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PubMed2006

"Sleepiness" is serious in adolescence: two surveys of 3235 Canadian students.

BACKGROUND: Evidence is growing that sleep problems in adolescents are significant impediments to learning and negatively affect behaviour, attainment of social competence and quality of life. The objectives of the study were to determine the level of sleepiness among students in high school, to identify factors to explain it, and to determine the association between sleepiness and performance in both academic and extracurricular activities METHODS: A cross-sectional survey of 2201 high school students in the Hamilton Wentworth District School Board and the Near North District School Board in Ontario was conducted in 1998/9. A similar survey was done three years later involving 1034 students in the Grand Erie District School Board in the same Province. The Epworth Sleepiness Scale (ESS) was used to measure sleepiness and we also assessed the reliability of this tool for this population. Descriptive analysis of the cohort and information on various measures of performance and demographic data were included. Regression analysis, using the generalised estimating equation (GEE), was utilized to investigate factors associated with risk of sleepiness (ESS>10). RESULTS: Seventy per cent of the students had less than 8.5 hours weeknight sleep. Bedtime habits such as a consistent bedtime routine, staying up late or drinking caffeinated beverages before bed were statistically significantly associated with ESS, as were weeknight sleep quantity and gender. As ESS increased there was an increase in the proportion of students who felt their grades had dropped because of sleepiness, were late for school, were often extremely sleepy at school, and were involved in fewer extracurricular activities. These performance measures were statistically significantly associated with ESS. Twenty-three percent of the students felt their grades had dropped because of sleepiness. Most students (58-68%) reported that they were "really sleepy" between 8 and 10 A.M. CONCLUSION: Sleep deprivation and excessive daytime sleepiness were common in two samples of Ontario high school students and were associated with a decrease in academic achievement and extracurricular activity. There is a need to increase awareness of this problem in the education and health communities and to translate knowledge already available to strategies to address it.

Adolescent↗

PubMed2003

Correlation of subjective and objective sleep measurements at different stages of the treatment of depression.

Studies of the correlation of subjective and objective sleep measures in depressed patients have produced mixed results so far. Further, they were carried out in sleep laboratories and tended to obtain one-off assessments, thus not taking into account the effect of treatment. We investigated forty (40) patients over the course of 8-week treatment of depression with either paroxetine or nefazodone. We used home polysomnography at baseline, nights 3 and 10, and week 8 of treatment, with extensive assessments of subjective sleep, the morning after each sleep recording. The patients were able to judge accurately their total sleep time and sleep onset latency, both before and during treatment. However, they were inaccurate in estimating the number of times they woke up during the night. Sleep satisfaction correlated negatively with Stage 1 sleep at baseline. Sleep quality was represented by a combination of subjective parameters measuring the ease of initiation and maintenance of sleep, and it appeared to derive from slow wave sleep and sleep continuity as seen in polysomnography. The partial discrepancy between subjective and objective measures suggests that a cognitive element is combined with the biological element to produce the sleep problems reported by depressed patients.

Adult↗

PubMed2006

Body Mass Index (BMI) as a first-line screening criterion for detection of excessive daytime sleepiness among professional drivers.

OBJECTIVES: Obstructive sleep apnea (OSA) is the main predisposing factor of excessive daytime sleepiness (EDS), and, therefore, increases the risk of road crashes. However, it is difficult to rely on medical intake for OSA or fatigue since drivers' symptoms reports are not reliable. On the other hand, direct measurement of EDS among large numbers of drivers carries serious practical drawbacks. Obstructive sleep apnea, in turn, is strongly related to obesity, and elevated body mass index (BMI) is considered one of the major risk factors for OSA. Thus, it could be postulated that BMI may carry predictive value for EDS proneness. METHODS: The present study examined the interrelation between BMI, degree of OSA, as measured with Respiratory Distress Index (RDI), and the degree of EDS, as measured with the mean sleep onset latency in the Multiple Sleep Latency Test (MSLT) among obese (BMI = 32) professional drivers. The drivers went through polysomnography followed by the five sessions of MSLT in the next day. RESULTS: In accordance with prior studies, we have found strong correlation between BMI and the degree of OSA on the one hand, and between the degree of OSA and EDS on the other hand. OSA was detected among 77.7% of the drivers, 47.1% were sleepy, 19% had severe sleepiness [mean sleep latency [MSL < or = 5 min.], 28.1% had moderate sleepiness [MSL < or = 10 min.]. None of the drivers complained about any sleep problem, including snoring, and all reported that they do not experience excessive daytime sleepiness. Thus, there was no correlation between their subjective report and objective findings. CONCLUSIONS: Obese drivers with BMI above 32 are highly prone to be sleepy during the day. Their subjective reports of OSA or fatigue symptoms are not reliable. Therefore it is highly recommended to screen them easily by weight and height measure for further sleep study and decision about their driving abilities.

Adult↗

PubMed2006

The natural history of juvenile or subacute GM2 gangliosidosis: 21 new cases and literature review of 134 previously reported.

OBJECTIVE: Juvenile GM2 gangliosidosis is a group of inherited neurodegenerative diseases caused by deficiency of lysosomal beta-hexosaminidase resulting in GM2 ganglioside accumulation in brain. The purpose of this study was to delineate the natural history of the condition and identify genotype-phenotype correlations that might be helpful in predicting the course of the disease in individual patients. METHODS: A cohort of 21 patients with juvenile GM2 gangliosidosis, 15 with the Tay-Sachs variant and 6 with the Sandhoff variant, was studied prospectively in 2 centers. Our experience was compared with previously published reports on 134 patients. Information about clinical features, beta-hexosaminidase enzyme activity, and mutation analysis was collected. RESULTS: In our cohort of patients, the mean (+/-SD) age of onset of symptoms was 5.3 +/- 4.1 years, with a mean follow-up time of 8.4 years. The most common symptoms at onset were gait disturbances (66.7%), incoordination (52.4%), speech problems (28.6%), and developmental delay (28.6%). The age of onset of gait disturbances was 7.1 +/- 5.6 years. The mean time for progression to becoming wheelchair-bound was 6.2 +/- 5.5 years. The mean age of onset of speech problems was 7.0 +/- 5.6 years, with a mean time of progression to anarthria of 5.6 +/- 5.3 years. Muscle wasting (10.6 +/- 7.4 years), proximal weakness (11.1 +/- 7.7 years), and incontinence of sphincters (14.6 +/- 9.7 years) appeared later in the course of the disease. Psychiatric disturbances and neuropathy were more prevalent in patients with the Sandhoff variant than in those with the Tay-Sachs variant. However, dysphagia, sphincter incontinence, and sleep problems occurred earlier in those with the Tay-Sachs variant. Cerebellar atrophy was the most common finding on brain MRI (52.9%). The median survival time among the studied and reviewed patients was 14.5 years. The genotype-phenotype correlation revealed that in patients with the Tay-Sachs variant, the presence of R178H and R499H mutations was predictive of an early onset and rapidly progressive course. The presence of either G269S or W474C mutations was associated with a later onset of symptoms along with a more slowly progressive disease course. CONCLUSIONS: Juvenile GM2 gangliosidosis is clinically heterogeneous, not only in terms of age of onset and clinical features but also with regard to the course of the disease. In general, the earlier the onset of symptoms, the more rapidly the disease progresses. The Tay-Sachs and Sandhoff variants differed somewhat in the frequency of specific clinical characteristics. Speech deterioration progressed more rapidly than gait abnormalities in both the Tay-Sachs variant and Sandhoff variant groups. Among patients with the Tay-Sachs variant, the HEXA genotype showed a significant correlation with the clinical course.

Acute Disease↗

PubMed2002

Erectile dysfunction and symptoms of sleep disorders.

STUDY OBJECTIVES: Sleep apnea often is associated with impotence and/or erectile dysfunction (ED). The purpose of this study was to test whether a presentation for ED confers a pretest probability for obstructive sleep apnea hypopnea syndrome (OSAHS). DESIGN: A self-report survey for sleep complaints was conducted in consecutive male patients (>16 years of age) presenting to a urologic practice site. SETTING: The survey was provided to new and follow-up out-patients over a 2 month period of time. Other information collected included the presenting complaint, the clinical diagnosis for ED, and history of preexisting medical conditions. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: 285 males [91% of the sample: 50 years old (range 16-82) and body mass index, 27.3 (range 16.8-52.5)] completed the survey. 181 (63%) had complaints of ED; of those, 76% had a final diagnosis of organic and 8.2%, psychogenic or both psychogenic and organic ED. Of all respondents, 35.4% reported persistent snoring, 14% reported persistent waketime sleepiness or fatigue, and 26.8% were at "high risk" (Netzer et al., 1999) for OSAHS. Some were high risk for insomnia (13.6%) and restless legs syndrome or for narcolepsy (2% each). There was a correlation between those with ED complaints (p<0.014) or those with a final diagnosis of organic ED (p<0.029) and snoring. In a logistic model that included age, snoring, and preexisting conditions, only age, depression, and history of hypercholesterolemia, were found to vary significantly among those with and without ED. CONCLUSIONS: Urology patients will report a variety of sleep problems, but neither persistent snoring nor suspected OSAHS is correlated uniquely to ED.

Adolescent↗

PubMed1999

[Psychological issues in manned spaceflight].

As the duration of manned spaceflight becomes longer and as crews become more heterogeneous, psychological and interpersonal factors will be more important in affecting the safety of crew and flight mission. In space environment there are four types of stressors: physical, physiological, psychological and interpersonal. Psychological issues include "Asthenia", alteration in time sense, transcendent experiences, sleep problem, career motivation, psychosomatic symptoms and psychiatric issues. Interpersonal issues include interpersonal tension, interpersonal relationships decreased cohesiveness and deprivation, displacement [correction of dispiacement] of anger to outside personnel over time.

Adaptation, Psychological↗

PubMed1983

Hypnotic efficacy of midazolam in pre-surgical patients: a dose-finding study.

The hypnotic effect of midazolam on the sleep of pre-surgical patients was studied in 99 patients (53 males, 46 females) due to undergo surgery the following day. One tablet of 15 mg midazolam was administered at 21.00 h and a second was given 45 min later if the subject had not fallen asleep, sleep-onset latency being measured from the time the second tablet was taken. Eighty patients required 1 tablet and 19 required 2 tablets. According to the subjective assessment, patients receiving 1 tablet fell asleep in 22.9 +/- 14.9 min and those taking 2 tablets fell asleep in 38.4 +/- 25.3 min (difference significant P less than 0.05). There was no statistically significant difference between the 1- and 2-tablet groups with regard to sleep duration, number of awakenings, overall assessment of the night's sleep, sleep quality and state on awakening. Factors which had a statistically significant influence on the dosage requirement were (a) sex, 30.4% females requiring a second tablet v. 9.4% males; (b) age, the mean age of the 2-tablet group being 36.5 v. 47 years in the lower dose group; (c) weight, patients with lower body weight requiring the higher dosage, mean 57.5 v. 66 kg; (d) current insomnia or a history of sleeping problems; (e) previous use of hypnotics; (f) degree of insomnia, moderate/severe insomnia needing a higher dosage (42% v. 21%).(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Anxiety Agents↗

PubMed2026

Variants leading to ELAVL2 haploinsufficiency cause a neurodevelopmental disorder with prominent cognitive, behavioral, and neurological features.

RNA-binding proteins (RBPs) regulate gene expression, and a number of RBPs have been implicated in brain function and behavior. Here, we report 16 individuals with a neurodevelopmental disorder and de novo heterozygous variants in ELAVL2, encoding an RBP not previously linked to Mendelian disease. Thirteen individuals were identified through GeneMatcher. Their ELAVL2 variants include two structural, five nonsense, and six missense variants, supporting haploinsufficiency as the primary disease mechanism. The cohort presented with developmental delay, intellectual disability, autism spectrum disorder, seizures, sleep problems, sensory processing issues, emotional instability, and difficulty with socialization. Three additional variants (two missense and one terminal exon truncation), each previously reported in a different large cohort study, were also included for follow-up investigations. We provide multiple lines of evidence linking variants in ELAVL2 to the observed neurodevelopmental and behavioral phenotypes. First, we show that common genetic variants in ELAVL2 are significantly associated with intelligence, motor development, sleep-related traits, and sociability in the general population. Drosophila loss-of-function models provide further independent evidence for a conserved role in the regulation of seizure-like behavior, sensory processing, and sleep. Molecular studies confirm that some of the missense variants are deleterious, leading to decreased protein levels. Together, our integrative study combining Mendelian genetics, clinical and association studies, and animal and molecular modeling supports variants in ELAVL2 as a cause of a neurodevelopmental disorder, with haploinsufficiency as the disease mechanism, and identifies crucial roles of ELAVL2 in neuronal function, cognition, and behavior.

Humans↗

PubMed1991

[Can the use of hypnotics be reduced? Systematic influence on attitudes and prescription practice in a psychiatric department].

Because of frequent use of hypnotics to treat insomnia in the population in general and in institutions especially, an alternative programme of treatment has been developed at the psychiatric hospital, Modum Bads Nervesanatorium. The programme includes different components and levels of treatment, wherein use of hypnotics is the last choice. The main focus is on sleep hygiene, which consists mainly of working on the patients' own attitude towards and experience of sleep problems. The pre-requisite for running such a programme is a systematic approach to these attitudes among the staff, and the prescribing patterns by physicians.

Attitude of Health Personnel↗

PubMedDate not supplied

[Behavioral dimensions and behavior problems in 2 1/2-year-old children].

The present article gives a literature review on rating scales and psychometric instruments used for behavior rating in infants and toddlers. The results of gender specific factor analysis in a German normative sample of 2 1/2 year old children (N = 751) are compared to Achenbach's syndrome scales of the CBCL 2-3. In contrast to psychiatric diagnostic manuals (DSM-IV, ICD-10), which currently do not provide correct descriptions of the developmental psychopathology in this age group an empirically derived classification of age specific behavior is presented. Our own factor analysis replicated identically Achenbach's sleep-problem-scale for this age group and came very next to Achenbach's syndrome scales. A comparison of the published international normative samples for the CBCL 2-3 shows, that the results in the Netherlands, in the United States and Canada are not statistically different from our German group. In the context of developmental psychopathology we prognose gender specific factor solutions derived from a normative sample and not from a clinical population. Psychometric data of these different versions are presented and discussed from a child psychiatrists view on developmental psychopathology.

Child Behavior Disorders↗

PubMed1991

Detection of alcoholism in hospitalized children and their families.

The study sought to measure provider recognition of family alcohol-related problems among hospitalized children and to identify characteristics distinguishing "positive" families. The study sample (N = 147) was drawn from admissions to the general pediatric medical service of a metropolitan teaching hospital. Positivity was assessed through parent and patient interviews that included standard alcohol abuse screening instruments. Provider recognition was assessed through record review and physician interview. Of the 22 families screened positive, only one was so identified by the child's attending or resident physician. Positive and "negative" families were similar in most respects, although parents in positive families were more likely to report stress and sleeping problems and adolescents were more likely to report being troubled by a parent's drinking. The similarity of positive and negative families and the low pediatrician recognition rate suggest that alcohol problems are likely to go unnoticed without a conscious screening effort.

Adolescent↗

PubMed2007

Reference values for sleep-related respiratory variables in asymptomatic European children and adolescents.

AIM: Only a limited number of studies, designed to establish normal values for sleep-related respiratory variables in children, have been reported, and all are non-European. The aim of this study was to expand the knowledge on normative data in children. METHODS: Subjects ranging from 6 to 16 years were recruited and underwent full polysomnography. Only subjects without sleep disordered breathing or other sleep problems as assessed by clinical history were included. RESULTS: Sixty subjects were studied ( = 11.7 +/- 2.6 years; 28 boys; = 118.8 +/- 30.6%). was 0.85 +/- 1.06 (range: 0.0-5.5). was 0.06 +/- 0.16 (range: 0.0-0.9); 11 patients had a total of 31 obstructive apneas. Only five obstructive hypopneas were detected with = 0.08 +/- 0.17 (range: 0.0-0.9). was 1.98 +/- 1.39 (range: 0.1-7.2). was 97.0 +/- 0.6% (range: 96.0-98.0); was 91.8 +/- 2.7% (range: 82.0-96.0); <% of total sleep time with SaO2 >or= 95%> was 98.7 +/- 2.1% (range: 90.8-100.0); was 0.8 +/- 0.9 (range: 0.0-4.9) and was 6.1 +/- 1.8 (range: 2.7-10.9). Snoring was detected in 15 patients (4 overweight subjects), with no difference in patient characteristics and sleep-related respiratory variables between snorers and non-snorers. Subjects in the overweight group (n = 22) had a lower SaO2nadir (90.8 +/- 2.7 vs. 92.4 +/- 2.6; P = 0.01) and a higher ODI (1.3 +/- 1.3 vs. 0.4 +/- 0.4; P = 0.0002) than their normal weight peers. CONCLUSION: Our data are in agreement with other non-European studies, designed to establish normal values in children.

Adolescent↗

PubMed1992

Periodic limb movement disorder is associated with normal motor conduction latencies when studied by central magnetic stimulation--successful use of a new technique.

This study prospectively tested the hypothesis that patients with periodic limb movement disorder (PLMD) have longer motor conduction latencies than normals. Six healthy adults, 13 patients with PLMD, and 8 patients with long-term multiple sclerosis (MS) had recordings of motor conduction latencies during wake and sleep. MS subjects were included only to show that we could detect prolongation of central conduction; nonMS subjects were used to test the hypothesis. Subjects had no other medical or sleep problems. A novel magnetic stimulator, the Cadwell MES-10, was discharged over the vertex and the C7 cervical spine. It triggered compound muscle action potentials that were recorded in the abductor digiti minimi in the hand. The conduction latencies were the total conduction time (TCT), measured vertex to hand, and the peripheral conduction time (PCT), measured C7 to hand. The difference was the central conduction time (CCT). Only TCT could be obtained during sleep. Supporting the use of TCT as an indirect measure of central conduction was that, in all waking subjects, TCT correlated with CCT (r = 0.91, p = 0.001) but not with PCT. Reliabilities during wake and sleep were 0.95 or higher for TCT and PCT measurements. Waking CCT was greater in MS subjects (13.77 milliseconds) than those without MS (9.21 milliseconds), p = 0.001. Sleeping TCT was much less impressive in distinguishing MS subjects [27.08 milliseconds in nonrapid eye movement (NREM) sleep; 28.64 milliseconds in rapid eye movement (REM) sleep] from nonMS subjects (24.45 milliseconds in NREM; 24.84 milliseconds for REM), p = 0.07 for NREM and p = 0.04 for REM.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2003

Psychological treatment of reported sleep disorder in adults with intellectual disability using a multiple baseline design.

BACKGROUND: The literature on sleep disturbance in adults with intellectual disability (ID) is sparse. Although prevalence rates for sleep disorders appear similar to those of non-disabled populations, previous treatment studies have largely been comprised of uncontrolled cases. Therefore, the present study adopted a single-case experimental methodology to evaluate behavioural sleep intervention. METHODS: A screening questionnaire was posted to 384 adults with ID and the sleep pattern of respondents with possible sleep disorders was further assessed using a structured diagnostic schedule. From the sleep-disordered subgroup, 12 participants were selected for a 4-week behavioural sleep intervention that was evaluated using randomly allocated, multiple-baseline, across-subjects designs and within-subject interrupted time series analyses (ITSAs). RESULTS: A total of 155 adults with ID (83 females and 72 males; mean age = 32 years, SD = 16.5 years), or their carers, completed the questionnaire (return rate = 40%). The application of sleep diagnostic criteria revealed that 17% had clinically significant difficulty getting to sleep and 11% had difficulty remaining asleep. Nine out of the 12 participants recruited for the intervention completed all the experimental phases, thus providing three sets of three multiple-baseline designs. Visual inspection of within- and between-subject effects suggested beneficial treatment-specific effects across a range of target variables. The ITSA confirmed significant effects (P < 0.05) or trends (P < 0.10) for six out of the nine participants. CONCLUSIONS: Behavioural sleep management may improve sleep pattern or sleep-related functioning in the majority of adults with ID who have significant sleep problems. The single-case methodology is helpful in addressing the heterogeneity of individual presentation, although clinical trial methodology is required to confirm these findings on a larger scale.

Adult↗

PubMed1982

Screening for mental disorder among primary care patients. Usefulness of the General Health Questionnaire.

The General Health Questionnaire (GHQ) and a structured psychiatric interview (lifetime version of the Schedule for Affective Disorders and Schizophrenia) were administered to a sample of primary care patients in the United States. Responses to the GHQ tended to form factors that have substantive interpretations, such as depression, anxiety, sleep problems, and social functioning. However, there seems to be little gain in using subscale scores to help identify persons with different types of psychiatric disorders.

Adult↗

PubMed2002

Sleep disturbance in mucopolysaccharidosis type III (Sanfilippo syndrome): a survey of managing clinicians.

Sanfilippo syndrome (mucopolysaccharidosis type III) is the commonest mucoploysaccharidosis. It causes neurodegeneration with often profound sleep and behavioral disturbance. Management of the sleep disturbance is difficult and inconsistent. In this study, we surveyed clinicians with particular expertise in the management of individuals with mucopolysaccharidoses. We found that sleep problems are almost universal in this patient population and that no one treatment is consistently viewed as beneficial. Among the clinicians surveyed, melatonin is reported as the medication most likely to be of benefit. Benzodiazepines, chloral hydrate, antihistamines and antipsychotic agents are overall reported as less efficacious. The major side-effect of the medications as a group was reported to be daytime somnolence. Based on this study, recommendations are given regarding the approach to sleep disturbance in Sanfilippo syndrome.

Behavior Therapy↗

PubMed1995

Effects of late-afternoon methylphenidate administration on behavior and sleep in attention-deficit hyperactivity disorder.

OBJECTIVE: This study evaluated the effects on behavior and sleep of methylphenidate (MPH) administered at 4 PM to children with attention-deficit hyperactivity disorder (ADHD). METHODOLOGY: Twelve children admitted to a child psychiatric inpatient service with ADHD participated in a double-blind, crossover study in which they received a 4 PM dose of either 15 mg of MPH, 10 mg of MPH, or a placebo in random order for 12 consecutive days. Ratings of behavior, including ADHD symptoms, pertaining to the period from dose administration until sleep onset, were supplied nightly by hospital staff. Sleep latency and sleep adequacy were also assessed for each night. RESULTS: MPH resulted in markedly improved behavioral control compared with placebo; there was no difference between 15-mg and 10-mg MPH doses. MPH did not alter sleep latencies observed with the placebo. Children were more often rated as less tired on awakening after nights that they received 10 mg of MPH compared with 15 mg of MPH and the placebo. Weight loss was apparent among 83% of the patients, but dinner intake did not vary with third-dose condition. CONCLUSIONS: Morning and noon administration of stimulants to children with ADHD is a near-universal practice, but many clinicians avoid a third, late-afternoon administration for fear of inducing insomnia. This study's findings show that children with ADHD derive substantial symptom reduction from MPH administered in late afternoon, with no untoward effects on sleep. Therefore, three-times-a-day dosing should be considered for those children exhibiting ADHD symptoms in the evening. Adverse effects on sleep latency were not apparent in the sample overall. Nonetheless, monitoring for possible aggravation of sleep problems and weight loss remains sound treatment practice.

Attention Deficit Disorder with Hyperactivity↗

PubMed1987

Empirically based assessment of the behavioral/emotional problems of 2- and 3- year-old children.

The aim was to determine whether ratings of 2- and 3-year-olds could yield more differentiation among their behavioral/emotional problems than the internalizing-externalizing dichotomy found in previous studies. The 99-item Child Behavior Checklist for Ages 2-3 (CBCL/2-3) was designed to extend previously developed empirically based assessment procedures to 2-and 3-year-olds. Factor analyses of the CBCL/2-3 completed by parents of 398 2- and 3-year-olds yielded six syndromes having at least eight items loading greater than or equal to .30 and designated as Social Withdrawal, Depressed, Sleep Problems, Somatic Problems, Aggressive, and Destructive. Second-order analyses showed that the first two were related to a broad-band internalizing grouping, whereas the last two were related to a broad-band externalizing grouping. Scales for the six syndromes, two broad-band groupings, and total problem score were constructed from scores obtained by 273 children in a general population sample. Mean test-retest reliability r was .87, 1-year stability r was .69, 1-year predictive r with CBCL/4-16 scales at age 4 was .63, 2-year predictive r was .55, and 3-year predictive r was .49. Children referred for mental health services scored significantly higher than nonreferred children on all scales. A lack of significant r's with the Minnesota Child Development Inventory, Bayley, and McCarthy indicate that the CBCL/2-3 taps behavioral/emotional problems independently of the developmental variance tapped by these measures.

Affective Symptoms↗