Topography and Function of Challenging Behaviors in Individuals with Autism Spectrum Disorder
Individuals with autism spectrum disorder (ASD) are at a greater risk for challenging behavior than individuals with other developmental disabilities. An essential step in the treatment of these behaviors is the identification of the function of the behavior. In the current study, data were collected from a large database, in which supervising clinicians from a community-based behavioral health agency recorded the topography and function(s) of behaviors treated as a part of an individual’s behavior intervention plan. In a sample of 3216 individuals (mean age = 10.67, SD = 4.61) with ASD, the frequency of the most common challenging behaviors and the identified function of the behavior were examined. Stereotypy was the most commonly reported topography, followed by noncompliance and aggression. Overall, escape was the most commonly reported function of behavior. To further evaluate how clinicians operationally define these behaviors, a part-of-speech text analysis was conducted and found a high degree of overlap in the operational definitions of challenging behavior (i.e., aggression, disruption and tantrum; noncompliance and tantrum; obsessive behavior and stereotypy; self-injurious behavior and aggression). These data are discussed in further detail.
KeywordsApplied behavior analysis Autism spectrum disorder Challenging behavior Function Topography
Individuals with autism spectrum disorder (ASD) are at significant risk for developing challenging behaviors (Horner et al. 2002), yet there is often variability in how these behaviors are defined (Horovitz 2015). Challenging behaviors can be defined as behaviors that are not culturally or socially acceptable, put the physical safety of the individual and/or others in jeopardy, affect learning, and/or limit access to community settings (Emerson 1995; Matson et al. 2010). The presence of challenging behaviors can impede educational, social, and adaptive development (Horner et al. 2002; Mace et al. 1986; Matson and Nebel-Schwalm 2007) and is not limited to one developmental stage such as early childhood. Indeed, challenging behaviors are present in young children, adolescents, and adults with ASD (McCarthy et al. 2010). Further, no significant relationship between symptom severity and frequency with age has been found (Matson et al. 2010; Murphy et al. 2009), which suggests that the occurrence of challenging behaviors persist throughout an individual’s life. Thus, effective interventions should be informed by an evaluation of the topography and the functions maintaining challenging behaviors in order to mitigate the detrimental effects on skill acquisition and quality of life.
Within the ASD population, researchers have described the relative prevalence of different topographies of challenging behavior. Jang et al. (2011), evaluated the presence of challenging behaviors in young children with ASD (2.42–18.17 years) receiving early intensive behavioral intervention (EIBI) and found that 94% of participants (N = 84) exhibited some form of challenging behavior. Of these behaviors, repetitive, stereotypic vocalizations (73.8%), repetitive, stereotypic behaviors (i.e., unusual play with objects; 57.1%), and elopement (i.e., leaving supervision of caregiver without permission; 56%) were the three most commonly reported challenging behaviors. In contrast, Horner et al. (2002) found that disruption/tantrums and aggression were the most commonly targeted in young children with ASD (i.e., 8 years and under), with self-injury and stereotypy reported as less concerning behaviors. However, the study conducted by Horner et al. (2002) was a review of published treatment studies while the study conducted by Jang et al. (2011) evaluated the prevalence of challenging behaviors among individuals receiving community-based intervention. Thus, this discrepancy in findings may be explained by the different study methods. Nevertheless, there appears to be common types of challenging behaviors among individuals with ASD.
In a recent analysis of challenging behaviors in a large sample of individuals with ASD receiving applied behavior analysis (ABA) intervention (N = 2116), Stevens et al. (2017) found that while individuals with ASD exhibit multiple challenging behaviors, in most cases, one behavior emerges as the dominant theme and occurs more frequently than others. Despite the high prevalence and pervasiveness of challenging behaviors among individuals with ASD (Jang et al. 2011; Matson and Nebel-Schwalm 2007), the presence of challenging behaviors is not a core feature of the diagnosis (American Psychiatric Association [APA] 2013). The ASD diagnosis alone does not communicate much information regarding challenging behaviors that need to be addressed to the treating clinician(s) during treatment. As a result, a thorough assessment of the topography and function of challenging behaviors may not be conducted until individuals with ASD enter treatment. In order for target behaviors to be accurately evaluated and treated, an objective, clear, and concise definition should be constructed (Cooper et al. 2014). Operational definitions of challenging behaviors may vary significantly across individuals and contexts due to individual differences. For example, one individual may exhibit physical aggression while another exhibits verbal aggression. While it is important to establish standard operational definitions of challenging behavior in the broad literature, it is equally important to identify topographies of challenging behavior across individuals in order to guide individualized behavioral interventions, evaluate differential responses to treatment, and accurately track treatment progress. As a result, researchers and clinicians are faced with the challenge of constructing operational definitions that allow future researchers to replicate interventions and accurately measure treatment responses while customizing interventions based on the individual’s strengths and deficits.
Compared to other challenging behaviors, stereotypy has been considered by some (reviewed by Matson and Nebel-Schwalm 2007) to be the least problematic behavior. However, in many cases, it may be appropriate to treat stereotypy because the presence of stereotypic behaviors may impede learning, interfere with successful social interactions, and in some cases, lead to self-injurious behavior (SIB). While stereotypy can be broadly defined as repetitive and non-functional behavior (APA 2013; Rapp and Vollmer 2005), there have been numerous and diverse behaviors described as “stereotypy” (Rapp and Vollmer 2005). There seems to be more variance in the operational definition of stereotypy based on individual differences and the type of stereotypic behavior (i.e., visual, motor or vocal). Stereotypy has been defined as placing a portion of the hand or fingers between lips, teeth, or tongue, including repetitive nail-biting, finger-licking, and mild hand-biting (Mace et al. 1987), hand flapping and body rocking (Durand and Carr 1987), and noncontextual or nonfunctional speech including singing, babbling, repetitive grunts, squeals, and phrases unrelated to the present situation (Ahearn et al. 2007). In spite of stereotypy being a core feature of ASD, what specifically is being communicated by clinicians or researches when using the term varies widely. The large differences in the operational definitions may be due to the high frequency of individuals displaying multiple behaviors that would fall under an umbrella definition of stereotypic behavior.
Aggression, tantrum, and disruption may result in long-term disability, placement in restrictive environments (e.g., institutionalization), and disruption of family life/education (Mace et al. 1986; Shoham-Vardi et al. 1996). As such, the operational definitions of these challenging behaviors have been evaluated in the context of the behavioral interventions used to reduce or eliminate these behaviors. In a review of behavioral treatments for aggression and tantrum in children with ASD, Matson (2009) found that aggressive and tantrum behaviors were most commonly defined as hitting, kicking, biting, punching, scratching, and throwing (i.e., furniture). In an evaluation of aggressive and disruptive behavior in three children with developmental disabilities (Mace et al. 1986), aggression was defined as “hitting, kicking, biting, scratching, or smearing feces on others” for Participant 1 and as “pulling at another person’s clothing, scratching or hitting others with a fist or hand-held object, and throwing objects in the direction of others” in Participant 3. Disruption was defined as “knocking over furniture, standing on furniture, throwing objects, attempting to leave the training room, and loud vocalizations” for Participant 1 and as “throwing objects, standing on furniture, spitting, damaging objects, knocking over furniture, pulling other’s shoe laces, undressing, and urinating on her clothes” for Participant 2. While there is some overlap among the operational definitions for aggression, tantrum, and disruption, there are also differences across individuals. These deviations in topographies should be considered when identifying the environmental variables maintaining these challenging behaviors and implementing individualized treatment procedures.
SIB has also received a great deal of attention in the research because, by definition, it causes injury to the individual and may impede social and intellectual development (Carr 1977). While SIB may be broadly defined as behaviors in which individuals cause physical damage to his or her own body, there have been commonly reported forms of SIB. These include scratching, biting (e.g., hand, arm), head banging (i.e., using hands, knees, or a stationary object), chin hitting, hair pulling, skin picking, eye pressing or gouging (Carr 1977; Matson and LoVullo 2008). Depending on the frequency and intensity of the behavior, SIB can cause bruises, swelling, bleeding or require medical attention (e.g., stitches for open wounds, treatment for irreparable vision damage).
Elopement is another commonly reported challenging behavior exhibited by persons with ASD. Elopement has been defined as wandering, leaving, and running from safe spaces or adult supervision. Elopement (e.g.., from classroom settings) can result in reduced learning time and also can raise safety concerns if the individual elopes to a dangerous situation (e.g., traffic; Piazza et al. 1997). The occurrence of elopement is often setting-specific (e.g., home, stores, classroom/schools) and the function that elopement serves may often vary within the same individual based upon the context (e.g., preferred vs non-preferred activity, presence of preferred stimuli).
Noncompliance is a challenging behavior exhibited to some extent by all children, but is of particular concern among children with ASD and other developmental disabilities (Hiebert et al. 2009). In a review of the existing literature, Lipschultz and Wilder (2017) found that noncompliance is most commonly defined as engaging in any behavior other than what has been requested within a specified period of time. Further, they found that treatment studies that focused on increasing compliance (the inverse of noncompliance) were effective, thus reducing noncompliant behavior. However, they found that participants demonstrated differential responses to consequence-based interventions depending on the function of the noncompliant behavior. This highlights the need for function-based interventions for the treatment of challenging behaviors.
A number of tools have been developed to assess for challenging behaviors in persons with developmental disabilities (Matson and Nebel-Schwalm 2007). The most commonly noted tools include the Aberrant Behavior Checklist (Aman et al. 1985), Behavior Problems Inventory (BPI-01; Rojahn et al. 2001), and the Overt Aggression Scale (Hellings et al. 2005). However, there is a lack of screening and assessment tools specific to identifying challenging behaviors in individuals with ASD (Matson et al. 2008). One assessment instrument that was developed specifically to assess for challenging behaviors in the ASD population is the Autism Spectrum Disorders-Behavior Problem for Children (ASD-BPC; Matson and González 2007). The ASD-BPC is an 18-item, informant-based assessment scale that has adequate to excellent test-retest and inter-rater reliability (Matson et al. 2008). Rating scales are a relatively efficient way to provide important information regarding the topography of behaviors and their possible functions.
A broad range of interventions to reduce challenging behaviors (i.e., behavioral and pharmacological) have been evaluated. In general, behavioral interventions have been found to result in 80–90% reductions in challenging behaviors (Horner et al. 2002) or even to virtually zero levels (Hagopian et al. 2001; Matson et al. 2005). Researchers have found that function-based behavioral treatments are effective in reducing challenging behaviors for the vast majority of cases and that individuals with a functional assessment had greater intervention success than those participants without (Didden et al. 2006; Horner et al. 2002). As such, the early assessment and treatment of challenging behaviors are critical in order to remove barriers to treatment and increase skill acquisition in individuals with ASD.
Identifying the environmental variables and consequences maintaining the target behavior are an essential step in the treatment of challenging behaviors. However, this process may be complex in that the maintaining factors vary significantly across individuals and even within individuals over contexts and/or time (Emerson 1995; Matson et al. 2003). Despite this challenge, the function for each target behavior should be identified so that the appropriate behavior intervention plan can be implemented. A large body of research has been conducted on functional analysis methods (Dixon et al. 2012). Functional analyses for challenging behaviors can typically be grouped within three categories: (a) observational descriptive strategies (e.g., ABC checklist), (b) experimental functional analysis (EFA; e.g., Iwata et al. 1994) and brief functional analysis (FA), (c) rating scales (e.g., Questions About Behavior Function; Matson and Vollmer 1995).
EFAs can provide valuable information regarding the function of behavior, but may not be the most practical method given that conducting a full EFA is very time- and resource-intensive (Sturmey 1995). In addition, some researchers have challenged the reliability and validity of EFAs (Matson et al. 1999). In response to these concerns, researchers have developed brief and indirect functional assessment methods, which are shorter and cost-effective. In a recent study on brief FA methods, Jessel et al. (2016) evaluated the effectiveness of the interview-informed synthesized contingency analysis (IISCA) approach to FAs. Using the results of an open-ended interview, researchers designed an individualized FA for each participant (N = 30), which included only one treatment condition per control condition. The participants required a minimum of sessions and the average duration of the IISCA approach was 25 min (with a range of 15–75 min). A subsequent analysis of the single-test IISCA, and analysis of a single test session, took an average of 3–5 min and was successful in identifying the function of behavior in 80% of cases. Although further replication of the IISCA is needed, this brief FA method is a promising approach to brief functional analyses.
Rating scales can be used to predict possible function(s) of challenging behavior. On such tool is the QABF (Matson and Vollmer 1995). The QABF is a 25-item, informant-based assessment with five possible functions of behavior (attention, escape, non-social, physical, and tangible). Informants rate each item on a 4-point Likert scale (0 = never, 1 = rarely, 2 = sometimes, 3 = often). The QABF has been found to predict the function of behavior in 75% of cases and up to 84% for SIB, aggression, and stereotypy (Hall 2005). Time- and cost-effective approaches to FAs such as the IISCA and QABF are valuable tools to design function-based interventions when the resources to conduct a full functional assessment are not available. Clinicians can use the data from these indirect measures to predict the most likely function of behavior and guide decisions regarding behavioral contingencies implemented during treatment.
The purpose of this study was to use a large dataset of individuals with ASD who received behavioral intervention to gain perspective on what are the most commonly treated topographies of challenging behaviors. The second aim was to identify the most commonly reported functions of those challenging behaviors. Lastly, a detailed textual analysis of the reported operational definitions of commonly treated challenging behaviors was conducted.
Participants were included in the current study if they met the following criteria: had a diagnosis of ASD (APA 2013), autistic disorder (APA 2000), pervasive developmental disorder-not otherwise specified (PDD-NOS; APA 2000), or Asperger’s disorder (APA 2000); an age of at least 18 months; receiving a minimum of 20 h of ABA treatment per month. Individuals who were in the first month of treatment were excluded from the dataset as their data may not be representative of a typical treatment period. These criteria were applied to a pool of 7822 participants and resulted in a sample size of 3216 participants. The mean age of participants was 10.67 years (SD = 4.61) with a range from 2.17 to 34.17 years. Of the included participants, 2505 of the sample were male and 711 were female. Study participants resided and received services in the states of Arizona, California, Colorado, Illinois, Louisiana, New York, Texas, and Virginia.
Each participant received an individualized ABA intervention that was customized to address the individual strengths, deficits, and challenging behaviors (if any) of the participant. Treatment programs followed the Center for Autism and Related Disorders (CARD) Model of ASD service delivery (Granpeesheh et al. 2014). There was variability in the average number of treatment hours received per week due to multiple factors (e.g., funding source, geographic location, clinical recommendation, patient availability). Treatment setting (i.e., home, school, clinic, or a combination of settings) was determined by the supervising clinician based on their clinical recommendation. Despite the individualization of each participant’s treatment program, these elements were common to all (a) treatment was delivered on a one-to-one basis by trained behavioral therapists; (b) treatment included both more-structured (i.e., discrete trial training) and less-structured (i.e., natural environment training) behavioral teaching strategies; (c) language intervention took a verbal behavior approach; (d) both errorless and least-to-most prompting strategies were used; (e) all major empirically validated behavioral principles and procedures were used (i.e., reinforcement, extinction, stimulus control, generalization training, chaining, and shaping), as appropriate; (f) assessment and treatment of challenging behaviors followed a function-based approach; (g) parents were included in all treatment decisions and received training on a regular basis; (h) direct supervision was provided frequently (e.g., biweekly) by an expert in behavioral intervention for children with ASD; and (i) treatment content was based upon the CARD Curriculum. Treatment programs were supervised by clinicians with a Board Certified Behavior Analyst (BCBA) or other licensed professional (e.g., licensed psychologist, licensed clinical social worker, licensed marriage and family therapist, etc.).
Clinical records were gathered from a pool of children who received behavioral intervention services from a large, community-based behavioral health agency from May 2012 to January 2017. Throughout the course of treatment, supervising clinicians entered and updated participants’ clinical records (e.g., diagnostic, medical, and/or treatment data) in the Skills™ ASD treatment platform. The Skills™ database includes an assessment that has been found to be reliable and valid in evaluating functioning across eight treatment domains (Persicke et al. 2014). Supervising clinicians used the Skills™ platform to identify developmental deficits, plan interventions, identify treatment targets, track treatment response, and identify the topography of targeted challenging behavior(s) and their respective functions (i.e., attention, automatic, escape, or access to tangible). The function of challenging behavior was identified by the supervising clinician using various assessment methods (e.g., observational descriptive strategies, parent interview, indirect functional assessment). In addition, treatment data were integrated with operational data (e.g., treatment hours, supervision hours) by the participating treatment centers. This treatment information provided a rich, relational database of challenging behavior instances. This database included the type of challenging behavior, the function(s) of the targeted behaviors, a detailed contextual description (i.e., operational definition) of the target behavior, and a timestamp of each occurrence of the challenging behavior.
The following behaviors and their respective frequencies were identified in the Skills™ database by aggregating instances of behaviors over patients and time: (a) aggression, (b) disruption, (c) elopement, (d) inappropriate sexual behavior, (e) lying, (f) noncompliance, (g) obsessive behaviors, (h) pica, (i) self-injurious behavior, (j) stealing, (k) stereotypy, (l) tantrums, and (m) teasing/bullying. If the frequency of reported behaviors was less than 500, the behavior was excluded. As a result, inappropriate sexual behavior, pica, lying hoarding, stealing, and teasing/bullying were excluded. While a frequency of 500 for a specific behavior may be seen as a considerable number, the behavior was excluded since it would have been observed in fewer than 16% of the participants.
In addition to specific behaviors, Skills™ also contains a field denoting the function of the behavior as identified by the supervising behavior analyst at the time of observation. Functions are classified as “attention,” “automatic,” “escape,” or “tangible.” For each of the 13 behaviors identified above, we aggregated the counts for each of these 4 functions. The resulting 13 × 4 matrix of function counts, representing a function distribution for each class of challenging behavior (e.g., aggression, elopement, etc.), was used for the frequency analysis presented here.
For the remaining challenging behaviors, a detailed textual analysis of the definitions reported by the supervising clinicians was carried out using computational techniques. Specifically, textual definitions were aggregated by challenging behavior in the database, and the resulting output was processed with scripts implemented in the Python programming language. These scripts transformed the aggregated data into a group of words (i.e., vectors) for each challenging behavior, consisting of each term used in the operational definition, as well as how many times that term was used. This corresponds to a standard bag-of-words representation that is a typical tool of text analysis (Baeza-Yates and Ribeiro-Neto 1999) and provides advantages over other analysis alternatives. First, the bag-of-words approach removes the need for computationally-intensive natural language processing algorithms that must model complex grammatical structures of language. Secondly, this approach simplifies visualization of results. After converting to bag-of-words format, common stop words (e.g., “a,” “and,” “the”) were excluded as per standard practice in text analysis. A subsequent part-of-speech analysis was conducted to further reduce the data to a list of the most frequently reported verbs used to describe each challenging behavior. Items with the same root word but different verb tense (e.g., hit, hits, hitting) were categorized as one verb term (e.g., hitting) and their relative frequencies were summed together. By analyzing these verb terms, we are able to gain insight into the most commonly reported and targeted challenging behaviors. It is worth noting that because the bag-of-words approach presented here relies on verbs only, it is important to consider the challenging behavior they are associated with to infer context. For example, while “hitting” is observed in both aggression and self-injurious behavior, it is implied that hitting in the context of aggression is targeted toward others, while hitting in SIB is targeted toward oneself.
Frequency of the most commonly reported challenging behaviors in individuals with ASD receiving behavioral intervention services
The results of the present study help to address important factors related to the assessment and treatment of challenging behaviors in individuals with ASD. First, the data show that the most commonly targeted challenging behaviors among individuals with ASD were stereotypy, noncompliance, aggression, tantrums, self-injurious behavior, elopement, disruption, and obsessive behaviors, respectively. Second, the results indicated that the most commonly reported function across behaviors was escape, with the exception of obsessive behaviors and stereotypy, which were most commonly maintained by automatic reinforcement. Lastly, the results of the textual analysis show interesting overlaps in operation definitions across behaviors that should help to further our understanding as to how these terms are commonly used by clinicians.
The current findings found that stereotypy was the most commonly treated challenging behavior, with a reported frequency of 5276. The frequency exceeds the study sample size (N = 3216), which suggests that some participants exhibited more than one type of stereotypy and that treatment plans were written for each specific topography. Given that stereotypy is a core feature of ASD, it is not surprising that this behavior is the most commonly treated among individuals in the present sample. It should be noted that while stereotypy was the most commonly reported behavior across participants, this does not necessarily indicate that stereotypy was rated as the most dominant behavior for these individuals.
Noncompliance, aggression, and tantrums were also commonly treated in individuals with ASD, with escape as the most common function reported for these behaviors. The current findings support the existing literature that have found that these behaviors are usually maintained by escape (Reimers et al. 1993). During ABA intervention, a high number of demands are placed on individuals in order to optimize the number of learning opportunities and to manage challenging behaviors. As such, these results may be specific to individuals receiving ABA intervention and may not be representative of other ASD populations. Further research is needed to identify other common environmental variables maintaining these challenging behaviors.
The results of the text analysis show several interesting factors related to the operational definitions of challenging behavior reported by supervising behavior analysts. There is a high degree of overlap in behaviors that are classified as disruption or tantrum. For example, crying, screaming, throwing, and yelling were among the top 10 words used in the operational definitions for both disruption and tantrum. Upon reflection, it is the authors’ hypothesis that what seems to distinguish these two terms is the inferred function of the behavior. That is, it is tacitly assumed that individuals with ASD engage in tantrums when they are not “getting their way.” In contrast, “disruptions” is a more general term that does not imply a function of the behavior. The results of this study found that operational definitions for behaviors categorized as disruptions tended to have a more varied function. It is concerning and risky for supervising clinicians to define behaviors using labels that a priori, incorrectly define the function of behavior. Rather, clinicians should first construct a clear, objective operational definition of behavior followed by an assessment of the function of behavior in order to determine the true variables maintaining the challenging behavior. If a formal functional assessment is not feasible, indirect methods of assessment may be used to help clinicians predict the most likely function of behavior. Additional research evaluating nuanced differences in the function of behavior between behaviors that have a high degree of overlap in their topography is needed.
Similarly, there was a high degree of overlap in the definitions for aggression and self-injurious behavior. Both behaviors tended to be defined as hitting, kicking, throwing, biting, pinching, grabbing, scratching, pulling, punching, and slapping. The distinction between the two behaviors is simply the target of the behavior, with the target of aggression being another individual and the target of self-injurious behavior being the individual exhibiting the behavior. This distinction may seem obvious, yet researchers and clinicians tend to consider these challenging behaviors as very distinct and different whereas the results of this analysis found that the distinction is rather small. Nevertheless, this distinction is critical to the operational definition of the behaviors and treatment planning.
Obsessive behavior and stereotypy also have overlaps in definitions. The lining-up of objects and/or items is common to both obsessive behaviors and stereotypy. Flapping (presumably hand flapping), a commonly reported stereotypic behavior in individuals with ASD, was also used to define obsessive behavior. Clinicians must be careful when describing a behavior as “obsessive” or “stereotypic” because unlike the relationship between disruption and tantrum, obsessive behavior and stereotypy have the same common function of behavior (i.e., automatic). The variance in definitions between the two behaviors is worth noting. Gross motor verb terms (e.g., jumping, running, tensing) seem to be reported as stereotypic behavior while more general verb items (e.g., talking, playing, asking) seem to be reported as obsessive behavior. While it is important to conduct a thorough assessment of the topography and function of an individual’s challenging behaviors, functional assessments of behavior are time and resource intensive. When these resources are not available, clinicians can use these data to support them in the process of developing hypotheses as to the function of the behavior. Further, the results from the current study can help to inform clinicians and agencies regarding what sort of training and support staff may need in order to provide effective treatment procedures. Treatment providers can prepare themselves and anticipate that clients will have these commonly found challenging behaviors, which may help mitigate interference of challenging behaviors during treatment. For example, the results show that aggression was the second most common topography of behavior and its most common function was escape. With this information, clinicians can anticipate that a client is likely to exhibit aggression with a function of escape. Therefore, clinicians can create an individualized behavior plan that starts with decreased demands in order to diminish the likelihood that a client will escape demands and engage in aggression. Further, clinicians, parents, and caregivers can be trained on aggressive behavior management and block aggression attempts in order to decrease the likelihood of injury to others.
A limitation of this study is that the data were collected from individuals already receiving ABA intervention and some challenging behaviors may have already been reduced or eliminated. Further, during the course of treatment, the method by which the function of behavior is determined is left to the clinician’s professional judgment. Therefore, the method by which the function was identified is an additional source of variance. Future research should evaluate the function of challenging behaviors among individuals receiving community-based behavioral intervention using more formal assessment methods to identify the function of behavior. Despite these limitations, the current study provides valuable insight into the most commonly treated challenging behaviors among persons with ASD receiving treatment within a community-based treatment setting.
EH: designed and executed the study, assisted with the textual data analysis, and wrote the paper. DDR: designed the study and assisted with data analyses and writing of the study. ES: wrote software and analyzed the data. COB: collaborated in the writing and editing of the final manuscript. EL: analyzed the data and wrote the methods and results.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
For this type of retrospective analysis, formal consent was not required.
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