Child: care, health and development

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1 bs_bs_banner Child: care, health and development Original Article doi: /cch Definitions of sleeplessness in children with attention-deficit hyperactivity disorder (ADHD): implications for mothers mental state, daytime sleepiness and sleep-related cognitions P. Montgomery* and L. Wiggs* *Section of Child and Adolescent Psychiatry, University of Oxford, Oxford, UK Centre for Evidence Based Intervention, University of Oxford, Oxford, UK, and Department of Psychology, Oxford Brookes University, Oxford, UK Accepted for publication 5 May 2014 Keywords ADHD, child, mental health, mothers, sleeplessness Correspondence: Paul Montgomery, Centre for Evidence Based Intervention, University of Oxford, 32 Wellington Square, Oxford, OX1 2ER, UK Abstract Background Sleep disturbances are common in children with attention-deficit hyperactivity disorder (ADHD). Sleeplessness is frequently reported although results are inconsistent perhaps because different definitions for it are applied. This study looked at maternal functioning and child objective sleep patterns in relation to different definitions of sleeplessness in children with ADHD. Methods The study included 45 children (aged 3 14 years) with ADHD and their mothers. Sleeplessness was defined according to: (i) yes/no report of whether mothers thought their children had a problem with sleeplessness (Maternal definition MD) and (ii) mothers responses to a quantitative standardized questionnaire (Quantitative definition QD) designed to detect the frequency and duration of parent-reported problems with settling, night waking and early waking. Objective sleep patterns were also assessed by means of actigraphy. Maternal mental health, daytime sleepiness and cognitions related to child sleep were assessed by questionnaire. Results Both definitions appeared to tap similar although slightly different constructs. There were no group differences in objective sleep patterns. Maternal mental health was found to be significantly worse in the mothers who considered their child to be sleepless (MD) (P < 0.025), but not in those mothers whose child was found to be sleepless according to the standardized criteria (QD). Maternal sleepiness did not differ between groups. For both categories of sleepless children (MD and QD), the mothers had significantly more doubts about their competency as a parent (P < 0.01 and P < 0.025, respectively) compared to mothers of children without sleeplessness. Conclusions Two different maternal assessments of child sleeplessness in children with ADHD may assess subtly different constructs, but both may provide useful information about potential problems across the family. Introduction Parents of children with attention-deficit hyperactivity disorder (ADHD) frequently report sleep disturbances in their children, as do the children themselves (Corkum et al. 1998; Owens et al. 2000). Certain sleep disorders (e.g. obstructive sleep apnoea, nightmares and bedwetting) may be associated with ADHD (Picchietti et al. 1998; Chervin & Archbold 2001; Chervin et al John Wiley & Sons Ltd 139

2 140 P. Montgomery and L. Wiggs 2002; O Brien et al. 2003; Owens et al. 2000), and persistent sleep loss can cause or exacerbate learning and behavioural problems, including ADHD-type symptoms (Fallone et al. 2002). Comparing findings concerning sleep in ADHD across studies, however, has been contradictory principally because of the variety of methods of assessment of ADHD, co-morbidity and sleep (Cortese et al. 2006). For example, some studies have assessed sleep objectively using either polysomnography or actigraphy; others have collected subjective data, typically from parent-reported questionnaires. Moreover, there are a variety of ways some sleep disturbances, most frequently insomnia or sleeplessness, may be defined, including using diagnostic criteria (some of which require clinical judgement), quantitatively standardized criteria (based on frequency and duration of sleeplessness) and parents perspectives about whether their child s sleeplessness is problematic. Previous work has indicated that, in infants, standardized questionnaire measures identify more severe sleeplessness problems, whereas what mothers report as problematic include much milder sleeplessness (in terms of frequency and duration) (Morrell 1999b). Indeed, it may not be the severity of the sleeplessness problem per se that has the greatest impact on families (Scott & Richards 1990): whether mothers recognize their child s sleeplessness as problematic is of interest clinically, as this appears to be related to maternal and child functioning (Wiggs & Stores 1998b), and is likely the first step towards accessing treatment. Children s sleeplessness is related to parental reports of stress, marital satisfaction, parent child interactions and parents attitudes towards their children (Quine 1992a; Minde et al. 1994; Richdale et al. 2000), possibly because of the reduced sleep that parents experience (Wiggs & Stores 1998a,b). In typically developing infants, sleeplessness is related to parents cognitions about their infant s sleep (specifically difficulty setting limits on their children s behaviour, feelings of anger, doubts about parenting competence and concerns about their infant s distress at night) (Morrell 1999b; Tikotzky & Sadeh 2009). This has not been similarly examined in older children, nor children with ADHD. The aim of this study was to describe (i) maternal mental state and daytime sleepiness and (ii) child objective sleep in children with ADHD with and without sleeplessness (maternally defined and quantitatively defined). We also conducted a preliminary exploration of maternal cognitions about sleep in mothers of children with ADHD with and without sleeplessness, using measures developed for use with infants (Morrell 1999a). It was hypothesized that child sleeplessness, however defined, would be associated with mothers having poorer mental state, more daytime sleepiness and more unhelpful sleep-related cognitions. Given the contradictory literature, no hypotheses were made in relation to the presence of sleeplessness and the children s objective sleep patterns. Methods Participants Consecutive male and female children aged under 16 years attending child psychiatry outpatient appointments at 12 clinics in the Oxfordshire region of the UK were invited to participate in the study if they had been diagnosed with ADHD [10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria] by one of the 12 senior child psychiatrists leading the clinics. The exclusion criterion was the use of stimulant medication either currently or over the last 6 months. Parents and, where appropriate, children provided informed consent. Ethical permission was given by the local relevant research ethics committees. Procedure Families attending child psychiatry appointments were informed about the study. With permission from their general practitioner, consenting families were visited at home. Mothers provided demographic data and reported on the child s sleep via a structured interview, completed questionnaire measures, and were given an actigraph for their child to wear. Measures ADHD All children had received a diagnosis of ADHD from their local senior child psychiatrist. Additionally, for cross-study comparison, and as a diagnostic confirmation, children were screened for symptoms of ADHD using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) AD/HD Rating Scale, completed by parents and the children s teachers (DuPaul et al. 1997, 1998), and were classified according to DSM-IV criteria (American Psychiatric Association 2000).

3 Sleeplessness definitions and mental state in mothers of children with ADHD 141 Mother s report of child sleep The aim of the sleep assessments was to divide the ADHD children into two groups: those with, and those without, sleeplessness. Children were excluded if mothers reported any other aspects of sleep being problematic. Sleeplessness was defined in two different ways for comparison: maternally defined and quantitatively defined. Maternally defined Each mother was asked the following questions: (a) In your opinion does your child have a sleep problem? (Yes/No response) (b) What would you say the problem is? (open-ended response) Each child was then categorized into either the maternally defined Sleeplessness-group (SM) or Comparison group (CM) based on the following criteria: SM mothers answered Yes to (a) and indicated a problem involving difficulty with settling, night waking and/or early waking in (b); CM mothers answered No to (a) and reported no problem in (b). Quantitatively defined Standardized information about three aspects of sleeplessness (settling difficulties, night waking and early waking) was gathered using the Simonds and Parraga Interview Schedule (Simonds & Parraga 1982). Mothers were asked to rate: the frequency of these three features on the following scale: Never, Less than once a month, About once a month, 2 to 4 times a month, 1 or 2 times a week, 3 to 6 times week or Daily ; the duration of (a) settling or (b) night waking on the following scale: a few minutes, up to 30 min, up to an hour, 1 2 hours, more than 2 hours ; the number of night wakes per night. The children were assigned to either the Quantitatively defined Sleeplessness-group (SQ) or Comparison group (CQ) based on whether or not they fulfilled the following criteria for a sleeplessness problem, drawn from widely used definitions (e.g. Richman & Graham 1971; Richman et al. 1982; Quine 1991; Wiggs & Stores 1996; Morrell 1999a; Montgomery et al. 2004): (a) an early waking problem (waking in the morning before 5 am), three to seven times per week; and/or (b) a night waking problem (waking in the night), three to seven times per week, plus either waking three or more times per night, or taking longer than a few minutes to return to sleep following a waking; and/or (c) a settling problem (reluctance to go to bed, being afraid to go to bed and/or settling difficulties) three to seven times per week plus the duration of any settling difficulty being longer than 30 min. Maternal functioning Maternal mental state was assessed using the General Health Questionnaire (GHQ) (12-item version) (Goldberg & Williams 1991). Maternal daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS) (Johns 1991). A modified version of the Maternal Cognitions about Infant Sleep Questionnaire (MCISQ) (Morrell 1999a) was used to assess parents cognitions concerning their child s sleep, specifically difficulty limit setting, anger towards child, concerns for child s safety at night and doubt about their parenting competency. Children s objective sleep Actigraphy (Mini Motionlogger, Ambulatory Monitoring Inc.) (Sadeh et al. 1995) was used to record the children s objective sleep/wake patterns for five nights. Parents concurrently completed a diary to aid interpretation of these data. The variables generated from the monitor were: sleep duration, sleep onset and offset times, minutes awake between onset and offset, number of wakes after sleep onset, and activity mean (amount of movement during sleep). Within-subject night-to-night variability for these measures was also analysed because previous work has suggested greater sleep instability in ADHD children (Gruber et al. 2000). Analysis Statistical analysis was conducted using SPSS version Exploration of the data suggested that non-parametric tests would be appropriate. All comparisons were performed using Mann Whitney tests. To correct for multiple comparisons, a significance level of P < was used for all tests. Results The numbers of families invited to participate were not consistently recorded at all recruiting sites. From discussion with

4 142 P. Montgomery and L. Wiggs Maternal definition Criteria Maternal definition sleeplessness (SM) no-sleeplessness comparison group (CM) Total n Quantitative definition sleeplessness (SQ) Quantitative definition no-sleeplessness comparison group (CQ) Total n Table 1. Number of children with reported sleeplessness according to maternal and quantitative definitions recruiting psychiatrists, it is estimated that approximately 83 consecutively eligible families were approached and about 15% (n = 12) chose not to participate, Twenty-six further families were excluded either because children s ADHD diagnoses were not confirmed by checklist scores (n = 21) (DuPaul et al. 1997, 1998), or because they had a maternally identified sleep problem other than sleeplessness (n = 5). Forty-five children [predominantly inattentive (n = 7), predominantly hyperactive-impulsive (n = 17) and combined type (n = 21)], ranging in age from 3 to 14 years (mean = 8.7, SD = 2.5), and their mothers comprised the final sample. Forty-one children were male, 42 attended mainstream schools and three attended a school specializing in the needs of children with particular educational requirements. None had significant medical conditions other than ADHD. Two took prescribed antibiotics, and five took prophylactic antiasthma medications during the study, but none had severe asthma. The numbers of children who met the criteria for reported sleeplessness (both the maternal and quantitative definitions) are shown in Table 1. Because the number of children in the four possible cells of Table 1 was small, comparisons focused on those with and without sleeplessness (rather than all four groups), defined according to both maternally defined and quantitative criteria. Although there was disparity in both directions, it was more common for children to meet the maternal criteria for a sleeplessness problem and not the quantitative criteria (n = 8) than for children to meet the quantitative criteria and not the maternal criteria (n = 3). The maternal mental state, daytime sleepiness and sleeprelated cognitions of SM and CM mothers, and SQ and CQ mothers, are shown in Tables 2 and 3, respectively. Mothers who reported that their child had a sleeplessness problem (SM) were significantly more likely to have poorer mental health than those who did not (CM). Both SM and SQ mothers were significantly more likely to have doubts about their parenting competency than relevant comparison mothers. Actigraphy revealed no significant differences in objective sleep patterns between SM and CM children, nor SQ and CQ children, as shown in Tables 4 and 5, respectively. The within-subject night-to-night variability of these data (not presented here) also showed no significant group differences. Discussion This study explored child sleep and maternal functioning using both maternally defined and quantitative criteria for the presence of sleeplessness in children with ADHD. Examination of the correspondence between these definitions suggests that they may be measuring slightly different, although similar, constructs. Interestingly, using either definition, the objective sleep patterns did not vary significantly across groups. This may indicate that in the current sample, by any criteria, the objective severity of the child s sleeplessness problem may not be the best means of identifying children and families who need help, as suggested by Choi and colleagues (2010); the child s behaviour during any wakeful periods may be more salient than their absolute minutes of wakefulness although further exploration with larger samples is needed. Mothers who perceived their child to have a sleeplessness problem scored significantly worse on mental health (GHQ) and had more doubts about their parenting competency than mothers of children who did not perceive their child to have sleeplessness. When the group was split by the standardized criteria, however, GHQ scores did not differ but again parenting competency doubt was significantly higher in the group with sleeplessness suggesting the importance of considering parenting in this population. These data also raise the possibility of an added effect of having a child with both ADHD and a sleep pattern considered to be problematic, or that parents with poorer mental health are more likely to report having a child with sleeplessness. In other groups of children, successful

5 Sleeplessness definitions and mental state in mothers of children with ADHD 143 Table 2. Maternal stress, sleepiness and sleep-related cognitions of mothers of sleepless and non-sleepless children defined according to maternal definition of the presence of childhood sleeplessness Maternal definition sleeplessness (SM) (n = 33) Maternal definition no-sleeplessness comparison group (CM) (n = 12) Mann Whitney U-test statistic General Health Questionnaire Mean 5.3 (3.5) Mean 2.8 (3.9) U = 103.5* Median 5.0 ( ) Median 1.0 ( ) Epworth Sleepiness Scale Mean 6.3 (4.2) Mean 5.2 (3.4) U = Median 6.0 ( ) Median 4.5 ( ) MCISQ difficulty limit setting Mean 13.3 (5.8) Mean 11.0 (3.2) U = Median 12 ( ) Median 10.5 (9.0 13) MCISQ anger at child Mean 9.1 (5.6) Mean 6.25 (3.6) U = Median 9.0 ( ) Median 6.0 ( ) MCISQ concerns for child s safety Mean 3.6 (3.3) Mean 1.8 (1.9) U = Median 3.0 (0 6.5) Median 1.0 ( ) MCISQ parenting competency doubt Mean 6.2 (4.7) Mean 2.2 (1.9) U = 96.0** Median 6.5 (2 11) Median 2.0 (0 4.0) *P < (one-tailed); **P < 0.01 (one-tailed). The General Health Questionnaire (GHQ-12) measures (non-psychotic psychiatric disorders, focusing on the ability to carry out normal functions and the appearance of new and distressing psychological phenomena. A threshold score of >1 is thought to indicate caseness (Goldberg et al. 1997). Scores on the Epworth Sleepiness Scale, which includes eight items assessing the propensity to fall asleep during various activities, range between 0 and 24, with scores <10 being considered normal. The 20-item Maternal Cognitions about Infant Sleep Questionnaire (MCISQ) was modified for use with older children via the removal of three items concerning night-feeding. Table 3. Maternal stress, sleepiness and sleep-related cognitions of mothers of sleepless and non-sleepless children defined according to quantitative definitions for the presence of childhood sleeplessness Quantitative definition sleeplessness (SQ) (n = 28) Quantitative definition no-sleeplessness comparison group (CQ) (n = 17) Mann Whitney U-test statistic General Health Questionnaire Mean 5.3 (3.7) Mean 3.6 (3.8) U = Median 5.0 ( ) Median 2.0 ( ) Epworth Sleepiness Scale Mean 6.3 (4.4) Mean 5.4 (3.3) U = Median 6.0 ( ) Median 4.5 ( ) MCISQ difficulty limit setting Mean 12.9 (6.2) Mean 12.2 (3.5) U = Median 12.0 ( ) Median 11.0 ( ) MCISQ anger at child Mean 9.2 (5.6) Mean 6.9 (4.5) U = Median 9.0 ( ) Median 9.0 ( ) MCISQ concerns for child s safety Mean 3.5 (3.2) Mean 2.5 (3.0) U = Median 3.5 (0 6.0) Median 1.0 (0 5.0) MCISQ parenting competency doubt Mean 6.3 (4.7) Mean 3.3 (3.5) U = 138.5* Median 6.0 ( ) Median 2.5 (0 4.8) *P < (one-tailed). The General Health Questionnaire (GHQ-12) measures (non-psychotic psychiatric disorders, focusing on the ability to carry out normal functions and the appearance of new and distressing psychological phenomena. A threshold score of >1 is thought to indicate caseness (Goldberg et al. 1997). Scores on the Epworth Sleepiness Scale, which includes eight items assessing the propensity to fall asleep during various activities, range between 0 and 24, with scores <10 being considered normal. The 20-item Maternal Cognitions about Infant Sleep Questionnaire (MCISQ) was modified for use with older children via the removal of three items concerning night-feeding. treatment of sleep disorders has been shown to improve maternal mental health (Quine 1992b; Wiggs & Stores 2001; Hiscock & Wake 2002); parents of children with ADHD may similarly benefit from resolution of their child s sleep problem (Sciberras et al. 2011) or where appropriate, intervention to address maternal mental health. In interpreting the results of this study, limitations must be considered. First, the sample is small and may be generalizable

6 144 P. Montgomery and L. Wiggs Table 4. Actigraphically derived objective child sleep measures of sleepless and non-sleepless children according to maternal definition of the presence of childhood sleeplessness Maternal definition sleeplessness (SM) (n = 33) Maternal definition no-sleeplessness comparison group (CM) (n = 12) Mann Whitney Median (inter-quartile range U-test statistic Duration of sleep (decimalized minutes) Mean (46.6) Mean (37.3) U = Median ( ) Median ( ) Time of falling asleep (24 h clock Mean 22:00 (1:12) Mean 21:42 (1:12) U = hours:minutes) Median 22:06 (21:30 22:27) Median 21:42 (20:54 22:54) Time of final waking (24 h clock Mean 7:30 (8:30) Mean 7:06 (0:48) U = hours:minutes) Median 7:30 (7:00 7:54) Median 7:06 (6:18 7:36) Wake minutes (decimalized minutes) Mean 52.7 (31.2) Mean 41.2 (27.7) U = Median 43.7 ( ) Median 27.3 ( ) Wake episodes (number) Mean 14.9 (5.9) Mean 13.5 (5.7) U = Median 14.8 ( ) Median 12.1 ( ) Activity during the sleep period Mean 16.4 (6.1) Mean 14.5 (4.3) U = Median 15.2 ( ) Median 13.3 ( ) Table 5. Actigraphically derived objective child sleep measures of sleepless and non-sleepless children defined according to quantitative criteria for the presence of childhood sleeplessness Quantitative definition sleeplessness (SQ) (n = 28) Quantitative definition no-sleeplessness comparison group (CQ) (n = 17) Mann Whitney U-test statistic Duration of sleep (decimalized minutes) Mean (49.0) Mean (35.1) U = Median ( ) Median ( ) Time of falling asleep (24 h clock Mean 21:54 (1:12) Mean 22:00 (1:06) U = hours:minutes) Median 21:54 (21:30 22:18) Median 22:18 (21:18 23:00) Time of final waking (24 h clock Mean 7:18 (0:48) Mean 7:26 (0:48) U = hours:minutes) Median 7:18 (7:00 7:36) Median 7:36 (6:42 8:12) Wake minutes (decimalized minutes) Mean 50.3 (33.7) Mean 48.5 (25.0) U = Median 47.4 ( ) Median 41.6 ( ) Wake episodes (number) Mean 14.2 (6.4) Mean 15.0 (4.9) U = Median 14.0 ( ) Median 14.0 ( ) Activity during the sleep period Mean 16.1 (6.4) Mean 15.6 (4.4) U = Median 15.3 ( ) Median 14.8 ( ) to all children with ADHD. Second, diagnosis of some co-morbid sleep problems (e.g. periodic limb movement disorders), which are likely to be present in a proportion of our sample (Picchietti et al. 1998; Owens et al. 2000) and may affect the interpretation of our findings, was not feasible. Third, we did not separately explore discrete types of sleeplessness (i.e. settling, night waking, early waking), which may result in differential effects on our outcomes of interest. Lastly, information about families who chose not to participate is limited as it was based upon clinicians reports and not assessed systematically. Conclusion Greater attention needs to be paid to the relationship between sleep and ADHD to unravel the direction of cause and effect. Furthermore, understanding the relationship between maternal mental state and child sleep in this population may help to determine therapeutic requirements. Objective assessment of child sleep, while unbiased by parental reporting, is not the only way of identifying children and families in need of help. Maternal reports of child sleeplessness, may also help to identify families in need but not necessarily guide choices

7 Sleeplessness definitions and mental state in mothers of children with ADHD 145 about what should be the key therapeutic targets (e.g. child sleep, parenting competency/self-efficacy, maternal depression). Key messages Maternal reports of sleeplessness as a problem in their child with ADHD is associated with maternal mental health problems. Increased doubts in parenting competency accompany mothers reports of sleeplessness (defined in terms of a yes/no problem and also in terms of frequency and duration of settling, night waking and early waking). Maternal reports of sleeplessness, while they may not relate to the child s objective sleep pattern, may still help to identify families where intervention of some kind may be appropriate. Funding This research was funded by the Medical Research Council. Acknowledgements The authors would like to thank all the children, parents, teachers and clinicians who helped with the research. References American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th edn, text revision (DSM-IV-TR). American Psychiatric Association, Washington, DC, USA. Chervin, R. D. & Archbold, K. H. (2001) Hyperactivity and polysomnographic findings in children evaluated for sleep-disordered breathing. Sleep, 24, Chervin, R. D., Archbold, K. H., Dillon, J. E., Piuch, K. J., Panahi, P., Dahl, R. E. & Guilleminault, C. (2002) Inattention, hyperactivity, and symptoms of sleep-disordered breathing. Pediatrics, 109, Choi, J., Yoon, I. Y., Kim, H. W., Chung, S. & Yoo, H. J. (2010) Differences between objective and subjective sleep measures in children with attention deficit hyperactivity disorder. Journal of Clinical Sleep Medicine, 15, Corkum, P., Tannock, R. & Moldofsky, H. (1998) Sleep disturbances in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, Cortese, S., Konofal, E., Yateman, N., Mouren, M. C. & Lecendreux, M. (2006) Sleep and alertness in children with attention-deficit/ hyperactivity disorder: a systematic review of the literature. Sleep, 29, DuPaul, G. J., Anastopoulos, A. D., Power, T. J., Reid, R., Ikeda, M. J. & McGoey, K. E. (1998) Parent ratings of attention deficit hyperactivity disorder symptoms: factor structure and normative data. Journal of Psychopathology and Behavioral Assessment, 20, DuPaul, G. J., Power, T. J., Anastopoulos, A. D., Reid, R., McGoey, K. E. & Ikeda, M. J. (1997) Teacher ratings of attention deficit hyperactivity disorder symptoms: factor structure and normative data. Psychological Assessment, 9, Fallone, G., Owens, J. A. & Deane, J. (2002) Sleepiness in children and adolescents: clinical implications. Sleep Medicine Reviews, 6, Goldberg, D. & Williams, P. (1991) A User s Guide to the General Health Questionnaire. NFER Nelson Publishing Company Ltd, Windsor, UK. Goldberg, D., Gater, R., Sartorius, N., Ustun, T. B., Piccinelli, M., Gurejeand, O. & Rutter, C. (1997) The validity of two versions of the GHQ in the WHO study of mental illness in general health care. Psychological Medicine, 27, Gruber, R., Sadeh, A. & Raviv, A. (2000) Instability of sleep patterns in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 39, Hiscock, H. & Wake, M. (2002) Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. British Medical Journal, 324, Johns, M. W. (1991) A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep, 14, Minde, K., Faucon, A. & Falkner, S. (1994) Sleep problems in toddlers: effects of treatment on their daytime behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 33, Montgomery, P., Stores, G. & Wiggs, L. (2004) The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: a randomised controlled trial. Archives of Disease in Childhood, 89, Morrell, J. M. B. (1999a) The Infant Sleep Questionnaire: a new tool to assess infant sleep problems for clinical and research purposes. Child Psychology and Psychiatry Review, 4, Morrell, J. M. B. (1999b) The role of maternal cognitions in infant sleep problems as assessed by a new instrument, the Maternal Cognitions about Infant Sleep Questionnaire. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 40, O Brien, L. M., Ivanenko, A., Crabtree, V., Holbrook, C., Bruner, J., Klaus, C. & Gozal, D. (2003) Sleep disturbances in children with attention deficit hyperactivity disorder. Pediatric Research, 54, Owens, J., Maxim, R., Nobile, C., McGuinn, M. & Msall, M. (2000) Parental and self-report of sleep in children with attention-deficit/ hyperactivity disorder. Archives of Pediatric and Adolescent Medicine, 154, Picchietti, D. L., England, S. J., Walters, A. S., Willis, K. & Verrico, T. (1998) Periodic limb movement disorder and restless legs

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