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International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2019 Jul 22;67(3):209–216. doi: 10.1080/20473869.2019.1640972

Frequency and origin (reactive/proactive) of aggressive behavior in young people with intellectual disability and autism spectrum disorder

Leïla Oubrahim 1,✉, Nicolas Combalbert 1
PMCID: PMC8211134  PMID: 34188900

Abstract

Background

The aim was to investigate the aggressive behavior of young people in specialized institutions with intellectual disability (ID) with or without autism spectrum disorder (ASD).

Method

Data on 305 institutionalized young people were collected using two aggression scales, the ‘Children's Scale of Hostility and Aggression: Reactive/Proactive’, and the ‘Behavior Problems Inventory – Short Form’.

Findings

Our results show that the behavioral manifestations differ between the clinical groups (ID/ID with ASD). In addition, they reveal a decrease in all aggressive and stereotyped behaviors at 16 years in participants with ID but not in those with the dual diagnosis (ID and ASD). There would be an increase in self-injury with age in people with ID and ASD. Finally, the aggressive behaviors (verbal, relational, bullying) of people with only ID are significantly more proactive than reactive.

Keywords: aggressive behaviors, proactive, reactive, intellectual disability, autism spectrum disorde

Introduction

Aggressive behavior and intellectual disability with or without ASD

Aggressive behavior is defined as any verbal, non-verbal or physical behavior that is threatening or causes harm to the person him or herself, to others or to objects (Morrison 1990). In a review of the literature, Benson and Brooks (2008) noted that aggression is a significant problem in individuals with intellectual disability (ID), from childhood to adulthood, and at all levels of intellectual impairment. We know that it is more common among individuals with ID than among those with normal development (Holden and Gitlesen 2006). The prevalence of ID in the population is approximately 2.5% (Maulik et al. 2011). According to the American Psychiatric Association (APA) (2013), the prevalence of intellectual disability is 1% among the general population. ID is characterized by an intellectual quotient (IQ) of less than 70, associated with significant impairments in adaptive behavior, which occur early in the developmental period (DSM-5; APA 2013).

From a review of the epidemiological literature on behavioral problems in ID, authors (Rojahn and Meier 2009) found that the prevalence rates of aggressive behavior range from 6.4% (Holden and Gitlesen 2006) to 32% (Lowe et al. 2007), the self-injury rate from 4.4% (Holden and Gitlesen 2006) to 21% (Lowe et al. 2007), and the destructive behavior rate from 2.3% (Holden and Gitlesen 2006) to 19% (Lowe et al. 2007). Aggression is also a major problem in the management of individuals with ID and a co-occurring Autism Spectrum Disorder (ASD). Currently we know that the prevalence of ASD at about 1/68 children (Schaefer 2016). Rates of individuals with ASD and ID are about 50–70% of all ASD cases (Matson and Shoemaker, 2009). La Malfa et al. (2004) observed that 40% of people with ID also have an ASD. Other researchers estimate a rate of 41–55% of individuals with ID and ASD (Baird et al. 2006). Autism spectrum disorders are a set of disorders whose symptomatology combines impaired social interactions, qualitative communication disorders and restricted, repetitive patterns of behaviors that appear during the early development period (DSM-5; APA 2013). ASD is one of the commonest neurodevelopmental disorders in people with ID, with a prevalence rate of approximately 30% (Adult Psychiatric Morbidity Survey (APMS) 2007). Lecavalier (2006) reported that up to 20% of children with ASD could manifest aggression and irritability.

We know that aggression, self-injurious behavior and property destruction are more common among individuals with a dual diagnosis of ID and ASD than among those with only ID (McClintock et al. 2003). Studies have shown that people with ID, in addition to aggressive and destructive behaviors, exhibit stereotyped and self-injurious behavior (Rojahn et al. 2012a). Also, adults with ID and co-occurring ASD exhibit higher levels of self-injurious and stereotypical behaviors than those with only ID (Rojahn et al. 2010). In the literature, aggressiveness is considered proactive or ‘instrumental’ when aggressive behavior is premeditated with the desire to gain a profit (Dodge and Coie 1987) (e.g. child A pushes his classmate B to grab his toy). On the other hand, aggression is reactive when the child or adolescent only harms someone as a result of perceived provocation (e.g. child B pushes child A who took his toy from him). However, there are very few studies of the reactive and proactive functions of the behaviors of people with ID with or without ASD. Nevertheless, some researchers (Farmer and Aman 2010) have observed that people with ASD display less relational aggression than their peers with ADHD, Down syndrome, or Conduct or Opposition Disorder. Recently, researchers (Pouw et al. 2013) found a positive association between reactive aggression and emotional empathy in children with ASD, in contrast to their typically developing peers. They hypothesized that poor regulation of emotions and reduced understanding of others' emotions is associated with aggressive behavior in children with ASD.

Intellectual disability and aggressive behavior

Oliver et al. (1987) found that the manifestation of self-injurious behavior in people with ID increases during childhood, reaches a peak at 15 and then decreases. In a literature review (Davies and Oliver 2013), studies involving only children (4 to 17 year old) found no significant age-related differences in aggression and self-injury. For example, Ando and Yoshimura (1978) studied aggression in 128 children with ID aged 6–14 years and found no difference in aggression between 11 to 14 year olds and 6 to 9 year olds. Likewise, in a study of 52 children with ID, Tavormina et al. (1976) found that children aged 8 to 12 and 12 to 17 showed no more aggression than those aged 4 to 6. Finally, Oubrahim et al. (2018) found that the frequency of several forms of aggression (physical, verbal, relational, hostility, and bullying) is greater in children than in adolescents with ID receiving specialized schooling.

Intellectual disability, autism spectrum disorder and aggressive behavior

There is no review of the literature on the prevalence of aggressive behavior in children and adolescents with both ID and ASD (Farmer 2011). Nevertheless, some recent studies have been conducted with this population. One of them used the Behavior Problems Inventory-01 in a sample of children (aged 3 to 14.2 years) with ASD living in Ireland and found no relationships between age and aggression, stereotypies, Self-Injurious Behavior (SIB) and severity of these behaviors (Murphy et al. 2009). Moreover, they found no significant correlation between level of intellectual disability and aggression or stereotyped behaviors. Other researchers (Matson et al. 2010) found no differences in physical aggression, property destruction, verbal aggression, SIB, stereotypies, and tantrums between young children (3 to 6 year old), children (7 to 10 year old), and young adolescents (11 to 14 year old) with ASD.

Aggressive behavior is a major problem in this population. The consequences of aggressive behavior are similar for people with ASD and those with ID (Matson et al. 2009). These behaviors can become chronic and cause such severe problems that they cannot be ignored (Rojahn et al. 2012b), as they can lead to maladjusted behavior (Vieillevoye and Nader-Grosbois 2008), limit the development of social relationships, and reduce the opportunities to participate in community-based activities (Anderson et al. 1992). They can also be an obstacle to learning new skills (Chadwick et al. 2000) and constitute a significant risk of injury (Lee et al. 2008). They may also require the long-term use of psychotropic drugs which can have harmful side effects (Singh et al. 2005). Nevertheless, there are few studies on this issue, particularly in relation to ASD. This can be explained by the fact that the tools that have been used to assess problem or aggressive behavior in children and adolescents with ID are inadequate to study aggression because they do not cover all aspects of aggressive behavior. Indeed, most instruments assess the psychopathological symptomatology and devote only one subscale to aggression (e.g. Child Behavior Checklist, Achenbach 1991; Developmental Behavior Checklist, Einfeld and Tonge 1992, 2002).

It is important to study the aggressive behavior of people with ID with and without ASD based on specific diagnostic criteria, to meet their specific needs (Galli Carminati et al. 2007). In addition, given that ASD is the most recurrent disorder in ID, we believe that it is essential to study the differences between the two diagnoses (ID and ID with ASD).

There has been no research investigating the different forms of aggression from a developmental and clinical point of view. Indeed, Benson and Brooks (2008) reviewed several articles about aggressive behavior in individuals with ID and concluded that research on this topic requires assessment instruments that address the topography and severity of aggression. Similarly, there is little knowledge about the functions of these aggressive behaviors (reactive-proactive). Thus, while this study is partly exploratory, its principal aim was to identify a detailed topography of aggressive behavior in people with ID with and without ASD. We evaluated the frequency and severity of aggressive behaviors at different ages in the two clinical groups. We hypothesized that the form, frequency, function and severity of aggressive behavior in children and adolescents with ID and in those with ID and ASD would differ, because these are two different neurodevelopmental disorders. In line with the literature (McClintock et al. 2003, Rojahn et al. 2010), we expected to find more frequent self-harm behaviors in people with the dual diagnosis (ID plus ASD) than those with only ID.

Method

Participants

The convenience sample was composed of 305 children and adolescents aged between 7 and 18 years (Mean 14.61 years; SD 3.44); 74 had the dual diagnosis of ID and ASD (age range 8–24, M = 14.5; SD = 3.6), and 231 were diagnosed with ID only (age range 7–24, M = 14.6; SD = 3.4). They had all been assessed by a psychologist and had been diagnosed with ID (IQ >70), with or without ASD (DSM-5) before placement in their specialized institutions. There were 178 girls and 172 boys. All the participants were recruited from seven specialized establishments in France providing multidisciplinary care for children and adolescents with ID.

Procedure

Once each institution had agreed to participate, an in-house meeting was organized to present the study. The data was collected between January 2016 and December 2017.

Key workers in each institution were provided with a package including a C-SHARP form, a BPI-S form, and a demographic questionnaire to collect information about each child or adolescent in their care. The participation rate of these professionals was 100%, and 50 key workers participated in the study. In accordance with the code of ethics, the anonymity of participants and questionnaires was assured.

Material

BPI-S

The Behavior Problems Inventory-Short Form (Rojahn et al. 2012a) is a structured interview conducted by a professional, with 30 items representing behavior problems in people with ID. It is divided into three subscales: ‘Self-injurious behaviors’ (8 items), ‘aggressive and destructive behaviors’ (10 items), and ‘stereotyped behaviors’ (12 items). The BPI-S assesses the frequency and intensity of problem behaviors over the two previous months. Frequency is rated on a scale ranging from (0) never, (1) monthly, (2) weekly, (3) daily, to (4) every hour; severity is rated on a scale ranging from (0) none, (1) mild, (2) moderate to, (3) severe. We used the French version of the tool (Oubrahim and Combalbert 2019), which has good psychometric properties, including acceptable inter-rater reliability with values ranging from 0.66 to 0.81, and high internal consistency (.90). In addition, confirmatory factor analysis clearly identified the three factors of the original BPI-S.

C-SHARP

The Children’s Scale of Hostility and Aggression: Reactive/Proactive (Farmer and Aman 2009) has 48 items divided into five subscales: verbal aggression, bullying, relational aggression, hostility, and physical aggression. Items are rated on two Likert scales. The Problem Scale items, which indicate the frequency and severity of the behavior, are scored from 0 (does not happen) to 3 (severe-frequent). If the item is rated 1 or above (the behavior happens), a Provocation Scale can be completed to indicate whether the behavior is usually provoked (proactive) or unprovoked (reactive); items are rated from -2 (provoked), through 0 (neutral), to +2 (not provoked). However, for the purposes of our study this scale was not used. We used the French version of the tool. The C-SHARP has been translated into French and is currently being validated with a population of children and adolescents with ID in France. The tool has good psychometric properties, including acceptable inter-rater reliability with values ranging from 0.75 to 0.93, and high internal consistency (.93). In addition, confirmatory factor analysis clearly identified the five factors of the original C-SHARP.

Analyses

The statistical tests were performed using Statistica 13 software. Pearson correlations were used to examine the relationship between age and aggression scores on each subscale of the C-SHARP and BPI-S. Next, t-tests were carried out to check whether there were differences in aggression between individuals aged under and over 16. Finally, an ANOVA was carried out to examine the influence of the diagnosis on each form of aggression. To evaluate the reactive and proactive function of aggressive behaviors, we used t-tests, as in the methodology described by Farmer et al. (2016): for each group, we calculated the number of proactive items (>0) and the number of reactive items (<0), and then compared the average of the proactive scores and the average of the reactive scores for each aggression subscale (verbal, relational, physical, hostility, bullying) with t-tests.

We compared the p value to a previously defined threshold (5%). If the p value is below this threshold, the test result is declared ‘statistically significant’.

Results

Intellectual disability only versus intellectual disability with ASD

Relationship between diagnostic group and aggression

There were significant differences between participants with ID only and those with ID and ASD in verbal aggression [F (1,303) = 18.23, p = .000] (M = 5.88, SD = 0.48; M = 1.7, SD = 0.85, respectively), relational aggression [F (1,303) = 11.93, p = .000] (M = 6.22, SD = 0.36; M = 3.66, SD = 0.64, respectively), SIB [F (1,303) = 27.1, p = .000] (M = 0.9, SD = 0.18; M = 3, SD = 0.32, respectively), and stereotypies [F (1,303) = 51.8, p = .000] (M = 3.7, SD = 0.51; M = 11.14, SD = 0.9, respectively).

Functions: reactive and proactive aggressive behaviors

People with intellectual disability (Table 1).

Table 1.

Reactive and proactive aggressive behaviors (ID)

Subscale Total proactive score Total reactive score p Value
OB 3.69 (±2.30) 1.94 (±1.18) .04
OH 2.05 (±1.62) 2.16 (±1.40) .42
OP 2 (±1) 1.66 (±0.58) .61
OR 2.47 (±1.88) 1.34 (±0.71) .000
OV 4.03 (±2.89) 2 (±1.72) .01
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Average ± Standard Deviation

O: origin of aggression (proactive and/or reactive); B: Bullying; H: Hostility; P: Physical; R: Relational; V: Verbal.

People with intellectual disability and autism spectrum disorder (Table 2).

Table 2.

Reactive and proactive aggressive behaviors (ID and ASD)

Subscale Total proactive score Total reactive score p Value
OB 2.71 (±1.60) 1.71 (±0.95) .41
OH 2.5 (±2.17) 2.10 (±1.72) .40
OP – – –
OR 2.37 (±1.18) 1.50 (±0.53) .43
OV 1.50 (±0.84) 2.17 (±1.17) .40
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Average ± Standard Deviation

O: origin of aggression (proactive and/or reactive); B: Bullying; H: Hostility; P: Physical; R: Relational; V: Verbal.

Intellectual disability without ASD

Relationship between age and aggression in participants with ID only

Scores on the C-SHARP for participants with ID only indicate that age was significantly related to aggression: Bullying (r = −0.15; p = .02), relational aggression (r = −0.16; p = .01), physical aggression (r = −0.13; p = .04). There was no correlation between age and verbal aggression (r = −0.02; p = .75) or hostile behavior (r = 0.02; p = .71).

With regard to the BPI-S, there was no correlation between age and SIB (r = −0.04; p = .47) or between age and aggression-destruction (r = −0.06; p = .34). However, there was a correlation between age and stereotypies (r = −0.14; p = .03). There were no correlations between age and the severity of SIB (r = −0.10; p = .47) or aggression-destruction (r = −0.001; p = .99).

T-tests showed that participants under 16 (n = 136) exhibited significantly more frequent bullying (p ≤ .05), relational aggression (p ≤ .01), physical aggression (p ≤ .01) and stereotypies (p ≤ .01) than those over 16 (n = 95). There were no significant differences between the two age groups in verbal aggression, hostile behavior, SIB, and severity of SIB and stereotypies (Tables 3 and 4).

Table 3.

Comparison of the frequency of aggressive behaviors: subscales of C-SHARP (ID)

C-SHARP
 Ages
  
–16
 +16
  
Frequency M SD M SD p
Verbal 6.32 8.6 5.25 7.6 .20
Bullying 5.84 6.82 3.5 5.1 .002
Relational 7 6.42 5 4.9 .008
Hostility 6.4 6.7 6.6 5.8 .12
Physical 2 3.02 1 2.22 .001
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Table 4.

Comparison of the frequency and severity of aggressive and stereotyped behaviors: subscales of BPI-S (ID)

  Ages
  
BPI-S
 –16
 +16
  
Frequency M SD M SD p
Self-Injury 1 2.3 0.9 2.5 .33
Aggression/Destruction 3.9 5.2 2.9 5.1 .78
Stereotypy
 4.6
 7.34
 2.3
 4.6
 .000
Severity
 M
 SD
 M
 SD
 p
Self-Injury 3.12 2.6 3.42 2.8 .58
Aggression/Destruction 5.42 4.83 4.4 4.4 .46
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Intellectual disability with ASD

Relationship between age and aggression

Scores on the C-SHARP for participants with ID and ASD indicate that there were no correlations between age and any form of aggression: verbal (r = –0.11; p = .34), bullying (r = –0.05; p = .67), relational (r = –13; p = .26), hostility (r = –0.04; p = .67), physical (r = –0.11; p = .37).

With regard to the BPI-S, there was a correlation between age and SIB (r = 0.25; p = .03). There was no correlation between age and aggression-destruction (r = –0.09; p = .42) or between age and stereotypies(r = –0.08; p = .46).

There was no correlation between age and the severity of aggressive behavior (r = −0.18; p = .24) or SIB (r = −0.09; p = .09) in the ID with ASD group.

T-tests showed that there was only a significant difference between the age and SIB (p < .05) (Tables 5 and 6).

Table 5.

Comparison of the frequency of aggressive behaviors: subscales of C-SHARP (ID and ASD)

  Ages
  
C-SHARP
 –16
 +16
  
Frequency M SD M SD p
Verbal 2.04 4.12 1.22 3.04 .34
Bullying 4.64 5.84 4.06 5.7 .67
Relational 4.1 4.1 3.06 3.7 .26
Hostility 6.07 6.4 5.6 5.7 .67
Physical 1.8 3.24 1.31 1.7 .37
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Table 6.

Comparison of the frequency and severity of aggressive and stereotyped behaviors: subscales of BPI-S (ID and ASD)

  Ages
  
BPI-S
 –16
 +16
  
Frequency M SD M SD p
Self-Injury 2.09 3.14 4.03 4.41 .03
Aggression/Destruction 3.9 4.62 3.09 4.1 .42
Stereotypy
 11.9
 7.34
 10.06
 4.6
 .46
Severity
 M
 SD
 M
 SD
 p
Self-Injury 3.3 2.4 4.84 3.24 .11
Aggression/Destruction 6.12 4.92 4.33 3.25 .18
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Discussion

The aim of our study was to evaluate the form, frequency and severity of aggressive behavior in the two clinical groups and as a function of age. We expected to observe different patterns of aggressive behavior in participants with ID only and those with ID and ASD.

Aggression in ID only and in ID with autism spectrum disorder

Our hypothesis that the type and frequency of aggressive behavior in children and adolescents with ID would differ according to the diagnosis was validated. Indeed, our results indicate that young people with only ID exhibit more verbal and relational aggression than those with ID and ASD. By contrast, those with the dual diagnosis show more self-injurious behavior and stereotypies than those with only ID. The literature (Rojahn et al. 2010) shows that adults with ID and ASD exhibit higher levels of self-injurious and stereotyped behaviors than those with ID only, and we found a similar pattern in our sample of children and adolescents. Furthermore, our study shows that self-injurious and stereotyped behaviors are more frequent in individuals with a dual diagnosis (ID and ASD), which is in line with the literature (McClintock et al. 2003, Rojahn et al. 2010). To conclude, people with ID turn their aggression towards others, while the behavior of those with ID and ASD is more egocentric. This can be explained by differences in symptomatology between the two groups, notably that children and adolescents with ID and ASD have a restricted range of activities and impaired social interactions (DSM-5; APA 2013), which would lead them to develop other ways of expressing themselves and interacting.

With regard to the functions of these behaviors, the results show that people with ID exhibit reactive and proactive aggressive behaviors. Results show that physical aggression and hostility are both reactive and proactive. This result is in line with the literature, showing that physical aggression is linked to impulsivity (Tremblay 2000). This could explain why this type of behavior is so reactive. Hostility includes angry and impulsive behaviors, which are also reactive. It is possible that the deficits of this population lead them to misunderstand events and consequently display aggressive behavior. Research with this type of population shows that reactive aggression is linked to hostile attribution biases in ambiguous situations (Crick and Dodge 1996) and low tolerance to frustration (Vitaro et al. 2002). These findings are consistent with the work of Berkowitz (1962), who observed that reactive aggression is the response to frustration or the perception of a threat. It is possible that an individual who is maladjusted would feel insecure and hence respond aggressively (Willaye and Magerotte 2003). Further research is needed to identify the characteristics of this maladjustment. However, we also observed the presence of proactive aggressive behaviors. Despite their deficiencies, it would appear that people with ID are able to develop an action plan to achieve their goals, which may involve various types of aggressive behavior. Indeed, our results indicate that bullying, relational and verbal aggressions are significantly more proactive than other forms of aggression.

Regarding children and adolescents with ID and ASD, while intellectual disability does not necessarily explain their difficulties in social interactions (DSM-5; APA 2013), we hypothesize that their behaviors are more reactive than proactive. In fact, these individuals are characterized by ‘autistic withdrawal’ and do not spontaneously seek to share their interests or to establish relationships (Tardif and Gepner 2014) (DSM-5; APA 2013). This suggests that the proactive behaviors observed in our results were repeated behaviors that have become learned answers. For example, children or adolescents with ID and ASD may have learned that the use of SIB allows their needs or suffering to be understood by the people around them. It is thus possible that this leads the evaluator to rate the behavior as proactive rather than reactive. Indeed, in the literature, this (proactive) aggressiveness corresponds to the theory of learning (Bandura 1973).

Intellectual disability and aggression

Regarding the aggressive behavior of people with ID only, our results show that this seems to decrease with age, with less bullying, less protest behavior (Relational aggression) and less physical aggression. In our study, this decrease was apparent at 16 years, compared to 12 years in other studies (Oubrahim et al. 2018). This difference can be explained by the fact that the participants in our study were all institutionalized, while those of the other studies were in special schools. However, other studies found no link between aggression and age (Ando and Yoshimura 1978, Tavormina et al. 1976, Davies and Oliver 2013). Our study investigated different forms of aggression and revealed that the age-related decrease concerns only verbal aggression and hostility. On the other hand, like Davies and Oliver (2013), we found no link between age and self-injury during childhood (4–17 years), and our study, with a larger age range, also found no link after the age of 17. Moreover, our results show that stereotypies decrease with age, also after 16, which seems to be consistent with the previous results showing a decrease in aggressive behavior. These results could be explained by the development of social skills allowing new ways of self-expression and hence a decrease in aggression and stereotypies. We found no difference in the severity of these less frequent stereotyped behaviors. It seems that severity is independent of frequency, and this finding could be explained by the fact that severity is linked to the impact of these stereotypies on the life of young persons with ID, notably in relation to social inclusion.

ID with ASD and aggression

With regard to people with the dual diagnosis (ID and ASD), our study confirms that they typically show several forms of aggression: verbal aggression, bullying, relational aggression, hostility, and physical aggression. They also engage in self-injurious behavior, destructive behavior and stereotypies. However, these behaviors do not seem to be related to age except SIB. The literature reveals similar findings for physical and verbal aggression, hostility, stereotypies, and aggressive-destructive behaviors (Matson et al. 2010, Murphy et al. 2009). Our study confirms these results in a sample with a larger age range (7–24 years), and shows that this lack of decrease with age also concerns relational aggression and bullying. However, our hypothesis that the type and frequency of aggressive behavior would vary with age was confirmed in people with ID. Growing up and the development of cognition, social skills, the learning of rules and other ways of responding can lead to a decrease in the aggressive behavior of people with ID. Intellectual disability slows down the development of cognitive abilities (DSM-5) and the decrease in aggressive behavior (16 years). However, when associated with ASD, this trend no longer occurs. Indeed, the aggressive behavior of people with ASD persists throughout life with the same severity. We, therefore, postulate that aggression in people with ID is related to cognition; firstly, because it decreases with age, and second because comparison of the aggressive behavior of the two clinical groups shows that the forms of aggression that have the greatest cognitive cost (e.g. relational or verbal aggression) are used to a greater extent by people with ID only than by those with ASD, who exhibit significantly more stereotyped and self-injurious behaviors. Furthermore, our results show that self-harm increases with age in people with ID and ASD. This is in line with a study (Ando and Yoshimura 1978) suggesting that individuals with ID and ASD may exhibit more SIB than those with ID only, due to an inability to process emotion or cope with sensory stimulation.

Limitations and recommendations for future research

Most findings in this study are supported by the literature, but some contradictory data were also observed. This can be explained by the nature of the data on aggression in these populations, and further work is needed with more precise measures (Farmer 2011). The main limitation of our studies on this issue is the lack of consensus on the terminology used to describe the behavior of these populations. Indeed, the multiplicity of terms makes it difficult to interpret the results of the scientific literature and to recommend appropriate interventions. It is, thus, important to review and reach a consensus on definitions, and to focus on studies with specific variables, to generalize findings across studies and design appropriate therapeutic strategies. In the future, it would be interesting to make further comparative studies, notably based on IQ level and communication skills. These studies should also include several age groups from childhood to adulthood to better understand how these behaviors develop over time.

Practical implications

Despite these limitations, the data from this study provide new insight into the topography of behavioral manifestations that vary between clinical groups and with age. Our research has an innovative character in that it focused on institutionalized people with a dual diagnosis of ASD and ID. Indeed, many studies have been conducted with adults or give insufficient information about the samples. Our study shows that the topography of aggressive or stereotyped behaviors is different depending on the nature of the disorder. This highlights the importance of implementing different interventions for people with and without ASD in ID because they have different needs. For example, people with only ID may need to learn to better understand the intents of others, to respond appropriately to different events by avoiding ambiguous interpretations (Oubrahim et al. 2018, Oubrahim and Combalbert 2018), for example through workshops involving discussion of social situations. In addition, our study reveals the chronicity of aggressive behaviors (verbal, physical, relational, hostility, bullying, destruction, self-injury) and stereotypies in people with ASD. This requires long-term management, by setting up appropriate interventions for the specific behavior(s). This can be achieved using specific assessment tools such as the BPI-S or C-SHARP, in order to identify the nature, frequency and severity of the behavior and to set up appropriate and specific intervention strategies. Adjustments will be necessary to understand and reduce the occurrence of these behaviors, for example by working on sensory stimulation, on the recognition of emotions, or by using different forms or tools of communication. This will require particular attention to behavioral changes during the course of interventions. Finally, the literature on the subject needs to be supported by new studies to better define and understand the function of these behaviors. This approach is of particular interest clinically, as it can help develop and optimize appropriate management strategies according to the particular type of aggressiveness (Dodge 1991, Kempes et al. 2005, Smithmyer et al. 2000). For example, a child with predominantly proactive aggression may not respond well to psychotropic treatment to help control impulses, while this type of treatment may inhibit reactive aggression (Farmer and Aman 2009). In order to better understand aggressive behavior, future research should take into account the heterogeneity of the functions of aggression. Indeed, the distinction between proactive and reactive aggression seems to offer an important perspective that could reveal the different etiological pathways of these aggressive behaviors (Crick and Dodge 1996).

Disclosure statement

No potential conflict of interest was reported by the authors.

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