Professional Documents
Culture Documents
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volume 54 part 7 pp 634649 july 2010
et al. 2001; Grey & Hastings 2005; Allen & Davies Because of the high prevalence and negative
2007; Didden et al. 2007; Benson & Brooks 2008). impact of challenging behaviours among persons
Challenging behaviours are especially prevalent with ID, considerably much research has been con-
in individuals with ID, and the more severe the ducted on interventions in this area (Moss et al.
disability, the higher the likelihood of the presence 1997; Kahng et al. 2002; Taylor 2002, 2005; Beail
of these behaviours (Borthwick-Duffy 1994; 2003; Prout & Nowak-Drabik 2003; Sturmey 2004;
Cormack et al. 2000; Janssen et al. 2002; McIntyre Grey & Hastings 2005; Willner 2005; McGillivray &
et al. 2002). Most studies report prevalence rates McCabe 2006; Deb et al. 2007; Sohanpal et al.
of challenging behaviour among persons with ID 2007; Antonacci et al. 2008). Treatment strategies
between 10 and 20% (Lowe et al. 1998; Emerson that are frequently employed are biological and psy-
et al. 2001; Kahng et al. 2002), while some authors chotherapeutic interventions, sometimes supple-
reporting substantially higher rates (Moss et al. mented with contextual strategies (Bouras 1999;
1997; Allen 2000; Deb et al. 2001; Dekker et al. Ager & OMay 2001; Dsen & Day 2001; Gavidia-
2002; Gavidia-Payne & Hudson 2002; Crocker Payne & Hudson 2002; Kahng et al. 2002; Taylor
et al. 2006, 2007; Cooper et al. 2009a). The devel- 2002; Grey & Hastings 2005; Benson & Brooks
opment of challenging behaviour is influenced by 2008; Mildon et al. 2008). Recently, some reviews
person- and environment-oriented factors, which and meta-analytic articles have studied these inter-
often interact with each other. Examples of these ventions for challenging behaviour among persons
factors that are frequently mentioned, are not only with ID (Brylewski & Duggan 1999; Prout &
the age, gender and level of ID of persons, but Nowak-Drabik 2003; Shogren et al. 2004; Didden
also poor adaptive and social skills, psychological et al. 2006; Lotan & Gold 2009; Matson & Neal
stress, inadequate problem-solving skills, impaired 2009; Thomson et al. 2009a, 2009b). None of these
language, socioeconomic deprivation, negative life articles included both the biological and the psy-
events, secondary disabilities and psychiatric disor- chotherapeutic and contextual interventions,
ders (Collacott et al. 1998; Hastings & Mount although it is interesting to compare effects of these
2001; Dekker et al. 2002; Janssen et al. 2002; three intervention types, either applied alone or
McClintock et al. 2003; Bradley et al. 2004; combined, with each other. Further advantages of
Blacher & McIntyre 2006; Hemmings et al. 2006; this meta-analysis that are often missing in previous
Allen & Davies 2007; Cooper et al. 2007; Crocker reviews and meta-analytic articles, are the quality
et al. 2007; Didden et al. 2007; Aunos et al. 2008; assessment of all included articles, the extensive
Chadwick et al. 2008; de Ruiter et al. 2008; moderator testing, and additional sensitivity and
Matson & Rivet 2008; Embregts et al. 2009; publication bias analyses.
Holden & Gitlesen 2009). The main purpose of the present study was to
Challenging behaviours have a negative impact review distinct biological, psychotherapeutic and
on persons with ID and their environment, inter contextual interventions that are applied to treat
alia because they increase risks on a reduced challenging behaviour among persons with ID, and
quality of life, stressful events, obstacles to social to analyse intervention effects and moderating
integration and the need for costly residential care variables. We did this by performing a meta-
(McIntyre et al. 2002; Knapp et al. 2005; Blacher analysis, in order to boost the total sample size
& McIntyre 2006; Didden et al. 2006; Benson & and effect precision by combining sufficiently
Brooks 2008; Hassiotis et al. 2008; Harvey et al. homogeneous results across studies. This was per-
2009; Matson & Boisjoli 2009; Cooper et al. formed by first describing the selected articles and
2009a). Moreover, because of their recurrent char- the interventions they report. Second, we per-
acter, challenging behaviours tend to become a formed a meta-analysis in order to broadly explore
lifelong challenge for the individuals with ID, their intervention effects and possible moderating effects
family and the involved services (Murphy et al. of study and participant variables. Additionally, we
2005, Tenneij & Koot 2008; Danquah et al. 2009; report on the quality assessment we carried out
Totsika & Hastings 2009; Cooper et al. 2009a; for each study included, and examine the moder-
2009b). ating role of study quality for reported interven-
cating that an item was properly, partially or not included studies intervention effects (Rosenthal
properly addressed or stated. Articles with good 1991; Borenstein et al. 2009). We generated a
quality were coded by maximum one C or two summary effect (effect size and variance) with a 95%
B head items; articles with moderate quality by confidence interval, and measures of heterogeneity
minimum two C or three B head items, or a (Q-value, Tau-squared, I-squared) (Higgins &
combination of both; and articles with poor Thompson 2002; Borenstein et al. 2009, Thompson
quality by minimum three C head items. 1994, Thompson & Sharp 1999). The studies were
weighted by study precision in order to minimise
Analysis procedure both the within-study error and the variation in the
true effects across studies: studies that yield more
In order to review different biological, psychothera-
precise estimates of the effect size are assigned more
peutic and contextual interventions that are applied
weight (Hedges & Vevea 1998; Borenstein et al.
to reduce challenging behaviour among persons with
2009). Next to that, we assessed the impact of mod-
ID, and to analyse intervention effects and moderat-
erating variables through subgroup and meta-
ing variables, we performed a meta-analysis1. A
regression analysis. The former implied analyses of
priori, we preferred a random-effects to a fixed-effect
variance to compare treatment effects across groups
meta-analysis, because random-effects models take a
concerning categorical variables, while the latter
between-study variance component as a descriptive
explored the impact of continuous moderators
index of variation into account; study weights are
(Thompson & Higgins 2002; Egger et al. 2007;
more balanced under the random-effects model
Borenstein et al. 2009). Furthermore, a sensitivity
assigning less relative weight to large studies;
analysis was performed by running the analysis 30
random-effects models provide inferential results
times, each time removing one study, in order to
referring to a universe of more diverse studies than
show each studys impact on the combined effect
fixed-effect analyses; and because the width of the
(Egger et al. 1997a; Borenstein et al. 2009). In addi-
confidence intervals calculated by the fixed-effect
tion, we analysed the possible impact of publication
model tends to imply a greater degree of precision
bias by a funnel plot-, a fail-safe N-, and Duvals and
than is actually the case, while analysis based on a
Tweedies trim and fill-analysis (Egger et al. 1997b;
random-effects model will generally be more con-
Duval & Tweedie 2000; Thornton & Lee 2000;
servative and realistic ( Wachter & Straf 1990;
Sutton et al. 2000b; Soeken & Sripusanapan 2003;
Petitti 1994; Wang & Bushman 1999; Fletcher &
Rothstein 2005; Kulinskaya et al. 2008; Borenstein
Fletcher 2005; Borenstein et al. 2009). In our
et al. 2009). The classic fail-safe N asks whether we
random-effects meta-analysis we allowed for varia-
need to be concerned that the entire observed effect
tion of the true effect size between studies, and
may be an artifact of bias, while trim and fill offers a
assumed that the studies in our analysis only repre-
more nuanced perspective by asking how the effect
sent a random sample of effect sizes that could have
size would shift if the apparent bias were to be
been observed (Cooper & Hedges 1994; Adr &
removed ( Wolf 1986; Cooper 1998; Lipsey & Wilson
Mellenbergh 1999; Kline 2005; Borenstein et al.
2001; Salovey & Rothman 2003; Hunter & Schmidt
2009). Therefore, the summary effect is our estimate
2004; Lewis-Beck et al. 2004; Riegelman 2005;
of the mean of these effects. In order to conduct the
Rothstein 2005; Higgins & Green 2008; Borenstein
meta-analysis, effect sizes (standardised mean differ-
et al. 2009; Vaughn & Howard 2009). Statistical
ence d)2 and variances were computed for all
analyses were conducted using Comprehensive
1
However, combining studies should not be performed lightly,
Meta-Analysis Version 2.0 (Borenstein et al. 2009,
considering assumptions behind the use of meta-analysis. The http://www.meta-analysis.com).
fixed-effect model assumes that the true effect size is the same in
all studies, while for random-effects meta-analysis the true effects
in the studies are assumed to have been sampled from a distribu- As the included studies did not report measures of skewness, we
tion of true effects (Borenstein et al. 2009). can not conclude whether more distribution-robust statistics such
2
The calculation of the standardised mean difference d is based as medians and interquartile ranges should be used instead of the
on means and standard deviations, which are not reliable indica- standardised mean difference (Everitt & Howell 2005; Larson
tors of location and spread for skewed distributions (Larson 2006). 2006).
Category of
Level of target
First Year Number of intellectual Male-female challenging Intervention Quality of Std diff Standard
author published participants disability* participants behaviour type the article in means error
From those 30 articles, 18 described a biological, ticipants, while for six articles the opposite was
13 a psychotherapeutic and nine a contextual inter- true. There were slightly more (16) studies
vention, with sometimes more than one imple- describing a mean age of participants above 18,
mented treatment discussed in a single article. compared with 11 studies describing a mean age
More specific, 14 studies reported a unimodal bio- of participants under 18, while three articles did
logical, five a unimodal psychotherapeutic and two not mention participants ages. Furthermore, 16
a unimodal contextual intervention, next to studies involved persons with mild ID, 14 moder-
five psychotherapeutic-contextual and two ate ID, 15 severe ID and eight profound ID. Six
biological-psychotherapeutic treatments, one articles did not mention the degree of ID of their
biological-contextual and one biological- participants. In grading the quality of the articles,
psychotherapeutic-contextual intervention. For the we found that 22 articles were of good and eight
biological treatments, especially atypical antipsy- of moderate quality. Especially Scope & Purpose-,
chotic medications (risperdone and olanzapine) Analysis- and Interpretation-items scored very well.
were studied (9), next to typical antipsychotics (2) Regarding the categories Design, Sampling and
and other biological interventions (5). Two articles Ethics, there was often information missing.
described sensory interventions. Regarding psycho-
therapeutic treatments, four behavioural, four sys- Meta-analysis
temic, three cognitive-behavioural and two other
Combined effect sizes and their standard errors
psychotherapeutic interventions were investigated.
computed for all 30 articles are presented in Table 1.
Concerning the explored contextual treatments,
The applied interventions made an improvement in
there were especially interventions situated within a
each study: all calculated effect sizes are positive3.
multidisciplinary approach (6) and interventions
Applying random-effects weights, the standardised
focusing on changing the environment (2).
mean difference is 0.671 with a 95% confidence
Describing methodological features, we looked
interval of 0.570 to 0.771. According to Cohen
at designs, data collection instruments and their
(1988) this is a medium (effect size around 0.5) to
reported reliability. The most often implemented
large (effect size around 0.8) effect. The null hypoth-
study design was an experiment (14), followed by
esis that the mean of these effects is zero, can be
a quasi-experiment (10) and a natural experiment
rejected, Z(n = 30) = 13.070, P < 0.0014.
(6). Regarding the data collection procedure, 22
In addition, we computed three measures quanti-
authors applied questionnaires, 11 interviews, nine
fying heterogeneity. First, the P-value for the
tests or experimental measures, nine observations
weighted sum of squares on a standardised scale,
and eight other data collection methods. In 16
Q = 30.277 with d.f. = 29, is 0.400. Applying 0.05
articles indices of reliability were reported for data
as criterion for statistical significance, we cannot
collection instruments. Turning to study character-
reject the null hypothesis that all studies share a
istics, the length of the research period (the
common effect size. Second, tau-squared, the vari-
average time between the first and last measure-
ance of the true effects calculated on the same scale
ment for each studied group of participants) was
(squared) as the effects themselves, is 0.003, with a
less than a year in 13 studies, more than 1 year in
standard error of 0.021. Third, I-squared, the pro-
10 studies, and not mentioned in seven articles.
The continent where most research took place was
3
Incidentally, if the null hypothesis of no treatment effect would
America (14), followed by Europe (11), Australia
be true, then there would be a 50% chance of observing positive
(4) and Asia (1). Finally, we recorded four partici- effect sizes. Because the studies can be considered as independent
pant features: the number of participants, and events, this setup constitutes a binomial situation with P = 0.50.
their age, gender and degree of ID. Seven articles The probability to observe 30 successes out of 30 trials is 0.5030,
described 20 or fewer participants, 12 articles or in other words P < 0.0001.
4
Applying the fixed-effect model, the standardised mean difference
reported on interventions implemented for 21 to
is 0.670 with a 95% confidence interval of 0.572 to 0.768, and the
50 participants, and 11 articles reported on inter- null hypothesis that the mean of these effects is zero, can be
vention effects for more than 50 participants. In rejected, Z(n = 30) = 13.452, P < 0.001. So, the results for the
21 studies there were more male than female par- fixed- and random-effects analysis are analogous.
portion of observed dispersion that is real, is Finally, we address possible publication bias
4.219%. This means that 4.219% of the observed effects by a funnel plot-, a fail-safe N-, and
variance comes from real differences between Duvals and Tweedies trim and fill-analysis. We
studies, and, as such, can potentially be explained refer to publication bias when studies included in
by study-level covariates (Cooper & Hedges 1994; an analysis differ systematically from all studies
Borenstein et al. 2009). that could be included: particularly, studies with
A sensitivity analysis was performed to determine larger effects are more likely to be published, and
the robustness of our results by examining whether this can lead to an upward bias in the summary
our conclusions might differ substantially if a study effect (Cooper & Hedges 1994; Lipsey & Wilson
was dropped (Cooper & Hedges 1994; Petitti 1994; 2001; Hunter & Schmidt 2004; Higgins & Green
Sutton et al. 2000a; Borenstein et al. 2009). We cal- 2008; Borenstein et al. 2009). First, we explore
culated for each study the overall standardised possible publication bias effects by a funnel plot.
mean difference when that study was hypothetically In Fig. 1 a measure of study size (precision, the
removed from the meta-analysis. As the 30 overall inverse of standard error) is plotted on the vertical
effect sizes formed by omitting each study sepa- axis as a function of effect size on the horizontal
rately varied between 0.649 and 0.689, our results axis. In the absence of publication bias, we would
look very robust. expect the included studies (white circles in Fig. 1)
Furthermore, the impact of moderating variables to be distributed symmetrically around the com-
was assessed through subgroup and meta-regression bined effect size (Petitti 1994; Adr & Mellenbergh
analysis. We applied analyses of variance to compare 1999; Rothstein 2005; Bowling & Ebrahim 2006;
treatment effects across groups for the following cat- Borenstein et al. 2009), and this seems to be the
egorical variables: intervention type (biological, psy- case for our meta-analysis.
chotherapeutic and contextual), intervention In the following, we assess some statistical proce-
combination (unimodal, multimodal), quality assess- dures to quantify this possible publication bias
ment, study design (experiment, quasi-experiment, effect.The classic fail-safe N analysis, yields a
natural experiment), data collection (test, question- Z-value of 13.22201, with a corresponding two-tailed
naire, observation, interview, other), reliability, P-value < 0.00001. The fail-safe N is 1336, meaning
length of the research period, continent, and the that we would need to locate and include 1336 null
gender, age and degree of ID (mild, moderate, studies in order for the combined two-tailed P-value
severe, profound) of participants. We present the to exceed 0.050. Because this number is large, we
descriptive statistics of these moderators in Appen- can be relatively confident that the treatment effect,
dix 2. After assessing the relationships between sub- while possibly inflated by the exclusion of some
group membership and effect size, we conclude for studies, is real. Duval and Tweedies trim and fill
all these variables that differences between groups analysis addressing the left side of the mean effect
are not significantly related to the effect size. suggests that four studies are missing. These four
In addition, we explored the impact of one con- imputed studies are plotted in Fig. 1. Under the
tinuous moderator: the year of publication. For this random-effects model the standardised mean differ-
moderator too, we cannot reject the null hypothesis ence and 95% confidence interval for the combined
of no effect. Applying the regression model (unre- studies is 0.67070 (0.57012, 0.77128). Using trim
stricted maximum likelihood), we see that the total and fill, the imputed standardised mean difference is
dispersion of studies about the grand mean 0.63436 (0.52493, 0.74378), which is a little bit lower
(Q-total) is 30.27744 with P = 0.40025 ( d.f. = 29), than our standardised mean difference. When
meaning that the amount of total variance is less addressing Duval and Tweedies trim and fill to the
than we would expect based on the within-study right side of the mean effect, the method suggests
error. Furthermore, the dispersion explained by the that no studies are missing.
covariates (Q-model) is 0.26403 with P = 0.60737 So, after applying a funnel plot-, a fail-safe N-,
(d.f. = 1), which means that the relationship and Duvals and Tweedies trim and fill-analysis, we
between publication year and treatment effect is conclude that our meta-analysis does not seem to
even weaker than we would expect by chance. suffer much from publication bias effects.
Figure 1 Funnel plot of precision by standardised difference in means: plot with observed (white circles) and imputed (black circles)
studies.
interventions, used alone or in combination. Fur- interventions function differently? And, how do they
thermore, we found no indications for the superior- work combined? To this end, it would be interesting
ity of one of the treatment approaches or to have more longitudinal research focusing on dif-
combination types. ferential effects of biological, psychotherapeutic and
Treatment effects also did not vary much across contextual interventions, taking into account theo-
groups for the categorical moderators included in retically relevant moderators and mediators.
our meta-analysis: quality assessment, study design,
data collection, reliability, length of the research period,
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Appendix 1
Articles included in the meta-analysis
Aman M.G., De Smedt G., Derivan A., Lyons B. & Findling R.L. (2002) Risperidone disruptive behaviour
study group. Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behav-
iours in children with subaverage intelligence. American Journal of Psychiatry 159, 13371346.
Buitelaar J.K., van der Gaag R.J., Cohen-Kettenis P. & Melman C.T.M. (2001) A randomized controlled
trial of risperidone in the treatment of aggression in hospitalized adolescents with subaverage cognitive
abilities. Journal of Clinical Psychiatry 62, 239248.
Capone G.T., Goyal P., Grados M., Smith B. & Kammann H. (2008) Risperidone use in children with
Down syndrome, severe intellectual disability, and comorbid autistic spectrum disorders. A naturalistic
study. Journal of Developmental & Behavioural Pediatrics 29, 106116.
Chan S., Fung M.Y., Tong C.W. & Thompson D. (2005) The clinical effectiveness of a multisensory therapy
on clients with developmental disability. Research in Developmental Disabilities 26, 131142.
Dowling S., Hubert J., White S. & Hollins S. (2006) Bereaved adults with intellectual disabilities. A com-
bined randomized controlled trial and qualitative study of two community-based interventions. Journal of
Intellectual Disability Research 50, 277287.
Duker P.C. & Seys D.M. (2000) A quasi-experimental study on the effect of electrical aversion treatment
on imposed mechanical restraint for severe self-injurious behaviour. Research in Developmental Disabilities 21,
235242.
Gates B., Newell R. & Wray J. (2001) Behaviour modification and gentle teaching workshops. Management
of children with learning disabilities exhibiting challenging behaviour and implications for learning disability
nursing. Journal of Advanced Nursing 34, 8695.
Holden P. & Neff J.A. (2000) Intensive outpatient treatment of persons with mental retardation and psychi-
atric disorder. A preliminary study. Mental Retardation 38, 2732.
Huang W.H., OBrien H.R.C., Kalinowski C.M., Vreeland R.G., Kleinbub L. & Hall G.A. (2007) Multidis-
ciplinary approach to optimizing pharmacological and behavioural interventions for persons with develop-
mental disabilities who are on psychotropic medications. Journal of Developmental and Physical Disabilities 19,
237250.
Hudson A.M., Matthews J.M., Gavidia-Payne S.T., Cameron C.A., Mildon R.L., Radler G.A. et al. (2003)
Evaluation of an intervention system for parents of children with intellectual disability and challenging
behaviour. Journal of Intellectual Disability Research 47, 238249.
Janowsky D.S., Barnhill L.J. & Davis J.M. (2003b) Olanzapine for self-injurious, aggressive, and disruptive
behaviours in intellectually disabled adults. A retrospective, open-label, naturalistic trial. Journal of Clinical
Psychiatry 64, 12581265.
Janowsky D.S., Barnhill L.J., Shetty M. & Davis J.M. (2005) Minimally effective doses of conventional
antipsychotic medications used to treat aggression, self-injurious and destructive behaviours in mentally
retarded adults. Journal of Clinical Psychopharmacology 25, 1925.
Janowsky D.S, Kraus J.E., Barnhill J., Elamir B. & Davis J.M. (2003a) Effects of topiramate on aggressive,
self-injurious and disruptive/destructive behaviours in the intellectually disabled. An open-label retrospective
study. Journal of Clinical Psychopharmacology 23, 500504.
Mace F.C., Blum N.J., Sierp B.J., Delaney B.A. & Mauk J.E. (2001) Differential response of operant self-
injury to pharmacologic versus behavioural treatment. Journal of Developmental & Behavioural Pediatrics 22,
8591.
McDonough M., Hillery J. & Kennedy N. (2000) Olanzapine for chronic, stereotypic self-injurious behav-
iour. A pilot study in seven adults with intellectual disability. Journal of Intellectual Disability Research 44,
677684.
Packman J. & Bratton S.C. (2003) A school-based group play/activity therapy intervention with
learning disabled preadolescents exhibiting behaviour problems. International Journal of Play Therapy 12,
729.
Pearson D.A., Santos C.W., Roache J.D., Casat C.D., Loveland K.A., Lachar D. et al. (2003) Treatment
effects of methylphenidate on behavioural adjustment in children with mental retardation and ADHD.
Journal of the American Academy of Child & Adolescent Psychiatry 42, 209216.
Plant K.M. & Sanders M.R. (2007) Reducing problem behaviour during care-giving in families of
preschool-aged children with developmental disabilities. Research in Developmental Disabilities 28, 362385.
Read S.G. & Rendall M. (2007) An open-label study of risperidone in the improvement of quality of life
and treatment of symptoms of violent and self-injurious behaviour in adults with intellectual disability.
Journal of Applied Research in Intellectual Disabilities 20, 256264.
Roberts C., Mazzucchelli T., Studman L. & Sanders M.R. (2006) Behavioural family
intervention for children with developmental disabilities and behavioural problems. Journal of
Clinical Child and Adolescent Psychology 35, 180193.
Rose J., Loftus M., Flint B. & Carey L. (2005) Factors associated with the efficacy of a group intervention
for anger in people with intellectual disabilities. British Journal of Clinical Psychology 44, 305317.
Rose J., West C. & Clifford D. (2000) Group interventions for anger in people with intellectual disabilities.
Research in Developmental Disabilities 21, 171181.
Shapira N.A., Lessig M.C., Lewis M.H., Goodman W.K. & Driscoll D.J. (2004) Effects of topiramate in
adults with Prader-Willi syndrome. American Journal on Mental Retardation 109, 301309.
Singh N.N., Lancioni G.E., Winton A.S.W., Molina E.J., Sage M., Brown S. et al. (2004) Effects of snoe-
zelen room, activities of daily living skills training, and vocational skills training on aggression and self-
injury by adults with mental retardation and mental illness. Research in Developmental Disabilities 25, 285
293.
Snyder R., Turgay A., Aman M., Binder C., Fisman S. & Carroll A. (2002) Effects of risperidone on
conduct and disruptive behaviour disorders in children with subaverage IQs. Journal of the American
Academy of Child & Adolescent Psychiatry 41, 10261036.
Taylor J.L., Novaco R.W., Gillmer B. & Thorne I. (2002) Cognitive-behavioural treatment of anger intensity
among offenders with intellectual disabilities. Journal of Applied Research in Intellectual Disabilities 15, 151
165.
Turgay A., Binder C., Snyder R. & Fisman S. (2002) Long-term safety and efficacy of risperidone for the
treatment of disruptive behaviour disorders in children with subaverage IQs. Pediatrics 110, e34-e45.
Xenitidis K., Gratsa A., Bouras N., Hammond R., Ditchfield H., Holt G. et al. (2004) Psychiatric inpatient
care for adults with intellectual disabilities. Generic or specialist units? Journal of Intellectual Disability
Research 48, 1118.
Young L. (2006) Community and cluster centre residential services for adults with intellectual disability.
Long-term results from an Australian-matched sample. Journal of Intellectual Disability Research 50, 419431.
Zarcone J.R., Hellings J.A., Crandall K., Reese R.M., Marquis J., Fleming K. et al. (2001) Effects of risperi-
done on aberrant behaviour of persons with developmental disabilities. A double-blind crossover study
using multiple measures. American Journal on Mental Retardation 106, 525538.
Appendix 2
Descriptive statistics of categorical moderators
Standardised
Groups of Number mean Standard
moderators of studies difference error