Article
The relationship between emotional recognition ability and challenging behaviour in adults with an intellectual disability: A systematic review
Journal of Intellectual Disabilities 1–14 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1744629515581730 jid.sagepub.com
Bronwen Davies Caswell Clinic, UK
Neil Frude Cardiff University, UK
Rosemary Jenkins Cardiff University, UK Date accepted: 20 March 2015
Abstract This review questions whether a relationship exists between emotional recognition ability and challenging behaviour in people with an intellectual disability. A search was completed of a number of databases to identify relevant articles, and these were then evaluated against defined criteria. Eight articles were reviewed and their aims, study methodology, samples, measurement tools and findings are discussed and evaluated. Overall, studies found no significant deficit in the emotional recognition abilities of those with challenging behaviour when they were asked to identify the emotions of others. Two areas for further investigation were identified. Firstly, to ascertain whether a bias for identifying anger or sadness is found in those with challenging behaviour, and secondly, to understand the role of context in recognition of emotions and the degree to which this is different in those who present with challenging behaviour. A critique relating to the research is provided and suggested clinical and research implications are put forward. Keywords challenging behaviour, emotional recognition, emotional perception, review, emotions
Corresponding author: Bronwen Davies, Caswell Clinic, Glanrhyd Hospital, Tondu Road, Bridgend Wales, CF31 4LN, UK. Email: [email protected]
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Introduction A definition of challenging behaviour often cited within the literature is that developed by Emerson (1995: 4): Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.
The prevalence of challenging behaviour within the intellectual disability population is between 10% and 15% (Emerson et al., 2001; Lowe et al., 2007). Emotional problems have been identified as being 3 to 4 times more prevalent in the intellectual disability population than in the general population (McClure et al., 2009; Prosser, 1999). Mental health difficulties have been found in between 20% and 39% of a population of people with intellectual disabilities (Hatton and Taylor, 2005). Across different cultures, people are able to identify the emotions of happiness, sadness, anger, fear, surprise and disgust from pictures (Ekman, 1973). Emotional recognition ability has been tested in a number of ways with people with intellectual disabilities including matching two faces expressing the same emotion, choosing an identified emotion from a set of pictures, matching words with pictures, matching emotional sounds with pictures or words, rating emotional intensity and selecting an appropriate emotional response to situations or stories (Moore, 2001). These different test procedures assess different elements of emotional recognition and involve a variety of information processing demands (see Moore, 2001). Overall, people with intellectual disabilities have been found to be significantly impaired in recognizing the emotions of others, compared to non-intellectually disabled control groups (Harwood et al., 1999; Owen et al., 2001) and intelligence quotient (IQ)-matched child control groups (Hippolyte et al., 2009; McAlpine et al., 1991, 1992). A number of considerations may lead us to question the relationship between emotional perception and challenging behaviour. In studies of the general population, challenging behaviour is not used as a construct. Studies have measured a wide variety of behaviours including self-harm, violence, aggression, destructiveness and delinquency. These would be described as challenging behaviour within a intellectual disability population. Wheeler et al. (2009) point out that the distinction between what is termed ‘antisocial’ as opposed to ‘challenging’ or ‘offending’ behaviour in people with a learning disability is problematic because each term can be applied to a broad and similar range of behaviours. Difficulties in emotional recognition have been observed in a number of clinical and forensic populations who present with challenging behaviours, for example, young offenders (McCown et al., 1986), violent offenders (Hoaken et al., 2007), men who perpetrate domestic violence (Marshall and Holtzworth-Monroe, 2010), populations who self-harm, including adolescents (Garisch and Wilson, 2010) and those who misuse substances (Oyefeso et al., 2008). Explanations of violent or challenging behaviour have hypothesized that lack of empathy reduces the inhibition to cause harm to others (Proctor and Beail, 2007). Theorists recognize that a precursor of empathy is the ability to recognize or perceive one’s own emotions. Without this ability, one would find it difficult to take the perspective of another, as required in empathy (Marshall et al., 1995). Emotional perception and challenging behaviour have also been considered within the intellectual disability literature. It has been argued that before an individual can accurately report their
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Table 1. Groups of search terms combined in this review. Group 1: intellectual disability
Group 2: challenging behaviour
Group 3: emotional recognition
Learning disab* Intellectual disabilit* Intellectual* impair* Mental* retard* Learning difficult* Mental* impair* Mental* handicap* Mental* subnormal* Challenging behav* Problem behav* Self injur* Aggress* Behav* problems Self harm Destruct* Violen* Behaviours that challenge Emotional literacy Emotional recognition Emotion* perception Fac* perception Emotion* cognition* Emotional awareness Emotional understanding Emotional* intell*
own emotional state they must be able to recognize different emotions and to understand what it means to be happy, sad, frightened or angry (Reed and Clements, 1989). If one is unable to interpret emotional stimuli, socio-emotional development may be impeded and antisocial or challenging behaviour, withdrawal or mood disorders may emerge (Zaja and Rojahn, 2008). Thus, if individuals with an intellectual impairment are not able to recognize their emotions, then they are unlikely to be able to regulate them. Such difficulties may lead to challenging behaviour or mental health issues. These theoretical issues led us to conduct a systematic review to evaluate the evidence base and to establish whether emotional recognition and challenging behaviour are related in individuals with an intellectual disability. Within this review, the terms ‘challenging behaviour’, ‘aggressive’ or ‘offender’ groups refer to the experimental groups within the studies. Within this review, when discussing a number of articles, the term challenging behaviour will be used to describe the experimental group.
Materials and methods Search strategy In the process of conducting this review, AMED, Medline, Psychlit and Psycharticles databases were searched. The search identified studies that had examined emotional recognition and challenging behaviour in people with an intellectual disability. The search involved search terms from groups 1, 2 and 3 in the lists above (Table 1). The date range searched was 1860 to December 2014, and searches were limited to English language and peer-reviewed journals. Google Scholar was also searched and Web of Knowledge was used to search for authors A Jahoda, E Matheson and K McKenzie, as they appeared to be the main authors in the field. Finally, the reference lists of relevant articles were also reviewed in order to identify possible additional articles.
Inclusion and exclusion criteria Inclusion of articles. To be included within the review, articles needed to meet a number of criteria. These were: Publication within a peer-reviewed journal. This represented an attempt to ensure that the review included only articles reporting research that had been favourably reviewed by experts in the field. A focus on either:
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the relationship between emotional recognition and challenging behaviour in people with intellectual disabilities or the difference in emotional perception skills in challenging/offending and nonchallenging populations of people with intellectual disability. Emotional reports given by participants with intellectual disabilities and reflecting their emotional understanding. Publication in English. Exclusion of articles. Specific areas of exclusion were identified: Studies focusing on the needs or experiences of carers. Studies focusing on interventions, service provision or policy. Studies focusing on people with autistic spectrum conditions. People with autism have welldocumented deficits in emotional processing including emotional recognition (Owen et al., 2001), and this review focused on articles that studied the intellectual disability population more generally. Reviewing the studies. Initially, 433 articles were identified and reviewed by title and abstract for relevance to emotional recognition and challenging behaviour in people with an intellectual disability. Articles that clearly met any of the exclusion criteria, or failed to meet the inclusion criteria, were eliminated from the review at this stage. Of the 434, 69 were duplicated on the searches, 46 related to people with autistic spectrum conditions, 47 related to service provision or interventions, 162 were not related to people with intellectual disabilities, 54 were not research articles (e.g. reports, reviews or editorials), 26 did not investigate both emotion and challenging behaviour and 24 focused on the needs and experiences of staff and carers. This process left six articles, and for these full texts were retrieved. Two relevant review articles were also downloaded and the reference lists of these and the identified articles were reviewed and another two eligible articles were found. Eight studies were eligible to be included in the systematic review after further application of the inclusion and exclusion criteria (for a summary of the articles, please see online supplementary Appendix 1). These were also reviewed by the second author to ensure quality of the review process. Quality. Criteria for assessing the quality of the studies in this review were based on a number of articles including earlier reviews that critiqued the body of research on the emotional recognition abilities of people with an intellectual disability (Moore, 2001; Rojahn et al., 1995). The Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) was also used in the development of quality criteria for this review (Elm et al., 2008; Vandenbroucke et al. 2007). Finally, a Step-by-Step Guide to Critiquing Quantitative Research (Coughlan et al., 2007) was used in considering which quality criteria to employ in this systematic review. Based upon these sources, a quality appraisal scheme was developed, which is set out below. If articles met all of the quality criteria set out under each heading, they were awarded two points, if the report met only some of the criteria they were given one point and if none of the issues were addressed no points were given on that criterion. Scores for the 10 criteria were then added to give a total quality score for the article. The maximum score obtainable was 20, please see online supplementary Appendix 2 for details of the scoring for each article.
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The 10 sections or aspects of articles delineated for quality evaluation are as follows: 1. Aims/purposes: Are specific aims, objectives or pre-specified hypotheses stated? Do they reflect the information in the literature review? Is the purpose of the study/research problem clearly identified? 2. Title, abstract and introduction: Is the study’s design indicated in the title or abstract? Is the title clear, accurate and unambiguous? Is the abstract an informative and balanced summary of what was done and what was found? Does the introduction explain the scientific background and rationale for the study being reported? Does the introduction give an overview of what is known about the topic and where the gaps in knowledge exist? Does it note most recent pertinent studies or reviews? Does it offer a balanced critical analysis of the literature? 3. Study design: Are the key elements of the study design presented? In comparison studies, is a control task included within the study? Are all variables defined? 4. Sampling: Has the target population been clearly identified? Are recruitment procedures and selection methods outlined? Are eligibility criteria for participation laid out? Are characteristics of the study participants outlined (e.g. age, gender, diagnosis, co-morbid conditions, IQ and language ability)? When a control group is used, are the samples matched for such variables as gender, receptive vocabulary and/or IQ? Is a rationale provided for author’s choice of matching variables? 5. Sample size and attrition: Does the study explain how the sample size was arrived at? Are the numbers of individuals at each stage of the study reported and reasons for nonparticipation identified at each stage? Is the sample size adequate (in comparison studies a group size of 19 or less will be considered weak, a group size of 20–25 will be considered sufficient and over 25 will be considered strong)? 6. Validity and reliability: Was adequate information on the validity and reliability of assessment measures provided? Did the authors report which previous studies had employed the measures used? If a measure was developed for the study, was sufficient information given on the development process? If measures were adapted to make them more accessible for people with intellectual disabilities (e.g. simplified language and pictorial representations), is there evidence of the reliability and validity of the adapted version? 7. Data collection: For each variable of interest, are sources of data and assessment methods explained? Has the data gathering process been fully described? Have appropriate questions been used in any questionnaire? 8. Analysis: Were descriptive statistics presented for each variable, with any missing values accounted for? Was the distribution of the data examined? Were appropriate parametric or non-parametric tests employed in any inferential analysis? Were all statistical methods used clearly described? Are the results of any tests fully reported and correctly interpreted? 9. Limitations: Were limitations of the study discussed, including any potential for bias or imprecision? Was consideration given to the possible confounding effects of variables not measured as part of the study? 10. Conclusions and recommendations: Was an overall interpretation of the results provided, with due consideration of the objectives, analyses and results of other studies? Was the relevance of results to specific hypotheses discussed? Were recommendations made for future research? Were clinical implications of findings outlined? Was the validity, generalizability and precision of results discussed in relation to other studies?
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Results The eight studies included in this review were cross-sectional and used either experimental/control group comparison designs or a correlational design. Clearly, the use of cross-sectional designs has limitations in relation to inferring causality and temporal order. In addition, many of the studies appear to have shown minimal consideration of possible confounding variables such as mental health, communication skills and poor coping skills, although a number do consider intelligence or language ability.
Samples and populations Sample sizes varied, with only two studies reporting power calculations to identify the necessary sample size (Davies et al., 2014; Proctor and Beail, 2007) and a number of the studies using small samples (Matheson and Jahoda, 2005; Moffatt et al., 1995; McKenzie et al., 2000a). Studies have employed stratified random sampling techniques, selecting participants from larger cohorts of people with an intellectual disability based on their ability and whether or not they present with aggressive, challenging or offending behaviour. Control groups have then been matched on a variety of factors including gender (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005; Moffatt et al., 1995), age (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005; McKenzie et al., 2000a; Ralfs and Beail, 2012; Walz and Benson, 1996) and ability, with all of the eight studies matching their control group based on either IQ or level of intellectual disability. Three studies used all male samples (Proctor and Beail, 2007; Ralfs and Beail, 2012; Walz and Benson, 1996) and in McKenzie et al.’s (2000a) sample, men were over-represented. This will impact on the ability to generalize these findings to women with an intellectual disability. In addition, a few studies included a small number of people with borderline IQ (IQ 70–80) (Matheson and Jahoda, 2005; Moffatt et al., 1995; Ralfs and Beail, 2012; Walz and Benson, 1996). This may have influenced the outcome of assessments, exaggerating participants’ abilities and limiting the generalizability of the findings to intellectual disability populations.
Measuring challenging behaviour Three studies used the Checklist of Challenging Behaviour (Harris et al., 1994) to differentiate the groups (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005). Walz and Benson (1996) used the conduct disorder subscale of the Revised Behaviour Problem Checklist (Quay and Peterson, 1983). McKenzie et al. (2000a) based inclusion in each group on whether staff reported the individual to have challenging behaviour or not. Moffatt et al. (1995) reviewed service users’ notes. The other two studies accessed groups of offenders with intellectual disabilities (Proctor and Beail, 2007; Ralfs and Beail, 2012).
Measuring emotional perception All of the studies in this review employed appropriate ways of collecting data from people with an intellectual disability. They all used open-ended questions or multiple-choice response formats and picture presentations of test stimuli as well as simplified language. This is in line with recommendations about how to involve people with intellectual disabilities in research (Heal and Sigelman, 1995; Lynch, 2004; Stenfert-Kroese 1997). In three of the studies, participants were asked to label the emotions depicted in sets of Ekman and Friesen’s (1975) normed photographs (Jahoda et al., 2006a; Matheson and Jahoda, 2005;
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Walz and Benson, 1996). Matheson and Jahoda (2005) also asked participants to identify emotions from photographs of individuals in context, for example, sadness at a funeral, and they presented participants with a set of cartoons with context. In the latter assessment, 12 cartoons were presented individually, each of which pictured two people in a specific context. The central character was depicted with an outline where their head should have been, and the participant was asked to select the appropriate head, from a range displaying various emotions, and to place it in position. Walz and Benson (1996) used a matching task to determine discrimination techniques used by individuals to identify emotion. There was a standard picture and five options from which the participant could select a picture to match the standard. The choice was between faces that had the same eyes, mouth or hair as the standard, no similarities or an identical or generalized version of the emotional expression of the standard. The researcher pointed to the standard face and said ‘This man/woman is (e.g. sad). Pick the other (e.g. sad) man/woman. Is anyone else feeling (e.g. sad)?’ McKenzie et al. (2000a) used three sets of materials depicting a number of different emotions (happy, sad, afraid, angry, bored and worried). These were line drawings, photographs of faces and photographs of an emotion in context. Participants were asked to (a) name the emotion depicted in the picture, (b) choose which picture showed the target emotion from a group of six and (c) choose which picture (of two presented simultaneously) showed the target emotion. Three studies used the ‘test of emotional perception’ (Negri-Shoultz and Donnellan, 1989) to assess emotional recognition (Moffatt et al., 1995; Proctor and Beail, 2007; Ralfs and Beail, 2012). This is an unpublished test designed for use with people with an intellectual disability (Proctor and Beail, 2007). Within this test, participants are shown six videos depicting happy, sad and angry scenes. They are then asked to identify how the key character in the video is feeling. They are also asked what will happen next. The response format for this task (Proctor and Beail, 2007; Ralfs and Beail, 2012) involves multiple choices in which the participant is asked to select from three photographs. A final question asks either how they would feel if the event depicted happened to them (perception) (Moffatt et al., 1995) or how they would feel if such an event happened to their friend (empathy) (Proctor and Beail, 2007; Ralfs and Beail, 2012). Finally, Davies et al. (2014) employed an Emotional Perception Questionnaire, also unpublished. This is a self-report measure that asks participants how they would feel if they found themselves in 20 situations, for example, ‘If you won first prize in a competition, how would you feel?’ Participants were asked to choose between pictures of happy, sad, angry, scared or worried emoticons (cartoon faces).
Findings Studies indicate that individuals with challenging behaviour are not significantly worse at identifying the emotions in Ekman and Friesen’s (1975) photographs than those without challenging behaviour (Jahoda et al., 2006a; Matheson and Jahoda, 2005; Walz and Benson, 1996). Similarly, with the variety of other assessments used, no difference was found in the ability of people who present with challenging behaviours or non-challenging individuals in labelling emotions in cartoons (Matheson and Jahoda, 2005), in a facial cues task (Walz and Benson, 1996) or in the tests employed by McKenzie et al. (2000a). In addition, Ralfs and Beail (2012) found no significant differences between sex offenders and non-sex offenders in emotional recognition. In fact, those with challenging behaviours have been shown to do better in two studies (McKenzie et al., 2000a; Proctor and Beail, 2007). When McKenzie et al. (2000a) compared those who presented with aggressive behaviours to a non-challenging behaviour group, they found that
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aggressive service users were significantly better than the non-challenging individuals at identifying and labelling emotions (t ¼ 2.442, df ¼ 12, p < 0.05). Also, Proctor and Beail (2007) found that offenders with an intellectual disability performed significantly better than non-offenders on emotional recognition, F(1, 49) ¼ 6.17, p ¼ 0.015, and needed significantly fewer prompts than non-offenders to provide emotional descriptors, F(1, 49) ¼ 5.01, p ¼ 0.03. Moffat et al. (1995) reported significant differences between people with a mild intellectual disability who did or did not exhibit challenging behaviours. There was no difference between those with moderate intellectual disability with and without behavioural problems. However, beyond reporting means, they did not present any statistical analyses of the difference, so it is not clear whether the differences reported were significant or not. Walz and Benson (1996) found a negative bias in emotional labelling, whereby the aggressive group was more likely to mislabel emotions as angry or sad than the non-aggressive group. Similarly, in the cartoon task, Matheson and Jahoda (2005) found that the aggressive group was significantly more likely to incorrectly identify an emotion as angry than the non-aggressive group. This negative bias was not, however, replicated by Jahoda et al. (2006a), who studied a larger sample and employed a sounder methodology. This issue would benefit from further study. Two studies did find that individuals with challenging behaviours were significantly worse at identifying emotions, and both of these included contextual information in the assessment process. Matheson and Jahoda (2005) found that a group, which was described as aggressive, was significantly more impaired than controls in identifying emotions within contextualized pictures (U ¼ 71.00, p < 0.05). Davies et al. (2014) looked at whether individuals could recognize and label their own emotions as opposed to identifying them in pictures of others. They found significant negative correlations between challenging behaviour frequency and emotional perception ability total (rs ¼ 0.290, p < 0.01), correct worried (rs ¼ 0.204, p < 0.05) and angry answers (rs ¼ 0.218, p < 0.05). They found a significant negative correlation between challenging behaviour management difficulty and correct angry answers (rs ¼ 0.229, p < 0.05). A significant negative correlation was also observed between aggression severity and emotional perception total (rs ¼ 0.178, p < 0.05). Whilst significant, these correlations account for a small amount of the variance, implying that other variables account for the majority of the variance. A post hoc betweengroups analysis found that those who present with high-frequency challenging behaviour were significantly poorer at emotional perception than those with no or low-frequency challenging behaviour (t ¼ 2.403, df ¼ 1,48, p ¼ 0.013).
Discussion The evidence within this review suggests that the recognition of emotions of others is not impaired in people with intellectual disabilities who present with challenging behaviours compared to controls. In fact, in two studies they were actually better than controls (McKenzie et al., 2000a; Proctor and Beail, 2007). This does not therefore support the findings of studies within other populations of people who present with challenging behaviours (e.g. Garisch and Wilson, 2010; Hoaken et al., 2007; Marshall and Holtzworth-Munroe, 2010; McCown et al., 1986; Oyefeso et al., 2008). Emotional recognition ability has been assessed using a variety of methods including matching tasks, labelling emotions in photographs, line drawings or cartoons and identifying emotions in videos. Although this is still a very limited pool of studies, most suggest that there is a limited or no relationship, regardless of the methods of assessment. Matheson and Jahoda (2005) argue that decontextualized measures may, however, underestimate
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the abilities of people with intellectual disabilities to accurately identify emotions. This is based on Moore et al.’s (1995) argument that assessment methods relying on simplified stimuli without dynamic or temporal cues may be a hindrance because they require the employment of more inferential, cognitively based, capacities. There are, however, two areas that would benefit from further exploration. Two studies found a negative bias in the labelling of emotions. Both Walz and Benson (1996) and Matheson and Jahoda (2005) found that their ‘aggressive groups’ were significantly more likely than controls to incorrectly identify an emotion as angry, and, in Walz and Benson’s (1996) study, a bias for identifying emotions as sad was found. This negative bias was not however supported by the work of Jahoda et al. (2006a). An angry (or sad) emotional attribution bias, should this be supported in further research, might be helpful in understanding why some people engage in challenging behaviours, for example, individuals could be responding to perceived anger in others. This may be linked to the ‘hostile attribution bias’ identified by Jahoda et al. (2006b). This area of research is in its infancy but may turn out to be a fruitful field of further enquiry. The other area worthy of further study is the consideration of context. Two studies reported significant differences between those who present with challenging behaviour and controls when context was included in the assessment method. One of the studies, that by Matheson and Jahoda (2005), asked participants whether they could recognize the emotions of others in pictures or cartoons including context whilst the other, Davies et al. (2014), asked participants how they would feel in emotionally arousing contexts. Based on these preliminary findings, it does appear that context may be an important element that contributes to the emotional recognition ability in people with an intellectual disability. Previous studies have shown that people with intellectual disabilities are better at describing their own emotions rather than the emotions of others (Lindsay et al., 1994; Owen et al., 2001), and other studies have shown that contextual information may be important in understanding emotions for people with intellectual disabilities (Hippolyte et al., 2009; Moore et al., 1995). The aggressive group in Matheson and Jahoda’s (2005) study may be presenting with the deficits in facial emotional recognition identified in the non-intellectually disabled aggressive populations (Garisch and Wilson, 2010; Hoaken et al., 2007; Marshall and Holtzworth-Munroe, 2010; McCown et al., 1986; Oyefeso et al., 2008). This area needs further exploration and replication to clarify the importance of context in recognizing one’s own emotions as well as other people’s and how this relates to challenging behaviour within an intellectual disability population. Matheson and Jahoda (2005) suggest that aggressive individuals may attend to fewer cues in the environment and therefore benefit less from additional contextual information. This is clearly an area for further research and further findings of this nature would be useful in informing formulation and intervention with respect to individuals’ behavioural and emotional understanding. The studies reviewed in this article have a number of methodological limitations. The quality of the older studies is poor (McKenzie et al., 2000a; Moffat et al., 1995; Walz and Benson, 1996), with methodological weaknesses casting doubt over the conclusions drawn. None of the older studies assessed the distribution of the data and where statistical analysis was carried out, parametric assumptions were made, possibly inappropriately (McKenzie et al., 2000a; Walz and Benson, 1996). Moffat et al. (1995) only reported means, employing no statistical analyses to identify whether differences were significant. A number of studies had small samples, so their findings are unlikely to have the necessary power to draw reliable conclusions (Matheson and Jahoda, 2005; McKenzie et al., 2000a; Moffatt et al., 1995). Only three studies had a large enough sample to ensure that they had significant power (Jahoda et al., 2006a; Proctor and Beail, 2007; Davies et al., 2014).
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All the studies used a cross-sectional design. Future longitudinal research may help to clarify the complex interrelationship between emotional perception and challenging behaviour and observe change over time. The studies were all based on assessments and future research could explore interventions that may change emotional perception or recognition ability and identify whether they have any impact on challenging behaviour in this client group. Studies have shown that emotion recognition skills can be effectively enhanced and maintained over time through training (McKenzie et al., 2000b; Rydin-Orwin et al., 1999; Wood and Stenfert-Kroese, 2007) but the impact of this training on service users’ behaviour would be a new area of research. Caution is needed in generalizing from offender populations to community populations due to the nature of the behaviours presented. There is no evidence to suggest that the behaviours presented are similar in terms of topography, frequency, management difficulty or severity. Unfortunately, the two offender studies in this review (Proctor and Beail, 2007; Ralfs and Beail, 2012) did not adequately describe the control groups in relation to challenging behaviours. It is possible that no differences existed because the control group also presented with challenging or aggressive behaviours. In addition, in the Proctor and Beail (2007) study, the mean IQ, though not significantly different, was higher in the offender group, and participants were younger than controls, possibly offering some explanation for the finding that the offender group was better at recognizing emotions than controls. There needs to be greater clarity with respect to definitions of the emotional concepts involved and the way in which the relevant variables are operationalized and measured. Many terms are used to describe the emotional concepts discussed in this review, many of which have subtle but important differences. Greater clarity and consistency of language would be beneficial to researchers and clinicians. It is important initially to distinguish between emotional recognition and emotional perception, the former being the recognition of emotions in others, the latter being the recognition of one’s own emotions. Individuals’ performance on each of these can be vastly different, leading to different presentations and different intervention needs. Limited information was provided regarding the reliability and validity of some of the tests used by researchers. McKenzie et al. (2000a) and Walz and Benson (1996) provided no information on this. The test of emotional perception was used by Ralfs and Beail (2012), Moffatt et al. (1995) and Proctor and Beail (2007). Very little data exists on the reliability and validity of this scale. However, Ralfs and Beail (2012) comment that this test has good face validity and was designed for use with people with an intellectual disability. Moffatt et al. (1995) claimed that they compared scores at two points in time in order to assess retest reliability, but they then fail to report the outcome of this comparison. Moffatt et al. (1995) made some effort to evaluate validity. A control group of 13 individuals without an intellectual disability was shown the videos and 10 of them correctly identified the emotion. This is a very small sample and suggests that even non-intellectually disabled individuals will only select the correct answer 76% of the time. As assessments of similar constructs are available, for example, the Ekman and Friesen’s (1975) photographs, more effort could have been employed to ensure construct validity. This adds further support for Rojahn et al.’s (1995) observation that the psychometric properties and value of emotional recognition tests used with people with intellectual disabilities are not known, creating concerns that the resulting data may not be sufficiently related to the construct being measured. This is in contrast to the work of Matheson and Jahoda (2005) who describe the substantial piloting they used to establish the ‘correct’ contexts and emotions shown in the pictures, including a final validation process involving judgements of the test materials by 18 people without an intellectual disability. For each test and control test, Matheson and Jahoda
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(2005) reported the percentage agreement between the judges (the lowest was 83.3%) and the degree of inter-rater reliability. Similarly, Davies et al. (2014) completed five pilot studies with groups of non-intellectually disabled adults to ensure that the contexts within the questions were appropriate and meaningful in relation to the emotions they were aiming to identify. However, the levels of concurrence were not reported within the article. The questions were then assessed by two adults with an intellectual disability with regard to accessibility and appropriateness, but it could be argued that two people with an intellectual disability were too few to ensure the suitability of the questions. Inter-rater reliability was reported as 100% across 200 items. It is noteworthy that none of the assessments described are published or available, other than Ekman and Freisen’s (1975) normed photographs, and many are designed for the purpose of the specific study. However, there are clear strategies in the way researchers have approached the assessment of emotional recognition in this population. Previous reviews have criticized studies for failing to use control tasks to ensure that observed difficulties were specific to emotional recognition ability (Moore, 2001; Rojahn et al., 1995). Only two of these studies included in the systematic review used control tasks (Matheson and Jahoda, 2005; Walz and Benson, 1996). This makes it difficult to determine whether, in the other studies, any deficits observed reflect a general visuoperceptual, information processing or language difficulty rather than a specific impairment of emotional recognition. Jahoda et al. (2006a) provided a rationale for not using a control task, claiming that because both groups were matched for language and IQ, the differences shown are unlikely to be due to general impairment. However, they did identify this as a limitation of their study. This review is also limited by the small number of studies published in this area. As a result, it is difficult to draw clear conclusions and suggestions for future research and practice must be viewed as tentative and thus preliminary until further research is completed in the area. In addition, the narrow focus excludes such areas as emotional understanding and mental health, and although focused reviews can be helpful in considering specific questions, further review questions may be generated and identified for future systematic reviews. In conclusion, research in this area have been scant and some of the studies that have been conducted have been of low quality, thus limiting the conclusions that can be drawn from them (McKenzie et al. 2000a; Moffatt et al., 1995; Walz and Benson, 1996). A key weakness of most of the studies is that the validity and reliability of the measures used have not been established. Better quality studies have generally failed to find a significant difference between the abilities of challenging or forensic populations and controls to recognize emotions in non-contextual photographs (Jahoda et al. 2006a; Matheson and Jahoda, 2005; Ralfs and Beail, 2012). However, two interesting areas for further research emerge from the findings of the studies. Firstly, there could be further examination of an apparent bias of those who present with behaviours that challenge to identify emotions as either angry or sad (Matheson and Jahoda, 2005; Walz and Benson, 1996). Secondly, there are grounds for further investigation of the role of context in recognizing one’s own and others’ emotions and whether this is different for those who present with challenging behaviour (Davies et al., 2014; Matheson and Jahoda, 2005). Suggestions for how these findings might be clinically useful have been offered and ideas for future research suggested. Supplemental material The online [appendices/data supplements/etc] are available at http://jid.sagepub.com/supplemental
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References Coughlan M, Cronin P and Ryan F (2007) Step-by-step guide to critiquing research. Part 1: quantitative research. British Journal of Nursing 16(11): 658–663. Davies B, Frude N, Jenkins R, et al. (2014) A preliminary study into the relationship between emotional perception ability and challenging behaviour in adults with an intellectual disability. Journal of Intellectual Disabilities 18(4): 382–392. Ekman P (1973) Cross cultural studies of facial expression. In: Ekman P (ed) Darwin and Facial Expression: A Century of Research in Review. New York: Academic Press, pp. 169–222. Ekman P and Friesen W (1975) Unmasking the Face: A Guide to Recognising Emotions from Facial Clues. New Jersey: Prentice Hall. Elm E, Altman D, Egger M, et al. (2008) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Journal of Clinical Epidemiology 61: 344–349. Emerson E (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties. Cambridge: Cambridge University Press. Emerson E, Kiernan C, Alborz A, et al. (2001) The prevalence of challenging behaviours: a total population study. Research in Developmental Disabilities 22: 77–93. Garisch J and Wilson M (2010) Vulnerabilities to deliberate self-harm among adolescents: the role of alexithymia and victimization. British Journal of Clinical Psychology 49: 151–162. Harris P, Humphreys J and Thomson G (1994) A checklist for challenging behaviour: the development of a survey instrument. Mental Handicap Research 7(2): 118–133. Harwood N, Hall L and Shinkfield A (1999) Recognition of facial emotional expressions from moving and static displays by individuals with mental retardation. American Journal on Mental Retardation 104(3): 270–278. Hatton C and Taylor J (2005) Promoting healthy lifestyles: mental health and illness. In: Grant G, Goward P, Richardson M and Ramcharan (eds) Learning Disability: A Life Cycle Approach to Valuing People. Maidenhead: Open University Press, pp. 559–603. Heal L and Sigelman C (1995) Response biases in interviews of individuals with limited mental ability. Journal of Intellectual Disability Research 39(4): 331–340. Hippolyte L, Barisnikov K, Van Der Linden M, et al. (2009) From facial emotional recognition abilities to emotional attribution: a study in down syndrome. Research in Developmental Disabilities 30: 1007–1022. Hoaken P, Allaby D and Earle J (2007) Executive cognitive functioning and the recognition of facial expressions of emotion in incarcerated violent offenders, non-violent offenders and controls. Aggressive Behaviour 33: 1–10. Jahoda A, Pert C and Trower P (2006a) Socio-emotional understanding and frequent aggression in people with mild to moderate intellectual disabilities. American Journal on Mental Retardation 111: 77–89. Jahoda A, Pert C, Trower P, et al. (2006b) Frequent aggression and attribution of hostile intent in people with mild to moderate intellectual disabilities: an empirical investigation. American Journal on Mental Retardation 111(2): 90–99. Lindsay W, Michie A, Baty F, et al. (1994) The consistency of reports about feelings and emotions from people with intellectual disability. Journal of Intellectual Disability Research 38: 61–66. Lowe K, Allen D, Jones E, et al. (2007) Challenging behaviours: prevalence and topographies. Journal of Intellectual Disability Research 51(8): 625–636. Lynch C (2004) Psychotherapy for persons with mental retardation. Mental Retardation 42: 399–405. Marshall WL, Hudson SM, Jones R, et al. (1995) Empathy in sex offenders. Clinical Psychology Review 15: 99–113. Marshall A and Holtzworth-Monroe A (2010) Recognition of wives’ emotional expressions: a mechanism in the relationship between psychopathology and intimate partner violence perpetration. Journal of Family Psychology 24(1): 21–30.
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Matheson E and Jahoda A (2005) Emotional understanding in aggressive and non-aggressive individuals with mild or moderate mental retardation. American Journal on Mental Retardation 110(1): 57–67. McAlpine C, Kendall K and Singh N (1991) Recognition of facial expressions of emotion by persons with mental retardation. American Journal on Mental Retardation 96(1): 29–36. McAlpine C, Singh N, Kendall K, et al. (1992) Recognition of facial expressions of emotion by persons with mental retardation. Behaviour Modification 16(4): 543–558. McClure K, Halpern J, Wolper P, et al. (2009) Emotion regulation and intellectual disability. Journal on Developmental Disabilities 15(2): 38–44. McCown W, Johnson J and Austin S (1986) Inability of delinquents to recognise facial affects. Journal of Social Behaviour and Personality 1(4): 489–496. McKenzie K, Hamilton L, Matheson E, et al. (2000a) An emotional challenge: how inability to recognise emotional states in others can lead to challenging behaviour. Learning Disability Practice 2(4): 20–23. McKenzie K, Matheson E, McKaskie K, et al. (2000b) Impact of group training on emotion recognition in individuals with a learning disability. British journal of Learning Disabilities 28: 143–147. Moffatt C, Hanley-Maxwell C and Donnellan A (1995) Discrimination of emotion, affective perspective taking and empathy in individuals with mental retardation. Education and Training in Mental retardation and Developmental Disabilities 30: 76–85. Moore D (2001) Reassessing emotion recognition performance in people with mental retardation: a review. American Journal on Mental Retardation 106(6): 481–502. Moore D, Hobson R and Anderson M (1995) Person perception: does it involve IQ-independent perceptual processing. Intelligence 20: 65–86. Negri-Shoultz N and Donnellan AM (1989) The test of emotional perception. Unpublished manuscript, University of Wisconsin. Owen A, Browning M and Jones R (2001) Emotion recognition in adults with mild–moderate learning disabilities. Journal of Intellectual Disabilities 5(3): 267–281. Oyefeso A, Brown S, Chiang Y, et al. (2008) Self-injurious behaviour, life events and alexithymia among treatment-seeking opiate addicts: prevalence, pattern and correlates. Drug and Alcohol Dependence 98: 227–234. Proctor T and Beail N (2007) Empathy and theory of mind in offenders with intellectual disability. Journal of Intellectual and Developmental Disability 32(2): 82–93. Prosser H (1999) An invisible morbidity? Psychologist 12: 234–237. Quay H and Peterson D (1983) Revised Behaviour Problem Checklist. Florida: Psychological Assessment Resources Inc. Ralfs S and Beail N (2012) Assessing components of empathy in sex-offenders with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities 25: 50–59. Reed J and Clements J (1989) Assessing the understanding of emotional states in a population of adolescents and young adults with mental handicaps. Journal of Mental Deficiency Research, 33, 229–233. Rojahn J, Lederer M and Tasse M (1995) Facial emotion recognition by persons with mental retardation: a review of the experimental literature. Research in Developmental Disabilities 16(5): 393–414. Rydin-Orwin T, Drake J and Bratt A (1999) The effects of training on emotion recognition skills for adults with an intellectual disability. Journal of Applied Research in Intellectual Disabilities 12(3): 253–262. Stenfert Kroesse B (1997) Cognitive behaviour therapy for people with learning disabilities: conceptual and contextual issues. In: Stenfert Kroesse B, Dagnan D and Loumidis K (eds) Cognitive Behaviour Therapy for People with Learning Disabilities. Hove: Routledge. Vandenbrouke J, Elm E, Altman D, et al. (2007) Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Medicine 4(10): 1628–1654. Walz N and Benson B (1996) Labelling and discrimination of facial expressions by aggressive and non-aggressive men with mental retardation. American Journal of Mental Retardation 101(3): 282–291.
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Wheeler J, Holland A, Bambrick M, et al. (2009). Community services and people with intellectual disabilities who engage in anti-social or offending behaviour: referral rates, characteristics, and care pathways. Journal of Forensic Psychiatry and Psychology 20(5): 717–740. Wood P and Stenfert-Kroese B (2007) Enhancing the emotion recognition skills of individuals with learning disabilities: a review of the literature. Journal of Applied Research in Intellectual Disabilities 20: 576–579. Zaja R and Rojahn J (2008) Facial emotion recognition in intellectual disabilities. Current Opinion in Psychiatry 21: 441–444.
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The relationship between emotional recognition ability and challenging behaviour in adults with an intellectual disability: A systematic review
Journal of Intellectual Disabilities 1–14 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1744629515581730 jid.sagepub.com
Bronwen Davies Caswell Clinic, UK
Neil Frude Cardiff University, UK
Rosemary Jenkins Cardiff University, UK Date accepted: 20 March 2015
Abstract This review questions whether a relationship exists between emotional recognition ability and challenging behaviour in people with an intellectual disability. A search was completed of a number of databases to identify relevant articles, and these were then evaluated against defined criteria. Eight articles were reviewed and their aims, study methodology, samples, measurement tools and findings are discussed and evaluated. Overall, studies found no significant deficit in the emotional recognition abilities of those with challenging behaviour when they were asked to identify the emotions of others. Two areas for further investigation were identified. Firstly, to ascertain whether a bias for identifying anger or sadness is found in those with challenging behaviour, and secondly, to understand the role of context in recognition of emotions and the degree to which this is different in those who present with challenging behaviour. A critique relating to the research is provided and suggested clinical and research implications are put forward. Keywords challenging behaviour, emotional recognition, emotional perception, review, emotions
Corresponding author: Bronwen Davies, Caswell Clinic, Glanrhyd Hospital, Tondu Road, Bridgend Wales, CF31 4LN, UK. Email: [email protected]
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Introduction A definition of challenging behaviour often cited within the literature is that developed by Emerson (1995: 4): Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities.
The prevalence of challenging behaviour within the intellectual disability population is between 10% and 15% (Emerson et al., 2001; Lowe et al., 2007). Emotional problems have been identified as being 3 to 4 times more prevalent in the intellectual disability population than in the general population (McClure et al., 2009; Prosser, 1999). Mental health difficulties have been found in between 20% and 39% of a population of people with intellectual disabilities (Hatton and Taylor, 2005). Across different cultures, people are able to identify the emotions of happiness, sadness, anger, fear, surprise and disgust from pictures (Ekman, 1973). Emotional recognition ability has been tested in a number of ways with people with intellectual disabilities including matching two faces expressing the same emotion, choosing an identified emotion from a set of pictures, matching words with pictures, matching emotional sounds with pictures or words, rating emotional intensity and selecting an appropriate emotional response to situations or stories (Moore, 2001). These different test procedures assess different elements of emotional recognition and involve a variety of information processing demands (see Moore, 2001). Overall, people with intellectual disabilities have been found to be significantly impaired in recognizing the emotions of others, compared to non-intellectually disabled control groups (Harwood et al., 1999; Owen et al., 2001) and intelligence quotient (IQ)-matched child control groups (Hippolyte et al., 2009; McAlpine et al., 1991, 1992). A number of considerations may lead us to question the relationship between emotional perception and challenging behaviour. In studies of the general population, challenging behaviour is not used as a construct. Studies have measured a wide variety of behaviours including self-harm, violence, aggression, destructiveness and delinquency. These would be described as challenging behaviour within a intellectual disability population. Wheeler et al. (2009) point out that the distinction between what is termed ‘antisocial’ as opposed to ‘challenging’ or ‘offending’ behaviour in people with a learning disability is problematic because each term can be applied to a broad and similar range of behaviours. Difficulties in emotional recognition have been observed in a number of clinical and forensic populations who present with challenging behaviours, for example, young offenders (McCown et al., 1986), violent offenders (Hoaken et al., 2007), men who perpetrate domestic violence (Marshall and Holtzworth-Monroe, 2010), populations who self-harm, including adolescents (Garisch and Wilson, 2010) and those who misuse substances (Oyefeso et al., 2008). Explanations of violent or challenging behaviour have hypothesized that lack of empathy reduces the inhibition to cause harm to others (Proctor and Beail, 2007). Theorists recognize that a precursor of empathy is the ability to recognize or perceive one’s own emotions. Without this ability, one would find it difficult to take the perspective of another, as required in empathy (Marshall et al., 1995). Emotional perception and challenging behaviour have also been considered within the intellectual disability literature. It has been argued that before an individual can accurately report their
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Table 1. Groups of search terms combined in this review. Group 1: intellectual disability
Group 2: challenging behaviour
Group 3: emotional recognition
Learning disab* Intellectual disabilit* Intellectual* impair* Mental* retard* Learning difficult* Mental* impair* Mental* handicap* Mental* subnormal* Challenging behav* Problem behav* Self injur* Aggress* Behav* problems Self harm Destruct* Violen* Behaviours that challenge Emotional literacy Emotional recognition Emotion* perception Fac* perception Emotion* cognition* Emotional awareness Emotional understanding Emotional* intell*
own emotional state they must be able to recognize different emotions and to understand what it means to be happy, sad, frightened or angry (Reed and Clements, 1989). If one is unable to interpret emotional stimuli, socio-emotional development may be impeded and antisocial or challenging behaviour, withdrawal or mood disorders may emerge (Zaja and Rojahn, 2008). Thus, if individuals with an intellectual impairment are not able to recognize their emotions, then they are unlikely to be able to regulate them. Such difficulties may lead to challenging behaviour or mental health issues. These theoretical issues led us to conduct a systematic review to evaluate the evidence base and to establish whether emotional recognition and challenging behaviour are related in individuals with an intellectual disability. Within this review, the terms ‘challenging behaviour’, ‘aggressive’ or ‘offender’ groups refer to the experimental groups within the studies. Within this review, when discussing a number of articles, the term challenging behaviour will be used to describe the experimental group.
Materials and methods Search strategy In the process of conducting this review, AMED, Medline, Psychlit and Psycharticles databases were searched. The search identified studies that had examined emotional recognition and challenging behaviour in people with an intellectual disability. The search involved search terms from groups 1, 2 and 3 in the lists above (Table 1). The date range searched was 1860 to December 2014, and searches were limited to English language and peer-reviewed journals. Google Scholar was also searched and Web of Knowledge was used to search for authors A Jahoda, E Matheson and K McKenzie, as they appeared to be the main authors in the field. Finally, the reference lists of relevant articles were also reviewed in order to identify possible additional articles.
Inclusion and exclusion criteria Inclusion of articles. To be included within the review, articles needed to meet a number of criteria. These were: Publication within a peer-reviewed journal. This represented an attempt to ensure that the review included only articles reporting research that had been favourably reviewed by experts in the field. A focus on either:
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the relationship between emotional recognition and challenging behaviour in people with intellectual disabilities or the difference in emotional perception skills in challenging/offending and nonchallenging populations of people with intellectual disability. Emotional reports given by participants with intellectual disabilities and reflecting their emotional understanding. Publication in English. Exclusion of articles. Specific areas of exclusion were identified: Studies focusing on the needs or experiences of carers. Studies focusing on interventions, service provision or policy. Studies focusing on people with autistic spectrum conditions. People with autism have welldocumented deficits in emotional processing including emotional recognition (Owen et al., 2001), and this review focused on articles that studied the intellectual disability population more generally. Reviewing the studies. Initially, 433 articles were identified and reviewed by title and abstract for relevance to emotional recognition and challenging behaviour in people with an intellectual disability. Articles that clearly met any of the exclusion criteria, or failed to meet the inclusion criteria, were eliminated from the review at this stage. Of the 434, 69 were duplicated on the searches, 46 related to people with autistic spectrum conditions, 47 related to service provision or interventions, 162 were not related to people with intellectual disabilities, 54 were not research articles (e.g. reports, reviews or editorials), 26 did not investigate both emotion and challenging behaviour and 24 focused on the needs and experiences of staff and carers. This process left six articles, and for these full texts were retrieved. Two relevant review articles were also downloaded and the reference lists of these and the identified articles were reviewed and another two eligible articles were found. Eight studies were eligible to be included in the systematic review after further application of the inclusion and exclusion criteria (for a summary of the articles, please see online supplementary Appendix 1). These were also reviewed by the second author to ensure quality of the review process. Quality. Criteria for assessing the quality of the studies in this review were based on a number of articles including earlier reviews that critiqued the body of research on the emotional recognition abilities of people with an intellectual disability (Moore, 2001; Rojahn et al., 1995). The Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) was also used in the development of quality criteria for this review (Elm et al., 2008; Vandenbroucke et al. 2007). Finally, a Step-by-Step Guide to Critiquing Quantitative Research (Coughlan et al., 2007) was used in considering which quality criteria to employ in this systematic review. Based upon these sources, a quality appraisal scheme was developed, which is set out below. If articles met all of the quality criteria set out under each heading, they were awarded two points, if the report met only some of the criteria they were given one point and if none of the issues were addressed no points were given on that criterion. Scores for the 10 criteria were then added to give a total quality score for the article. The maximum score obtainable was 20, please see online supplementary Appendix 2 for details of the scoring for each article.
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The 10 sections or aspects of articles delineated for quality evaluation are as follows: 1. Aims/purposes: Are specific aims, objectives or pre-specified hypotheses stated? Do they reflect the information in the literature review? Is the purpose of the study/research problem clearly identified? 2. Title, abstract and introduction: Is the study’s design indicated in the title or abstract? Is the title clear, accurate and unambiguous? Is the abstract an informative and balanced summary of what was done and what was found? Does the introduction explain the scientific background and rationale for the study being reported? Does the introduction give an overview of what is known about the topic and where the gaps in knowledge exist? Does it note most recent pertinent studies or reviews? Does it offer a balanced critical analysis of the literature? 3. Study design: Are the key elements of the study design presented? In comparison studies, is a control task included within the study? Are all variables defined? 4. Sampling: Has the target population been clearly identified? Are recruitment procedures and selection methods outlined? Are eligibility criteria for participation laid out? Are characteristics of the study participants outlined (e.g. age, gender, diagnosis, co-morbid conditions, IQ and language ability)? When a control group is used, are the samples matched for such variables as gender, receptive vocabulary and/or IQ? Is a rationale provided for author’s choice of matching variables? 5. Sample size and attrition: Does the study explain how the sample size was arrived at? Are the numbers of individuals at each stage of the study reported and reasons for nonparticipation identified at each stage? Is the sample size adequate (in comparison studies a group size of 19 or less will be considered weak, a group size of 20–25 will be considered sufficient and over 25 will be considered strong)? 6. Validity and reliability: Was adequate information on the validity and reliability of assessment measures provided? Did the authors report which previous studies had employed the measures used? If a measure was developed for the study, was sufficient information given on the development process? If measures were adapted to make them more accessible for people with intellectual disabilities (e.g. simplified language and pictorial representations), is there evidence of the reliability and validity of the adapted version? 7. Data collection: For each variable of interest, are sources of data and assessment methods explained? Has the data gathering process been fully described? Have appropriate questions been used in any questionnaire? 8. Analysis: Were descriptive statistics presented for each variable, with any missing values accounted for? Was the distribution of the data examined? Were appropriate parametric or non-parametric tests employed in any inferential analysis? Were all statistical methods used clearly described? Are the results of any tests fully reported and correctly interpreted? 9. Limitations: Were limitations of the study discussed, including any potential for bias or imprecision? Was consideration given to the possible confounding effects of variables not measured as part of the study? 10. Conclusions and recommendations: Was an overall interpretation of the results provided, with due consideration of the objectives, analyses and results of other studies? Was the relevance of results to specific hypotheses discussed? Were recommendations made for future research? Were clinical implications of findings outlined? Was the validity, generalizability and precision of results discussed in relation to other studies?
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Results The eight studies included in this review were cross-sectional and used either experimental/control group comparison designs or a correlational design. Clearly, the use of cross-sectional designs has limitations in relation to inferring causality and temporal order. In addition, many of the studies appear to have shown minimal consideration of possible confounding variables such as mental health, communication skills and poor coping skills, although a number do consider intelligence or language ability.
Samples and populations Sample sizes varied, with only two studies reporting power calculations to identify the necessary sample size (Davies et al., 2014; Proctor and Beail, 2007) and a number of the studies using small samples (Matheson and Jahoda, 2005; Moffatt et al., 1995; McKenzie et al., 2000a). Studies have employed stratified random sampling techniques, selecting participants from larger cohorts of people with an intellectual disability based on their ability and whether or not they present with aggressive, challenging or offending behaviour. Control groups have then been matched on a variety of factors including gender (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005; Moffatt et al., 1995), age (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005; McKenzie et al., 2000a; Ralfs and Beail, 2012; Walz and Benson, 1996) and ability, with all of the eight studies matching their control group based on either IQ or level of intellectual disability. Three studies used all male samples (Proctor and Beail, 2007; Ralfs and Beail, 2012; Walz and Benson, 1996) and in McKenzie et al.’s (2000a) sample, men were over-represented. This will impact on the ability to generalize these findings to women with an intellectual disability. In addition, a few studies included a small number of people with borderline IQ (IQ 70–80) (Matheson and Jahoda, 2005; Moffatt et al., 1995; Ralfs and Beail, 2012; Walz and Benson, 1996). This may have influenced the outcome of assessments, exaggerating participants’ abilities and limiting the generalizability of the findings to intellectual disability populations.
Measuring challenging behaviour Three studies used the Checklist of Challenging Behaviour (Harris et al., 1994) to differentiate the groups (Davies et al., 2014; Jahoda et al., 2006a; Matheson and Jahoda, 2005). Walz and Benson (1996) used the conduct disorder subscale of the Revised Behaviour Problem Checklist (Quay and Peterson, 1983). McKenzie et al. (2000a) based inclusion in each group on whether staff reported the individual to have challenging behaviour or not. Moffatt et al. (1995) reviewed service users’ notes. The other two studies accessed groups of offenders with intellectual disabilities (Proctor and Beail, 2007; Ralfs and Beail, 2012).
Measuring emotional perception All of the studies in this review employed appropriate ways of collecting data from people with an intellectual disability. They all used open-ended questions or multiple-choice response formats and picture presentations of test stimuli as well as simplified language. This is in line with recommendations about how to involve people with intellectual disabilities in research (Heal and Sigelman, 1995; Lynch, 2004; Stenfert-Kroese 1997). In three of the studies, participants were asked to label the emotions depicted in sets of Ekman and Friesen’s (1975) normed photographs (Jahoda et al., 2006a; Matheson and Jahoda, 2005;
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Walz and Benson, 1996). Matheson and Jahoda (2005) also asked participants to identify emotions from photographs of individuals in context, for example, sadness at a funeral, and they presented participants with a set of cartoons with context. In the latter assessment, 12 cartoons were presented individually, each of which pictured two people in a specific context. The central character was depicted with an outline where their head should have been, and the participant was asked to select the appropriate head, from a range displaying various emotions, and to place it in position. Walz and Benson (1996) used a matching task to determine discrimination techniques used by individuals to identify emotion. There was a standard picture and five options from which the participant could select a picture to match the standard. The choice was between faces that had the same eyes, mouth or hair as the standard, no similarities or an identical or generalized version of the emotional expression of the standard. The researcher pointed to the standard face and said ‘This man/woman is (e.g. sad). Pick the other (e.g. sad) man/woman. Is anyone else feeling (e.g. sad)?’ McKenzie et al. (2000a) used three sets of materials depicting a number of different emotions (happy, sad, afraid, angry, bored and worried). These were line drawings, photographs of faces and photographs of an emotion in context. Participants were asked to (a) name the emotion depicted in the picture, (b) choose which picture showed the target emotion from a group of six and (c) choose which picture (of two presented simultaneously) showed the target emotion. Three studies used the ‘test of emotional perception’ (Negri-Shoultz and Donnellan, 1989) to assess emotional recognition (Moffatt et al., 1995; Proctor and Beail, 2007; Ralfs and Beail, 2012). This is an unpublished test designed for use with people with an intellectual disability (Proctor and Beail, 2007). Within this test, participants are shown six videos depicting happy, sad and angry scenes. They are then asked to identify how the key character in the video is feeling. They are also asked what will happen next. The response format for this task (Proctor and Beail, 2007; Ralfs and Beail, 2012) involves multiple choices in which the participant is asked to select from three photographs. A final question asks either how they would feel if the event depicted happened to them (perception) (Moffatt et al., 1995) or how they would feel if such an event happened to their friend (empathy) (Proctor and Beail, 2007; Ralfs and Beail, 2012). Finally, Davies et al. (2014) employed an Emotional Perception Questionnaire, also unpublished. This is a self-report measure that asks participants how they would feel if they found themselves in 20 situations, for example, ‘If you won first prize in a competition, how would you feel?’ Participants were asked to choose between pictures of happy, sad, angry, scared or worried emoticons (cartoon faces).
Findings Studies indicate that individuals with challenging behaviour are not significantly worse at identifying the emotions in Ekman and Friesen’s (1975) photographs than those without challenging behaviour (Jahoda et al., 2006a; Matheson and Jahoda, 2005; Walz and Benson, 1996). Similarly, with the variety of other assessments used, no difference was found in the ability of people who present with challenging behaviours or non-challenging individuals in labelling emotions in cartoons (Matheson and Jahoda, 2005), in a facial cues task (Walz and Benson, 1996) or in the tests employed by McKenzie et al. (2000a). In addition, Ralfs and Beail (2012) found no significant differences between sex offenders and non-sex offenders in emotional recognition. In fact, those with challenging behaviours have been shown to do better in two studies (McKenzie et al., 2000a; Proctor and Beail, 2007). When McKenzie et al. (2000a) compared those who presented with aggressive behaviours to a non-challenging behaviour group, they found that
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aggressive service users were significantly better than the non-challenging individuals at identifying and labelling emotions (t ¼ 2.442, df ¼ 12, p < 0.05). Also, Proctor and Beail (2007) found that offenders with an intellectual disability performed significantly better than non-offenders on emotional recognition, F(1, 49) ¼ 6.17, p ¼ 0.015, and needed significantly fewer prompts than non-offenders to provide emotional descriptors, F(1, 49) ¼ 5.01, p ¼ 0.03. Moffat et al. (1995) reported significant differences between people with a mild intellectual disability who did or did not exhibit challenging behaviours. There was no difference between those with moderate intellectual disability with and without behavioural problems. However, beyond reporting means, they did not present any statistical analyses of the difference, so it is not clear whether the differences reported were significant or not. Walz and Benson (1996) found a negative bias in emotional labelling, whereby the aggressive group was more likely to mislabel emotions as angry or sad than the non-aggressive group. Similarly, in the cartoon task, Matheson and Jahoda (2005) found that the aggressive group was significantly more likely to incorrectly identify an emotion as angry than the non-aggressive group. This negative bias was not, however, replicated by Jahoda et al. (2006a), who studied a larger sample and employed a sounder methodology. This issue would benefit from further study. Two studies did find that individuals with challenging behaviours were significantly worse at identifying emotions, and both of these included contextual information in the assessment process. Matheson and Jahoda (2005) found that a group, which was described as aggressive, was significantly more impaired than controls in identifying emotions within contextualized pictures (U ¼ 71.00, p < 0.05). Davies et al. (2014) looked at whether individuals could recognize and label their own emotions as opposed to identifying them in pictures of others. They found significant negative correlations between challenging behaviour frequency and emotional perception ability total (rs ¼ 0.290, p < 0.01), correct worried (rs ¼ 0.204, p < 0.05) and angry answers (rs ¼ 0.218, p < 0.05). They found a significant negative correlation between challenging behaviour management difficulty and correct angry answers (rs ¼ 0.229, p < 0.05). A significant negative correlation was also observed between aggression severity and emotional perception total (rs ¼ 0.178, p < 0.05). Whilst significant, these correlations account for a small amount of the variance, implying that other variables account for the majority of the variance. A post hoc betweengroups analysis found that those who present with high-frequency challenging behaviour were significantly poorer at emotional perception than those with no or low-frequency challenging behaviour (t ¼ 2.403, df ¼ 1,48, p ¼ 0.013).
Discussion The evidence within this review suggests that the recognition of emotions of others is not impaired in people with intellectual disabilities who present with challenging behaviours compared to controls. In fact, in two studies they were actually better than controls (McKenzie et al., 2000a; Proctor and Beail, 2007). This does not therefore support the findings of studies within other populations of people who present with challenging behaviours (e.g. Garisch and Wilson, 2010; Hoaken et al., 2007; Marshall and Holtzworth-Munroe, 2010; McCown et al., 1986; Oyefeso et al., 2008). Emotional recognition ability has been assessed using a variety of methods including matching tasks, labelling emotions in photographs, line drawings or cartoons and identifying emotions in videos. Although this is still a very limited pool of studies, most suggest that there is a limited or no relationship, regardless of the methods of assessment. Matheson and Jahoda (2005) argue that decontextualized measures may, however, underestimate
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the abilities of people with intellectual disabilities to accurately identify emotions. This is based on Moore et al.’s (1995) argument that assessment methods relying on simplified stimuli without dynamic or temporal cues may be a hindrance because they require the employment of more inferential, cognitively based, capacities. There are, however, two areas that would benefit from further exploration. Two studies found a negative bias in the labelling of emotions. Both Walz and Benson (1996) and Matheson and Jahoda (2005) found that their ‘aggressive groups’ were significantly more likely than controls to incorrectly identify an emotion as angry, and, in Walz and Benson’s (1996) study, a bias for identifying emotions as sad was found. This negative bias was not however supported by the work of Jahoda et al. (2006a). An angry (or sad) emotional attribution bias, should this be supported in further research, might be helpful in understanding why some people engage in challenging behaviours, for example, individuals could be responding to perceived anger in others. This may be linked to the ‘hostile attribution bias’ identified by Jahoda et al. (2006b). This area of research is in its infancy but may turn out to be a fruitful field of further enquiry. The other area worthy of further study is the consideration of context. Two studies reported significant differences between those who present with challenging behaviour and controls when context was included in the assessment method. One of the studies, that by Matheson and Jahoda (2005), asked participants whether they could recognize the emotions of others in pictures or cartoons including context whilst the other, Davies et al. (2014), asked participants how they would feel in emotionally arousing contexts. Based on these preliminary findings, it does appear that context may be an important element that contributes to the emotional recognition ability in people with an intellectual disability. Previous studies have shown that people with intellectual disabilities are better at describing their own emotions rather than the emotions of others (Lindsay et al., 1994; Owen et al., 2001), and other studies have shown that contextual information may be important in understanding emotions for people with intellectual disabilities (Hippolyte et al., 2009; Moore et al., 1995). The aggressive group in Matheson and Jahoda’s (2005) study may be presenting with the deficits in facial emotional recognition identified in the non-intellectually disabled aggressive populations (Garisch and Wilson, 2010; Hoaken et al., 2007; Marshall and Holtzworth-Munroe, 2010; McCown et al., 1986; Oyefeso et al., 2008). This area needs further exploration and replication to clarify the importance of context in recognizing one’s own emotions as well as other people’s and how this relates to challenging behaviour within an intellectual disability population. Matheson and Jahoda (2005) suggest that aggressive individuals may attend to fewer cues in the environment and therefore benefit less from additional contextual information. This is clearly an area for further research and further findings of this nature would be useful in informing formulation and intervention with respect to individuals’ behavioural and emotional understanding. The studies reviewed in this article have a number of methodological limitations. The quality of the older studies is poor (McKenzie et al., 2000a; Moffat et al., 1995; Walz and Benson, 1996), with methodological weaknesses casting doubt over the conclusions drawn. None of the older studies assessed the distribution of the data and where statistical analysis was carried out, parametric assumptions were made, possibly inappropriately (McKenzie et al., 2000a; Walz and Benson, 1996). Moffat et al. (1995) only reported means, employing no statistical analyses to identify whether differences were significant. A number of studies had small samples, so their findings are unlikely to have the necessary power to draw reliable conclusions (Matheson and Jahoda, 2005; McKenzie et al., 2000a; Moffatt et al., 1995). Only three studies had a large enough sample to ensure that they had significant power (Jahoda et al., 2006a; Proctor and Beail, 2007; Davies et al., 2014).
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All the studies used a cross-sectional design. Future longitudinal research may help to clarify the complex interrelationship between emotional perception and challenging behaviour and observe change over time. The studies were all based on assessments and future research could explore interventions that may change emotional perception or recognition ability and identify whether they have any impact on challenging behaviour in this client group. Studies have shown that emotion recognition skills can be effectively enhanced and maintained over time through training (McKenzie et al., 2000b; Rydin-Orwin et al., 1999; Wood and Stenfert-Kroese, 2007) but the impact of this training on service users’ behaviour would be a new area of research. Caution is needed in generalizing from offender populations to community populations due to the nature of the behaviours presented. There is no evidence to suggest that the behaviours presented are similar in terms of topography, frequency, management difficulty or severity. Unfortunately, the two offender studies in this review (Proctor and Beail, 2007; Ralfs and Beail, 2012) did not adequately describe the control groups in relation to challenging behaviours. It is possible that no differences existed because the control group also presented with challenging or aggressive behaviours. In addition, in the Proctor and Beail (2007) study, the mean IQ, though not significantly different, was higher in the offender group, and participants were younger than controls, possibly offering some explanation for the finding that the offender group was better at recognizing emotions than controls. There needs to be greater clarity with respect to definitions of the emotional concepts involved and the way in which the relevant variables are operationalized and measured. Many terms are used to describe the emotional concepts discussed in this review, many of which have subtle but important differences. Greater clarity and consistency of language would be beneficial to researchers and clinicians. It is important initially to distinguish between emotional recognition and emotional perception, the former being the recognition of emotions in others, the latter being the recognition of one’s own emotions. Individuals’ performance on each of these can be vastly different, leading to different presentations and different intervention needs. Limited information was provided regarding the reliability and validity of some of the tests used by researchers. McKenzie et al. (2000a) and Walz and Benson (1996) provided no information on this. The test of emotional perception was used by Ralfs and Beail (2012), Moffatt et al. (1995) and Proctor and Beail (2007). Very little data exists on the reliability and validity of this scale. However, Ralfs and Beail (2012) comment that this test has good face validity and was designed for use with people with an intellectual disability. Moffatt et al. (1995) claimed that they compared scores at two points in time in order to assess retest reliability, but they then fail to report the outcome of this comparison. Moffatt et al. (1995) made some effort to evaluate validity. A control group of 13 individuals without an intellectual disability was shown the videos and 10 of them correctly identified the emotion. This is a very small sample and suggests that even non-intellectually disabled individuals will only select the correct answer 76% of the time. As assessments of similar constructs are available, for example, the Ekman and Friesen’s (1975) photographs, more effort could have been employed to ensure construct validity. This adds further support for Rojahn et al.’s (1995) observation that the psychometric properties and value of emotional recognition tests used with people with intellectual disabilities are not known, creating concerns that the resulting data may not be sufficiently related to the construct being measured. This is in contrast to the work of Matheson and Jahoda (2005) who describe the substantial piloting they used to establish the ‘correct’ contexts and emotions shown in the pictures, including a final validation process involving judgements of the test materials by 18 people without an intellectual disability. For each test and control test, Matheson and Jahoda
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(2005) reported the percentage agreement between the judges (the lowest was 83.3%) and the degree of inter-rater reliability. Similarly, Davies et al. (2014) completed five pilot studies with groups of non-intellectually disabled adults to ensure that the contexts within the questions were appropriate and meaningful in relation to the emotions they were aiming to identify. However, the levels of concurrence were not reported within the article. The questions were then assessed by two adults with an intellectual disability with regard to accessibility and appropriateness, but it could be argued that two people with an intellectual disability were too few to ensure the suitability of the questions. Inter-rater reliability was reported as 100% across 200 items. It is noteworthy that none of the assessments described are published or available, other than Ekman and Freisen’s (1975) normed photographs, and many are designed for the purpose of the specific study. However, there are clear strategies in the way researchers have approached the assessment of emotional recognition in this population. Previous reviews have criticized studies for failing to use control tasks to ensure that observed difficulties were specific to emotional recognition ability (Moore, 2001; Rojahn et al., 1995). Only two of these studies included in the systematic review used control tasks (Matheson and Jahoda, 2005; Walz and Benson, 1996). This makes it difficult to determine whether, in the other studies, any deficits observed reflect a general visuoperceptual, information processing or language difficulty rather than a specific impairment of emotional recognition. Jahoda et al. (2006a) provided a rationale for not using a control task, claiming that because both groups were matched for language and IQ, the differences shown are unlikely to be due to general impairment. However, they did identify this as a limitation of their study. This review is also limited by the small number of studies published in this area. As a result, it is difficult to draw clear conclusions and suggestions for future research and practice must be viewed as tentative and thus preliminary until further research is completed in the area. In addition, the narrow focus excludes such areas as emotional understanding and mental health, and although focused reviews can be helpful in considering specific questions, further review questions may be generated and identified for future systematic reviews. In conclusion, research in this area have been scant and some of the studies that have been conducted have been of low quality, thus limiting the conclusions that can be drawn from them (McKenzie et al. 2000a; Moffatt et al., 1995; Walz and Benson, 1996). A key weakness of most of the studies is that the validity and reliability of the measures used have not been established. Better quality studies have generally failed to find a significant difference between the abilities of challenging or forensic populations and controls to recognize emotions in non-contextual photographs (Jahoda et al. 2006a; Matheson and Jahoda, 2005; Ralfs and Beail, 2012). However, two interesting areas for further research emerge from the findings of the studies. Firstly, there could be further examination of an apparent bias of those who present with behaviours that challenge to identify emotions as either angry or sad (Matheson and Jahoda, 2005; Walz and Benson, 1996). Secondly, there are grounds for further investigation of the role of context in recognizing one’s own and others’ emotions and whether this is different for those who present with challenging behaviour (Davies et al., 2014; Matheson and Jahoda, 2005). Suggestions for how these findings might be clinically useful have been offered and ideas for future research suggested. Supplemental material The online [appendices/data supplements/etc] are available at http://jid.sagepub.com/supplemental
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