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Psychometrics and utility of Psycho-Educational Profile-Revised as a

developmental quotient measure among children with the dual disability of
intellectual disability and autism

Article  in  Journal of Intellectual Disabilities · July 2012

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Article

Psychometrics and utility

of Psycho-Educational
Profile–Revised as a
developmental quotient Journal of Intellectual Disabilities
16(3) 193–203
measure among children ª The Author(s) 2012
Reprints and permission:
with the dual disability sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1744629512455594

of intellectual disability jid.sagepub.com

and autism

Merlin Thanka Jemi Alwinesh

Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Rachel Beulah Jansirani Joseph

Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Anna Daniel
Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Julie Sandra Abel

Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Satya Raj Shankar

Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Priya Mammen
Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Sushila Russell
Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Paul Swamidhas Sudhakar Russell

Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India

Corresponding author:
Paul Swamidhas Sudhakar Russell, Child and Adolescent Psychiatry Unit, Department of Psychiatry, Christian Medical
College, Vellore 632002, Tamil Nadu, India
Email: [email protected]

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194 Journal of Intellectual Disabilities 16(3)

Abstract
There is no agreement about the measure to quantify the intellectual/developmental level in
children with the dual disability of intellectual disability and autism. Therefore, we studied the
psychometric properties and utility of Psycho-Educational Profile–Revised (PEP-R) as a devel-
opmental test in this population. We identified 116 children with dual disability from the day
care and inpatient database of a specialised Autism Clinic. Scale and domain level scores of
PEP-R were collected and analyzed. We examined the internal consistency, domain-total cor-
relation of PEP-R and concurrent validity of PEP-R against Gesell’s Developmental Schedule,
inter-rater and test–retest reliability and utility of PEP-R among children with dual disability in
different ages, functional level and severity of autism. Besides the adequate face and content
validity, PEP-R demonstrates a good internal consistency (Cronbach’s a ranging from 0.91 to
0.93) and domain-total correlation (ranging from 0.75 to 0.90). The inter-rater reliability
(intraclass correlation coefficient, ICC ¼ 0.96) and test–retest reliability (ICC ¼ 0.87) for
PEP-R is good. There is moderate-to-high concurrent validity with GDS (r ranging from
0.61 to 0.82; all Ps ¼ 0.001). The utility of PEP-R as a developmental measure was good with
infants, toddlers, pre-school and primary school children. The ability of PEP-R to measure the
developmental age was good, irrespective of the severity of autism but was better with high-
functioning children. The PEP-R as an intellectual/developmental test has strong psychometric
properties in children with dual disability. It could be used in children with different age
groups and severity of autism. PEP-R should be used with caution as a developmental test
in children with dual disability who are low functioning.

Keywords
Autism, intellectual disability, PEP-R, validation, utility

Date accepted: 24/06/2012

Introduction
The prevalence of autism spectrum disorders (ASDs) in children with intellectual disability (ID)
ranges from 16.7 to 30% when autism was defined with Diagnostic and Statistical Manual-Fourth
Edition-Text Revision (DSM-IV-TR) and International Classification of Diseases-Tenth Edition
(ICD-10) criteria, respectively (de Bildt et al., 2005; Morgan et al., 2002). When psychological
measures like the Pervasive Developmental Disorder in Mentally Retarded Persons Scale and
Autism Diagnostic Interview–Revised were used to identify children with ASD in the ID popu-
lation, the prevalence ranged from 28 to 39.2%, respectively (Bryson et al., 2008; La Malfa et al.,
2004). Differentiating autism from severe or profound ID, by itself, is difficult as children in both
groups have a combination of deviations and delays in language as well as social interaction.
Children with severe ID often have stereotypic movements and self-injurious behaviours similar to
that of the repetitive movements or self-injurious behaviours in ASD (Goldman et al., 2009; Mat-
son et al., 1997).
Children with this dual disability of ID and ASD often need specialized care. Intellectual
functioning measured as developmental age or mental age is the single most important prognostic
marker for autism (Howlin et al., 2004). An understanding about the intellectual level is required to
tailor the Individualized Educational Program (IEP) and is the primary outcome measures in many

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Alwinesh et al. 195

interventional researches. Therefore, it is essential to quantify the intellectual level from an

intervention, prognostication and research perspectives in this doubly vulnerable population
(Harris et al., 1991; Lovaas, 1987).
Despite these compelling needs to quantify the developmental or mental age, testing
children with autism and ID who are younger, nonverbal, have lower functioning, and have
challenging behaviours is difficult and inaccurate (Klin et al., 1997). For these reasons, the
use of standardized measures of intellectual and developmental functioning in this group of
children is arduous (Koegel et al., 1997; National Research Council, 2001). Because of these
inherent challenges, the intellectual level of these children with dual disability is often not
quantified correctly unless the clinician uses specialized assessment techniques to minimise
the effect of compromised functions of comprehension, language, social interaction, attention,
atypical interests, repetitive behaviours, disruptive behaviours during assessment and poor
motivation (Koegel et al., 1997). Instead, they are classified as Intellectual Disability-Not
Otherwise Specified (Mental Retardation-Not Otherwise Specified:F 79 in ICD-10 and 319
in DSM-IV-TR), a diagnostic category of no clinical significance in prognostication or inter-
ventional planning.
The consequential lack of consensus about the measure to quantify the intellectual level,
overcoming the challenges mentioned, in this population remains. However, Psycho-Educational
Profile–Revised (PEP-R), a measure originally designed to assist in educational planning for chil-
dren with autism and developmental disorders, has qualities to overcome the inherent challenges
mentioned in assessing the developmental age in this special population.
The PEP-R has flexibility in administration, concrete and interesting materials to keep children
engaged in assessment, lacks timed items, and separation of language items from general assess-
ment items that are not dependent on language (Schopler et al., 1990). The psychometric data of
PEP-R Development Quotient (PEP-R DQ) have demonstrated high concurrent validity with Stan-
ford–Binet Fourth edition and Vineland Adaptive Behaviour Scale. The correlation (r) between
PEP-R DQ and Stanford–Binet Fourth edition subscales varied from 0.37 to 0.84 (Delmolino,
2006). The correlation between the developmental age and developmental score of PEP-R with
Vineland Adaptive Behaviour Scale ranged from 0.75 to 0.85 and 0.78 to 0.87, respectively (Villa
et al., 2010). The internal consistency (a) of the Estonian version of PEP-R ranged from 0.75 to
0.95 (Kikas and Häidkind, 2003); of the Chinese version, the internal consistency varied from
0.81 to 0.98 (Shek et al., 2005); and of the Italian version, it ranged from 0.90 to a > 0.99 (Villa
et al., 2010).
Nevertheless, there is little published research comparing the revised version of the PEP to
other standardized schedules of development. One of the most widely used developmental
tests in seminal research and clinical work with children with autism over the years for
measuring development has been the Gesell’s Developmental Schedule (GDS; Lovaas, 1987)
and has been suggested for use in developmental assessment of children with autism (Helena
and Smith, 2001). Therefore, the current study was designed to (1) assess the internal consistency,
total domain correlation and concurrent validity of the PEP-R as a measure to estimate the devel-
opmental level among children with dual disability in comparison with a standardized develop-
mental assessment measure namely the GDS; (2) evaluate the inter-rater and test–retest
reliability of PEP-R as a developmental test in this population with dual disability; and (3)
appraise the utility of PEP-R as a developmental measure among (a) toddlers and young children
with dual disability, (b) participants with varying severity of autism and (c) participants with varying
functional levels.

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196 Journal of Intellectual Disabilities 16(3)

Methods
Setting and population
This study was conducted at the Autism Clinic, Child and Adolescent Psychiatry Unit of a tertiary
care teaching hospital in Southern India. This facility does not have a geographical catchment
population and it provides its services to about 1500 children every year. The children to this
specialised clinic are referred by various hospitals and schools in the country with a suspected
diagnosis of autism and ID. An equal number of children are brought by the primary caregivers
after the problem behaviours or developmental delay were recognised by primary caregivers
themselves, the teacher or neighbours. The charts of children and adolescents thus enrolled in the
clinic were identified from the unit’s day care and inpatient database for a 3-year period of 2009 to
2011. We collected the data for each clinic visit made by the child and included the individual in to
the study if he or she was suspected to have an ICD-10 (World Health Organization, 1992) based
clinical diagnosis of autism (Pervasive Developmental Disorder) and intellectual disability (mental
retardation). Thus the children included either had Childhood autism (F84.0), Atypical autism
(F84.1), Rett’s Syndrome (F84.2), Other childhood disintegrative disorder (F84.3), or Asperger’s
Syndrome (F84.5)] and Mild mental retardation (F70), Moderate mental retardation (F71), Severe
mental retardation (F72), Profound mental retardation (F73) or Mental retardation not otherwise
specified (F79). All clinical diagnoses, based on ICD-10, were made by consultant psychiatrists
on the day of enrolment and within 1 week endorsed by the multidisciplinary team (consisting
of clinical psychologist, rehabilitation psychologists, special educators, occupational therapists,
speech therapists and specialist psychiatric nurses). At any point during the clinical course and hos-
pital visit, if the child was diagnosed with the dual disability then the child was considered eligible
for this study. Children with a diagnosis of overactive disorder associated with mental retardation
and stereotyped movements (F84.4) were excluded because of its uncertain nosological status
(Sponheim, 1996). A subgroup of participants who had data on test–retest and inter-rater reliability
were selected for the reliability analyses. Case notes for each eligible participant were reviewed
and the following psychological and clinical data were collected to determine the various aspects
of validation.
The characteristics of the participants were that the mean (SD) chronological age of the entire
sample (N ¼ 116) was 4.18 (1.94) years (range 1.09–11 years). There was an overrepresentation of
boys (76.9%) than girls (22.2%), which probably reflected the higher prevalence of autism in boys
as against girls globally. Most of the children were from low- and middle-socioeconomic back-
ground (87%). Among children with autism, 55 had childhood autism, 54 had atypical autism, 5
had Asperger’s syndrome and 2 had Rett’s syndrome. There were 10 children with average intel-
ligence, 13 children with borderline and low average intelligence, 72 with mild or moderate and 21
children with severe or profound ID and autism. The mean (SD) DQ in GDS and developmental
age (in years) as well as developmental score in PEP-R were 52.81(20.98) with a range of 9.86–
144.09 as well as 21.62 (8.73) and 46.34 (24.32), respectively. The mean (SD) Childhood Autism
Rating Scale (CARS) score was 37.70 (3.60) with a range of 31–47.50.

Measures
The PEP-R (Schopler et al., 1990) was developed to assess children with autism, between 6 and
12 years of age and formulate IEP for them. The Developmental Scale of PEP-R assesses the func-
tioning of the child in the following areas: imitation (16 items), perception (13 items), fine motor

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Alwinesh et al. 197

(16 items), gross motor (18 items), eye–hand coordination (15 items), cognitive performance (26 items)
and cognitive verbal (27 items). Overall, these seven scales make up the Developmental Scale, which
yields a developmental age measure. The scoring system for Developmental Scale is divided into three
levels: passing, emerging and failing. The developmental score is the sum of all individual item-passing
scores on the Developmental Scale and yields a standardized developmental age score. The PEP-R also
includes a Behavioural Scale which is used to identify the degree of behavioural abnormality and aty-
pical behavioural characteristics of a child with autism. This scale covers four areas: relating and affect
(12 items), play and interest in materials (8 items), sensory responses (12 items) and language (11
items). The Developmental Scale of PEP-R was the index measure for validation.
GDS (Gesell, 1940) gives the developmental skills in four areas: motor behaviour, adaptive
behaviour, language and personal as well as social behaviour. The score details of GDS were
compiled from psychological reports of these children and used as the reference standard for
developmental age to measure the concurrent validity of PEP-R.
The CARS (Schopler et al., 1980) is a 15-item behaviour-rating scale designed to detect and
quantify symptoms of autism as well as to distinguish them from other developmental disabilities.
Each item on the CARS is scored on a Likert-type scale, ranging from 1 (no signs of autism) to
4 (severe symptoms). The maximum CARS score is 60, and the cut off for a diagnosis of autism
is 30. Children with scores of 30.5–37 are rated as mildly moderately autistic, and 37.5–60 as
severely autistic. The CARS scores were collected from the psychologist’s reports, occupational
therapists record as well as speech therapist’s notes. This measure was used to assess the severity
of autism among the participants.
The socioeconomic status was assessed by a social worker as part of the pre-enrolment
evaluation based on the education and occupation of the head of the family as well as the
monthly income.

Data source and extraction

All the details about autism and ID were made by the multidisciplinary treating team much ahead
of the time when data were collected for the study. The mean (SD) duration of clinical experience
of this multidisciplinary team in working with children with dual disability was 12.74 (8.21) years.
The routine clinical assessment of the children in the autism clinic was in the temporal order of
GDS by a psychologist independently on the day of enrolment if the child is cooperative, followed
by CARS by a psychologist and speech therapist independently within a week and finally the PEP-
R by a psychologists or special educator independently within a fortnight. These data were
available in the patients’ clinical case notes made by the psychiatrist, psychological assessment
notes, special educators’ reports, occupational therapy details or speech therapist’s notes. The data
were extracted from these sources by two psychologists, an occupational therapist and a speech
therapist independently, with a mean (SD) experience of 7.5 (1.5) years of working with children
with dual disability. The data on a subgroup of participants who had been assessed twice, with
PEP-R with a mean (SD) of 4(0.3) weeks between the two consecutive assessments, were collected
to evaluate the test–retest reliability. Data of another subgroup of participants who were rated by
two assessors, using PEP-R, on the same day were selected for the inter-rater reliability analysis.
An independent consultant psychiatrist, experienced in dual disabilities, resolved any conflict in
data interpretation. The data protection was ensured by reversible anonymisation and restricted
availability of the data to others. The study was reviewed and approved by the local institutional
review board.

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198 Journal of Intellectual Disabilities 16(3)

Table 1. Internal consistency and domain-total correlation

PEP-R domains Internal consistency Domain-total correlation

Imitation 0.91 0.85

Perception 0.93 0.75
Fine motor 0.91 0.85
Gross motor 0.92 0.78
Eye hand coordination 0.92 0.84
Cognitive performance 0.91 0.90
Cognitive verbal 0.93 0.75
Developmental score 0.93 –

PEP-R: Psycho-Educational Profile–Revised.

Data analysis
As part of the data analysis, preliminary checks of skewness verified that our data were suitable for
parametric analysis and the psychometric properties of PEP-R were analysed at domain and scale
level. First, Cronbach’s a coefficient was used to estimate the internal consistency for the various
PEP-R domains. Also to identify the domains that contribute to and discriminate between children
who score high and low on the total set of domains, we performed a domain-total correlation with
Pearson correlation test. The Pearson correlation coefficient between the PEP-R Developmental
Scale (developmental score and developmental age) and GDS domain scores was also used to
examine the PEP-R’s concurrent validity. Second, the intra-class correlation coefficient (ICC) was
used to evaluate the inter-rater agreement and test–retest reliability of PEP-R. Finally, to assess the
utility of PEP-R, the participants were divided in to three educational/age groups: infants and toddler
(0–3 years), preschool age (3–6 years), and primary school age (6–12 years), and the correlation
between the PEP-R Developmental Scale (developmental score and developmental age) and the GDS
domain scores was calculated using Pearson Correlation coefficient . The total sample was split at the
median (Ragin, 1994) PEP-R developmental age value of 19 months into two groups of children
with high functioning and low functioning autism to analyse the correlation between the PEP-R and
GDS domains in these two groups. Partial correlation technique was used to control for the effect
of the chronological age on the correlation between the PEP-R and GDS domains. Similarly, using the
suggested cutoff (Schopler et al., 1980), the sample was divided in to those with mild (CARS
score 37) and severe autism (CARS score 37.5) and the partial correlation coefficient was calcu-
lated. All correlation coefficient values were interpreted using Cicchetti’s criteria (Cicchetti, 1994).
p <0.05 (two tailed) was considered significant and data were analysed using SPSS (version 19).

Results
Reliability
When we examined the validity of PEP-R, Cronbach’s a coefficient for the whole scale was excel-
lent (a ¼ 0.93), suggesting that the PEP-R in this population with dual disability has high internal
consistency. The domain total correlation ranged from 0.75 to 0.90, suggesting that all the domains
of the PEP-R significantly contributed to the total developmental age and developmental score of
PEP-R (Table 1).

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Alwinesh et al. 199

Table 2. Correlation between PEP-R (developmental age and developmental score) and Gesell’s Develop-
mental Schedule (GDS) for all participants (N ¼ 116)

GDS domains PEP-R DA PEP-R DS

Gross motor 0.68a 0.69a

Fine motor 0.61a 0.60a
Language 0.69a 0.68a
Adaptive 0.80a 0.79a
Personal and social 0.70a 0.68a
Mental age 0.82a 0.81a

PEP-R DA: PEP-R developmental age; PEP-R DS: PEP-R developmental score.
a
p < 0.001

The test–retest reliability to assess the reproducibility of PEP-R as a developmental test using
the ICC was found to be excellent (ICC ¼ 0.87)
The inter-rater reliability of PEP-R as measured with ICC was also found to be excellent
(ICC ¼ 0.96).

Concurrent validity and utility

The correlation between the developmental age of GDS and subscales of GDS with the devel-
opmental age and developmental score of PEP-R was high among all educational/age groups
(Table 2). Between the developmental age and developmental score of PEP-R, the correlation
coefficients were marginally higher for the developmental age than the scores across the groups.
This relationship was more pronounced in the infant and toddler age group but statistically not
different (Table 2).
In the infant and toddler group, all the subscales of GDS had a moderate-to-high correlation
with the developmental age and developmental score of PEP-R (range from 0.66 to 0.79 at signif-
icant levels) except the fine motor domain of GDS that demonstrated only a low and statistically
insignificant correlation. Among the preschool age group, all the subscales of GDS had a
moderate-to-high correlation, including the fine motor domain, with the developmental age and
developmental score of PEP-R (range from 0.61 to 0.75 at significant levels). Among the primary
school children also all domains of GDS demonstrated a moderate-to-high correlation with the devel-
opmental age and developmental score of PEP-R (range from 0.53 to 0.84 at significant levels). The
details of the correlation between the mental age and subscales of GDS with the developmental age
and developmental score of PEP-R for all educational/age groups are summarized in Table 3.
There was a statistically significant difference in the correlation between the mental age of GDS
with the developmental age and developmental score of PEP-R between the low functioning and
high functioning autism group. There was only a low-to-moderate, insignificant correlation in the
low-functioning group as compared to moderate-to-high significant correlation in the high-
functioning group. Thus, the correlations were significantly better in the high-functioning group.
The statistical difference was most prominent between the groups in the domain of language and
was not statistically dissimilar in the adaptive domain of GDS. The correlation between GDS and
PEP developmental age was marginally better than the developmental score. The details of the
correlation between the mental age and subscales of GDS with the developmental age and devel-
opmental score of PEP-R between the high- and low-function groups are summarized in Table 4.

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200 Journal of Intellectual Disabilities 16(3)

Table 3. Correlation between PEP-R (developmental age and developmental score) and Gesell’s Develop-
mental Schedule (GDS) among participants in different age groups

0–3 years, N ¼ 23 3–6 years, N ¼ 68 6–12 years, N ¼ 25

GDS domains PEP-R DA PEP-R DS PEP-R DA PEP-R DS PEP-R DA PEP-R DS

a a a a b
Gross motor 0.79 0.78 0.62 0.61 0.65 0.69b
Fine motor 0.31 0.34 0.75a 0.71a 0.54b 0.53c
Language 0.79a 0.77a 0.61a 0.63a 0.73a 0.66b
Adaptive 0.66b 0.66b 0.78a 0.75a 0.84a 0.82a
Personal and social 0.76a 0.72a 0.68a 0.63a 0.57b 0.55b
Mental age 0.86a 0.84a 0.81a 0.79a 0.81a 0.79a

PEP-R DA: PEP-R developmental age; PEP-R DS: PEP-R developmental score.
a
p ¼ 0.001p
b
p ¼ 0.01
c
p < 0.05.

Table 4. Partial correlations between GDS and PEP-R in low- and high-functioning autism as well as
correlation between GDS and PEP-R in children with mild and severe autism

Level of functioninga Severity of autismb

Low-functioning group (N ¼ 56) Mild autism (N ¼ 54)

GDS domains PEP-R DA PEP-R DS PEP-R DA PEP-R DS

Gross motor 0.44c 0.36c 0.76d 0.79d

Fine motor 0.43c 0.44c 0.77d 0.79d
d
Language 0.26 0.21 0.72 0.73d
Adaptive 0.51d 0.45c 0.80 d
0.81d
Personal and social 0.48c 0.37c 0.75 d
0.78d
Mental age 0.56d 0.46d 0.86d 0.87d
High-functioning group (N ¼ 60) Severe autism (N ¼ 62)
GDS domains PEP-R DA PEP-R DS PEP-R DA PEP-R DS
Gross motor 0.55d 0.54d 0.60d 0.56d
Fine motor 0.57d 0.50d 0.64 d
0.57d
Language 0.72d 0.71d 0.47 c
0.45c
Adaptive 0.72d 0.64d 0.77 d
0.71d
Personal and social 0.49d 0.39c 0.66d 0.57d
Mental age 0.76d 0.69d 0.75 d
0.70d

PEP-R DA: PEP-R developmental age; PEP-R DS: PEP-R developmental score.
a
Level of functioning dichotomized in to low (PEP-R score of 18) and high (PEP-R score of 19); chronological age
adjusted with partial correlation.
b
Severity of autism dichotomized in to mild (CARS score of 37) and severe (CARS score of 37.5) autism; chronological
age adjusted with partial correlation.
c
p ¼ 0.01.
d
p ¼ 0.001.

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Alwinesh et al. 201

Among participants with mild and severe autism, overall there was high correlation with the
mental age and domain scores of GDS and PEP-R developmental age and score. In the group with
severe autism, the correlations were moderate to high, and all correlations were statistically signif-
icant at p < 0.001, except the language domain significant at p < 0.01. It was also noted that the
correlation coefficients between the GDS and PEP-R developmental score were better in the mild
autism groups, and the correlation coefficients between the GDS and PEP-R developmental age
were better in the sever autism groups. The correlation between the mental age and subscales of
GDS with the developmental age and developmental score of PEP-R in the mild and severe autism
groups is also summarized in Table 4.

Discussion
One of the aims of the present study was to evaluate the internal consistency, total domain cor-
relation and concurrent validity of the PEP-R in comparison to GDS. The internal consistency
measured by the a coefficient was high in this study (ranged from 0.92 to 0.93) and is comparable
with the data from Italy (range from 0.84 to 0.99; Villa et al., 2010). This is higher than that
reported in other countries like Estonia (ranged from 0.72 to 0.95; Kikas and Häidkind, 2003) and
China (ranged from 0.74 to 0.98; Shek et al., 2005). Thus, the high internal consistency demon-
strated that the items of PEP-R while used in the Indian context were homogeneous with the pri-
mary construct in PEP-R. Also, the domain-total correlation used to determine the role of each of
the seven PEP-R domains with respect to the entire measure showed that all domains contributed
effectively to the total score. This also suggests that all the domains measured the same construct of
intellectual/developmental level among children with dual disability. The domain-total correlation
for PEP-R could not be compared because data are not available in the published literature.
The evaluation of the concurrent validity of the PEP-R as a measure to estimate the develop-
mental level in comparison with a standardized developmental assessment measure of the GDS
among children with dual disability demonstrated that PEP-R can be used to effectively quantify
the developmental level in this population. This finding is generally consistent with the Western
literature on the original PEP wherein there was significant correlation between PEP and Bayley
Scales of Infant Development (Schopler et al., 1990) and between PEP-R and Stanford–Binet Intel-
ligence Scales (Fourth edition) among children of 3 to 6 years (Delmolino, 2006).
The inter-rater between two raters, one being a psychologists and other an occupational thera-
pist, and the test–retest reliability at 4 weeks were high. This is comparable with the studies in the
past where the inter-rater and test–retest reliability had been as high as 0.97 to 0.99 and 0.89 to 0.99
respectively for PEP-R (Shek et al., 2005). The inter-rater reliability in a more recent study was
0.84 to 0.98 (Villa et al., 2010).
The utility of the PEP-R as a developmental measure was good despite the chronological age
and severity of autism. These findings lend support to the fact that challenges associated with test-
ing of DQ of young children with autism and those with severe autism could be minimized by
using the developmental age or score as presented by PEP-R (Delmolino, 2006). This could be due
to the nature of the PEP-R that has been described to be flexible for administration, use of concrete
and interesting materials, lack of timed items, and separation of language items from general
assessment items, especially those that are not dependent on language (Schopler et al., 1990).
However, among the low-functioning children with the dual disability, the developmental age
and score of PEP-R showed only moderate correlation with GDS mental age and domain scores.
This could be because that despite the above mentioned advantages PEP-R has two domains

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202 Journal of Intellectual Disabilities 16(3)

namely, cognitive verbal and cognitive performance that overtly or covertly assess the linguistic
ability of the responded compromising the instruments concurrent validity in measuring the devel-
opmental level among the children with low functioning.
Our limitations are that, first, the study was conducted in a tertiary care hospital; therefore, the
participants may not be representative of the children with autism in the general population.
Second, the high prevalence of autism in this clinic sample should theoretically improve the
statistical power and stability of the analyses regarding the psychometric properties. In community
and clinical samples with different prevalence rates of autism, the changing prevalence might lead
to different psychometric scores. Therefore, using this study as the focus, further studies on
community samples to establish the psychometric properties of PEP-R are suggested, resulting in
psychometric maturity of PEP-R.

Conclusion
Our study has documented that PEP-R-based developmental age and score has a high correlation with
the standardized developmental assessment measure of the GDS among children with the dual disabil-
ity of ID and autism, irrespective of the age and severity of autism. In future, a measure that performs
well among low-functioning children, like PEP-3, needs to be further identified and validated.

Acknowledgement
The authors gratefully acknowledge the assistance provided by George Devadoss David and Mary Pauline
Paul in collecting the case notes.

Funding
The authors have contributed equally to the development of this paper. This study was supported by a Fluid
Research Grant (grant number: 22X825), Christian Medical College, Vellore.

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