used BSP infrequently. A multiple regression model revealed a significant association between the interaction of child challenging behavior and gender and teachers' delivery of BSP. An examination of the simple slopes revealed a disordinal interaction where the relation between challenging behavior and teachers' delivery of BSP differed as a function of child gender. These findings point to an increased need for training to support teachers' use of BSP and understanding of the influence of child gender and behavior on the use of BSP.

ProVIA-Kids - outcomes of an uncontrolled study on smartphone-based behaviour analysis for challenging behaviour in children with intellectual and developmental disabilities or autism spectrum disorder.

Challenging behaviour (CB) is a common issue among children with autism spectrum disorder or intellectual and developmental disability. Mental health applications are low-threshold cost-effective tools to address the lack of resources for caregivers. This pre-post study evaluated the feasibility and preliminary effectiveness of the smartphone app ProVIA-Kids using algorithm-based behaviour analysis to identify causes of CB and provide individualized practical guidance to manage and prevent CB. A total of 18 caregivers (M = 38.9 ± 5.0) of children with a diagnosis of autism spectrum disorder (44%), intellectual and developmental disabilities (33%) or both (22%) aged 4-11 years (M = 7.6 ± 1.8) were included. Assessments were performed before and after an 8-week intervention period. The primary outcome was the change in parental stress. Caregiver stress experience due to CB was also rated daily via ecological momentary assessments within the app. Secondary outcomes included the intensity of the child's CB, dysfunctional parenting, feelings of parental competency as well as caregivers' mood (rated daily in the app) and feedback on the app collected via the Mobile Application Rating Scale. We observed increases in parental stress in terms of conscious feelings of incompetence. However, we also saw improvements in parental stress experience due to CB and overreactive parenting, and descriptive improvements in CB intensity and caregiver mood. ProVIA-Kids pioneers behaviour analysis in a digital and automated format, with participants reporting high acceptance. Pilot results highlight the potential of the ProVIA-Kids app to positively influence child behaviour and caregiver mental health over a longer intervention period. The study was registered at https://www.drks.de (ID = DRKS00029039) on May 31, 2022.

Learning from educators: Implementation of a positive behavior support program targeting challenging behavior in children with autism

Challenging behaviors (CB) are a frequent co-occurring problem in children with autism spectrum disorder (ASD) and hinder their response to recommended interventions such as early intensive behavioral intervention (EIBI). The Prevent-Teach-Reinforce for young children (PTR-YC) program was implemented to meet community-based EIBI educators’ training and support needs in managing CB in their day-to-day work with families. Although this positive behavior support program has a strong empirical basis, its implementation by community-based educators has yet to be assessed from a systematic and structured program evaluation perspective. Using Chen’s (2015) theoretical framework for program evaluation, this study assessed the quality of implementation of PTR-YC as perceived by 17 educators who received training and supervision on applying PTR-YC among families of children with ASD receiving EIBI services. Educators’ post-intervention interviews and questionnaires were analyzed using the logical model for program evaluation to identify obstacles and facilitators to the implementation of PTR-YC.

Using Technologies to Promote Adaptive Responding and Reduce Challenging Behaviors in Children with Autism Spectrum Disorder: A Selective Review

Using Technologies to Promote Adaptive Responding and Reduce Challenging Behaviors in Children with Autism Spectrum Disorder: A Selective Review

An investigation of sleep problems, gastrointestinal symptoms, comorbid psychopathology and challenging behavior in children and adolescents with Down Syndrome

BackgroundDown syndrome (DS) is one of the most common chromosomal abnormalities, and children with DS have increased risks of receiving diagnoses of specific comorbidities. AimsThis study aimed to assess the frequencies and relationships between sleep problems, gastrointestinal (GI) symptoms, comorbid psychopathology, and challenging behavior. Methods and proceduresThe Children’s Sleep Habits Questionnaire, Gastrointestinal Symptom Inventory, Autism Spectrum Disorder-Comorbid for Children, and Behavior Problems Inventory-Short Form were completed by 123 parents of children and adolescents with DS. Outcomes and resultsThe frequency of GI symptoms was 74.8 %, with high frequencies also found for: sleep problems (100 %), challenging behavior (100 %), and moderate to severe levels of comorbid psychopathology (tantrum=80 %; repetitive behavior=63 %; avoidant behavior=82 %; worry/depressed=61 %; conduct behavior=100 %; over-eating=100 %; under-eating=100 %). A significant moderate correlation was found between total GI symptoms and self-injurious behavior frequency. Children who presented with abdominal pain engaged in self-injurious behavior more frequently than those with no abdominal pain. Conclusions and implicationsFindings indicated a high frequency of sleep problems, comorbid psychopathology, GI symptoms, and challenging behavior and demonstrated a relationship between GI symptoms and self-injurious behavior in children and adolescents with DS. This research illustrated the importance of investigating comorbid conditions in individuals with DS. What this paper adds?Down Syndrome (DS) is a genetic condition characterized by trisomy 21 and is a leading cause of intellectual disability worldwide. The prevalence of DS is commonly associated with advanced maternal age and is associated with multiple comorbid conditions. The current study aimed to investigate the frequency of and relationship between sleep problems, gastrointestinal symptoms, comorbid psychopathology, and challenging behavior in children and adolescents with DS. High-frequency levels were found for sleep problems (100 %), challenging behavior (100 %), gastrointestinal symptoms (74.8 %), and moderate to severe levels of the different comorbid psychopathologies (tantrum=80 %; repetitive behavior=63 %; avoidant behavior=82 %; worry/depressed=61 %; conduct behavior=100 %; over-eating=100 %; under-eating=100 %). Results indicated a significant difference in self-injurious behavior frequency between individuals who presented with abdominal pain and those who did not. This study is the first to investigate the relationship of multiple comorbid conditions in a sample of children with DS. This paper adds to the literature by demonstrating the frequency of a number of comorbid conditions in children and adolescents with DS. The paper also adds novel findings to the literature by investigating the relationships between comorbid conditions in this population. The findings of this paper highlighted the frequency and comorbidities that exist between gastrointestinal symptoms, sleep problems, comorbid psychopathology, and challenging behavior. Analyses indicated that those who presented with abdominal pain, engaged in self-injurious behavior more frequently.Sleep problems, gastrointestinal symptoms, comorbid psychopathology, and challenging behavior in children and adolescents with Down Syndrome.

Parent-Mediated Behavioural Intervention in Children with Autism Spectrum Disorder: A Scoping Review

ABSTRACT Children with autism spectrum disorder (ASD) exhibit deficits in social interaction and communication, show repetitive behaviours, and have restricted interests. They are at high risk of developing challenging behaviours, which can hinder social relationships, academic achievement, language skills, overall adaptive development, and also increase the risk of abuse in educational settings. This scoping review addresses the limited focus on parent-mediated behavioural intervention (PMBI) for managing challenging behaviours in children with ASD. Using the Arksey and O’Malley scoping review framework, we retrieved articles published between 2011 and 2022 from SCOPUS, ERIC, and SAGE Publications. Twelve articles met the inclusion criteria. Five themes emerged from the review regarding parents adopting PMBI: (1) performing functional behaviour analysis and developing behaviour intervention plans; (2) applying modification strategies and techniques of antecedent, behaviours and consequence; (3) establishing parent-child secure attachment relationship with child’s lead, positive and natural reinforcement; (4) decreasing child’s challenging behaviours; (5) improving child’s compliance, social responsiveness, and prosocial behaviours. The findings highlight parents as primary intervention agent, emphasising the importance of parental involvement in supporting their child’s development. This review suggests developing cost-effective parent education training programmes to support PMBI as part of comprehensive interventions for children with ASD.

Using Remote Consultation to Decrease Several Challenging Behaviors in Children with Autism Spectrum Disorder

Using Remote Consultation to Decrease Several Challenging Behaviors in Children with Autism Spectrum Disorder

Learning From Parents: Implementation of a Parent-Mediated Positive Behavior Support Program Targeting Challenging Behavior in Children With Autism

Challenging behaviors (CBs) are frequently observed in children with autism spectrum disorder (ASD) and are known to have negative effects on parents’ stress and well-being, as well as on overall family quality of life. Research has shown that professional support such as the Prevent-Teach-Reinforce (PTR) program has the potential to alleviate those effects. Although several studies have empirically demonstrated this positive behavior support program in managing children’s CB, its implementation by community-based educators among parents of children with ASD has yet to be examined. This study assessed the facilitators and obstacles to this program’s implementation as perceived by 19 parents using interviews and questionnaires. Participants emphasized the significance of setting clear expectations, defining roles, and providing continuous feedback during the implementation process to promote their initiative and enhance their active participation. They recognized the difficulties of implementing the program within a family setting but emphasized the valuable presence of educators in the home, which improved their understanding of family dynamics. Parents valued effective and respectful support from educators, although some encountered disagreements during coaching sessions, highlighting the need for improved educator training with practical coaching and a greater recognition of the family’s perspective.

Associations between challenging parenting behavior and creative tendencies of children: the chain mediating roles of positive emotion and creative self-efficacy.

Parenting behavior has been reported to be closely associated with children's creativity, yet the association between challenging parenting behavior and children's creative tendencies, as well as the potential mechanisms connecting the two, remains ambiguous. Based on the Social Cognitive Theory and the Self-efficacy Theory, this study aims to examine the correlation between Chinese parents' challenging parenting behaviors and their children's creative tendencies, as well as the chain mediating role of children's positive emotions and creative self-efficacy. In total, 2,647 families were surveyed with questionnaires completed by parents on the Challenging Parenting Behaviors Scale and by children on the Positive/Negative Emotions Scale, the Creative Self-efficacy Scale, and the Williams Creative Tendency Test Scale, and analyzed using structural equation modeling (SEM) in SPSS 22.0 and Mplus 8.3. The findings indicate that challenging parenting behavior has a positive correlation with children's positive emotions, creative self-efficacy, and creative tendencies. Through positive emotions, creative self-efficacy, and a chain mediated pathway between these two variables, challenging parenting behaviors increase children's creative tendencies. The favorable impacts of challenging parenting behaviors on children's creative tendencies, with the mediating effects of children's positive emotions and creative self-efficacy, may help Chinese parents better grasp the mechanisms underlying this association.

Associations Between Social–Emotional Teaching Practices and Reductions in Preschoolers' Challenging Behavior

It is widely assumed that (1) children with challenging behavior may lack the social–emotional skills to be successful in classroom settings and (2) instruction in social–emotional skills can help prevent the occurrence of young children's challenging behavior. However, no data are available to indicate whether specific social–emotional skills might be most effective in reducing existing challenging behavior. In this study, we used an archival database to examine possible relationships between types of social–emotional instruction and changes over a 4-month period in levels of social skills and challenging behavior. The database, from a randomized trial of an intervention for preschoolers' challenging behavior, included measures of types of social–emotional instruction and children's social skills and challenging behaviors. Correlational analyses revealed statistically significant relationships between two types of social–emotional teaching practices and reductions in preschoolers' challenging behavior for children in the intervention group, teaching children behavior expectations and teaching problem-solving. No other statistically significant associations were identified. The results are discussed in relation to possible implications for social–emotional instruction for preschool children already exhibiting challenging behavior and the value of further research focused on preventing challenging behavior in young children.

The Evaluation of Parenting Styles of Children with Attention Deficit/ Hyperactivity Disorder

Background: Parenting has an important role in improving the performance of children with ADHD and in their families, this study will create awareness about parenting styles among parents addressing differences in parenting styles and improving the quality of child mental health.
 Objective: This study was intended to evaluate the different parenting styles of parents having children with ADHD and healthy children. It also aimed to find out any relationship between the socio-demographic variables of children and parents with the parenting style of the diseased child. 
 Methodology: This was a case-control study. The study was conducted in the Department of Psychiatry, Sylhet MAG Osmani Medical College, Sylhet during the period from September 2020 to August 2022. ADHD was diagnosed using DSM-5 and confirmed by a consultant psychiatrist. A total of 60 parents of children (ADHD=30, Healthy=30) were interviewed who fulfilled the enrollment criteria. Semi-structured questionnaire for socio-demographic variables and a Bangla Parenting Style and Dimension Questionnaire (PSDQ) were used for assessing parenting style. The data analysis was conducted utilizing the one-way analysis of variance (ANOVA) method, followed by post-hoc comparisons using the Bonferroni correction.
 Results: The predominant parenting style found to be applied to children with ADHD was authoritative (56.67%), followed by 26.67% authoritarian parenting and 16.33% permissive parenting style. Among the parents of healthy children, 53.33% were authoritative, 23.33% were authoritarian and permissive. There was a statistically significant association of parenting styles with education level and occupation. ADHD children's parents who studied up to the primary level had a significantly higher authoritarian score and (authoritarian p = 0.005) and the normal children's parents who studied up to the secondary level had a significantly higher authoritarian score (authoritarian p = 0.007. A significant association was found in the authoritarian domain in parents who were housewives (p = 0.032). Individuals within 6-9 years age range exhibit significantly higher scores in the authoritative domain (p=.001). Both boys and girls groups exhibit a considerably higher score in the authoritative domain (p=.003, p=.001). 
 Conclusion: The fact that parenting styles influence ADHD may appear to be a burden, but it can also be an opportunity to change one's life. Solutions like parent training programs can provide skills and strategies as well as help build resilience in parents to manage the challenging behavior of children with ADHD.

Factoren geassocieerd aan agressiviteit en verwante gedragsproblemen bij kinderen en adolescenten met ASS: een grondige review

Factors associated with externalizing challenging behaviour in children and adolescents with ASD: a systematic review Autism spectrum disorder (ASD) is a neurodevelopmental syndrome with a high prevalence of comorbid challenging behaviours. Externalizing challenging behaviours are known to have a negative prognostic impact on children with ASD and their caregivers. Studies have shown several risk factors for externalizing challenging behaviours in the typically developing population. Less is known about the risk factors for children with ASD. The databases PubMed, Embase and Web of Science Core Collection were systematically searched. A systematic analysis of the selected articles was performed. A total of 95 studies were found. Despite the multitude of withheld articles, only a few factors showed to be clearly associated with externalizing challenging behaviour in children with ASD. The studies in this review mainly investigate cross-sectional and some prognostic associations, and often find conflicting results. Consequently, the authors cannot make strong statements about possible direct causal relationships of the studied factors with externalising behavioural problems. Nevertheless, they emphasize some possible implications for clinical practice. First, more attention should be paid to the adaptive skills of children with ASD. In addition, they underline the importance of systematic screening regarding the severity of the rigidity, encouraging flexibility and learning to cope with change. Furthermore, it is crucial to diagnose and treat ADHD and sleep disorders. Finally, the results mark the importance of early detection and intervention of contextual factors.

Managing Challenging Child Behaviour in Pediatric Dentistry Using Pharmacologic Approaches: A Vanishing Art

Amongst the skills and competency expected of the pediatric dental specialist is an enhanced ability to circumvent and obtund interfering and refractory behaviour of moderately to severely apprehensive and resistive children. Wide variation exists among this specialist with respect to individual talents to accomplish treatment on this population making use of both nonpharmacological as well as pharmacological approaches. While advanced training programs vary greatly in the extent to which their residents are exposed to various modalities, likely explanation to account for such lies in the diversity to which their faculty bring competent and diversified experience. Some bring extensive background to the use of a variety of agents and dosing; others conceivably offer limited exposure to residents by not having had extensive use during their own training programs. Expertise and a propensity to include a broad repertoire of agents and modalities by Program Directors is highly variable. External sources include administrative perspectives, safety records, formulary limitations, and biases of state and regulatory agencies as to what agents and regimens impose restrictions on this teaching experience. This editorial expresses observations of this author over the past 40 plus years concludes that the use of pediatric sedation has diminished to the extent that its safe and successful use is at risk of becoming a vanishing art. The end result is that an increasing number of children by virtue of a lack of skilled clinicians in its safe use will be subjected to excessive if not unnecessary use of unconscious techniques and/or physical restraint.

Associations Between Parenting Behaviors and Behavioral Problems in Young Children With Developmental Delays.

Children with developmental delays (DD) are at heightened risk for developing behavior problems, which contribute to parenting stress and caregiving burden. There is an established relation between parenting behaviors and child developmental outcomes with less known about parent-child interactions in young children with DD. The present study examined the associations between parenting behaviors and child behavior in a sample of 180 families with preschool-aged children with DD. Results indicated that caregivers' harsh and coercive behaviors were associated with observed challenging behavior in children. Child age, as well as the number of commands issued by caregivers were associated with noncompliance in children. The significance and limitations of these findings are discussed, as well as recommendations for interventions and future research.

Noncompliance Assessments, Interventions, and Ethical Considerations for Young Children: A Systematic Review

Noncompliance is a frequently reported challenging behavior for young children. However, many interventions that address noncompliance fail to consider crucial self-advocacy skills that may be jeopardized when compliance is taught in isolation. We examined the noncompliance literature in the context of ethical considerations for young children: (1) decision-making skills related to compliance, (2) teaching discrimination within contexts where compliance may or may not be appropriate, and (3) addressing support needs that may impact compliance. We found that many noncompliance assessments were not developmentally appropriate, related support needs were largely unaddressed, and ethical factors were infrequently considered when designing noncompliance interventions. Researchers and practitioners should consider assessments that identify ecological factors and support needs related to noncompliance. Young children should be taught discrimination of contexts where noncompliance is appropriate and where compliance is appropriate to promote volitional skills that are necessary for future independence.

Individualized Parent-Mediated Behavioral Treatment for Challenging Behavior: A Program Description.

Past research suggests behavioral treatments are effective for challenging behavior in children and young adults with neurodevelopmental disorders, such as autism spectrum disorder (ASD). However, access to these services can be limited and require substantial resources. To address this issue, the current study provides a programmatic description of an individualized parent-mediated service model targeting moderate challenging behavior. In the program, therapists coached parents to implement functional analyses and individualized function-based treatment packages. Forty-one families of children and young adults with neurodevelopmental disorders participated. Most clients (75.6%) met all admission treatment goals and parents reported significant decreases in frequency and severity of challenging behaviors at discharge. Parents also reported less stress at discharge. Outcomes of the study suggest this parent-mediated treatment model is a viable option to treating moderate challenging behavior in children and young adults with intellectual and developmental disorders.

Environmental Factors Related to Quality of Life of Parents of Children with Autism Spectrum Disorder : A Scoping Review

Introduction: Concerns about the quality of life (QoL) of parents of children with autism spectrum disorder have been raised by previous study. Policy decision-makers and healthcare professionals can be better informed about the environmental factors associated with parental QoL, which will enhance outcomes for both parents and children. The objective of this review is to perform a comprehensive review that assessed the environmental relevant factors associated with quality of life (QoL) of parents of ASD children (under 18 years old). Methodology: To identify the environmental factors associated with parental QoL, a scoping review was conducted using the Arksey and O'Malley original and enhanced framework. Three electronic data bases (PubMed, Scopus & WOS) and reference list checks were used in the search. Results: Social support, family support, residential condition and access to services were all factors linked to parental quality of life in this group. Conclusion: The review clarified environmental factors as one of variables that have association with parental QoL. The results of this analysis also highlighted potential areas of support that have implications on future policy and practices. Keywords : environmental factors, autism spectrum disorder, quality of life, parents, children References CDC. Prevalence of autism spectrum disorders--Autism and Developmental Disabilities Monitoring Network, 14 sites, United States, 2008. MMWR Surveill Summ. 2012;61(3):1-19. CDC. Prevalence of autism spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, United States, 2010. MMWR Surveill Summ. 2014;63(2):1-21. Elsabbagh M, Divan G, Koh Y-J, Kim YS, Kauchali S, Marcín C, et al. Global Prevalence of Autism and Other Pervasive Developmental Disorders. Autism Research. 2012;5(3):160-79. McTiernan A, Leader G, Healy O, Mannion A. Analysis of risk factors and early predictors of challenging behavior for children with autism spectrum disorder. Research in Autism Spectrum Disorders. 2011;5(3):1215-22. Simonoff E, Pickles A, Charman T, Chandler S, Loucas T, Baird G. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adolesc Psychiatry. 2008;47(8):921-9. Bolton PF. Medical conditions in autism spectrum disorders. Journal of Neurodevelopmental Disorders. 2009;1(2):102-13. Khanna R, Madhavan SS, Smith MJ, Patrick JH, Tworek C, Becker-Cottrill B. Assessment of Health-Related Quality of Life Among Primary Caregivers of Children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. 2011;41(9):1214-27.