Journal of Autism and Developmental Disorders, Vol. 29, No.

2, 1999

Behavior Problems of Children with Down Syndrome

and Life Events

David A. Coe,1,4 Johnny L. Matson,2 Deirdre W. Russell,2 Keith J. Slifer,1,3

George T. Capone,1,3 Christopher Baglio,2 and Sydney Stallings2

Behavior problems of 44 children with Down syndrome between the ages of 6 and 15 and
44 controls without mental retardation matched for age, sex, and socioeconomic status were com-
pared on the basis of mother and teacher ratings. Ratings from both sources indicated that chil-
dren with Down syndrome had more behavior problems, in particular attention deficit, noncom-
pliance, thought disorder, and social withdrawal. Life events from the past year were significantly
associated with mother but not teacher ratings of Down syndrome behavior problems.

KEY WORDS: Down syndrome; behavior problems.

INTRODUCTION vary appreciably between studies. Conduct disorders

(e.g., noncompliance, aggression) figure most promi-
Down syndrome is the most common autosomal nently, diagnosed in over 10% of children, in contrast
abnormality identified to date in humans with an inci- to attention deficit/hyperactivity, mood disorders (anx-
dence of 1 for every 800 to 1,200 live births (Pueschel iety, depression), and autism/childhood psychosis each
& Thuline, 1983). John Langdon Down, the English typically evident in 10% or less of children with the
physician who first described the condition, also iden- syndrome (Ellis & Beechley, 1950; Gath & Gumley,
tified characteristic behaviors (Down, 1866). Features 1986a; Howlin, Wing, & Gould, 1995; Menolascino,
cited with regularity include affectionate nature, even 1965, 1967; Myers & Pueschel, 1991). Male children
temper, and propensity to imitation (Gibbs & Thorpe, appear at greater risk for disorder than female coun-
1983; Menolascino, 1965). Behavior problems of chil- terparts although by a less than a 2 to 1 margin (Gath
dren of school age (i.e., 4 to 16) with this syndrome & Gumley, 1986a; Menolascino, 1965).
have also been examined in some depth over the last Ratings by parents and teachers of school age chil-
50 years. On average, one quarter to one third are re- dren have typically involved use of instruments orig-
ported as having significant emotional and conduct inally developed for use with children ranging from
problems, with noncompliance, aggression, and hyper- middle childhood through adolescence (Quay & Pe-
activity most prominent (Cuskelly & Dadds, 1992; Gath terson, 1983; Rutter, Tizard, & Whitmore, 1970). In
& Gumley, 1984, 1986a; Menolascino, 1965, 1967; most cases, parent ratings have been supplied by moth-
Myers & Pueschel, 1991). ers. Results indicate that approximately 1 in 3 children
Prevalence estimates of psychiatric disorder by with Down syndrome have significant behavior prob-
mental health professionals average close to 25% but lems relative to 1 in 10 controls without a major de-
velopmental disability (Cuskelly & Dadds, 1992; Gath
& Gumley, 1987). On average, children with Down
1
Kennedy Krieger Institute, Baltimore, Maryland. syndrome score half a standard deviation higher on
2
Louisiana State University, Baton Rouge, Louisiana. behavior problem rating scales than controls. Sex
3
Johns Hopkins Medical Institutions, Baltimore, Maryland.
4
Address all correspondence to David Coe, Miami Children's Hos- differences are comparable to those reported by
pital, Pediatric Behavioral Medicine, 3100 SW 62 Avenue, Miami, mental health professionals (Cuskelly & Dadds, 1992;
Florida. Gath & Gumley, 1986a). At the level of individual

149
0162-3257/99/0400-0149$16.00/0 © 1999 Plenum Publishing Corporation
150 Coe et al.

behavior, differences with controls have been most Preliminary studies involving individuals with
frequently demonstrated in the case of attention deficit/ mental retardation or related developmental conditions
hyperactivity (Cuskelly & Dadds, 1992; Gath & have examined referrals to mental health services (For-
Gumley, 1987). ness & Polloway, 1987; Ghaziuddin, 1988). Forness
Most investigations to date on behavior problems and Polloway (1987) determined that more than 80%
of children with Down syndrome have focused solely of referrals with mild mental retardation had experi-
on description and prevalence. However, several reports enced a recent stressor. The association between cur-
have been released indicating that behavior problems of rent behavior status and stressors in this study was .67,
children with Down syndrome reflect the operation of a value considerably in excess of those generally re-
multiple risk factors. Factors implicated by statistical ported in the general child literature. Ghaziuddin (1988)
analysis include parent and sibling adjustment (Cuskelly concluded that life events exert greater influence on in-
& Dadds, 1992; Gath & Gumley, 1986b; Menolascino, dividuals with less severe intellectual impairment and
1965, 1967; Rollin, 1946), level of mental retardation that behavior problems precipitating referral were typ-
(Gath & Gumley, 1986a), and medical problems (Turner, ically externalizing (e.g., aggression, noncompliance)
Sloper, & Cunningham, 1990). rather than internalizing (e.g., tearfulness, inconti-
To date, the influence of life events on the men- nence) in nature. More recently, Ghaziuddin, Allesi,
tal health problems of individuals with major devel- and Greden (1995) have demonstrated that patients with
opmental disabilities has received relatively little at- Pervasive Developmental Disorder (PDD) and depres-
tention although such a relationship has been the sion experienced significantly more life events over a
subject of considerable attention in the general child 12-month period preceding evaluation than patients
and adult literature. A life event is an experience with with PDD alone.
a determinable origin and limited duration, which can The present investigation examined behavior prob-
be related to a person's psychological status (Goodyer, lems of children between the ages of 6 and 15 and their
1990, 1996). Essentially, a life event markedly changes relationship to Down syndrome and recent life events.
the social and/or physical environment. Examples in- Although correlational in nature, the investigation's
clude deaths or divorces in the immediate family, goal was to examine how a major developmental dis-
births of siblings, outstanding personal achievements, order places children at risk for behavior problems and
and home moves (Coddington, 1972a). Life events coacts with situational adversity.
may be distinguished from other factors that may also
exert control over mental health—chronic social and
family adversity (e.g., low socioeconomic status, poor
METHOD
marriage) and future events (i.e., expectation of future
circumstances that influences behavior; Goodyer,
Participants
1990). The class of life event that has received partic-
ular scrutiny is the negative life event, characterized Subjects of the present study were mothers and
by loss, conflict, or significant increase in situational teachers of 88 children between the ages of 6 and 15,
demands. Life events have been analyzed on the basis 44 children with Down syndrome and 44 children in
of frequency or intensity as determined by profes- regular elementary or secondary school classes. Moth-
sionals or subjects themselves, in the latter case fre- ers of children with Down syndrome were recruited
quently expressed in terms of life change units (LCUs) from Down syndrome and mental retardation advocacy
(Coddington, 1972a, 1972b). Recent community stud- groups, schools and ambulatory clinics by two research
ies examining associations between childhood behav- centers in metropolitan areas, one located in the Mid-
ior problems and life events have reported correlation Atlantic region and one located in the South-Central
coefficients in the .3 range with an average of 3 events region of the United States. Control mothers were re-
and 135 LCUs per year for life events in general, cor- cruited from pediatric practices and ambulatory clin-
relation coefficents in the .4 range with an average of ics as well as through the media in the same metro-
1 event and 60 LCUs per year for negative life events politan regions. Each mother selected to participate in
specifically (L. H. Cohen, Burt, & Bjorck, 1987; the control group was matched with a mother of a child
DuBois, Felner, Brand, Adan, & Evans, 1992; Jensen, with Down syndrome on the basis of the child's sex,
Bloedau, Degroot, Ussery, & Davis, 1990; Masten chronological age (± 6 months) as well as Hollingshead
et al., 1988; Pryor-Brown & Cowen, 1989; Walker & index of family socioeconomic status (SES; Holling-
Green, 1987). shead, 1975).
Behavior Problems of Children with Down Syndrome 151

Measures rated. Adaptive behavior performance is scored in

terms of three general domains: Communication, Daily
The Revised Behavior Problem Checklist
Living Skills, and Socialization Skills as well as
The Revised Behavior Problem Checklist (RBPC) overall competency (Adaptive Behavior Composite).
includes 77 items distributed among six factor-derived Psychometric properties are discussed by Sparrow
scales: I. Conduct Disorder; II. Socialized Aggression; et al. (1984).
III. Attention Problem-Immaturity; IV. Anxiety-With-
drawal; V. Psychotic Behavior; and, VI. Motor Excess
Procedure
(Quay & Peterson, 1983). An additional set of 12 items
do not load on any factor but largely assess social with- Mothers who consented to participate were sched-
drawal (designated Social Withdrawal/Miscellaneous uled for an interview at either their home or one of
in this report). The checklist was developed for use with the two research centers sponsoring the study. Inter-
children between the ages of 6 and 18. RBPC psycho- views were conducted by five graduate students in-
metric properties are discussed in Quay and Peterson cluding the principal investigator. Prior to data col-
(1987). To improve RBPC specificity for diagnosis of lection, all interviewers trained to greater than 80%
emotional and conduct problems distinct from mental reliability on interview administration. Mothers who
retardation and expressive language disorder, two participated completed in order a demographic/family
RBPC items (16. incoherent speech, what is said does background questionnaire specifically developed for
not make sense; 76. does not use language to commu- the study, the VABS-SF, the RBPC, and the CLES.
nicate) were not scored. Previous studies have demon- The demographic/family background questionnaire
strated the RBPC's utility with children who have and VABS-SF were administered in a semistructured
major developmental disorders (e.g., Cuskelly & format. Afterwards, mothers themselves completed the
Dadds, 1992). RBPC and CLES. Instructions stipulated that CLES
ratings of life events should cover the 12-month pe-
riod preceding the interview. With guardian consent,
Coddington Life Events Schedule
the target child's primary teacher was later mailed a
The Coddington Life Events Schedule, a popular copy of the RBPC for completion. Remuneration was
measure of childhood life events, exists in four ver- provided to all participants—$25 for mother, $10 for
sions: Preschool, Elementary, Junior High, and Senior teachers.
High Age Groups (Coddington, 1972a, 1972b). Each
version contains between 30 and 42 items, each item
assigned a LCU weighting (range 21 to 101) determined RESULTS
by a survey of professional workers. Ratings are sup-
plied for a 12-month period preceding assessment. In The average age of the children with Down syn-
the current study, CLES schedule assignment was de- drome for whom interviews were conducted was 9.7
termined by chronological age as follows: Elementary, years old. Their average Hollingshead SES class was
ages 5-12, Junior High, ages 13-14, and Senior High, 2.0, indicative of middle- to upper-middle-class status.
age 15. (Preliminary analyses taking developmental Statistical analyses revealed no significant differences
level of Down syndrome children into account yielded from the control group with respect to child's age or
comparable findings.) Psychometric properties have SES (p > .05). However, children with Down syndrome
been addressed by several independent investigations scored lower in overall adaptive behavior, t(86) =
(e.g., Bailey & Garralda, 1986). -24.81,p < .01. Medical records specifying karyotype
were available for 52% of these children. For those for
whom records were available, 91% had Trisomy 21,
Vineland Adaptive Behavior Scales: Survey Form
9% translocation. Demographic and adaptive behavior
Representativeness of samples with regard to score data are reported in Table I.
global adaptive functioning was established through At this time, RBPC norms have only been de-
administration of the Vineland Adaptive Behavior veloped for teacher ratings of children from kinder-
Scales: Survey Form (VABS-SF; Sparrow, Balla, & garten through Grade 8 (Quay & Peterson, 1987).
Cicchetti, 1984). The VABS-SF is completed by a Based on recommendations by the instrument's au-
trained examiner who interviews a respondent ac- thors to develop local norms (Quay & Peterson, 1987),
quainted with the behavior of the individual being T scores were calculated for both groups based on con-
152 Coe et al.

Table I. Sample Characteristics scores. For overall scores, a correlation of .38 was ob-
tained (p < .05). At the subscale level, the average cor-
Down syndrome Control
relation was .34 (p < .05 or p < .01).
M SD M SD For overall RPBC scores, a significant effect was
obtained for group, F(l, 154) = 17.06, p < .001 (Down
Age (years) 9.7 2.7 9.7 2.7 syndrome M = 56.98, control M = 50.00); but not Rater,
SES (Hollingshead
scale) 2.0 0.9 1.9 0.8
F(l, 154) = 2.41, or Group x Rater interaction,
Vineland Adaptive F(l, 154) = 2.49, p > .05. RBPC subscale scores were
Behavior Scales initially evaluated with a 2 (Group) x 2 (Rater)
Adaptive Behavior MANOVA. Significant main effects were obtained for
Composite 51.4 14.1 106.0 10.5 Group, F(7, 148) = 17.99, p < .001, Rater, F(7, 148) =
Communication Skills 50.5 15.5 110.9 9.9
Daily Living Skills 49.8 18.4 99.1 10.4
3.91, p < .01, and Group x Rater interaction, F(7, 148)
Socialization Skills 67.1 14.9 103.7 11.4 = 3.95, p < .01. Univariate analyses were used to ex-
amine relations at the subscale level. On account of the
Sex ratio
Male : Female 1:1 1 :1 significant MANOVA interaction, group and rater were
treated separately in this set of analyses. Significant
ANOVAs were followed up with a priori contrast tests,
using Dunn's multiple comparison procedure, compar-
trol group linear z scores (Crocker & Algina, 1986). ing groups on the basis of parent or teacher report. To
Separate norms were developed for mother and control for Type II error, a significance criterion of
teacher reports as well as for overall and subscale alpha less than .01 was used for this set of analyses.
scores. Given the relatively small samples participat- Results are reported in Table II. Significant univariate
ing in the study, ratings of male and female children results were obtained for Conduct Disorder, Attention
were combined. Problem, Psychotic Behavior, and Social Withdrawal/
No statistically significant differences in RBPC Miscellaneous subscales. In turn, significant contrasts
ratings were identified on the basis of geographical lo- were identified for conduct disorder (teacher report),
cation (p > .05) and so data from both collection sites attention problem (mother and teacher report), psy-
were combined. RBPC ratings were completed by 74% chotic behavior (teacher report), and social withdrawal/
of teachers contacted. No statistically significant dif- miscellaneous behavior (teacher report).
ferences were identified between children for whom To provide continuity with standard categorical
teacher ratings were and were not obtained with respect methods of diagnosis, group differences were also ex-
to group status, age, SES, mother RBPC rating, and sex amined by identifying children in both groups with clin-
composition (all p > .05). Statistically significant Pear- ically significant behavior problems on the basis of
son r correlations between parent and teacher RBPC T scores of 70 or greater on at least one RBPC subscale
reports were identified for both overall and all subscale and running chi-square analyses. Based on mother re-

Table II. Mean Behavior Problem T Scores

Parent report Teacher report

Down Down
syndrome Control syndrome Control
RBPC subscale (1) (2) (3) (4) F(3, 154) Contrasts

Conduct disorder 53.5 50.0 60.4 50.0 7.49b

3>4a
Socialized aggression 48.7 50.0 49.6 50.0 0.23
Attention problem 60.6 50,0 64.2 50.0 17.92* 1>2a, 3>4a
Anxiety-withdrawal 46.1 50.0 53.3 50.0 3.61
Psychotic behavior 53.3 50.0 70.6 50.0 15.94b 3>4a
Motor excess 53.0 50.0 54.9 50.0 1.74
Social withdraw./misc. 54.7 50.0 72.1 50.0 22.49b 3>4a
a
p<.01.
b
p<.00l.
Behavior Problems of Children with Down Syndrome 153

port, 14 children with Down syndrome (31.8%) had se- Table III. Correlation of Behavior Problem to Life Events
vere behavior problems, relative to 6 controls (13.6%), (Total Behavior Scores)
X2, (1, N = 88) = 4.14, p < .05. Based on teacher re- Pearson r
port, 20 children with Down syndrome (58.8%) had se-
vere behavior problems, relative to 7 controls (19.4%), Down syndrome Control
x2, (1,N = 65) = 11.4, P<.01.
CLES overall
Categorization and analysis of life events was Parent report
modeled on earlier work by Jensen, Richters, Ussery, Frequency .23 .26"
Bloedau, and Davis (1991). Analyses were conducted Life change units .25a .24
for all CLES events as well as negative life events Teacher report
specifically, omitting events with positive valence (e.g., Frequency -.15 .28
Life change units -.18 .17
peer acceptance, parents argue less, parent-child argue
less, personal achievement). With respect to life events CLES negative life events
as a whole, children with Down syndrome experienced Parent report
Frequency .23 .35*
significantly fewer events and life change units over Life change units .25a .30a
the preceding 12-month period. Children with Down Teacher report
syndrome experienced 1.8 events (SD = 1.5) versus 2.5 Frequency -.12 .38a
for controls (SD = 1.7),t(86)= -2.11, p < .05. In the Life change units -.15 .25
same period, children with Down syndrome experi- a
p < .05, one-tailed.
enced 67.8 (SD = 60.7) life change units versus 100.7 b
p < .01, one-tailed.
(SD = 74.2) for controls, t(86) = -2.27, p < .05. Sub-
sequent analysis of negative life events revealed that
both groups of children were exposed to similar fre- conduct, psychotic, and social withdrawal/miscella-
quencies of events and life change units in the last 12 neous behavior problems. Finding of overall difference
months. Children with Down syndrome experienced 1.6 is consistent with earlier work by Gath and Gumley
negative events during this time (SD = 1.4) compared (1984, 1987) and Cuskelly and Dadds (1992). The
to 2.2 for controls (SD = 1.6), t(86) = -1.62, p > .05. prominence of attention and pervasive developmental
Similar results were obtained with life change units, (i.e., psychosis, withdrawal) problems substantiates
children with Down syndrome experiencing 62.8 neg- earlier findings by Menolascino (1965, 1967), Gath
ative life change units (SD 57.1) compared to 87.8 (SD and Gumley (1987), Myer and Pueschel (1991),
= 71.2) for controls, t(86) = -1.82, p > .05. Cuskelly and Dadds (1992) as well as Howlin et al.
Correlational analyses were used to evaluate in- (1995). The current investigation, however, expanded
fluence of life events with respect to frequency as well on these earlier efforts by providing comparison to an
as life change units. Due to the large number of po- appropriate control group, matched on chronological
tential analyses with individual subscales and to pro- age, sex, and socioeconomic level and judged by in-
vide comparison with previous community studies (see dependent raters.
Introduction), analyses were only carried out with total Percentages of Down syndrome and control chil-
RBPC scores. Table III summarizes these analyses. For dren identified with clinically significant behavior prob-
both groups of children, parent behavior ratings were lems by mothers were comparable with results from ear-
associated with life events, overall and negative. For lier studies. Approximately one in three children with
only control group children were teacher ratings sig- Down syndrome was identified by mothers as having a
nificant, specifically in the case of negative life events. significant behavior problem, exceeding control sub-
jects by almost a three to one margin. Attention prob-
lems were most prominent in mother reports. Teachers
DISCUSSION identified a larger percentage of children with Down
syndrome as having significant behavior problems, al-
Results from the present study are consistent with most 60%, though also by an approximately three to one
those of earlier investigations of Down syndrome and margin over controls which is consistent with earlier
are also unique in several respects. studies. Conduct disorder, social withdrawal, attention
Both mothers and teachers of children with Down problems, as well as psychotic behaviors (i.e., repeti-
syndrome reported more behavior problems overall tive speech and major preoccupations of thought) were
than control raters, especially with respect to attention, of greatest concern to teachers.
154 Coe et al.

Although children with Down syndrome were were related to parent report measures of behavior for
identified as having more behavior problems overall, it Down syndrome and control groups alike. However,
should be noted that these children were rated similarly for teacher report, only negative events were associ-
to controls by both mothers and teachers with respect ated with behavioral status and in the case of control
to anxiety, motor excess, and socialized aggression subjects alone.
problems. Moreover, T score analyses make clear that In earlier investigations, teacher reports have
in most respects the Down syndrome group exceeded yielded smaller correlations with life events compared
the control group by only Vi to VA standard deviations. with both child and parent reports (L. H. Cohen et al.,
In contrast, the adaptive behavior skills of the former 1987; Dubow et al., 1991, Pryor-Brown & Cohen,
group fell more than 2 standard deviations below those 1989). Absence of significant correlation between the
of the control group. Consistent with anecdotal reports school behavior of children with Down syndrome and
of adults who participated in this project, Down syn- life events in the current study may reflect several fac-
drome should by no means be considered synonymous tors. First, the obtained results may reflect true dif-
with mental illness. To be sure, the RBPC does not ferences, perhaps indicative of dissimilar susceptibil-
cover all behavior problems confronting children with ity to environmental contingencies. By virtue of a
Down syndrome. Participants in the current study iden- lower developmental level, children with Down syn-
tified a number of additional concerns including brux- drome may be relatively more influenced by immedi-
ism, self-injury, stereotypy, sleep disorder, feeding dis- ate or short-term antecedents and consequences which
order (food selectivity and excessive consumption), vary from one setting to another. For example, for a
perseveration, and excessive speech. With respect to child with Down syndrome or a less advanced devel-
ratings for the RBPC Psychotic Behavior subscale, opmental level, conduct in the class may be more in-
Cuskelly and Dadds (1992) were correct to point out fluenced by quality of academic instruction (e.g., re-
that this scale may not measure psychosis as tradition- inforcement rate, task difficulty) than recent family
ally conceived and may also reflect general cognitive changes. Second, since teacher ratings were obtained
and language delays. However, this scale also assesses on the average 2 to 3 weeks after parent ratings, an at-
behaviors indicative of PDD and therefore may be im- tenuation of relationships over time may have occurred
portant. Earlier reports indicate that PDD is relatively due to the impact of additional life events or other
commonly associated with Down syndrome, affecting variables in the interim. Typically, cross-lag studies
as many as 10% of all children (Gath & Gumley, 1986a; of relationships between life events and behavior yield
Howlin et al., 1995; Lund, 1988). Internalizing behav- weaker statistical relationships (L. H. Cohen et al.,
iors may be more difficult for parents and teachers to 1987; Dubow et al., 1991). Third, obtained differences
evaluate, however, and additional studies incorporat- may reflect rating biases of mothers and teachers. Pre-
ing professional diagnoses along the lines of Gath and vious investigations have demonstrated that the per-
Gumley (1986a) and Myers and Pueschel (1991) would sonal experience of raters can mediate the relationship
be of great benefit. Results reported here must be in- between ratings of behavior and life events (Jensen
terpreted cautiously because they were obtained with et al., 1991).
community volunteers although adaptive behavior Analysis in the present case was limited to con-
scores for both groups are comparable with those re- sideration of events from Coddington's original in-
ported by other investigators (Loveland & Kelley, struments although children with Down syndrome may
1988; Rodrigue, Morgan, & Geffen, 1991). Separate be exposed to events unique to them or which exert
analyses for male and female children also merit in- unique effects and therefore are worthy of considera-
vestigation. tion, for example, changes in daily routine, exposure
Children with Down syndrome were identified as to outbursts of peers with emotional or conduct distur-
experiencing fewer overall life events with respect to bances in special education settings, or more frequent
frequency and life change units. Both groups experi- illnesses which do not necessarily result in hospital-
enced comparable negative life events. This particular ization but disrupt ongoing educational programming
finding suggests that interpretation of differences in and community routine. Another topic worthy of in-
behavior status between individuals with develop- vestigation for different developmental disability dis-
mental disabilities and controls needs to take into ac- orders is how life events coact with different forms of
count possible differences in life events even when behavior disorder. The recent interest in environmen-
age, sex, and SES are equated. In the current investi- tal influences on the behavior of children and adults
gation, overall and specifically negative life events with mental retardation and other major developmen-
Behavior Problems of Children with Down Syndrome 155

tal disabilities has so far largely focused on immediate Forness, S. R., & Polloway, E. A. (1987). Physical and psychiatric
diagnoses of pupils with mild mental retardation currently being
environmental contingencies and their effects on indi- referred for related services. Education and Training in Mental
viduals (Hagopian et al., 1997; Northup et al., 1991). Retardation, 22, 221-228.
However, examination of more global variables and Gath, A., & Gumley, D. (1984). Down's syndrome and the family:
Follow up of children first seen in infancy. Developmental Med-
their relative effects on groups of individuals with dif- icine and Child Neurology, 26, 500-508.
ferent forms of developmental disability may also be Gath, A., & Gumley, D. (1986a). Behaviour problems in retarded
important. children with special reference to Down's syndrome. British
Journal of Psychiatry, 149, 156-161.
Gath, A., & Gumley, D. (1986b). Family background of children with
ACKNOWLEDGMENTS Down's syndrome and of children with a similar degree of men-
tal retardation. British Journal of Psychiatry, 149, 161-171.
Gath, A., & Gumley, D. (1987). Retarded children and their siblings.
The authors thank all the families and teachers Journal of Child Psychology and Psychiatry, 28, 715-730.
who participated in this project as well as the follow- Ghaziuddin, M. (1988). Behavioural disorder in the mentally hand-
icapped: The role of life events. British Journal of Psychiatry,
ing individuals: Roberta Babbit, Karen Callahan, Keith 152, 683-686.
Williams, Debra Benavidez, Linda LeBlanc, Ronald Ghaziuddin, M., Alessi, N., & Greden, J. F. (1995). Life events and
Walcher, Aenid Mason, Alma Suter, Paige Dobry, and depression in children with Pervasive Developmental Disorders.
Journal of Autism and Developmental Disorders, 25, 495-502.
Dee Duncan. Recruitment of subjects was made possi- Gibbs, M. V., & Thorpe, J. G. (1983). Personality stereotype of non-
ble by the generous assistance of the following organ- institutionalized Down syndrome children. American Journal of
izations: the Baton Rouge (Louisiana) Down Syndrome Mental Deficiency, 87, 601-605.
Goodyer, I. M. (1990). Annotation: Recent life events and psychi-
Society, the Chesapeake (Maryland) Down Syndrome atric disorder in school age children. Journal of Child Psychol-
Society, the Down Syndrome Support Group of Howard ogy and Psychiatry, 31, 839-848.
County (Maryland), the Maryland Association for Re- Goodyer, I. M. (1996). Recent undesirable life events: Their influ-
ence on subsequent psychopathology. European Child and Ado-
tarded Citizens, the Louisiana Association for Retarded lescent Psychiatry, 5, 33-37.
Citizens, the East Baton Rouge Parish (Louisiana) Pub- Hagopian, L. P., Fisher, W. W., Thompson, R. H., Owen-DeSchryver,
lic School System, the Baltimore County (Maryland) J., Iwata, B. A., & Wacker, D. P. (1997). Toward the develop-
ment of structured criteria for interpretation of functional analy-
Public School System, and the Howard County (Mary- sis data. Journal of Applied Behavior Analysis, 30, 313-326.
land) Public School System. Hollingshead, A. B. (1975). Four-factor index of social status. New
Haven, CT: Department of Sociology, Yale University.
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