Research in Developmental Disabilities 36 (2015) 256–263
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Research in Developmental Disabilities
Psychometric properties of the Chinese Behavior Problems Inventory-01 in children and adolescents with or at risk for intellectual disabilities Xiaozhu An a, Johannes Rojahn a,*, Timothy W. Curby a, Yuezeng Ding b a b
George Mason University, United States Qingdao University, China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 September 2014 Accepted 2 October 2014 Available online
As the world’s most populous country, China is likely to have the highest number of people with intellectual disabilities (ID) in the world. As many people with ID are susceptible to serious and persistent behavior problems, research by Chinese scientists on this public health issue is needed. However, there are only very few reliable Chinese-language behavior assessment instruments for problem behaviors. To fill this gap we translated the Behavior Problems Inventory-01 (BPI-01; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001) into Chinese. The BPI-01 is an informant-based behavior rating instrument that was designed to assess self-injurious behavior (SIB), stereotyped behavior, and aggressive/ destructive behavior in individuals with ID. We then assessed the behavior of 222 children and young adults (age range 1.5–21.5 years) with or at risk for ID from three special needs service programs in mainland China. Teachers or staff members, respectively, served as respondents. The Chinese version of the BPI-01 showed good reliability (internal consistency) and good factor validity tested by confirmatory factorial analysis. We conclude that the Chinese version of the BPI-01 can be used for research and clinical evaluation of Chinese children and adolescents with ID. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Behavior Problems Inventory BPI-01 Intellectual disabilities Challenging behavior Self-injurious behavior Aggressive behavior Stereotyped behavior Chinese
1. Introduction Intellectual disability (ID) refers to a condition that is characterized by a combination of limitations in intellectual functioning and adaptive behavior that are manifested prior to the age of 18 (American Association on Intellectual and Developmental Disabilities, 2010; American Psychiatric Association, 2013). Intellectual functioning or intelligence refers to a general mental capacity (e.g., learning, reasoning, problem solving, etc.), which is assessed by intelligence tests. Typically, IQ test scores of around 70 or below (i.e., two standard deviations below the mean) are seen as indicators of a limitation in intellectual functioning. Adaptive behavior refers to skills necessary to function in everyday live and include conceptual, social, and practical domains. Adaptive behavior is assessed by a variety of standardized instruments (American Association on Intellectual and Developmental Disabilities, 2010), including the Adaptive Behavior Scale (ABS; Lambert, Nihira, & Leland, 1993), Adaptive Behavior Assessment System – Second Edition (ABAS-II; Harrison & Oakland, 2003), and Vineland Adaptive Behavior Scales – Revision (Vineland II; Sparrow, Cicchetti, & Balla, 2005).
* Corresponding author. Tel.: +1 703 993 4241. E-mail address: [email protected] (J. Rojahn). http://dx.doi.org/10.1016/j.ridd.2014.10.006 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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As the world’s most populous country with over 1.37 billion people, China is likely to have the highest number of people with ID in the world. A national survey conducted in 2006 sampled 2.5 million people and yielded an ID prevalence rate of 0.75% (Wu, Qiu, Wong, Hernandez & Zhao, 2010). This rate is comparable with international prevalence estimates (Maulik, Mascarenhas, Mathers, Dua, & Saxena, 2011). People with ID are at a high risk to develop seriously problematic behaviors such as self-injurious behavior (SIB) and aggressive or destructive behavior that are physically dangerous or otherwise socially unacceptable and tend have a variety of negative direct and indirect effects that are not only harmful to the perpetrator’s current and future wellbeing, but also to the family and the support system. If not treated they have a tendency to become chronic. The prevalence rates of such behaviors vary from study to study. Rojahn and Meier (2010) reviewed the international epidemiological literature on behavior problems in ID and found the prevalence rates for aggressive behavior to range from 6.4% (Holden & Gitlesen, 2006) to 32% (Lowe et al., 2007); the rate of SIB from 4.4% (Holden & Gitlesen, 2006) to 21% (Lowe et al., 2007), and the rate of destructive behavior from 2.3% (Holden & Gitlesen, 2006) to 19% (Lowe et al., 2007). Cooper, Smiley, Morrison, Williamson, and Allan (2007) estimated the prevalence of significant problem behaviors in the ID population in the UK to be 22.5%. In the US, Rojahn, Borthwick-Duffy, and Jacobson (1993) reported that in the State of New York 11.3% and in California 12.5% of the individuals with ID who were receiving public state services had aggressive behavior, 7.0% and 8.0%, respectively, had SIB, and 6.5% had stereotyped behavior in both states. Although there are about 10 million people with ID in China we have not been able to identify even a single survey of behavior problems prevalence in that country. In China, epidemiological and clinical research on problem behaviors in ID is held back, at least in part, by the lack of psychometrically sound behavior rating instruments in Chinese. Indeed, a comprehensive literature search in both Chinese and English found not a single assessment instruments for challenging behaviors in people with ID that was developed in China. We discovered, however, two recent Chinese translations of English-language assessment instruments for problem behaviors in ID whose translations into Chinese had been tested for their psychometric properties: the Aberrant Behavior Checklist (ABC; Aman, Singh, Stewart, & Field, 1985) and the Repetitive Behavior Scale-Revised (RBS-R; Bodfish, Symons, & Lewis, 1999). The ABC assesses behavior challenges in five broad areas (irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech). Ma, Guo, Jia, Li, and Liu (2011) found that the Chinese version of the ABC, tested with in 206 subjects with Autism Spectrum Disorder (ASD) aged one and a half to 14 years of age had good inter-rater reliability, test-retest reliability, internal consistency reliability, and structural validity. Likewise, the RBS-R has six subscales (stereotyped behavior, SIB, compulsive behavior, ritualistic behavior, sameness behavior, and restricted behavior). Li, Jiang, Cui, Guo, and Zhu (2013) explored the Chinese version of the RSB-R in 104 subjects with ASD aged 2 to 7 years. The RBS-R also had good inter-rater reliability, test-retest reliability, internal consistency reliability, and structure validity. While the Chinese ABC and RBS-R proved psychometrically sound, the Behavior Problems Inventory-01 (BPI-01; Rojahn et al., 2001) would still represent a useful alternative for some types of studies. Compared with the broad range of behaviors targeted by the ABC, the BPI-01 provides more detailed assessments of a narrower range of behavior, namely specific types of SIB, stereotyped behavior, and aggressive/destructive topographies. And whereas the RBS-R targets a variety of specific SIBs and stereotyped behaviors, it does not assess aggressive and destructive behaviors at all. Therefore, the BPI-01 can fill a gap in available assessment instruments for problem behaviors in the ID population in Chinese language. Hence, the purpose of the present study was first to translate the BPI-01 into Chinese and then to evaluate its psychometric properties (internal consistency and factorial validity using confirmatory factor analysis).
2. Method 2.1. Participants A total of 222 individuals from three service providers (two rehabilitation and training centers in Qingdao [n = 44] and Changzhou [n = 135], and one special education school in Shanghai city [n = 43]) participated in the study. Their mean age was 8.0 years (SD = 3.61), ranging from one and a half to 21.5 years. All three service providers were located in urban area, although they accepted referrals from both urban and rural areas. Table 1 shows the makeup of our sample broken down by gender, age group, and level of ID. As reported to us by the service providers only 70% had a clinical diagnosis of ID. The remaining individuals either had ID, or they were considered to be at risk for ID and were therefore believed to benefit from special needs services.1
1 None of the three participating agencies conducted routine standardized testing and some of the participants had never been psychometrically tested at all. Those who had a diagnosis of ID had received it from other agencies. We assume that those with relatively higher cognitive abilities were more likely not to have had any formal psychometric testing. To examine this hypothesis, we computed ANOVAs with ID levels (including the missing value group) as a predictor and three BPI-01 sub-scale scores as dependent variables. Corroborating our assumption, we found that the group with missing ID information had the lowest mean scores for the BPI-01 subscales stereotyped behavior and aggressive/destructive behavior and the second lowest mean score (a litter bit higher than mild ID group) for the SIB subscale.
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258 Table 1 Demographic information of the sample. Gender
Male Age
Level of ID Mild
Moderate
Severe/profound
Unknown
Total
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
13 10 3 0 3 29
12 27 11 0 2 52
1 14 12 3 2 32
8 32 5 4 5 54
34 83 31 7 12 167
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
2 2 0 0 0 4
6 14 0 0 1 21
2 1 7 1 0 11
4 5 2 1 0 12
14 22 9 2 1 48
0–4.99 5–9.99 15–21.50
1 0 0 1
3 1 1 5
0 0 0 0
0 1 0 1
4 2 1 7
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
16 12 3 0 3 34
21 42 11 1 3 78
3 15 19 4 2 43
12 38 7 5 5 67
52 107 40 10 13 222
Total Female Age
Total Missing Age
Total Total Age
Total
3. Respondents Teachers and staff members completed the BPI-01 on behalf of their students or clients, respectively. The average time that the respondents spent with the participants was about 9 h (SD = 7.01) per day ranging from a half to 24 h. The average time the respondents had known the participants was 30.5 months (SD = 29.36), ranging from 1 to 153 months. In addition, the respondents also provided the participants’ birth dates, clinical diagnoses, and IQ test scores if available from the clients’ records. 4. Instrument The Behavior Problems Inventory-012 (BPI-01; Rojahn et al., 2001, 2012a, 2012b) is a respondent-based rating instrument that was designed to assess maladaptive behaviors in individuals with ID. It contains 52 items that respondents can use to rate the observed frequency and severity of the problem behaviors for individuals with intellectual or developmental disabilities (Rojahn et al., 2001). There are three sub-scales: SIB (15 items), stereotyped behavior (25 items), and aggressive/ destructive behavior (12 items). Each item is rated on a frequency scale (0 = never to 4 = hourly), and a severity scale (0 = no problem to 3 = severe problem). The BPI-01 has been successfully used in several studies and has been shown to have good psychometric properties with fair to excellent internal consistency and good validity as tested by confirmatory factor analysis and discriminant factor analysis (Rojahn et al., 2012b). In addition, the instrument has been translated into many different languages and the foreign language versions have also been proven to have good reliability and validity (e.g., Baraldi, Rojahn, Seabra, Carreiro, & Teixeira, 2013; Dumont, Kroes, Korzilius, Didden, & Rojahn, 2014; Mircea, Rojahn, & Esbensen, 2010). 5. Procedure First we translated the English original of the BPI-01 into Chinese.3 This translation was then back-translated into English by two Chinese psychology graduate students in the US. The original and the back-translated English versions were then compared by another, US native-English speaking graduate student. Minor differences in phrasing and vocabulary were then
2 3
A copy of the Chinese BPI-01 can be obtained for free from Johannes Rojahn, Ph.D., at [email protected]. Simplified.
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discussed and reconciled by the US student and the first author. There were no significant differences between the original and the back-translated English versions. Data were originally collected by teachers or and staff members under the direction of the fourth author (Y.D.) and with approval and active support of the respective program directors in China. Using the Chinese version of the BPI-01, the respondents rated the participants’ behavior. The data were then analyzed in the US with approval of the George Mason University IRB. Previous studies have repeatedly shown that there is high redundancy (r 0.90) between the BPI frequency and severity scores (Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Schroeder, & Hoch, 2007). The Pearson correlation between the BPI frequency severity total scores in the present data set was 0.96. Therefore, only frequency scale data were used in the following analyses. At the end of each of the items of the three sub-scales there is a question asking about ‘‘other behavior’’ that may have been observed in a participant, that is not part of the standard set of items. These three questions have the purpose of identifying important behaviors that are not listed in the BPI-01. We excluded these three questions from our analysis, leaving a total of 49 items to examine. 6. Results 6.1. Descriptive statistics Table 2 summarizes the sub-scale and sub-item survey scores for the 49 items in the BPI-01 frequency scores. At least one problem behavior was checked for 91% of the 222 surveyed individuals. About 63.5% of them showed at least one type of SIB, 85.1% had at least one stereotyped behavior, and 63.5% had at least one aggressive/destructive behavior. The two most frequently reported SIB topographies were head-hitting (33.8%) and body-hitting (27.5%). The two most frequently reported stereotyped behaviors were yelling (48.6%) and hand movements (46.4%). The two most frequently reported aggressive/ destructive behaviors were pushing (35.6%) and grabbing and pulling (32.4%). Table 2 provides additional information about the prevalence of each sub-item in the BPI-01. About 74% of the respondents (n = 164) reported frequency values for all of the 49 problem behaviors on the BPI-01 without missing values. About 11% of the respondents failed to report frequency values for some of the SIBs of their participants, about 17% failed to report frequency values for some of the stereotyped behaviors, and about 10% of the respondents failed to report frequency values for some of the aggressive/destructive behaviors. For more detailed information about missing values for each problem behavior, see Table 2. 6.2. Reliability and validity properties of the Chinese BPI-01 A first pass of the psychometric properties was conducted using Cronbach’s a-coefficients. Separate evaluations were done for each of the three BPI-01 subscales and for the entire inventory. The a-coefficient for the entire inventory was 0.92; the SIB subscale had an a of 0.81, the stereotyped behavior sub-scale had an a of 0.92, and the aggressive/destructive behavior sub-scale had an a of 0.86. According to guidelines by Cicchetti (1994), an a of 0.90 and above = excellent reliability; 0.80–0.89 = good; 0.70–0.79 = fair; 0.00–0.69. = poor. A confirmatory factor analysis (CFA) was also performed using the SEM software SPSS AMOS. Three correlated latent factors were created using their respective 49 items of the BPI-01 frequency scores. When conducting analysis with the SEM framework, it is often assumed that the variable distributions are normal and continuous. However, all of the observed variables in our model failed the test of normality and they all had positively skewed distributions. Because the data were non-normal, Bayesian estimation option provided by the AMOS software procedures were used to handle it. Bayesian estimation is non-parametric and, as such, not sensitive to non-normality. Model fit was evaluated using the posterior predictive p value. Latent variables were standardized by setting their variances to 1. Standardized regression weights were examined to determine the degree to which the factors accounted for the items. Correlations between the subscale factors were also examined. The data fit the model quite well with a posterior predictive p of 0.50 (with convergence statistics = 1.0, DIC = 8494.2, effective number of parameters = 148.6, iterations = [2000 + 65036] 4, and random walk = 0.35). The standardized weights for the regression paths ranged from 0.21 to 1.24 and all were significant (p < 0.05). The two highest loading SIB items were head-hitting (0.80) and body-hitting (0.76), while the two lowest loading SIB items were hair pulling (0.21) and air swallowing (0.22). The two highest loading stereotyped behavior items were hand movements (1.24) and body movements (1.12), while the two lowest loading stereotyped behavior items were grimacing (0.28) and sniffing self (0.50). The two highest loading aggressive/destructive behavior items were grabbing and pulling (0.88) and scratching (0.75), while the two lowest loading aggressive/destructive behavior items were verbally abusive (0.21) and spitting (0.34). (For more information of the best-fit model, see Table 3). We also calculated the Pearson correlation coefficients between the three sub-scale scores. The correlation coefficients were significant between SIB and stereotyped behavior (r = 0.51) and between SIB and aggressive/destructive behavior (r = 0.51). Interestingly, the correlation coefficient between stereotyped behavior and aggressive/destructive behavior was non-significant (r = 0.19).
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Table 2 Descriptive item statistics for the Chinese BPI-01. BPI-01 items
n
Missing
Prevalence (in %)
M
SD
Skewness (SE)
a
a
Subscales (average score ) SIB Stereotypy Aggression
222 220 220
0 2 2
63.5 85.1 63.5
0.33 0.79 0.45
0.45 0.73 0.61
1.73 (0.16) 0.84 (0.16) 1.97 (0.16)
Itemsb SIB 1. Self-biting 2. Head-hitting 3. Body-hitting 4. Self-scratching 5. Vomiting 6. Self-pinching 7. Pica 8. Inserting objects 9. Nail-pulling 10. Inserting fingers 11. Air swallowing 12. Hair pulling 13. Drinking 14. Teeth-grinding
215 220 220 218 219 217 220 221 217 219 221 220 221 215
7 2 2 4 3 5 2 1 5 3 1 2 1 7
21.6 33.8 27.5 20.3 13.1 17.6 15.8 7.7 9.0 10.4 5.9 6.8 9.5 20.7
0.46 0.71 0.56 0.44 0.26 0.35 0.39 0.15 0.22 0.20 0.12 0.14 0.22 0.47
0.95 1.13 1.05 0.98 0.76 0.84 0.98 0.60 0.75 0.67 0.53 0.56 0.75 1.02
2.01 1.39 1.82 2.28 3.25 2.54 2.44 4.69 3.71 4.04 5.32 4.62 3.47 2.08
(0.17) (0.16) (0.16) (0.16) (0.16) (0.17) (0.16) (0.16) (0.17) (0.16) (0.16) (0.16) (0.16) (0.17)
Stereotyped behavior 15. Rocking 16. Sniffing objects 17. Spinning self 18. Arm-waving 19. Head-rolling 20. Whirling 21. Body movements 22. Pacing 23. Twirling 24. Hand movements 25. Yelling 26. Sniffing self 27. Bouncing 28. Spinning objects 29. Running 30. Finger movements 31. Manipulating 32. Sustained finger 33. Rubbing self 34. Gazing 35. Postures 36. Clapping 37. Grimacing 38. Hand-waving
214 215 212 219 219 216 213 218 218 216 217 215 219 217 217 217 216 213 215 214 218 218 214 219
8 7 10 3 3 6 9 4 4 6 5 7 3 5 5 5 6 9 7 8 4 4 8 3
39.6 38.3 29.7 41.0 40.1 30.2 39.6 25.2 37.4 46.4 48.6 21.2 32.4 28.4 45.0 27.0 35.6 27.9 17.1 34.7 24.3 23.4 19.4 24.3
1.04 0.87 0.67 0.98 0.97 0.61 1.03 0.59 0.97 1.29 1.10 0.45 0.84 0.64 1.17 0.67 0.82 0.77 0.44 0.89 0.52 0.54 0.41 0.61
1.45 1.22 1.13 1.36 1.38 1.05 1.39 1.13 1.38 1.54 1.30 0.95 1.34 1.14 1.44 1.23 1.26 1.36 1.06 1.37 1.04 1.09 0.94 1.19
1.01 1.12 1.57 1.04 1.11 1.68 0.92 1.78 1.03 0.66 0.78 2.10 1.28 1.64 0.74 1.65 1.29 1.49 2.39 1.26 1.99 1.94 2.48 1.77
(0.17) (0.17) (0.17) (0.16) (0.16) (0.17) (0.17) (0.16) (0.16) (0.17) (0.17) (0.17) (0.16) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.16) (0.16) (0.17) (0.16)
Aggressive/destructive behavior 39. Hitting 40. Kicking 41. Pushing 42. Biting 43. Grabbing, pulling 44. Scratching 45. Pinching 46. Spitting 47. Verbally abusive 48. Destroys 49. Cruel
218 217 216 218 216 213 215 214 212 211 214
4 5 6 4 6 9 7 8 10 11 8
31.5 20.3 35.6 19.4 32.4 19.8 19.8 15.3 6.3 25.2 26.1
0.60 0.36 0.67 0.40 0.70 0.38 0.40 0.26 0.14 0.56 0.51
1.00 0.82 1.04 0.93 1.14 0.88 0.87 0.69 0.57 1.08 1.00
1.54 2.42 1.45 2.51 1.42 2.51 2.16 3.19 4.61 1.93 2.06
(0.16) (0.17) (0.17) (0.16) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17)
When calculating average scores for sub-scales, the missing values are automatically regarded as 0 by SPSS. The average score shows as missing only when all of the scores included in the calculation are missing. For missing value information on the level of sub-scales, see the text above. Many items are abbreviated.
b
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Table 3 Parameter estimates in SEM. Standardized weights
Intercepts
M (SE)
95% CI lower
95% CI upper
M (SE)
95% CI lower
95% CI upper
SIB 1. Self-biting 2. Head-hitting 3. Body-hitting 4. Self-scratching 5. Vomiting 6. Self-pinching 7. Pica 8. Inserting objects 9. Nail-pulling 10. Inserting fingers 11. Air swallowing 12. Hair pulling 13. Drinking 14. Teeth-grinding
0.45 0.80 0.76 0.62 0.31 0.59 0.41 0.29 0.29 0.30 0.22 0.21 0.34 0.36
(0.004) (0.004) (0.003) (0.004) (0.002) (0.003) (0.003) (0.002) (0.003) (0.002) (0.002) (0.002) (0.002) (0.002)
0.32 0.65 0.63 0.49 0.20 0.47 0.27 0.21 0.18 0.20 0.14 0.13 0.23 0.22
0.60 0.95 0.90 0.77 0.42 0.71 0.56 0.38 0.40 0.40 0.30 0.30 0.46 0.51
0.46 0.71 0.57 0.44 0.26 0.35 0.40 0.15 0.21 0.20 0.12 0.14 0.22 0.47
(0.002) (0.003) (0.003) (0.003) (0.002) (0.002) (0.004) (0.002) (0.002) (0.002) (0.002) (0.002) (0.003) (0.003)
0.33 0.56 0.42 0.31 0.16 0.23 0.26 0.07 0.11 0.10 0.05 0.06 0.13 0.33
0.58 0.86 0.71 0.57 0.36 0.46 0.54 0.23 0.31 0.29 0.19 0.21 0.33 0.60
Stereotyped behavior 15. Rocking 16. Sniffing objects 17. Spinning self 18. Arm-waving 19. Head-rolling 20. Whirling 21. Body movements 22. Pacing 23. Twirling 24. Hand movements 25. Yelling 26. Sniffing self 27. Bouncing 28. Spinning objects 29. Running 30. Finger movements 31. Manipulating 32. Sustained finger 33. Rubbing self 34. Gazing 35. Postures 36. Clapping 37. Grimacing 38. Hand-waving
0.80 0.72 0.62 0.95 0.95 0.64 1.12 0.57 0.85 1.24 0.53 0.50 0.95 0.56 0.93 0.77 0.83 0.94 0.62 0.83 0.54 0.67 0.28 0.70
(0.005) (0.004) (0.004) (0.004) (0.004) (0.003) (0.004) (0.005) (0.005) (0.004) (0.005) (0.003) (0.004) (0.004) (0.003) (0.004) (0.005) (0.005) (0.004) (0.004) (0.004) (0.003) (0.004) (0.004)
0.60 0.56 0.47 0.78 0.77 0.50 0.94 0.41 0.67 1.05 0.34 0.35 0.78 0.39 0.73 0.60 0.66 0.75 0.47 0.64 0.39 0.53 0.14 0.54
1.02 0.90 0.79 1.14 1.13 0.79 1.31 0.74 1.05 1.45 0.72 0.64 1.15 0.73 1.13 0.95 1.01 1.13 0.78 1.04 0.69 0.83 0.43 0.87
1.03 0.85 0.66 0.98 0.96 0.61 1.04 0.60 0.97 1.29 1.10 0.45 0.85 0.64 1.17 0.67 0.84 0.78 0.45 0.88 0.52 0.55 0.41 0.61
(0.004) (0.003) (0.004) (0.004) (0.005) (0.003) (0.004) (0.003) (0.005) (0.005) (0.002) (0.002) (0.004) (0.004) (0.004) (0.004) (0.004) (0.003) (0.003) (0.003) (0.004) (0.003) (0.003) (0.003)
0.83 0.68 0.50 0.80 0.77 0.46 0.85 0.45 0.77 1.07 0.93 0.32 0.66 0.48 0.98 0.51 0.67 0.60 0.31 0.70 0.38 0.40 0.27 0.45
1.23 1.02 0.83 1.17 1.16 0.75 1.25 0.75 1.16 1.51 1.28 0.57 1.04 0.81 1.36 0.85 1.01 0.96 0.60 1.07 0.67 0.70 0.53 0.78
Aggressive/destructive behavior 39. Hitting 40. Kicking 41. Pushing 42. Biting 43. Grabbing, pulling 44. Scratching 45. Pinching 46. Spitting 47. Verbally abusive 48. Destroys 49. Cruel
0.70 0.65 0.73 0.63 0.88 0.75 0.59 0.34 0.21 0.57 0.47
(0.002) (0.002) (0.002) (0.003) (0.004) (0.002) (0.003) (0.001) (0.002) (0.004) (0.003)
0.57 0.55 0.60 0.51 0.74 0.64 0.47 0.24 0.13 0.42 0.34
0.84 0.75 0.87 0.75 1.04 0.87 0.71 0.44 0.30 0.72 0.62
0.60 0.37 0.67 0.40 0.70 0.40 0.39 0.26 0.14 0.56 0.51
(0.003) (0.002) (0.003) (0.002) (0.004) (0.003) (0.003) (0.003) (0.002) (0.003) (0.003)
0.46 0.26 0.53 0.27 0.54 0.27 0.28 0.16 0.06 0.41 0.38
0.74 0.48 0.80 0.53 0.86 0.52 0.51 0.35 0.23 0.71 0.65
All the standardized weights shown in the table are significant. a, b Since the latent variables were standardized by fixing their variances to 1 in our model, we got two loadings >1.
7. Discussion The BPI-01 was translated into Chinese using a rigorous procedure. An initial translation was back-translated to doublecheck the semantic equivalence between the original English and the Chinese translated versions of the BPI-01. Psychometric property analysis indicated good reliability (internal consistency) and good factorial validity. Internal consistency of total scales was excellent (0.92) and the subscale internal consistencies ranged from good to excellent (from 0.81 to 0.92). Compared to the internal consistency of original English BPI-01, which has a total scales internal consistencies of 0.83 (Rojahn et al., 2001), and the sub-scale internal consistencies ranged from 0.74 to 0.92 (Rojahn et al., 2012b), the Chinese BPI-01 exhibits even higher internal consistencies.
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In addition, the hypothesized three-factor model was also confirmed by CFA for the Chinese translation version BPI-01. This is in consistent with the English BPI-01 (Rojahn et al., 2012b) as well as with other translations of the BPI-01 (e.g., Baraldi et al., 2013; Dumont et al., 2014; Mircea et al., 2010). This supports the notion that the behavior problems manifested by individuals with ID are universal not sensitive to cultural differences. There are limitations to this study. In particular, our sample size was relatively small for some of the analyses (such as the CFA) and the information about the level of ID was incomplete, unavailable and in many cases even non-existent. We, therefore, assume that some individuals in our sample may not have met criteria for a formal diagnosis if ID. Given that they were receiving special needs services at the time, we assumed that some of those without a formal ID diagnosis may have fallen into the ID borderline range. That it was not possible to keep track of the individual respondents is another problem. It is most likely that several of the raters rated more than one participant. Therefore, we were unable to isolate a respondenteffect in our results. We must assume that the range in the number of participants that respondents rated varied greatly, which undermines the principle of independent sampling as it would give extra weight to those respondents who rated larger numbers of participants. We were also unable to conduct respondent-agreement analyses. Considering the purpose of this study (namely examining general psychometric properties of an assessment instrument), we felt that a convenience sample with a reasonable range of personal characteristics was acceptable. It should be noted that this was not an epidemiological study and that our sample is not representative of the Chinese ID population. This, therefore, precludes any epidemiological interpretations of our data. Thus, although we reported having detected gender effects in our sample (males had significantly higher stereotyped behavior scores that females), we cannot and do not conclude that the same applies to the Chinese ID population in general (a finding which, by the way, would differ from most previous research [Baghdadli, Pascal, Grisi, & Aussilloux, 2003; Holden & Gitlesen, 2006; McTiernan, Leader, Healy, & Mannion, 2011; Murphy, Healy, & Leader, 2009; Rojahn et al., 2001]). These results were simply part of our sample characteristics analysis. In summary, and despite those limitations, we conclude that this Chinese translation of the BPI-01 can be used for research as well as for clinical evaluations of Chinese individuals with ID. In present study, however, only preliminary analyses (Cronbach’s alpha and factor validity) were conducted, more tests are needed to further examine the psychometric property of the Chinese version of BPI-01 and verify the cross-cultural adaptation of it. After that, unique problem behavior patterns among Chinese individuals with ID due to the cultural background of China can be explored and analyzed. Acknowledgments The authors wish to acknowledge Yue Ji, Alec Bernstein, Chen Qiu, Zitong Sheng, Ronald Jeremias and Dr. Ellen Rowe for their active support without whom this study could not have been possible. We would also like to thank the teachers and staff members of the three service provider organizations in China for their assistance with data collection. This study was conducted as part of the first author’s master’s thesis.
References Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985). The aberrant behavior checklist: A behavior rating scale for the assessment of treatment effects. American Journal of Mental Deficiency, 89(5), 485–491. American Association on Intellectual and Developmental Disabilities (2010). Intellectual disability: Definition, classification, and systems of supports (11th ed.). Washington, DC: American Association on Intellectual and Developmental Disabilities. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Baghdadli, A., Pascal, S., Grisi, S., & Aussilloux, C. (2003). Risk factors for self-injurious behaviors among 222 young children with autistic disorders. Journal of Intellectual Disability Research, 47, 622–627. Baraldi, G. D. S., Rojahn, J., Seabra, A. G., Carreiro, L. R. R., & Teixeira, M. C. T. V. (2013). Translation, adaptation, and preliminary validation of the Brazilian version of the Behavior Problems Inventory (BPI-01). Trends in Psychiatry and Psychotherapy, 35(3), 198–211. Bodfish, J. W., Symons, F. W., & Lewis, M. H. (1999). The repetitive behavior scale. Western Carolina Center Research Reports. Cicchetti, D. V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment, 6, 284–290. Cooper, S.-A., Smiley, E., Morrison, J., Williamson, A., & Allan, L. (2007). Mental ill-health in adults with intellectual disabilities: Prevalence and associated factors. British Journal of Psychiatry, 190, 27–35. Dumont, E., Kroes, D., Korzilius, H., Didden, R., & Rojahn, J. (2014). Psychometric properties of a Dutch version of the Behavior Problems Inventory-01 (BPI-01). Research in Developmental Disabilities, 35, 603–610. http://dx.doi.org/10.1016/j.ridd.2014.01.003 Harrison, P., & Oakland, T. (2003). Adaptive behavior assessment system (ABAS-II). San Antonio, TX: The Psychological Corporation. Holden, B., & Gitlesen, J. P. (2006). A total population study of challenging behavior in the county of Hedmark, Norway: Prevalence and risk markers. Research in Developmental Disabilities, 27, 456–465. Lambert, N., Nihira, K., & Leland, H. (1993). AAMR adaptive behavior scale – School. Austin, TX: Pro-Ed. Lowe, K., Allen, D., Jones, E., Brophy, S., Moore, K., & James, W. (2007). Challenging behaviors: Prevalence and topographies. Journal of Intellectual Disability Research, 51, 625–636. [Li, J.], [Jiang, Z.], [Cui, G.], [Guo, L.], & [Zhu, J.] (2013). ( ) [Reliability and validity of the Chinese version of the Repetitive Behavior Scale-Revised (RBS-R) in children with autism]. , 5(3), 208–211. [Ma, J.], [Guo, Y.], [Jia, M.], [Li, X.], & [Liu, J.] (2011). [Reliability and validity of the Chinese version of the Aberrant Behavior Checklist (ABC) in children with autism]. , 25(001), 14–19. Maulik, P. K., Mascarenhas, M. N., Mathers, C. D., Dua, T., & Saxena, S. (2011). Prevalence of intellectual disability: A meta-analysis of population-based studies. Research in Developmental Disabilities, 32, 419–436. http://dx.doi.org/10.1016/j.ridd.2010.12.018 McTiernan, A., Leader, G., Healy, O., & Mannion, A. (2011). Analysis of risk factors and risk factors of challenging behavior for children with autism spectrum disorder. Research in Autism Spectrum Disorders, 5(3), 1215–1222.
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Mircea, C. E., Rojahn, J., & Esbensen, A. J. (2010). Psychometric evaluation of Romanian translations of the Behavior Problems Inventory-01 and the Nisonger Child Behavior Rating Form. Journal of Mental Health Research in Intellectual Disabilities, 3(1), 51–65. Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for challenging behaviors among 157 children with autism spectrum disorder in Ireland. Research in Autism Spectrum Disorders, 3, 291–570. Rojahn, J., Aman, M. G., Matson, J. L., & Mayville, E. (2003). The aberrant behavior checklist and the behavior problems inventory: Convergent and divergent validity. Research in Developmental Disabilities, 24(5), 391–404. Rojahn, J., Borthwick-Duffy, S. A., & Jacobson, J. W. (1993). The association between psychiatric diagnoses and severe behavior problems in mental retardation. Annals of Clinical Psychiatry, 5, 163–170. Rojahn, J., Matson, J. L., Lott, D., Esbensen, A. J., & Smalls, Y. (2001). The Behavior Problems Inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Journal of Autism & Developmental Disorders, 31(6), 577–588. Rojahn, J., & Meier, L. J. (2010). Psychopathology in intellectual disabilities: Epidemiology and assessment. In R. M. Hodapp (Ed.), International review of research in mental retardation (vol. 38, pp. 239–287). Amsterdam: Elsevier. Rojahn, J., Rowe, E. W., Sharber, A. C., Hastings, R., Matson, J. L., Didden, R., et al. (2012a). The Behavior Problems Inventory Short Form for individuals with intellectual disabilities: Part I: Development and provisional clinical reference data. Journal of Intellectual Disability Research, 56(5), 527–545. Rojahn, J., Rowe, E. W., Sharber, A. C., Hastings, R., Matson, J. L., Didden, R., et al. (2012b). The Behavior Problems Inventory-Short Form for individuals with intellectual disabilities: Part II: Reliability and validity. Journal of Intellectual Disability Research, 56(5), 546–565. Rojahn, J., Schroeder, S. R., & Hoch, T. A. (2007). Self-injurious behavior in intellectual disabilities. Elsevier. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland adaptive behavior scales: (Vineland II), survey interview form/caregiver rating form. Livonia, MN: Pearson Assessments. Wu, L., Qiu, Z., Wong, D., Hernandez, L. W., & Zhao, Q. (2010). The research on the status, rehabilitation, education, vocational development, social integration and support services related to intellectual disability in China. Research in Developmental Disabilities, 31(6), 1216–1222.
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Psychometric properties of the Chinese Behavior Problems Inventory-01 in children and adolescents with or at risk for intellectual disabilities Xiaozhu An a, Johannes Rojahn a,*, Timothy W. Curby a, Yuezeng Ding b a b
George Mason University, United States Qingdao University, China
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 September 2014 Accepted 2 October 2014 Available online
As the world’s most populous country, China is likely to have the highest number of people with intellectual disabilities (ID) in the world. As many people with ID are susceptible to serious and persistent behavior problems, research by Chinese scientists on this public health issue is needed. However, there are only very few reliable Chinese-language behavior assessment instruments for problem behaviors. To fill this gap we translated the Behavior Problems Inventory-01 (BPI-01; Rojahn, Matson, Lott, Esbensen, & Smalls, 2001) into Chinese. The BPI-01 is an informant-based behavior rating instrument that was designed to assess self-injurious behavior (SIB), stereotyped behavior, and aggressive/ destructive behavior in individuals with ID. We then assessed the behavior of 222 children and young adults (age range 1.5–21.5 years) with or at risk for ID from three special needs service programs in mainland China. Teachers or staff members, respectively, served as respondents. The Chinese version of the BPI-01 showed good reliability (internal consistency) and good factor validity tested by confirmatory factorial analysis. We conclude that the Chinese version of the BPI-01 can be used for research and clinical evaluation of Chinese children and adolescents with ID. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Behavior Problems Inventory BPI-01 Intellectual disabilities Challenging behavior Self-injurious behavior Aggressive behavior Stereotyped behavior Chinese
1. Introduction Intellectual disability (ID) refers to a condition that is characterized by a combination of limitations in intellectual functioning and adaptive behavior that are manifested prior to the age of 18 (American Association on Intellectual and Developmental Disabilities, 2010; American Psychiatric Association, 2013). Intellectual functioning or intelligence refers to a general mental capacity (e.g., learning, reasoning, problem solving, etc.), which is assessed by intelligence tests. Typically, IQ test scores of around 70 or below (i.e., two standard deviations below the mean) are seen as indicators of a limitation in intellectual functioning. Adaptive behavior refers to skills necessary to function in everyday live and include conceptual, social, and practical domains. Adaptive behavior is assessed by a variety of standardized instruments (American Association on Intellectual and Developmental Disabilities, 2010), including the Adaptive Behavior Scale (ABS; Lambert, Nihira, & Leland, 1993), Adaptive Behavior Assessment System – Second Edition (ABAS-II; Harrison & Oakland, 2003), and Vineland Adaptive Behavior Scales – Revision (Vineland II; Sparrow, Cicchetti, & Balla, 2005).
* Corresponding author. Tel.: +1 703 993 4241. E-mail address: [email protected] (J. Rojahn). http://dx.doi.org/10.1016/j.ridd.2014.10.006 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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As the world’s most populous country with over 1.37 billion people, China is likely to have the highest number of people with ID in the world. A national survey conducted in 2006 sampled 2.5 million people and yielded an ID prevalence rate of 0.75% (Wu, Qiu, Wong, Hernandez & Zhao, 2010). This rate is comparable with international prevalence estimates (Maulik, Mascarenhas, Mathers, Dua, & Saxena, 2011). People with ID are at a high risk to develop seriously problematic behaviors such as self-injurious behavior (SIB) and aggressive or destructive behavior that are physically dangerous or otherwise socially unacceptable and tend have a variety of negative direct and indirect effects that are not only harmful to the perpetrator’s current and future wellbeing, but also to the family and the support system. If not treated they have a tendency to become chronic. The prevalence rates of such behaviors vary from study to study. Rojahn and Meier (2010) reviewed the international epidemiological literature on behavior problems in ID and found the prevalence rates for aggressive behavior to range from 6.4% (Holden & Gitlesen, 2006) to 32% (Lowe et al., 2007); the rate of SIB from 4.4% (Holden & Gitlesen, 2006) to 21% (Lowe et al., 2007), and the rate of destructive behavior from 2.3% (Holden & Gitlesen, 2006) to 19% (Lowe et al., 2007). Cooper, Smiley, Morrison, Williamson, and Allan (2007) estimated the prevalence of significant problem behaviors in the ID population in the UK to be 22.5%. In the US, Rojahn, Borthwick-Duffy, and Jacobson (1993) reported that in the State of New York 11.3% and in California 12.5% of the individuals with ID who were receiving public state services had aggressive behavior, 7.0% and 8.0%, respectively, had SIB, and 6.5% had stereotyped behavior in both states. Although there are about 10 million people with ID in China we have not been able to identify even a single survey of behavior problems prevalence in that country. In China, epidemiological and clinical research on problem behaviors in ID is held back, at least in part, by the lack of psychometrically sound behavior rating instruments in Chinese. Indeed, a comprehensive literature search in both Chinese and English found not a single assessment instruments for challenging behaviors in people with ID that was developed in China. We discovered, however, two recent Chinese translations of English-language assessment instruments for problem behaviors in ID whose translations into Chinese had been tested for their psychometric properties: the Aberrant Behavior Checklist (ABC; Aman, Singh, Stewart, & Field, 1985) and the Repetitive Behavior Scale-Revised (RBS-R; Bodfish, Symons, & Lewis, 1999). The ABC assesses behavior challenges in five broad areas (irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech). Ma, Guo, Jia, Li, and Liu (2011) found that the Chinese version of the ABC, tested with in 206 subjects with Autism Spectrum Disorder (ASD) aged one and a half to 14 years of age had good inter-rater reliability, test-retest reliability, internal consistency reliability, and structural validity. Likewise, the RBS-R has six subscales (stereotyped behavior, SIB, compulsive behavior, ritualistic behavior, sameness behavior, and restricted behavior). Li, Jiang, Cui, Guo, and Zhu (2013) explored the Chinese version of the RSB-R in 104 subjects with ASD aged 2 to 7 years. The RBS-R also had good inter-rater reliability, test-retest reliability, internal consistency reliability, and structure validity. While the Chinese ABC and RBS-R proved psychometrically sound, the Behavior Problems Inventory-01 (BPI-01; Rojahn et al., 2001) would still represent a useful alternative for some types of studies. Compared with the broad range of behaviors targeted by the ABC, the BPI-01 provides more detailed assessments of a narrower range of behavior, namely specific types of SIB, stereotyped behavior, and aggressive/destructive topographies. And whereas the RBS-R targets a variety of specific SIBs and stereotyped behaviors, it does not assess aggressive and destructive behaviors at all. Therefore, the BPI-01 can fill a gap in available assessment instruments for problem behaviors in the ID population in Chinese language. Hence, the purpose of the present study was first to translate the BPI-01 into Chinese and then to evaluate its psychometric properties (internal consistency and factorial validity using confirmatory factor analysis).
2. Method 2.1. Participants A total of 222 individuals from three service providers (two rehabilitation and training centers in Qingdao [n = 44] and Changzhou [n = 135], and one special education school in Shanghai city [n = 43]) participated in the study. Their mean age was 8.0 years (SD = 3.61), ranging from one and a half to 21.5 years. All three service providers were located in urban area, although they accepted referrals from both urban and rural areas. Table 1 shows the makeup of our sample broken down by gender, age group, and level of ID. As reported to us by the service providers only 70% had a clinical diagnosis of ID. The remaining individuals either had ID, or they were considered to be at risk for ID and were therefore believed to benefit from special needs services.1
1 None of the three participating agencies conducted routine standardized testing and some of the participants had never been psychometrically tested at all. Those who had a diagnosis of ID had received it from other agencies. We assume that those with relatively higher cognitive abilities were more likely not to have had any formal psychometric testing. To examine this hypothesis, we computed ANOVAs with ID levels (including the missing value group) as a predictor and three BPI-01 sub-scale scores as dependent variables. Corroborating our assumption, we found that the group with missing ID information had the lowest mean scores for the BPI-01 subscales stereotyped behavior and aggressive/destructive behavior and the second lowest mean score (a litter bit higher than mild ID group) for the SIB subscale.
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258 Table 1 Demographic information of the sample. Gender
Male Age
Level of ID Mild
Moderate
Severe/profound
Unknown
Total
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
13 10 3 0 3 29
12 27 11 0 2 52
1 14 12 3 2 32
8 32 5 4 5 54
34 83 31 7 12 167
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
2 2 0 0 0 4
6 14 0 0 1 21
2 1 7 1 0 11
4 5 2 1 0 12
14 22 9 2 1 48
0–4.99 5–9.99 15–21.50
1 0 0 1
3 1 1 5
0 0 0 0
0 1 0 1
4 2 1 7
0–4.99 5–9.99 10–14.99 15–21.50 Unknown
16 12 3 0 3 34
21 42 11 1 3 78
3 15 19 4 2 43
12 38 7 5 5 67
52 107 40 10 13 222
Total Female Age
Total Missing Age
Total Total Age
Total
3. Respondents Teachers and staff members completed the BPI-01 on behalf of their students or clients, respectively. The average time that the respondents spent with the participants was about 9 h (SD = 7.01) per day ranging from a half to 24 h. The average time the respondents had known the participants was 30.5 months (SD = 29.36), ranging from 1 to 153 months. In addition, the respondents also provided the participants’ birth dates, clinical diagnoses, and IQ test scores if available from the clients’ records. 4. Instrument The Behavior Problems Inventory-012 (BPI-01; Rojahn et al., 2001, 2012a, 2012b) is a respondent-based rating instrument that was designed to assess maladaptive behaviors in individuals with ID. It contains 52 items that respondents can use to rate the observed frequency and severity of the problem behaviors for individuals with intellectual or developmental disabilities (Rojahn et al., 2001). There are three sub-scales: SIB (15 items), stereotyped behavior (25 items), and aggressive/ destructive behavior (12 items). Each item is rated on a frequency scale (0 = never to 4 = hourly), and a severity scale (0 = no problem to 3 = severe problem). The BPI-01 has been successfully used in several studies and has been shown to have good psychometric properties with fair to excellent internal consistency and good validity as tested by confirmatory factor analysis and discriminant factor analysis (Rojahn et al., 2012b). In addition, the instrument has been translated into many different languages and the foreign language versions have also been proven to have good reliability and validity (e.g., Baraldi, Rojahn, Seabra, Carreiro, & Teixeira, 2013; Dumont, Kroes, Korzilius, Didden, & Rojahn, 2014; Mircea, Rojahn, & Esbensen, 2010). 5. Procedure First we translated the English original of the BPI-01 into Chinese.3 This translation was then back-translated into English by two Chinese psychology graduate students in the US. The original and the back-translated English versions were then compared by another, US native-English speaking graduate student. Minor differences in phrasing and vocabulary were then
2 3
A copy of the Chinese BPI-01 can be obtained for free from Johannes Rojahn, Ph.D., at [email protected]. Simplified.
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discussed and reconciled by the US student and the first author. There were no significant differences between the original and the back-translated English versions. Data were originally collected by teachers or and staff members under the direction of the fourth author (Y.D.) and with approval and active support of the respective program directors in China. Using the Chinese version of the BPI-01, the respondents rated the participants’ behavior. The data were then analyzed in the US with approval of the George Mason University IRB. Previous studies have repeatedly shown that there is high redundancy (r 0.90) between the BPI frequency and severity scores (Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Schroeder, & Hoch, 2007). The Pearson correlation between the BPI frequency severity total scores in the present data set was 0.96. Therefore, only frequency scale data were used in the following analyses. At the end of each of the items of the three sub-scales there is a question asking about ‘‘other behavior’’ that may have been observed in a participant, that is not part of the standard set of items. These three questions have the purpose of identifying important behaviors that are not listed in the BPI-01. We excluded these three questions from our analysis, leaving a total of 49 items to examine. 6. Results 6.1. Descriptive statistics Table 2 summarizes the sub-scale and sub-item survey scores for the 49 items in the BPI-01 frequency scores. At least one problem behavior was checked for 91% of the 222 surveyed individuals. About 63.5% of them showed at least one type of SIB, 85.1% had at least one stereotyped behavior, and 63.5% had at least one aggressive/destructive behavior. The two most frequently reported SIB topographies were head-hitting (33.8%) and body-hitting (27.5%). The two most frequently reported stereotyped behaviors were yelling (48.6%) and hand movements (46.4%). The two most frequently reported aggressive/ destructive behaviors were pushing (35.6%) and grabbing and pulling (32.4%). Table 2 provides additional information about the prevalence of each sub-item in the BPI-01. About 74% of the respondents (n = 164) reported frequency values for all of the 49 problem behaviors on the BPI-01 without missing values. About 11% of the respondents failed to report frequency values for some of the SIBs of their participants, about 17% failed to report frequency values for some of the stereotyped behaviors, and about 10% of the respondents failed to report frequency values for some of the aggressive/destructive behaviors. For more detailed information about missing values for each problem behavior, see Table 2. 6.2. Reliability and validity properties of the Chinese BPI-01 A first pass of the psychometric properties was conducted using Cronbach’s a-coefficients. Separate evaluations were done for each of the three BPI-01 subscales and for the entire inventory. The a-coefficient for the entire inventory was 0.92; the SIB subscale had an a of 0.81, the stereotyped behavior sub-scale had an a of 0.92, and the aggressive/destructive behavior sub-scale had an a of 0.86. According to guidelines by Cicchetti (1994), an a of 0.90 and above = excellent reliability; 0.80–0.89 = good; 0.70–0.79 = fair; 0.00–0.69. = poor. A confirmatory factor analysis (CFA) was also performed using the SEM software SPSS AMOS. Three correlated latent factors were created using their respective 49 items of the BPI-01 frequency scores. When conducting analysis with the SEM framework, it is often assumed that the variable distributions are normal and continuous. However, all of the observed variables in our model failed the test of normality and they all had positively skewed distributions. Because the data were non-normal, Bayesian estimation option provided by the AMOS software procedures were used to handle it. Bayesian estimation is non-parametric and, as such, not sensitive to non-normality. Model fit was evaluated using the posterior predictive p value. Latent variables were standardized by setting their variances to 1. Standardized regression weights were examined to determine the degree to which the factors accounted for the items. Correlations between the subscale factors were also examined. The data fit the model quite well with a posterior predictive p of 0.50 (with convergence statistics = 1.0, DIC = 8494.2, effective number of parameters = 148.6, iterations = [2000 + 65036] 4, and random walk = 0.35). The standardized weights for the regression paths ranged from 0.21 to 1.24 and all were significant (p < 0.05). The two highest loading SIB items were head-hitting (0.80) and body-hitting (0.76), while the two lowest loading SIB items were hair pulling (0.21) and air swallowing (0.22). The two highest loading stereotyped behavior items were hand movements (1.24) and body movements (1.12), while the two lowest loading stereotyped behavior items were grimacing (0.28) and sniffing self (0.50). The two highest loading aggressive/destructive behavior items were grabbing and pulling (0.88) and scratching (0.75), while the two lowest loading aggressive/destructive behavior items were verbally abusive (0.21) and spitting (0.34). (For more information of the best-fit model, see Table 3). We also calculated the Pearson correlation coefficients between the three sub-scale scores. The correlation coefficients were significant between SIB and stereotyped behavior (r = 0.51) and between SIB and aggressive/destructive behavior (r = 0.51). Interestingly, the correlation coefficient between stereotyped behavior and aggressive/destructive behavior was non-significant (r = 0.19).
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Table 2 Descriptive item statistics for the Chinese BPI-01. BPI-01 items
n
Missing
Prevalence (in %)
M
SD
Skewness (SE)
a
a
Subscales (average score ) SIB Stereotypy Aggression
222 220 220
0 2 2
63.5 85.1 63.5
0.33 0.79 0.45
0.45 0.73 0.61
1.73 (0.16) 0.84 (0.16) 1.97 (0.16)
Itemsb SIB 1. Self-biting 2. Head-hitting 3. Body-hitting 4. Self-scratching 5. Vomiting 6. Self-pinching 7. Pica 8. Inserting objects 9. Nail-pulling 10. Inserting fingers 11. Air swallowing 12. Hair pulling 13. Drinking 14. Teeth-grinding
215 220 220 218 219 217 220 221 217 219 221 220 221 215
7 2 2 4 3 5 2 1 5 3 1 2 1 7
21.6 33.8 27.5 20.3 13.1 17.6 15.8 7.7 9.0 10.4 5.9 6.8 9.5 20.7
0.46 0.71 0.56 0.44 0.26 0.35 0.39 0.15 0.22 0.20 0.12 0.14 0.22 0.47
0.95 1.13 1.05 0.98 0.76 0.84 0.98 0.60 0.75 0.67 0.53 0.56 0.75 1.02
2.01 1.39 1.82 2.28 3.25 2.54 2.44 4.69 3.71 4.04 5.32 4.62 3.47 2.08
(0.17) (0.16) (0.16) (0.16) (0.16) (0.17) (0.16) (0.16) (0.17) (0.16) (0.16) (0.16) (0.16) (0.17)
Stereotyped behavior 15. Rocking 16. Sniffing objects 17. Spinning self 18. Arm-waving 19. Head-rolling 20. Whirling 21. Body movements 22. Pacing 23. Twirling 24. Hand movements 25. Yelling 26. Sniffing self 27. Bouncing 28. Spinning objects 29. Running 30. Finger movements 31. Manipulating 32. Sustained finger 33. Rubbing self 34. Gazing 35. Postures 36. Clapping 37. Grimacing 38. Hand-waving
214 215 212 219 219 216 213 218 218 216 217 215 219 217 217 217 216 213 215 214 218 218 214 219
8 7 10 3 3 6 9 4 4 6 5 7 3 5 5 5 6 9 7 8 4 4 8 3
39.6 38.3 29.7 41.0 40.1 30.2 39.6 25.2 37.4 46.4 48.6 21.2 32.4 28.4 45.0 27.0 35.6 27.9 17.1 34.7 24.3 23.4 19.4 24.3
1.04 0.87 0.67 0.98 0.97 0.61 1.03 0.59 0.97 1.29 1.10 0.45 0.84 0.64 1.17 0.67 0.82 0.77 0.44 0.89 0.52 0.54 0.41 0.61
1.45 1.22 1.13 1.36 1.38 1.05 1.39 1.13 1.38 1.54 1.30 0.95 1.34 1.14 1.44 1.23 1.26 1.36 1.06 1.37 1.04 1.09 0.94 1.19
1.01 1.12 1.57 1.04 1.11 1.68 0.92 1.78 1.03 0.66 0.78 2.10 1.28 1.64 0.74 1.65 1.29 1.49 2.39 1.26 1.99 1.94 2.48 1.77
(0.17) (0.17) (0.17) (0.16) (0.16) (0.17) (0.17) (0.16) (0.16) (0.17) (0.17) (0.17) (0.16) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.16) (0.16) (0.17) (0.16)
Aggressive/destructive behavior 39. Hitting 40. Kicking 41. Pushing 42. Biting 43. Grabbing, pulling 44. Scratching 45. Pinching 46. Spitting 47. Verbally abusive 48. Destroys 49. Cruel
218 217 216 218 216 213 215 214 212 211 214
4 5 6 4 6 9 7 8 10 11 8
31.5 20.3 35.6 19.4 32.4 19.8 19.8 15.3 6.3 25.2 26.1
0.60 0.36 0.67 0.40 0.70 0.38 0.40 0.26 0.14 0.56 0.51
1.00 0.82 1.04 0.93 1.14 0.88 0.87 0.69 0.57 1.08 1.00
1.54 2.42 1.45 2.51 1.42 2.51 2.16 3.19 4.61 1.93 2.06
(0.16) (0.17) (0.17) (0.16) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17) (0.17)
When calculating average scores for sub-scales, the missing values are automatically regarded as 0 by SPSS. The average score shows as missing only when all of the scores included in the calculation are missing. For missing value information on the level of sub-scales, see the text above. Many items are abbreviated.
b
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Table 3 Parameter estimates in SEM. Standardized weights
Intercepts
M (SE)
95% CI lower
95% CI upper
M (SE)
95% CI lower
95% CI upper
SIB 1. Self-biting 2. Head-hitting 3. Body-hitting 4. Self-scratching 5. Vomiting 6. Self-pinching 7. Pica 8. Inserting objects 9. Nail-pulling 10. Inserting fingers 11. Air swallowing 12. Hair pulling 13. Drinking 14. Teeth-grinding
0.45 0.80 0.76 0.62 0.31 0.59 0.41 0.29 0.29 0.30 0.22 0.21 0.34 0.36
(0.004) (0.004) (0.003) (0.004) (0.002) (0.003) (0.003) (0.002) (0.003) (0.002) (0.002) (0.002) (0.002) (0.002)
0.32 0.65 0.63 0.49 0.20 0.47 0.27 0.21 0.18 0.20 0.14 0.13 0.23 0.22
0.60 0.95 0.90 0.77 0.42 0.71 0.56 0.38 0.40 0.40 0.30 0.30 0.46 0.51
0.46 0.71 0.57 0.44 0.26 0.35 0.40 0.15 0.21 0.20 0.12 0.14 0.22 0.47
(0.002) (0.003) (0.003) (0.003) (0.002) (0.002) (0.004) (0.002) (0.002) (0.002) (0.002) (0.002) (0.003) (0.003)
0.33 0.56 0.42 0.31 0.16 0.23 0.26 0.07 0.11 0.10 0.05 0.06 0.13 0.33
0.58 0.86 0.71 0.57 0.36 0.46 0.54 0.23 0.31 0.29 0.19 0.21 0.33 0.60
Stereotyped behavior 15. Rocking 16. Sniffing objects 17. Spinning self 18. Arm-waving 19. Head-rolling 20. Whirling 21. Body movements 22. Pacing 23. Twirling 24. Hand movements 25. Yelling 26. Sniffing self 27. Bouncing 28. Spinning objects 29. Running 30. Finger movements 31. Manipulating 32. Sustained finger 33. Rubbing self 34. Gazing 35. Postures 36. Clapping 37. Grimacing 38. Hand-waving
0.80 0.72 0.62 0.95 0.95 0.64 1.12 0.57 0.85 1.24 0.53 0.50 0.95 0.56 0.93 0.77 0.83 0.94 0.62 0.83 0.54 0.67 0.28 0.70
(0.005) (0.004) (0.004) (0.004) (0.004) (0.003) (0.004) (0.005) (0.005) (0.004) (0.005) (0.003) (0.004) (0.004) (0.003) (0.004) (0.005) (0.005) (0.004) (0.004) (0.004) (0.003) (0.004) (0.004)
0.60 0.56 0.47 0.78 0.77 0.50 0.94 0.41 0.67 1.05 0.34 0.35 0.78 0.39 0.73 0.60 0.66 0.75 0.47 0.64 0.39 0.53 0.14 0.54
1.02 0.90 0.79 1.14 1.13 0.79 1.31 0.74 1.05 1.45 0.72 0.64 1.15 0.73 1.13 0.95 1.01 1.13 0.78 1.04 0.69 0.83 0.43 0.87
1.03 0.85 0.66 0.98 0.96 0.61 1.04 0.60 0.97 1.29 1.10 0.45 0.85 0.64 1.17 0.67 0.84 0.78 0.45 0.88 0.52 0.55 0.41 0.61
(0.004) (0.003) (0.004) (0.004) (0.005) (0.003) (0.004) (0.003) (0.005) (0.005) (0.002) (0.002) (0.004) (0.004) (0.004) (0.004) (0.004) (0.003) (0.003) (0.003) (0.004) (0.003) (0.003) (0.003)
0.83 0.68 0.50 0.80 0.77 0.46 0.85 0.45 0.77 1.07 0.93 0.32 0.66 0.48 0.98 0.51 0.67 0.60 0.31 0.70 0.38 0.40 0.27 0.45
1.23 1.02 0.83 1.17 1.16 0.75 1.25 0.75 1.16 1.51 1.28 0.57 1.04 0.81 1.36 0.85 1.01 0.96 0.60 1.07 0.67 0.70 0.53 0.78
Aggressive/destructive behavior 39. Hitting 40. Kicking 41. Pushing 42. Biting 43. Grabbing, pulling 44. Scratching 45. Pinching 46. Spitting 47. Verbally abusive 48. Destroys 49. Cruel
0.70 0.65 0.73 0.63 0.88 0.75 0.59 0.34 0.21 0.57 0.47
(0.002) (0.002) (0.002) (0.003) (0.004) (0.002) (0.003) (0.001) (0.002) (0.004) (0.003)
0.57 0.55 0.60 0.51 0.74 0.64 0.47 0.24 0.13 0.42 0.34
0.84 0.75 0.87 0.75 1.04 0.87 0.71 0.44 0.30 0.72 0.62
0.60 0.37 0.67 0.40 0.70 0.40 0.39 0.26 0.14 0.56 0.51
(0.003) (0.002) (0.003) (0.002) (0.004) (0.003) (0.003) (0.003) (0.002) (0.003) (0.003)
0.46 0.26 0.53 0.27 0.54 0.27 0.28 0.16 0.06 0.41 0.38
0.74 0.48 0.80 0.53 0.86 0.52 0.51 0.35 0.23 0.71 0.65
All the standardized weights shown in the table are significant. a, b Since the latent variables were standardized by fixing their variances to 1 in our model, we got two loadings >1.
7. Discussion The BPI-01 was translated into Chinese using a rigorous procedure. An initial translation was back-translated to doublecheck the semantic equivalence between the original English and the Chinese translated versions of the BPI-01. Psychometric property analysis indicated good reliability (internal consistency) and good factorial validity. Internal consistency of total scales was excellent (0.92) and the subscale internal consistencies ranged from good to excellent (from 0.81 to 0.92). Compared to the internal consistency of original English BPI-01, which has a total scales internal consistencies of 0.83 (Rojahn et al., 2001), and the sub-scale internal consistencies ranged from 0.74 to 0.92 (Rojahn et al., 2012b), the Chinese BPI-01 exhibits even higher internal consistencies.
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In addition, the hypothesized three-factor model was also confirmed by CFA for the Chinese translation version BPI-01. This is in consistent with the English BPI-01 (Rojahn et al., 2012b) as well as with other translations of the BPI-01 (e.g., Baraldi et al., 2013; Dumont et al., 2014; Mircea et al., 2010). This supports the notion that the behavior problems manifested by individuals with ID are universal not sensitive to cultural differences. There are limitations to this study. In particular, our sample size was relatively small for some of the analyses (such as the CFA) and the information about the level of ID was incomplete, unavailable and in many cases even non-existent. We, therefore, assume that some individuals in our sample may not have met criteria for a formal diagnosis if ID. Given that they were receiving special needs services at the time, we assumed that some of those without a formal ID diagnosis may have fallen into the ID borderline range. That it was not possible to keep track of the individual respondents is another problem. It is most likely that several of the raters rated more than one participant. Therefore, we were unable to isolate a respondenteffect in our results. We must assume that the range in the number of participants that respondents rated varied greatly, which undermines the principle of independent sampling as it would give extra weight to those respondents who rated larger numbers of participants. We were also unable to conduct respondent-agreement analyses. Considering the purpose of this study (namely examining general psychometric properties of an assessment instrument), we felt that a convenience sample with a reasonable range of personal characteristics was acceptable. It should be noted that this was not an epidemiological study and that our sample is not representative of the Chinese ID population. This, therefore, precludes any epidemiological interpretations of our data. Thus, although we reported having detected gender effects in our sample (males had significantly higher stereotyped behavior scores that females), we cannot and do not conclude that the same applies to the Chinese ID population in general (a finding which, by the way, would differ from most previous research [Baghdadli, Pascal, Grisi, & Aussilloux, 2003; Holden & Gitlesen, 2006; McTiernan, Leader, Healy, & Mannion, 2011; Murphy, Healy, & Leader, 2009; Rojahn et al., 2001]). These results were simply part of our sample characteristics analysis. In summary, and despite those limitations, we conclude that this Chinese translation of the BPI-01 can be used for research as well as for clinical evaluations of Chinese individuals with ID. In present study, however, only preliminary analyses (Cronbach’s alpha and factor validity) were conducted, more tests are needed to further examine the psychometric property of the Chinese version of BPI-01 and verify the cross-cultural adaptation of it. After that, unique problem behavior patterns among Chinese individuals with ID due to the cultural background of China can be explored and analyzed. Acknowledgments The authors wish to acknowledge Yue Ji, Alec Bernstein, Chen Qiu, Zitong Sheng, Ronald Jeremias and Dr. Ellen Rowe for their active support without whom this study could not have been possible. We would also like to thank the teachers and staff members of the three service provider organizations in China for their assistance with data collection. This study was conducted as part of the first author’s master’s thesis.
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