Depression and anxiety in parents of children with ...



Running head: PREDICTORS OF PSYCHOLOGICAL MORBIDITY Predictors of Psychological Morbidity in Parents of Children with Intellectual DisabilitiesStephen Gallagher1* MSc, Anna C. Phillips1 PhD, Christopher Oliver2 PhD, and Douglas Carroll1 PhD1 School of Sport and Exercise Sciences, University of Birmingham, Birmingham, England 2 School of Psychology, University of Birmingham, Birmingham, EnglandCorrespondence to: Stephen Gallagher, School of Sport and Exercise Sciences, University of Birmingham, Birmingham, B15 2TT, England,Tel: ++44 121 4148747. Fax: ++44 121 4144121E-mail: sxg598@bham.ac.ukAbstractObjective: This study examined predictors of excess psychological morbidity in parents of children with intellectual disabilities.Methods: Thirty two parents of children with intellectual disabilities and 29 parents of typically developing children completed the Hospital Depression and Anxiety Scale, and measures of social support, child problem behaviours, sleep quality, and perceived caregiver burden. Results: Parents of children with intellectual disabilities registered high depression and anxiety scores and the majority met the criteria for possible clinical depression and/or anxiety. The strongest predictor of psychological morbidity was caregiver burden. Analyses of its component dimensions indicated that feelings of guilt held the greatest consequence for depression and anxiety. Conclusions: Caregiver burden, in general, and its guilt component, in particular, predicted symptoms of depression and anxiety in parents of children with intellectual disabilities. Assisting such parents to resolve their feelings of guilt should benefit their psychological status. Key words: Anxiety, Caregiving, Depression, Parents of Children with Intellectual DisabilityParents of children with intellectual disabilities frequently report symptoms of depression and anxiety ADDIN EN.CITE <EndNote><Cite><Author>Dunn</Author><Year>2001</Year><RecNum>91</RecNum><record><rec-number>91</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dunn, M. E.</author><author>Burbine, T.</author><author>Bowers, C. A.</author><author>Tantleff-Dunn, S.</author></authors></contributors><auth-address>Department of Psychology, University of Central Florida, Orlando 32816-1390, USA. mdunn@.ucf.edu</auth-address><titles><title>Moderators of stress in parents of children with autism</title><secondary-title>Community Mental Health Journal</secondary-title></titles><periodical><full-title>Community Mental Health Journal</full-title></periodical><pages>39-52</pages><volume>37</volume><number>1</number><keywords><keyword>Adaptation, Psychological/*classification</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Autistic Disorder/complications/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Cost of Illness</keyword><keyword>Disabled Children/*psychology</keyword><keyword>Florida</keyword><keyword>Humans</keyword><keyword>Internal-External Control</keyword><keyword>Middle Aged</keyword><keyword>Outcome Assessment (Health Care)</keyword><keyword>Parents/*psychology</keyword><keyword>Personal Satisfaction</keyword><keyword>*Social Support</keyword><keyword>Stress, Psychological/etiology/*prevention &amp; control</keyword></keywords><dates><year>2001</year><pub-dates><date>Feb</date></pub-dates></dates><accession-num>11300666</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Eisenhower</Author><Year>2005</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eisenhower, A. S.</author><author>Baker, B. L.</author><author>Blacher, J.</author></authors></contributors><auth-address>Department of Psychology, University of California, Los Angeles, CA 90095, USA. aeisenho@ucla.edu</auth-address><titles><title>Preschool children with intellectual disability: syndrome specificity, behaviour problems, and maternal well-being</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>657-71</pages><volume>49</volume><number>Pt 9</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/diagnosis/psychology</keyword><keyword>Cerebral Palsy/diagnosis/psychology</keyword><keyword>Child Behavior Disorders/diagnosis/*psychology</keyword><keyword>Child, Preschool</keyword><keyword>Developmental Disabilities/diagnosis/psychology</keyword><keyword>Down Syndrome/diagnosis/psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Retardation/diagnosis/*psychology</keyword><keyword>Mothers/*psychology</keyword><keyword>Parenting/psychology</keyword><keyword>Quality of Life/*psychology</keyword><keyword>Reference Values</keyword><keyword>Syndrome</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>16108983</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Hastings</Author><Year>2005</Year><RecNum>39</RecNum><record><rec-number>39</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hastings, R. P.</author><author>Kovshoff, H.</author><author>Brown, T.</author><author>Ward, N. J.</author><author>Espinosa, F. D.</author><author>Remington, B.</author></authors></contributors><auth-address>School of Psychology, University of Wales Bangor, Gwynedd, UK. r.hastings@bangor.ac.uk</auth-address><titles><title>Coping strategies in mothers and fathers of preschool and school-age children with autism</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>377-91</pages><volume>9</volume><number>4</number><keywords><keyword>*Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Autistic Disorder/*psychology</keyword><keyword>Caregivers/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Father-Child Relations</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Mother-Child Relations</keyword><keyword>Problem Solving</keyword><keyword>Religion</keyword></keywords><dates><year>2005</year><pub-dates><date>Oct</date></pub-dates></dates><accession-num>16155055</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Yirmiya</Author><Year>2005</Year><RecNum>79</RecNum><record><rec-number>79</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yirmiya, N.</author><author>Shaked, M.</author></authors></contributors><auth-address>Department of Psychology and School of Education, The Hebrew University of Jerusalem, Israel. NuritYirmiya@mscc.huji.ac.il</auth-address><titles><title>Psychiatric disorders in parents of children with autism: a meta-analysis</title><secondary-title>Journal of Child Psychology &amp; Psychiatry</secondary-title></titles><periodical><full-title>Journal of Child Psychology &amp; Psychiatry</full-title></periodical><pages>69-83</pages><volume>46</volume><number>1</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/*psychology</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Mental Disorders/*epidemiology/*psychology</keyword><keyword>*Parent-Child Relations</keyword><keyword>Phenotype</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2005</year><pub-dates><date>Jan</date></pub-dates></dates><accession-num>15660645</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Hastings, Kovshoff, Brown, Ward, Espinosa et al., 2005; Yirmiya & Shaked, 2005). Two key factors: the adequacy of social support and the extent of the child’s problem behaviours have been argued to account for much of the distress observed. Social support has generally been found to be inversely related to depression and anxiety in such parents ADDIN EN.CITE <EndNote><Cite><Author>Gray</Author><Year>1992</Year><RecNum>127</RecNum><record><rec-number>127</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Gray, D. E.</style></author><author><style face="normal" font="Times New Roman" size="100%">Holden, W. J</style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Psycho-social well-being among the parents of children with autism &#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">Journal of Intellectual and Developmental Disability&#xD;</style></secondary-title></titles><pages><style face="normal" font="Times New Roman" size="100%"> 83-93</style></pages><volume><style face="normal" font="Times New Roman" size="100%">Volume 18&#xD;</style></volume><number><style face="normal" font="Times New Roman" size="100%">Number 2</style></number><dates><year>1992</year><pub-dates><date>1992</date></pub-dates></dates><publisher><style face="normal" font="Times New Roman" size="100%">Taylor and Francis Ltd&#xD;</style></publisher><urls></urls></record></Cite><Cite><Author>Hare</Author><Year>2004</Year><RecNum>92</RecNum><record><rec-number>92</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hare, D. J.</author><author>Pratt, C.</author><author>Burton, M.</author><author>Bromley, J.</author><author>Emerson, E.</author></authors></contributors><auth-address>Academic Division of Clinical Psychology, University of Manchester, Education and Research Building, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK. dougal.hare@man.ac.uk</auth-address><titles><title>The health and social care needs of family carers supporting adults with autistic spectrum disorders</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>425-44</pages><volume>8</volume><number>4</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/*rehabilitation/*therapy</keyword><keyword>Data Collection</keyword><keyword>Family Health</keyword><keyword>Female</keyword><keyword>Health Services/*utilization</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Needs Assessment</keyword><keyword>Parent-Child Relations</keyword><keyword>Social Work/*statistics &amp; numerical data</keyword><keyword>Stress, Psychological</keyword></keywords><dates><year>2004</year><pub-dates><date>Dec</date></pub-dates></dates><accession-num>15556960</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Weiss</Author><Year>2002</Year><RecNum>63</RecNum><record><rec-number>63</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weiss, M. J.</author></authors></contributors><auth-address>Weiss, MJ&#xD;Rutgers State Univ, Douglass Dev Disabil Ctr, 25 Gibbons Circle, New Brunswick, NJ 08901 USA&#xD;Rutgers State Univ, Douglass Dev Disabil Ctr, New Brunswick, NJ 08901 USA</auth-address><titles><title>Hardiness and social support as predictors of stress in mothers of typical children, children with autism, and children with mental retardation</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>115-130</pages><volume>6</volume><number>1</number><keywords><keyword>autism</keyword><keyword>parental stress</keyword><keyword>social support</keyword><keyword>family stress</keyword><keyword>handicapped-children</keyword><keyword>life stress</keyword><keyword>profiles</keyword><keyword>parents</keyword><keyword>events</keyword></keywords><dates><year>2002</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1362-3613</isbn><accession-num>ISI:000174094500008</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000174094500008</url></related-urls></urls><language>English</language></record></Cite><Cite><Author>White</Author><Year>2004</Year><RecNum>59</RecNum><record><rec-number>59</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>White, N.</author><author>Hastings, R. P.</author></authors></contributors><auth-address>Hastings, RP&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales</auth-address><titles><title>Social and professional support for parents of adolescents with severe intellectual disabilities</title><secondary-title>Journal of Applied Research in Intellectual Disabilities</secondary-title></titles><periodical><full-title>Journal of Applied Research in Intellectual Disabilities</full-title></periodical><pages>181-190</pages><volume>17</volume><number>3</number><keywords><keyword>adolescence</keyword><keyword>parents</keyword><keyword>services</keyword><keyword>severe intellectual disabilities</keyword><keyword>social support</keyword><keyword>developmentally disabled-children</keyword><keyword>family-life-styles</keyword><keyword>behavior-problems</keyword><keyword>mental-retardation</keyword><keyword>positive perceptions</keyword><keyword>handicapped-child</keyword><keyword>autistic-children</keyword><keyword>2-factor model</keyword><keyword>downs-syndrome</keyword><keyword>stress</keyword></keywords><dates><year>2004</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1360-2322</isbn><accession-num>ISI:000223367200005</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000223367200005</url></related-urls></urls><language>English</language></record></Cite></EndNote>(Gray & Holden, 1992; White & Hastings, 2004), whereas the child's problem behaviours are positively associated with these symptoms ADDIN EN.CITE <EndNote><Cite><Author>Baker</Author><Year>2003</Year><RecNum>94</RecNum><record><rec-number>94</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baker, B. L.</author><author>McIntyre, L. L.</author><author>Blacher, J.</author><author>Crnic, K.</author><author>Edelbrock, C.</author><author>Low, C.</author></authors></contributors><auth-address>Department of Psychology, University of California, Los Angeles, CA 90095, USA. baker@psych.ucla.edu</auth-address><titles><title>Pre-school children with and without developmental delay: behaviour problems and parenting stress over time</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>217-30</pages><volume>47</volume><number>Pt 4-5</number><keywords><keyword>Adult</keyword><keyword>Child Behavior Disorders/*etiology</keyword><keyword>Child, Preschool</keyword><keyword>Developmental Disabilities/*psychology</keyword><keyword>Family/psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>*Parenting</keyword><keyword>Parents/psychology</keyword><keyword>Questionnaires</keyword><keyword>Stress, Psychological/psychology</keyword></keywords><dates><year>2003</year><pub-dates><date>May-Jun</date></pub-dates></dates><accession-num>12787154</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Blacher</Author><Year>2006</Year><RecNum>37</RecNum><record><rec-number>37</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Blacher, J.</author><author>McIntyre, L. L.</author></authors></contributors><auth-address>Graduate School of Education, University of California, Riverside, 92521-1028, USA. jan.blacher@ucr.edu</auth-address><titles><title>Syndrome specificity and behavioural disorders in young adults with intellectual disability: cultural differences in family impact</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>184-98</pages><volume>50</volume><number>Pt 3</number><keywords><keyword>Activities of Daily Living/classification/psychology</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Autistic Disorder/diagnosis/ethnology/psychology</keyword><keyword>Caregivers/*psychology</keyword><keyword>Cerebral Palsy/diagnosis/ethnology/psychology</keyword><keyword>Comorbidity</keyword><keyword>*Cost of Illness</keyword><keyword>*Cross-Cultural Comparison</keyword><keyword>Down Syndrome/diagnosis/ethnology/psychology</keyword><keyword>European Continental Ancestry Group/*psychology</keyword><keyword>Female</keyword><keyword>Hispanic Americans/*psychology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Disorders/*diagnosis/ethnology/psychology</keyword><keyword>Mental Retardation/*diagnosis/ethnology/psychology</keyword><keyword>Middle Aged</keyword><keyword>Mothers/*psychology</keyword><keyword>Quality of Life/psychology</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>16430730</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Blacher & McIntyre, 2006; White & Hastings, 2004)). More recently, within the wider caregiving context, sleep quality and caregiver burden have been identified as significant predictors of psychological morbidity ADDIN EN.CITE <EndNote><Cite><Author>Brummett</Author><Year>2006</Year><RecNum>139</RecNum><record><rec-number>139</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Brummett, B.H</style></author><author><style face="normal" font="Times New Roman" size="100%">Babyak, M.A</style></author><author><style face="normal" font="Times New Roman" size="100%">Segler, I.C,</style></author><author><style face="normal" font="Times New Roman" size="100%">Vitaliano, P.P</style></author><author><style face="normal" font="Times New Roman" size="100%">Ballard, E.L, </style></author><author><style face="normal" font="Times New Roman" size="100%">Gwyther, L.P, </style></author><author><style face="normal" font="Times New Roman" size="100%">Williams, R.B. </style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Associations among perceptions of social support, negative affect, and quality of sleep in caregivers and noncaregivers.&#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">Health Psychology</style></secondary-title></titles><periodical><full-title>Health Psychology</full-title></periodical><pages><style face="normal" font="Times New Roman" size="100%">220-225. &#xD;</style></pages><volume>25</volume><dates><year>2006</year></dates><urls></urls></record></Cite><Cite><Author>Magana</Author><Year>2007</Year><RecNum>146</RecNum><record><rec-number>146</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Magana, S. M.</author><author>Ramirez Garcia, J. I.</author><author>Hernandez, M. G.</author><author>Cortez, R.</author></authors></contributors><auth-address>Department of Social Work, Waisman Center, University of Wisconsin-Madison 53705, USA. magana@waisman.wisc.edu</auth-address><titles><title>Psychological distress among latino family caregivers of adults with schizophrenia: the roles of burden and stigma</title><secondary-title>Psychiatr Serv</secondary-title></titles><periodical><full-title>Psychiatr Serv</full-title></periodical><pages>378-84</pages><volume>58</volume><number>3</number><keywords><keyword>Adult</keyword><keyword>Caregivers/*psychology/*statistics &amp; numerical data</keyword><keyword>*Cost of Illness</keyword><keyword>Depressive Disorder, Major/*ethnology</keyword><keyword>Female</keyword><keyword>Hispanic Americans/*psychology/*statistics &amp; numerical data</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Questionnaires</keyword><keyword>Schizophrenia/*therapy</keyword><keyword>*Stereotyping</keyword></keywords><dates><year>2007</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>17325112</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Meltzer</Author><Year>2006</Year><RecNum>97</RecNum><record><rec-number>97</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Meltzer, L. J.</author><author>Mindell, J. A.</author></authors></contributors><auth-address>Division of Pulmonary Medicine, The Children&apos;s Hospital of Philadelphia, Department of Pediatrics, The University of Pennsylvania, Philadelphia 19104, USA. MeltzerL@email.chop.edu</auth-address><titles><title>Impact of a child&apos;s chronic illness on maternal sleep and daytime functioning</title><secondary-title>Archives of Internal Medicine</secondary-title></titles><periodical><full-title>Archives of Internal Medicine</full-title></periodical><pages>1749-55</pages><volume>166</volume><number>16</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Caregivers</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Chronic Disease</keyword><keyword>Cystic Fibrosis/*complications</keyword><keyword>Depression/epidemiology</keyword><keyword>Fatigue/epidemiology</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Interviews</keyword><keyword>Middle Aged</keyword><keyword>*Mothers</keyword><keyword>Pennsylvania/epidemiology</keyword><keyword>Questionnaires</keyword><keyword>*Respiration, Artificial</keyword><keyword>Sleep Disorders/*epidemiology</keyword><keyword>Stress, Psychological/epidemiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Sep 18</date></pub-dates></dates><accession-num>16983054</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Phipps</Author><Year>2005</Year><RecNum>154</RecNum><record><rec-number>154</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Phipps, S.</author><author>Dunavant, M.</author><author>Lensing, S.</author><author>Rai, S. N.</author></authors></contributors><auth-address>Division of Behavioral Medicine, St. Jude Children&apos;s Research Hospital, Memphis, Tennessee 38105-2794, USA. sean.phipps@</auth-address><titles><title>Psychosocial predictors of distress in parents of children undergoing stem cell or bone marrow transplantation</title><secondary-title>J Pediatr Psychol</secondary-title></titles><periodical><full-title>J Pediatr Psychol</full-title></periodical><pages>139-53</pages><volume>30</volume><number>2</number><keywords><keyword>*Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Affective Symptoms/diagnosis/*etiology/*psychology</keyword><keyword>*Bone Marrow Transplantation</keyword><keyword>Caregivers/*psychology</keyword><keyword>Child</keyword><keyword>Child Behavior/psychology</keyword><keyword>Cost of Illness</keyword><keyword>Family</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Parents/*psychology</keyword><keyword>Prospective Studies</keyword><keyword>Psychology</keyword><keyword>Questionnaires</keyword><keyword>Risk Factors</keyword><keyword>Social Environment</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>15681309</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Thompson</Author><Year>2007</Year><RecNum>148</RecNum><record><rec-number>148</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Thompson, A.</author><author>Fan, M. Y.</author><author>Unutzer, J.</author><author>Katon, W.</author></authors></contributors><auth-address>University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Seattle, WA, USA.</auth-address><titles><title>One extra month of depression: the effects of caregiving on depression outcomes in the IMPACT trial</title><secondary-title>Int J Geriatr Psychiatry</secondary-title></titles><periodical><full-title>Int J Geriatr Psychiatry</full-title></periodical><dates><year>2007</year><pub-dates><date>Oct 18</date></pub-dates></dates><accession-num>17944005</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Brummett, Babyak, Segler, Vitaliano, Ballard et al., 2006; Meltzer & Moore in press; Phipps, Dunavant, Lensing, & Rai, 2005; Thompson, Fan, Unutzer, & Katon, in press). These are factors amenable to psychological intervention ADDIN EN.CITE <EndNote><Cite><Author>Carter</Author><Year>2006</Year><RecNum>147</RecNum><record><rec-number>147</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Carter, P. A.</author></authors></contributors><auth-address>School of Nursing, University of Texas at Austin, Austin, TX 78701, USA. pcarter@mail.nur.utexas.edu</auth-address><titles><title>A brief behavioral sleep intervention for family caregivers of persons with cancer</title><secondary-title>Cancer Nurs</secondary-title></titles><periodical><full-title>Cancer Nurs</full-title></periodical><pages>95-103</pages><volume>29</volume><number>2</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Behavior Therapy/*methods</keyword><keyword>Caregivers/*psychology</keyword><keyword>Depression/complications/therapy</keyword><keyword>Feasibility Studies</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Neoplasms</keyword><keyword>Quality of Life</keyword><keyword>Sleep Initiation and Maintenance Disorders/etiology/*nursing</keyword><keyword>Texas</keyword></keywords><dates><year>2006</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><accession-num>16565618</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Ostwald</Author><Year>1999</Year><RecNum>149</RecNum><record><rec-number>149</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ostwald, S. K.</author><author>Hepburn, K. W.</author><author>Caron, W.</author><author>Burns, T.</author><author>Mantell, R.</author></authors></contributors><auth-address>University of Texas-Houston, Center on Aging, Houston 77030, USA. sostwald@admin4.hsc.uth.tmc.edu</auth-address><titles><title>Reducing caregiver burden: a randomized psychoeducational intervention for caregivers of persons with dementia</title><secondary-title>Gerontologist</secondary-title></titles><periodical><full-title>Gerontologist</full-title></periodical><pages>299-309</pages><volume>39</volume><number>3</number><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Caregivers/*education/*psychology</keyword><keyword>Cognition</keyword><keyword>Dementia/*nursing/psychology</keyword><keyword>Depression/etiology</keyword><keyword>Family</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword></keywords><dates><year>1999</year><pub-dates><date>Jun</date></pub-dates></dates><accession-num>10396888</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Carter, 2006; Ostwald, Hepburn, Caron, Burns, & Mantell, 1999). However, sleep quality and caregiving burden have rarely been examined as possible predictors of depression and anxiety in parents caring for children with intellectual disabilities. Sleep quality is an important aspect of well-being and is strongly related to overall quality of life ADDIN EN.CITE <EndNote><Cite><Author>Zammit</Author><Year>1999</Year><RecNum>95</RecNum><record><rec-number>95</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zammit, G. K.</author><author>Weiner, J.</author><author>Damato, N.</author><author>Sillup, G. P.</author><author>McMillan, C. A.</author></authors></contributors><auth-address>Columbia University College of Physicians and Surgeon, New York, NY, USA.</auth-address><titles><title>Quality of life in people with insomnia</title><secondary-title>Sleep</secondary-title></titles><periodical><full-title>Sleep</full-title></periodical><pages>S379-85</pages><volume>22 Suppl 2</volume><keywords><keyword>Activities of Daily Living</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Quality of Life</keyword><keyword>Questionnaires</keyword><keyword>Sleep Initiation and Maintenance Disorders/diagnosis/*psychology/therapy</keyword></keywords><dates><year>1999</year><pub-dates><date>May 1</date></pub-dates></dates><accession-num>10394611</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Zammit, Weiner, Damato, Sillup, & McMillan, 1999), and to the increased prevalence of depression and anxiety in various caregiver groups ADDIN EN.CITE <EndNote><Cite><Author>Brummett</Author><Year>2006</Year><RecNum>139</RecNum><record><rec-number>139</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Brummett, B.H</style></author><author><style face="normal" font="Times New Roman" size="100%">Babyak, M.A</style></author><author><style face="normal" font="Times New Roman" size="100%">Segler, I.C,</style></author><author><style face="normal" font="Times New Roman" size="100%">Vitaliano, P.P</style></author><author><style face="normal" font="Times New Roman" size="100%">Ballard, E.L, </style></author><author><style face="normal" font="Times New Roman" size="100%">Gwyther, L.P, </style></author><author><style face="normal" font="Times New Roman" size="100%">Williams, R.B. </style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Associations among perceptions of social support, negative affect, and quality of sleep in caregivers and noncaregivers.&#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">Health Psychology</style></secondary-title></titles><periodical><full-title>Health Psychology</full-title></periodical><pages><style face="normal" font="Times New Roman" size="100%">220-225. &#xD;</style></pages><volume>25</volume><dates><year>2006</year></dates><urls></urls></record></Cite><Cite><Author>Flaskerud</Author><Year>2000</Year><RecNum>96</RecNum><record><rec-number>96</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Flaskerud, J. H.</author><author>Carter, P. A.</author><author>Lee, P.</author></authors></contributors><auth-address>UCLA School of Nursing, Los Angeles, USA. jflasker@sonnet.ucla.edu</auth-address><titles><title>Distressing emotions in female caregivers of people with AIDS, age-related dementias, and advanced-stage cancers</title><secondary-title>Perspectives in Psychiatric Care</secondary-title></titles><periodical><full-title>Perspectives in Psychiatric Care</full-title></periodical><pages>121-30</pages><volume>36</volume><number>4</number><keywords><keyword>Acquired Immunodeficiency Syndrome/*nursing/psychology</keyword><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Affective Symptoms/nursing/psychology</keyword><keyword>Aged</keyword><keyword>Alzheimer Disease/*nursing/psychology</keyword><keyword>Caregivers/*psychology</keyword><keyword>Female</keyword><keyword>Home Nursing/psychology</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Neoplasms/*nursing/psychology</keyword><keyword>Personality Inventory</keyword><keyword>Terminal Care/*psychology</keyword></keywords><dates><year>2000</year><pub-dates><date>Oct-Dec</date></pub-dates></dates><accession-num>12035204</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Brummett et al., 2006; Flaskerud, Carter, & Lee, 2000). For example, parents caring for children with physical disabilities were characterized by both poor sleep quality and depression ADDIN EN.CITE <EndNote><Cite><Author>Meltzer</Author><Year>2007</Year><RecNum>153</RecNum><record><rec-number>153</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Meltzer, L. J.</author><author>Moore, M.</author></authors></contributors><auth-address>The Children&apos;s Hospital of Philadelphia and The University of Pennsylvania.</auth-address><titles><title>Sleep Disruptions in Parents of Children and Adolescents with Chronic Illnesses: Prevalence, Causes, and Consequences</title><secondary-title>Journal of Pediatric Psychology</secondary-title></titles><periodical><full-title>Journal of Pediatric Psychology</full-title></periodical><dates><year>2007</year><pub-dates><date>Dec 15</date></pub-dates></dates><accession-num>18084038</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Meltzer & Moore, in press). Another source of psychological morbidity in those caring for demanding others is perceived caregiver burden (Thompson, et al., in press; Maes, Broekman, Dosen & Nauts, 2003) ADDIN EN.CITE <EndNote><Cite><Author>Clyburn</Author><Year>2000</Year><RecNum>98</RecNum><record><rec-number>98</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clyburn, L. D.</author><author>Stones, M. J.</author><author>Hadjistavropoulos, T.</author><author>Tuokko, H.</author></authors></contributors><auth-address>Department of Psychology, Lakehead University, Thunder Bay, Ontario.</auth-address><titles><title>Predicting caregiver burden and depression in Alzheimer&apos;s disease</title><secondary-title>Journals of Gerontology B: Psychological Science and Social Sciences</secondary-title></titles><periodical><full-title>Journals of Gerontology B: Psychological Science and Social Sciences</full-title></periodical><pages>S2-13</pages><volume>55</volume><number>1</number><keywords><keyword>Activities of Daily Living/psychology</keyword><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Alzheimer Disease/*psychology</keyword><keyword>Canada</keyword><keyword>Caregivers/*psychology</keyword><keyword>*Cost of Illness</keyword><keyword>Depression/diagnosis/*psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Institutionalization</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Models, Psychological</keyword><keyword>Social Support</keyword></keywords><dates><year>2000</year><pub-dates><date>Jan</date></pub-dates></dates><accession-num>10728125</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Maes</Author><Year>2003</Year><RecNum>113</RecNum><record><rec-number>113</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maes, B.</author><author>Broekman, T. G.</author><author>Dosen, A.</author><author>Nauts, J.</author></authors></contributors><auth-address>Department of Special Education, University of Leuven, Vesaliusstraat 2, Leuven, Belgium. bea.maes@ped.kuleuven.ac.be</auth-address><titles><title>Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>447-55</pages><volume>47</volume><number>Pt 6</number><keywords><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Belgium</keyword><keyword>Caregivers/*psychology</keyword><keyword>*Cost of Illness</keyword><keyword>Family/*psychology</keyword><keyword>Humans</keyword><keyword>Mental Disorders/*psychology</keyword><keyword>Mental Retardation/*psychology</keyword><keyword>Needs Assessment</keyword><keyword>Netherlands</keyword><keyword>Social Behavior Disorders/*psychology</keyword></keywords><dates><year>2003</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>12919195</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>. Perceived burden includes embarrassment, guilt, overload, feelings of entrapment, resentment, isolation from society, and loss of control ADDIN EN.CITE <EndNote><Cite><Author>Zarit</Author><Year>1980</Year><RecNum>101</RecNum><record><rec-number>101</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zarit, S. H.</author><author>Reever, K. E.</author><author>Bach-Peterson, J.</author></authors></contributors><titles><title>Relatives of the impaired elderly: correlates of feelings of burden</title><secondary-title>Gerontologist</secondary-title></titles><periodical><full-title>Gerontologist</full-title></periodical><pages>649-55</pages><volume>20</volume><number>6</number><keywords><keyword>*Aged</keyword><keyword>Dementia/rehabilitation</keyword><keyword>*Guilt</keyword><keyword>Humans</keyword><keyword>*Life Support Care</keyword></keywords><dates><year>1980</year><pub-dates><date>Dec</date></pub-dates></dates><accession-num>7203086</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Zarit, Reever, & Bach-Peterson, 1980). In parents of children with intellectual disabilities, curtailed employment opportunities, a likely consequence of burden, were associated with feelings of isolation, lack of fulfillment, and low self-esteem ADDIN EN.CITE <EndNote><Cite><Author>Shearn</Author><Year>2000</Year><RecNum>103</RecNum><record><rec-number>103</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Shearn, J.</author><author>Todd, S.</author></authors></contributors><auth-address>Shearn, J&#xD;Univ Wales, Coll Med, Welsh Ctr Learning Disabil, Meridian Court,North Rd, Cardiff CF14 3BG, S Glam, Wales&#xD;Univ Wales, Coll Med, Welsh Ctr Learning Disabil, Cardiff CF14 3BG, S Glam, Wales</auth-address><titles><title>Maternal employment and family responsibilities: the perspectives of mothers of children with intellectual disabilities</title><secondary-title>Journal of Applied Research in Intellectual Disabilities</secondary-title></titles><periodical><full-title>Journal of Applied Research in Intellectual Disabilities</full-title></periodical><pages>109-131</pages><volume>13</volume><number>3</number><keywords><keyword>parent care</keyword><keyword>learning-disabilities</keyword><keyword>stress</keyword><keyword>work</keyword><keyword>attitudes</keyword><keyword>adults</keyword><keyword>women</keyword><keyword>life</keyword><keyword>adaptation</keyword><keyword>support</keyword></keywords><dates><year>2000</year></dates><isbn>1360-2322</isbn><accession-num>ISI:000090093200001</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000090093200001</url></related-urls></urls><language>English</language></record></Cite></EndNote>(Shearn & Todd, 2000). Further, a higher caregiver burden in parents caring for children with intellectual disabilities has been related to a greater use of external health services ADDIN EN.CITE <EndNote><Cite><Author>Maes</Author><Year>2003</Year><RecNum>113</RecNum><record><rec-number>113</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Maes, B.</author><author>Broekman, T. G.</author><author>Dosen, A.</author><author>Nauts, J.</author></authors></contributors><auth-address>Department of Special Education, University of Leuven, Vesaliusstraat 2, Leuven, Belgium. bea.maes@ped.kuleuven.ac.be</auth-address><titles><title>Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>447-55</pages><volume>47</volume><number>Pt 6</number><keywords><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Belgium</keyword><keyword>Caregivers/*psychology</keyword><keyword>*Cost of Illness</keyword><keyword>Family/*psychology</keyword><keyword>Humans</keyword><keyword>Mental Disorders/*psychology</keyword><keyword>Mental Retardation/*psychology</keyword><keyword>Needs Assessment</keyword><keyword>Netherlands</keyword><keyword>Social Behavior Disorders/*psychology</keyword></keywords><dates><year>2003</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>12919195</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Maes et al., 2003). The present study aimed to confirm the high levels of depression and anxiety in parents of children with intellectual disabilities using a case control design and then to explore the role social support, child behaviour problems, sleep quality, and caregiver burden in the excess psychological morbidity observed in this group. It was hypothesized: first, that parents of children with intellectual disabilities would report much higher levels of both depression and anxiety than parents of children who were typically developing; and second, that poorer social support and sleep quality, more problematic offspring behaviour, and higher perceived caregiver burden would be associated with their greater psychological morbidity.MethodsParticipants Participants were 32 parents of children with intellectual disabilities and 29 parents of typically developing children. Cases, i.e. parents of intellectual disabled children, were recruited via invitation letters distributed by their respective associations and by adverts in local newspapers and syndrome newsletters, family support groups and by word of mouth. Inclusion criteria for these parents were: caring for at least one child with Downs, Autism, Cornelia de Lange, or Smith-Magenis syndromes; the intellectually disabled child had to be aged between 3 and 19 years and cared for at home during the school term. The majority of these parents self-reported caring for a child with Autism (66%); the remainder reported caring for a child with Downs syndrome (22%) and children with other syndromes (e.g. Cornelia de Lange) (12%). Controls, i.e. parents of typically developing children, were recruited via local schools, media campaigns and advertisements placed within University newspapers. The same age of child and domicile inclusion criteria applied. ProceduresOne hundred and one parents contacted us about participating and 61 agreed to participate. Participants were each given a pack of questionnaires to complete and had the option of completing the questionnaires at the University or at home, returning them in a prepaid envelope. The study was approved by the relevant Research Ethics Committees and all participants gave informed consent. Measures Depression and anxietyParental psychological morbidity was measured using the Hospital Anxiety and Depression Scale (HADS) ADDIN EN.CITE <EndNote><Cite><Author>Zigmond</Author><Year>1983</Year><RecNum>104</RecNum><record><rec-number>104</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zigmond, A. S.</author><author>Snaith, R. P.</author></authors></contributors><titles><title>The hospital anxiety and depression scale</title><secondary-title>Acta Psychiatrica Scandavia</secondary-title></titles><periodical><full-title>Acta Psychiatrica Scandavia</full-title></periodical><pages>361-70</pages><volume>67</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Anxiety Disorders/*diagnosis</keyword><keyword>Depressive Disorder/*diagnosis</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Interview, Psychological</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Outpatient Clinics, Hospital</keyword><keyword>Outpatients/*psychology</keyword><keyword>Patients/*psychology</keyword><keyword>*Psychiatric Status Rating Scales</keyword><keyword>Psychometrics</keyword></keywords><dates><year>1983</year><pub-dates><date>Jun</date></pub-dates></dates><accession-num>6880820</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Zigmond & Snaith, 1983). The scale contains 14 four-point items, from 0 (not present) to 3 (considerable), with seven assessing largely the anhedonic rather the somatic aspects of depression (e.g., ‘I have lost interest in my appearance’) and seven assessing anxiety (e.g., ‘I feel tense or wound up’). The scale has been used in research with parents of children with intellectual disabilities ADDIN EN.CITE <EndNote><Cite><Author>Hastings</Author><Year>2002</Year><RecNum>49</RecNum><record><rec-number>49</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hastings, R. P.</author><author>Brown, T.</author></authors></contributors><auth-address>Hastings, RP&#xD;Univ Southampton, Dept Psychol, Ctr Behav Res Anal &amp; Intervent Dev Disabil, Southampton SO17 1BJ, Hants, England&#xD;Univ Southampton, Dept Psychol, Ctr Behav Res Anal &amp; Intervent Dev Disabil, Southampton SO17 1BJ, Hants, England</auth-address><titles><title>Behavior problems of children with autism, parental self-efficacy, and mental health</title><secondary-title>American Journal on Mental Retardation</secondary-title></titles><periodical><full-title>American Journal on Mental Retardation</full-title></periodical><pages>222-232</pages><volume>107</volume><number>3</number><keywords><keyword>direct-care staff</keyword><keyword>severe intellectual disability</keyword><keyword>challenging behaviors</keyword><keyword>learning-disabilities</keyword><keyword>handicapped-children</keyword><keyword>stress</keyword><keyword>mothers</keyword><keyword>depression</keyword><keyword>competence</keyword><keyword>people</keyword></keywords><dates><year>2002</year><pub-dates><date>May</date></pub-dates></dates><isbn>0895-8017</isbn><accession-num>ISI:000175518200007</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000175518200007</url></related-urls></urls><language>English</language></record></Cite><Cite><Author>Hastings</Author><Year>2005</Year><RecNum>39</RecNum><record><rec-number>39</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hastings, R. P.</author><author>Kovshoff, H.</author><author>Brown, T.</author><author>Ward, N. J.</author><author>Espinosa, F. D.</author><author>Remington, B.</author></authors></contributors><auth-address>School of Psychology, University of Wales Bangor, Gwynedd, UK. r.hastings@bangor.ac.uk</auth-address><titles><title>Coping strategies in mothers and fathers of preschool and school-age children with autism</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>377-91</pages><volume>9</volume><number>4</number><keywords><keyword>*Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Autistic Disorder/*psychology</keyword><keyword>Caregivers/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Father-Child Relations</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Mother-Child Relations</keyword><keyword>Problem Solving</keyword><keyword>Religion</keyword></keywords><dates><year>2005</year><pub-dates><date>Oct</date></pub-dates></dates><accession-num>16155055</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Hastings et al., 2005). For the present sample, Cronbach’s α was .86 for both the depression and the anxiety subscales.Social supportSocial support was assessed using the 12-item Support Functions Scale ADDIN EN.CITE <EndNote><Cite><Author>Dunst</Author><Year>1988</Year><RecNum>132</RecNum><record><rec-number>132</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Dunst, C.J, </style></author><author><style face="normal" font="Times New Roman" size="100%">Trivette, C.M, </style></author><author><style face="normal" font="Times New Roman" size="100%">Deal, A.G,</style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Enabling and Empowering&#xD;Families: Principles and Guidelines for Practice.</style><style face="italic" font="Times New Roman" size="100%"> </style></title><secondary-title><style face="normal" font="default" size="100%">Cambridge,</style><style face="normal" font="default" size="8">&#xD;</style><style face="normal" font="Times New Roman" size="100%">MA: Brookline Books.</style><style face="normal" font="default" size="8"> </style><style face="normal" font="default" size="10">&#xD;</style></secondary-title></titles><dates><year>1988</year></dates><urls></urls></record></Cite></EndNote>(Dunst, Trivette, & Deal, 1988). Parents rate sources of support available to them (e.g. ‘someone to help take care of my child’ and (e.g. ‘someone to talk to about things that worry me’) support on a 5-point Likert scale ranging from 1, never, to 5, quite often. This scale has been used previously in intellectual disability research ADDIN EN.CITE <EndNote><Cite><Author>White</Author><Year>2004</Year><RecNum>59</RecNum><record><rec-number>59</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>White, N.</author><author>Hastings, R. P.</author></authors></contributors><auth-address>Hastings, RP&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales</auth-address><titles><title>Social and professional support for parents of adolescents with severe intellectual disabilities</title><secondary-title>Journal of Applied Research in Intellectual Disabilities</secondary-title></titles><periodical><full-title>Journal of Applied Research in Intellectual Disabilities</full-title></periodical><pages>181-190</pages><volume>17</volume><number>3</number><keywords><keyword>adolescence</keyword><keyword>parents</keyword><keyword>services</keyword><keyword>severe intellectual disabilities</keyword><keyword>social support</keyword><keyword>developmentally disabled-children</keyword><keyword>family-life-styles</keyword><keyword>behavior-problems</keyword><keyword>mental-retardation</keyword><keyword>positive perceptions</keyword><keyword>handicapped-child</keyword><keyword>autistic-children</keyword><keyword>2-factor model</keyword><keyword>downs-syndrome</keyword><keyword>stress</keyword></keywords><dates><year>2004</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1360-2322</isbn><accession-num>ISI:000223367200005</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000223367200005</url></related-urls></urls><language>English</language></record></Cite></EndNote>(White & Hastings, 2004). A high internal consistency (Cronbach’s α =.89) was also evident for the present sample.Child’s problem behaviour The 25-item Strengths and Difficulties Questionnaire ADDIN EN.CITE <EndNote><Cite><Author>Goodman</Author><Year>1997</Year><RecNum>151</RecNum><record><rec-number>151</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goodman, R.</author></authors></contributors><auth-address>Department of Child and Adolescent Psychiatry, Institute of Psychiatry, De Crespigny Park, London, U.K.</auth-address><titles><title>The Strengths and Difficulties Questionnaire: a research note</title><secondary-title>J Child Psychol Psychiatry</secondary-title></titles><periodical><full-title>J Child Psychol Psychiatry</full-title></periodical><pages>581-6</pages><volume>38</volume><number>5</number><keywords><keyword>Adolescent</keyword><keyword>Child</keyword><keyword>Child Behavior/*classification</keyword><keyword>Child Psychiatry/*methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Disorders/*diagnosis</keyword><keyword>*Psychiatric Status Rating Scales</keyword><keyword>Questionnaires</keyword><keyword>Reproducibility of Results</keyword><keyword>Social Behavior</keyword></keywords><dates><year>1997</year><pub-dates><date>Jul</date></pub-dates></dates><accession-num>9255702</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Goodman, 1997), was used to screen for child behaviour problems. The scale has five subscales, with one assessing prosocial behaviour and four assessing problems behaviours. Parents are asked to rate whether a behaviour is true (1), somewhat true (0) or certainly true (2) of their child with higher scores indicating more problem behaviours. For the purposes of our analyses only the problem behaviour total score was used and a satisfactory Cronbach's alpha was obtained in the present sample α =.88. Sleep quality The 19-item Pittsburgh Sleep Quality Index ADDIN EN.CITE <EndNote><Cite><Author>Buysse</Author><Year>1989</Year><RecNum>111</RecNum><record><rec-number>111</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Buysse, D. J.</author><author>Reynolds, C. F., 3rd</author><author>Monk, T. H.</author><author>Berman, S. R.</author><author>Kupfer, D. J.</author></authors></contributors><auth-address>Department of Psychiatry, University of Pittsburgh School of Medicine, PA.</auth-address><titles><title>The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research</title><secondary-title>Psychiatry Research</secondary-title></titles><periodical><full-title>Psychiatry Research</full-title></periodical><pages>193-213</pages><volume>28</volume><number>2</number><keywords><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Depression/*psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>*Psychological Tests</keyword><keyword>Psychometrics</keyword><keyword>Sleep Initiation and Maintenance Disorders/*diagnosis/psychology</keyword><keyword>*Sleep Stages</keyword></keywords><dates><year>1989</year><pub-dates><date>May</date></pub-dates></dates><accession-num>2748771</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) was used to assess sleep quality and disturbance. This index encompasses several dimensions of sleep from subjective sleep quality, sleep latency, to daytime dysfunction. Scores on items range from 0 (no difficulty) to 3 (severe difficulty). By summing component scores, a total sleep quality score is obtained that ranges from 0 (good sleep quality) to 21 (poor sleep quality). In the present study Cronbach’s α for the total scale was .86. The scale has also recently been used to assess sleep quality in caregiver research ADDIN EN.CITE <EndNote><Cite><Author>Brummett</Author><Year>2006</Year><RecNum>139</RecNum><record><rec-number>139</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Brummett, B.H</style></author><author><style face="normal" font="Times New Roman" size="100%">Babyak, M.A</style></author><author><style face="normal" font="Times New Roman" size="100%">Segler, I.C,</style></author><author><style face="normal" font="Times New Roman" size="100%">Vitaliano, P.P</style></author><author><style face="normal" font="Times New Roman" size="100%">Ballard, E.L, </style></author><author><style face="normal" font="Times New Roman" size="100%">Gwyther, L.P, </style></author><author><style face="normal" font="Times New Roman" size="100%">Williams, R.B. </style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Associations among perceptions of social support, negative affect, and quality of sleep in caregivers and noncaregivers.&#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">Health Psychology</style></secondary-title></titles><periodical><full-title>Health Psychology</full-title></periodical><pages><style face="normal" font="Times New Roman" size="100%">220-225. &#xD;</style></pages><volume>25</volume><dates><year>2006</year></dates><urls></urls></record></Cite></EndNote>(Brummett et al., 2006). Caregiver burdenAs a measure of parental caregiver burden, an adapted version of the 22-item Caregiver Burden Index was used (Zarit, Reever, & Bach-Peterson, 1980). Examples of items include ‘Do you feel that because of the time you spend with your child that you don’t have enough time for yourself?’, ‘Are you afraid what the future holds for your child?’, and ‘Overall, how burdened do you feel in caring for your child?’. Responses range from never (0) to nearly always (4). High internal consistency (Cronbach’s α = .94) was evident for the present sample.Statistical analysesInitial analyses of group differences were by Chi-square and univariate ANOVA and ANCOVA, with η2 reported as a measure of effect size. Subsequent analysis within the parents of children with intellectual disabilities was by regression. Linear regression was applied with continuous HADS depression and anxiety scores, and logistic regression was used when possible pathology was determined, yielding binary variables, using established cut-off values ≥ 8. Results Group differences in depression and anxietySince the parents of children with Downs syndrome and other syndromes did not differ from the parents of children on the autistic spectrum on the outcome variables, the cases were treated as a uniform group. The summary characteristics of the cases and controls are presented in Table 1. As can be seen, there are substantial differences between parental groups in depression and anxiety. In addition, the parents of children with intellectual disabilities were slightly older, cared for older children, and were less likely to be currently employed outside the home. Accordingly, variations in depression and anxiety were re-examined with adjustment for these variables. The large differences in depression, F (1, 54) = 29.04, p < .001, η2 = .350, and anxiety, F(1, 54) = 33.08, p < .001, η2 = .380, scores remained. [Insert Table 1 about here]Within group analyses Analyses now focused on whether social support, child behaviour problems, sleep quality, and caregiver burden accounted for this excess depression and anxiety among the cases. Child behaviour problems, β = .34, t = 2.08, p = .04, R2 = .13, social support, β = -.40, t = 2.39, p = .02, R2 = .16, sleep quality, β = .56, t = 3.69, p = .001, R2 = .31, and caregiver burden, β = .64, t = 4.34, p <.001, R2 = .41, all separately predicted depression. However, in a model, in which all four of these variables were entered simultaneously, only social support, β = -.34, p = .02, and caregiver burden, β = .53, p = .009, were significant predictors of depressive symptomatology. This model accounted for 56% of the variation in depression scores among parents caring for intellectual disabled children. With regard to anxiety scores, sleep quality, β = .50, t = 3.13, p = .004, R2 = .25, and caregiver burden, β = .66, t = 4.65, p <.001, R2 = .44, predicted anxiety levels. In a model in which sleep quality and caregiver burden were both entered, only the latter emerged as a significant predictor, β = .57, p = .004, and the model accounted for 45% of the variation in anxiety scores. In analyses using the criterion ≥ 8 for possible pathology, it was burden which again emerged as the single predictor of depression, OR = 1.33, 95% CI = 1.04 – 1.69, p =.013, and anxiety, OR = 1.15, 95% CI = 1.00 – 1.32, p =.019. Caregiver burden Previous principal component analysis of the caregiver burden index has uncovered three dimensions of burden: negative social and personal consequences, psychological burden, and guilt ADDIN EN.CITE <EndNote><Cite><Author>Ankri</Author><Year>2005</Year><RecNum>138</RecNum><record><rec-number>138</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Ankri, J</style></author><author><style face="normal" font="Times New Roman" size="100%">Andrieu,S </style></author><author><style face="normal" font="Times New Roman" size="100%">Beaufils, B </style></author><author><style face="normal" font="Times New Roman" size="100%">Grand, A </style></author><author><style face="normal" font="Times New Roman" size="100%">Henrard, JC.</style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians&#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">International Journal of Geriatric Psychiatry&#xD;</style></secondary-title></titles><pages>254-260</pages><volume>20</volume><number>3</number><dates><year>2005</year></dates><urls></urls></record></Cite></EndNote>(Ankri, Andrieu, Beaufils, Grand, & Henrard, 2005). Examples of items loading on these factors are ‘Do you feel that your child currently affects your relationship with other family and friends in a negative way?’, ‘Do you feel strained when you are around your child?’, ‘Do you feel you could do a better job in caring for your child?’, respectively. In regression analyses, entering all three components, it was guilt that emerged as the strongest predictor of both depression, β = .35, p = .07, and anxiety, β = .49, p = .008, scores.Discussion The present study confirmed that parents caring for a child with an intellectual disability report substantial symptoms of depression and anxiety ADDIN EN.CITE <EndNote><Cite><Author>Dunn</Author><Year>2001</Year><RecNum>91</RecNum><record><rec-number>91</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dunn, M. E.</author><author>Burbine, T.</author><author>Bowers, C. A.</author><author>Tantleff-Dunn, S.</author></authors></contributors><auth-address>Department of Psychology, University of Central Florida, Orlando 32816-1390, USA. mdunn@.ucf.edu</auth-address><titles><title>Moderators of stress in parents of children with autism</title><secondary-title>Community Mental Health Journal</secondary-title></titles><periodical><full-title>Community Mental Health Journal</full-title></periodical><pages>39-52</pages><volume>37</volume><number>1</number><keywords><keyword>Adaptation, Psychological/*classification</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Autistic Disorder/complications/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Cost of Illness</keyword><keyword>Disabled Children/*psychology</keyword><keyword>Florida</keyword><keyword>Humans</keyword><keyword>Internal-External Control</keyword><keyword>Middle Aged</keyword><keyword>Outcome Assessment (Health Care)</keyword><keyword>Parents/*psychology</keyword><keyword>Personal Satisfaction</keyword><keyword>*Social Support</keyword><keyword>Stress, Psychological/etiology/*prevention &amp; control</keyword></keywords><dates><year>2001</year><pub-dates><date>Feb</date></pub-dates></dates><accession-num>11300666</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Eisenhower</Author><Year>2005</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eisenhower, A. S.</author><author>Baker, B. L.</author><author>Blacher, J.</author></authors></contributors><auth-address>Department of Psychology, University of California, Los Angeles, CA 90095, USA. aeisenho@ucla.edu</auth-address><titles><title>Preschool children with intellectual disability: syndrome specificity, behaviour problems, and maternal well-being</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>657-71</pages><volume>49</volume><number>Pt 9</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/diagnosis/psychology</keyword><keyword>Cerebral Palsy/diagnosis/psychology</keyword><keyword>Child Behavior Disorders/diagnosis/*psychology</keyword><keyword>Child, Preschool</keyword><keyword>Developmental Disabilities/diagnosis/psychology</keyword><keyword>Down Syndrome/diagnosis/psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Retardation/diagnosis/*psychology</keyword><keyword>Mothers/*psychology</keyword><keyword>Parenting/psychology</keyword><keyword>Quality of Life/*psychology</keyword><keyword>Reference Values</keyword><keyword>Syndrome</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>16108983</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Yirmiya</Author><Year>2005</Year><RecNum>79</RecNum><record><rec-number>79</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yirmiya, N.</author><author>Shaked, M.</author></authors></contributors><auth-address>Department of Psychology and School of Education, The Hebrew University of Jerusalem, Israel. NuritYirmiya@mscc.huji.ac.il</auth-address><titles><title>Psychiatric disorders in parents of children with autism: a meta-analysis</title><secondary-title>Journal of Child Psychology &amp; Psychiatry</secondary-title></titles><periodical><full-title>Journal of Child Psychology &amp; Psychiatry</full-title></periodical><pages>69-83</pages><volume>46</volume><number>1</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/*psychology</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Mental Disorders/*epidemiology/*psychology</keyword><keyword>*Parent-Child Relations</keyword><keyword>Phenotype</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2005</year><pub-dates><date>Jan</date></pub-dates></dates><accession-num>15660645</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Hastings et al., 2005; Yirmiya & Shaked, 2005). Almost two thirds of the parents of intellectually disabled children in the current study met the conventional criterion for possible clinical depression, and three quarters for possible anxiety. Similar levels of caseness for depression on the HADS were observed in an earlier UK study, although lower estimates of anxiety were reported ADDIN EN.CITE <EndNote><Cite><Author>White</Author><Year>2004</Year><RecNum>59</RecNum><record><rec-number>59</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>White, N.</author><author>Hastings, R. P.</author></authors></contributors><auth-address>Hastings, RP&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales</auth-address><titles><title>Social and professional support for parents of adolescents with severe intellectual disabilities</title><secondary-title>Journal of Applied Research in Intellectual Disabilities</secondary-title></titles><periodical><full-title>Journal of Applied Research in Intellectual Disabilities</full-title></periodical><pages>181-190</pages><volume>17</volume><number>3</number><keywords><keyword>adolescence</keyword><keyword>parents</keyword><keyword>services</keyword><keyword>severe intellectual disabilities</keyword><keyword>social support</keyword><keyword>developmentally disabled-children</keyword><keyword>family-life-styles</keyword><keyword>behavior-problems</keyword><keyword>mental-retardation</keyword><keyword>positive perceptions</keyword><keyword>handicapped-child</keyword><keyword>autistic-children</keyword><keyword>2-factor model</keyword><keyword>downs-syndrome</keyword><keyword>stress</keyword></keywords><dates><year>2004</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1360-2322</isbn><accession-num>ISI:000223367200005</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000223367200005</url></related-urls></urls><language>English</language></record></Cite></EndNote>(White & Hastings, 2004). Further, whereas none of the control parents met the criteria (HADS cutoff > 11) for definite depression or anxiety, a third and a half, respectively, of the parents caring for an intellectually disabled child did. In spite of this, none of these parents reported taking anti-depressants, only one was using anxiolytic medication, and none were receiving formal cognitive behaviour therapy. In line with previous research, poor social support and more problematic child behaviours were associated with increased psychological morbidity in parents caring for a child with an intellectual disability ADDIN EN.CITE <EndNote><Cite><Author>Dunn</Author><Year>2001</Year><RecNum>91</RecNum><record><rec-number>91</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dunn, M. E.</author><author>Burbine, T.</author><author>Bowers, C. A.</author><author>Tantleff-Dunn, S.</author></authors></contributors><auth-address>Department of Psychology, University of Central Florida, Orlando 32816-1390, USA. mdunn@.ucf.edu</auth-address><titles><title>Moderators of stress in parents of children with autism</title><secondary-title>Community Mental Health Journal</secondary-title></titles><periodical><full-title>Community Mental Health Journal</full-title></periodical><pages>39-52</pages><volume>37</volume><number>1</number><keywords><keyword>Adaptation, Psychological/*classification</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Autistic Disorder/complications/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>*Cost of Illness</keyword><keyword>Disabled Children/*psychology</keyword><keyword>Florida</keyword><keyword>Humans</keyword><keyword>Internal-External Control</keyword><keyword>Middle Aged</keyword><keyword>Outcome Assessment (Health Care)</keyword><keyword>Parents/*psychology</keyword><keyword>Personal Satisfaction</keyword><keyword>*Social Support</keyword><keyword>Stress, Psychological/etiology/*prevention &amp; control</keyword></keywords><dates><year>2001</year><pub-dates><date>Feb</date></pub-dates></dates><accession-num>11300666</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Eisenhower</Author><Year>2005</Year><RecNum>3</RecNum><record><rec-number>3</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eisenhower, A. S.</author><author>Baker, B. L.</author><author>Blacher, J.</author></authors></contributors><auth-address>Department of Psychology, University of California, Los Angeles, CA 90095, USA. aeisenho@ucla.edu</auth-address><titles><title>Preschool children with intellectual disability: syndrome specificity, behaviour problems, and maternal well-being</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>657-71</pages><volume>49</volume><number>Pt 9</number><keywords><keyword>Adult</keyword><keyword>Autistic Disorder/diagnosis/psychology</keyword><keyword>Cerebral Palsy/diagnosis/psychology</keyword><keyword>Child Behavior Disorders/diagnosis/*psychology</keyword><keyword>Child, Preschool</keyword><keyword>Developmental Disabilities/diagnosis/psychology</keyword><keyword>Down Syndrome/diagnosis/psychology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Retardation/diagnosis/*psychology</keyword><keyword>Mothers/*psychology</keyword><keyword>Parenting/psychology</keyword><keyword>Quality of Life/*psychology</keyword><keyword>Reference Values</keyword><keyword>Syndrome</keyword></keywords><dates><year>2005</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>16108983</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Gray</Author><Year>1992</Year><RecNum>127</RecNum><record><rec-number>127</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Gray, D. E.</style></author><author><style face="normal" font="Times New Roman" size="100%">Holden, W. J</style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Psycho-social well-being among the parents of children with autism &#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">Journal of Intellectual and Developmental Disability&#xD;</style></secondary-title></titles><pages><style face="normal" font="Times New Roman" size="100%"> 83-93</style></pages><volume><style face="normal" font="Times New Roman" size="100%">Volume 18&#xD;</style></volume><number><style face="normal" font="Times New Roman" size="100%">Number 2</style></number><dates><year>1992</year><pub-dates><date>1992</date></pub-dates></dates><publisher><style face="normal" font="Times New Roman" size="100%">Taylor and Francis Ltd&#xD;</style></publisher><urls></urls></record></Cite><Cite><Author>White</Author><Year>2004</Year><RecNum>59</RecNum><record><rec-number>59</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>White, N.</author><author>Hastings, R. P.</author></authors></contributors><auth-address>Hastings, RP&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales&#xD;Univ Wales Bangor, Sch Psychol, Bangor LL57 2DG, Gwynedd, Wales</auth-address><titles><title>Social and professional support for parents of adolescents with severe intellectual disabilities</title><secondary-title>Journal of Applied Research in Intellectual Disabilities</secondary-title></titles><periodical><full-title>Journal of Applied Research in Intellectual Disabilities</full-title></periodical><pages>181-190</pages><volume>17</volume><number>3</number><keywords><keyword>adolescence</keyword><keyword>parents</keyword><keyword>services</keyword><keyword>severe intellectual disabilities</keyword><keyword>social support</keyword><keyword>developmentally disabled-children</keyword><keyword>family-life-styles</keyword><keyword>behavior-problems</keyword><keyword>mental-retardation</keyword><keyword>positive perceptions</keyword><keyword>handicapped-child</keyword><keyword>autistic-children</keyword><keyword>2-factor model</keyword><keyword>downs-syndrome</keyword><keyword>stress</keyword></keywords><dates><year>2004</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1360-2322</isbn><accession-num>ISI:000223367200005</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000223367200005</url></related-urls></urls><language>English</language></record></Cite></EndNote>(Hastings et al., 2005; Gray & Holden, 1992; White & Hastings, 2004). Although, not previously studied in this context, poor sleep quality and a high caregiver burden were, as expected, associated with higher levels of both depression and anxiety. This extends results from other caregiving contexts ADDIN EN.CITE <EndNote><Cite><Author>Meltzer</Author><Year>2006</Year><RecNum>97</RecNum><record><rec-number>97</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Meltzer, L. J.</author><author>Mindell, J. A.</author></authors></contributors><auth-address>Division of Pulmonary Medicine, The Children&apos;s Hospital of Philadelphia, Department of Pediatrics, The University of Pennsylvania, Philadelphia 19104, USA. MeltzerL@email.chop.edu</auth-address><titles><title>Impact of a child&apos;s chronic illness on maternal sleep and daytime functioning</title><secondary-title>Archives of Internal Medicine</secondary-title></titles><periodical><full-title>Archives of Internal Medicine</full-title></periodical><pages>1749-55</pages><volume>166</volume><number>16</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Caregivers</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Chronic Disease</keyword><keyword>Cystic Fibrosis/*complications</keyword><keyword>Depression/epidemiology</keyword><keyword>Fatigue/epidemiology</keyword><keyword>Female</keyword><keyword>Health Status</keyword><keyword>Humans</keyword><keyword>Interviews</keyword><keyword>Middle Aged</keyword><keyword>*Mothers</keyword><keyword>Pennsylvania/epidemiology</keyword><keyword>Questionnaires</keyword><keyword>*Respiration, Artificial</keyword><keyword>Sleep Disorders/*epidemiology</keyword><keyword>Stress, Psychological/epidemiology</keyword></keywords><dates><year>2006</year><pub-dates><date>Sep 18</date></pub-dates></dates><accession-num>16983054</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Vedhara</Author><Year>2002</Year><RecNum>116</RecNum><record><rec-number>116</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vedhara, K.</author><author>McDermott, M. P.</author><author>Evans, T. G.</author><author>Treanor, J. J.</author><author>Plummer, S.</author><author>Tallon, D.</author><author>Cruttenden, K. A.</author><author>Schifitto, G.</author></authors></contributors><auth-address>MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Canynge Hall, UK. k.vedhara@bris.ac.uk</auth-address><titles><title>Chronic stress in nonelderly caregivers: psychological, endocrine and immune implications</title><secondary-title>Journal of Psychosomatic Research</secondary-title></titles><periodical><full-title>Journal of Psychosomatic Research</full-title></periodical><pages>1153-61</pages><volume>53</volume><number>6</number><keywords><keyword>Adult</keyword><keyword>Caregivers/*psychology</keyword><keyword>Chronic Disease/rehabilitation</keyword><keyword>Dehydroepiandrosterone/analysis</keyword><keyword>Endocrine System/physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hydrocortisone/analysis</keyword><keyword>Immune System/*physiology</keyword><keyword>Immunoglobulin G/analysis</keyword><keyword>Male</keyword><keyword>Morbidity</keyword><keyword>Saliva/chemistry</keyword><keyword>Spouses</keyword><keyword>*Stress, Psychological</keyword></keywords><dates><year>2002</year><pub-dates><date>Dec</date></pub-dates></dates><accession-num>12479999</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Wright</Author><Year>2006</Year><RecNum>76</RecNum><record><rec-number>76</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wright, M.</author><author>Tancredi, A.</author><author>Yundt, B.</author><author>Larin, H. M.</author></authors></contributors><auth-address>McMaster Children&apos;s Hospital-CDRP, Hamilton, ON, Canada. wrightm@hhsc.ca</auth-address><titles><title>Sleep issues in children with physical disabilities and their families</title><secondary-title>Physical &amp; Occupational Therapy in Pediatrics</secondary-title></titles><periodical><full-title>Physical &amp; Occupational Therapy in Pediatrics</full-title></periodical><pages>55-72</pages><volume>26</volume><number>3</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Caregivers/*psychology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Disabled Children/psychology/*rehabilitation</keyword><keyword>Family/*psychology</keyword><keyword>Female</keyword><keyword>Health Surveys</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Ontario/epidemiology</keyword><keyword>Parents/psychology</keyword><keyword>Prevalence</keyword><keyword>Risk Factors</keyword><keyword>Siblings/psychology</keyword><keyword>Sleep Disorders/*epidemiology/prevention &amp; control</keyword></keywords><dates><year>2006</year></dates><accession-num>16966316</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Meltzer & Mindell, in press; Thompson et al., in press). However, it is possible that whether or not an independent association emerges in studies between some of these variables and psychological morbidity depends on what has been included in the analyses. In competitive analyses in the current study, caregiving burden emerged as by far the strongest independent predictor of depression and anxiety. Caregiver burden is a broad concept that has been shown to encompass three principal components: negative social and personal consequences; psychological burden; and guilt ADDIN EN.CITE <EndNote><Cite><Author>Ankri</Author><Year>2005</Year><RecNum>138</RecNum><record><rec-number>138</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author><style face="normal" font="Times New Roman" size="100%">Ankri, J</style></author><author><style face="normal" font="Times New Roman" size="100%">Andrieu,S </style></author><author><style face="normal" font="Times New Roman" size="100%">Beaufils, B </style></author><author><style face="normal" font="Times New Roman" size="100%">Grand, A </style></author><author><style face="normal" font="Times New Roman" size="100%">Henrard, JC.</style></author></authors></contributors><titles><title><style face="normal" font="Times New Roman" size="100%">Beyond the global score of the Zarit Burden Interview: useful dimensions for clinicians&#xD;</style></title><secondary-title><style face="normal" font="Times New Roman" size="100%">International Journal of Geriatric Psychiatry&#xD;</style></secondary-title></titles><pages>254-260</pages><volume>20</volume><number>3</number><dates><year>2005</year></dates><urls></urls></record></Cite></EndNote>(Ankri et al., 2005). It was the latter of these that proved to be the strongest predictor of psychological morbidity in parents caring for an intellectually disabled child. There is indirect evidence in favor of this contention. A number of studies have observed that the parents of children with intellectual disabilities who reported feelings of guilt also indicated that they lacked confidence in their parenting abilities and decision-making which, in turn, was associated with increased distress, including anxiety ADDIN EN.CITE <EndNote><Cite><Author>Benderix</Author><Year>2006</Year><RecNum>124</RecNum><record><rec-number>124</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Benderix, Y.</author><author>Nordstrom, B.</author><author>Sivberg, B.</author></authors></contributors><auth-address>Health Science Division, Faculty of Medicine, Lund University, Lund, Sweden. ylva.benderix@med.lu.se</auth-address><titles><title>Parents&apos; experience of having a child with autism and learning disabilities living in a group home: a case study</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>629-41</pages><volume>10</volume><number>6</number><keywords><keyword>Adult</keyword><keyword>Asperger Syndrome/complications/*psychology/*therapy</keyword><keyword>*Attitude to Health</keyword><keyword>Child</keyword><keyword>*Group Homes</keyword><keyword>Humans</keyword><keyword>Interviews</keyword><keyword>Learning Disorders/complications</keyword><keyword>Male</keyword><keyword>Parent-Child Relations</keyword><keyword>Parents/*psychology</keyword><keyword>Residential Treatment</keyword></keywords><dates><year>2006</year><pub-dates><date>Nov</date></pub-dates></dates><accession-num>17088278</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Lenhard</Author><Year>2005</Year><RecNum>56</RecNum><record><rec-number>56</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lenhard, W.</author><author>Breitenbach, E.</author><author>Ebert, H.</author><author>Schindelhauer-Deutscher, H. J.</author><author>Henn, W.</author></authors></contributors><auth-address>Lenhard, W&#xD;Univ Wurzburg, Inst Special Educ, D-97074 Wurzburg, Germany&#xD;Univ Wurzburg, Inst Special Educ, D-97074 Wurzburg, Germany&#xA;Univ Saarland, Inst Human Genet, D-6650 Homburg, Germany</auth-address><titles><title>Psychological benefit of diagnostic certainty for mothers of children with disabilities: Lessons from Down syndrome</title><secondary-title>American Journal of Medical Genetics Part A</secondary-title></titles><periodical><full-title>American Journal of Medical Genetics Part A</full-title></periodical><pages>170-175</pages><volume>133A</volume><number>2</number><keywords><keyword>diagnostic certainty and uncertainty</keyword><keyword>mental retardation</keyword><keyword>unclear diagnosis</keyword><keyword>down syndrome</keyword><keyword>coping</keyword><keyword>anxiety</keyword><keyword>guilt</keyword><keyword>mental-retardation</keyword><keyword>chronic sorrow</keyword><keyword>aging mothers</keyword><keyword>parents</keyword><keyword>uncertainty</keyword><keyword>stress</keyword><keyword>adjustment</keyword><keyword>distress</keyword><keyword>care</keyword><keyword>illness</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar 1</date></pub-dates></dates><isbn>1552-4825</isbn><accession-num>ISI:000227194100010</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000227194100010</url></related-urls></urls><language>English</language></record></Cite></EndNote>(Benderix, Nordstrom, & Sivberg, 2006; Lenhard, Breitenbach, Ebert, Schindelhauer-Deutscher, & Henn, 2005). The current study has a number of limitations. First, the data are cross-sectional. Accordingly, the high levels of psychological morbidity observed in parents caring for children with intellectual disabilities may be transitory. However, there is evidence that high levels of depression in this population persist over time ADDIN EN.CITE <EndNote><Cite><Author>Dyson</Author><Year>1993</Year><RecNum>88</RecNum><record><rec-number>88</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dyson, L. L.</author></authors></contributors><auth-address>Faculty of Education, University of Victoria, British Columbia, Canada.</auth-address><titles><title>Response to the presence of a child with disabilities: parental stress and family functioning over time</title><secondary-title>American Journal of Mental Retardation</secondary-title></titles><periodical><full-title>American Journal of Mental Retardation</full-title></periodical><pages>207-18</pages><volume>98</volume><number>2</number><keywords><keyword>Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>*Attitude to Health</keyword><keyword>Caregivers</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Developmental Disabilities/psychology</keyword><keyword>*Disabled Persons/psychology</keyword><keyword>*Family</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mental Retardation/psychology</keyword><keyword>Parent-Child Relations</keyword><keyword>Parents/psychology</keyword><keyword>Probability</keyword><keyword>Stress, Psychological/*psychology</keyword></keywords><dates><year>1993</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>7691096</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite><Cite><Author>Glidden</Author><Year>2003</Year><RecNum>26</RecNum><record><rec-number>26</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Glidden, L. M.</author><author>Schoolcraft, S. A.</author></authors></contributors><auth-address>St Mary&apos;s College of Maryland, St Mary&apos;s City, Maryland 20686, USA. lmglidden@smcm.edu</auth-address><titles><title>Depression: its trajectory and correlates in mothers rearing children with intellectual disability</title><secondary-title>Journal of Intellectual Disability Research</secondary-title></titles><periodical><full-title>Journal of Intellectual Disability Research</full-title></periodical><pages>250-63</pages><volume>47</volume><number>Pt 4-5</number><keywords><keyword>Adult</keyword><keyword>Child</keyword><keyword>Depression/diagnosis/epidemiology/*psychology</keyword><keyword>*Disabled Children</keyword><keyword>Family/psychology</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>*Mental Retardation/etiology</keyword><keyword>Mothers</keyword><keyword>Psychological Tests</keyword><keyword>Questionnaires</keyword><keyword>Time Factors</keyword></keywords><dates><year>2003</year><pub-dates><date>May-Jun</date></pub-dates></dates><accession-num>12787157</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Glidden & Schoolcraft, 2003). Further, in the present study, perceived stress scores were stable over a 6-month period. Second, our sample size might be regarded as small. Parents of intellectually disabled children are, for obvious reasons, notoriously difficult to recruit for research purposes and this study is of the same order of magnitude of other published studies ADDIN EN.CITE <EndNote><Cite><Author>Weiss</Author><Year>2002</Year><RecNum>63</RecNum><record><rec-number>63</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Weiss, M. J.</author></authors></contributors><auth-address>Weiss, MJ&#xD;Rutgers State Univ, Douglass Dev Disabil Ctr, 25 Gibbons Circle, New Brunswick, NJ 08901 USA&#xD;Rutgers State Univ, Douglass Dev Disabil Ctr, New Brunswick, NJ 08901 USA</auth-address><titles><title>Hardiness and social support as predictors of stress in mothers of typical children, children with autism, and children with mental retardation</title><secondary-title>Autism</secondary-title></titles><periodical><full-title>Autism</full-title></periodical><pages>115-130</pages><volume>6</volume><number>1</number><keywords><keyword>autism</keyword><keyword>parental stress</keyword><keyword>social support</keyword><keyword>family stress</keyword><keyword>handicapped-children</keyword><keyword>life stress</keyword><keyword>profiles</keyword><keyword>parents</keyword><keyword>events</keyword></keywords><dates><year>2002</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1362-3613</isbn><accession-num>ISI:000174094500008</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000174094500008</url></related-urls></urls><language>English</language></record></Cite></EndNote>(White and Hastings, 2004). Finally, employment outside the home and age of caregiver and age of care recipient differentiated the groups. However, the main differences in psychological morbidity between cases and controls were still evident following adjustment for these variables. In summary, relative to parents of typically developing children, parents caring for children with intellectual disabilities reported high levels of depression and anxiety; the majority of these parents met the established criteria for possible clinical depression and/or anxiety. The strongest and most consistent predictor of morbidity was caregiver burden. Guilt was the component of burden that was most associated with depression and anxiety. In the context of bereavement, formally addressing guilt through psychological intervention has been reported to ameliorate symptoms of depression and anxiety ADDIN EN.CITE <EndNote><Cite><Author>Nikcevic</Author><Year>2007</Year><RecNum>150</RecNum><record><rec-number>150</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nikcevic, A. V.</author><author>Kuczmierczyk, A. R.</author><author>Nicolaides, K. H.</author></authors></contributors><auth-address>Harris Birthright Research Centre for Fetal Medicine, King&apos;s College Hospital Medical, School, London, United Kingdom. a.nikcevic@kingston.ac.uk</auth-address><titles><title>The influence of medical and psychological interventions on women&apos;s distress after miscarriage</title><secondary-title>J Psychosom Res</secondary-title></titles><periodical><full-title>J Psychosom Res</full-title></periodical><pages>283-90</pages><volume>63</volume><number>3</number><keywords><keyword>Abortion, Missed/etiology/*psychology</keyword><keyword>*Adaptation, Psychological</keyword><keyword>Adult</keyword><keyword>Anxiety/diagnosis/psychology</keyword><keyword>*Counseling</keyword><keyword>Depression/diagnosis/psychology</keyword><keyword>Family Practice</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Grief</keyword><keyword>Guilt</keyword><keyword>Humans</keyword><keyword>Patient Education as Topic</keyword><keyword>Patient Satisfaction</keyword><keyword>Physician-Patient Relations</keyword><keyword>Pregnancy</keyword><keyword>Pregnancy Trimester, First</keyword><keyword>Pregnancy Trimester, Second</keyword><keyword>Prospective Studies</keyword><keyword>Questionnaires</keyword></keywords><dates><year>2007</year><pub-dates><date>Sep</date></pub-dates></dates><accession-num>17719366</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>(Nikcevic, Kuczmierczyk, & Nicolaides, 2007). Thus, assisting parents to resolve the feelings of guilt that are frequently a consequence of caring for an intellectually disabled child should yield similar dividends for psychological morbidity. References ADDIN EN.REFLIST Ankri, J., Andrieu, S., Beaufils, B., Grand, A., & Henrard, J. (2005). Beyond the global score of the Zarit Burden Interview: Useful dimensions for clinicians. International Journal of Geriatric Psychiatry, 20, 254-260.Benderix, Y., Nordstrom, B., & Sivberg, B. (2006). Parents' experience of having a child with autism and learning disabilities living in a group home: A case study. Autism, 10, 629-641.Brummett, B. H., Babyak, M. A., Segler, I. C., Vitaliano, P. P., Ballard, E. L., Gwyther, L. P., et al. (2006). Associations among perceptions of social support, negative affect, and quality of sleep in caregivers and noncaregivers. Health Psychology, 25, 220-225.Buysse, D. J., Reynolds, C. F., 3rd, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). 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(1992). Psycho-social well-being among the parents of children with autism. Journal of Intellectual and Developmental Disability, Volume 18, 83-93.Hastings, R. P., Kovshoff, H., Brown, T., Ward, N. J., Espinosa, F. D., & Remington, B. (2005). Coping strategies in mothers and fathers of preschool and school-age children with autism. Autism, 9, 377-391.Lenhard, W., Breitenbach, E., Ebert, H., Schindelhauer-Deutscher, H. J., & Henn, W. (2005). Psychological benefit of diagnostic certainty for mothers of children with disabilities: Lessons from Down syndrome. American Journal of Medical Genetics Part A, 133A, 170-175.Maes, B., Broekman, T. G., Dosen, A., & Nauts, J. (2003). Caregiving burden of families looking after persons with intellectual disability and behavioural or psychiatric problems. Journal of Intellectual Disability Research, 47, 447-455.Meltzer, L. J., & Moore, M. (in press). 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The hospital anxiety and depression scale. Acta Psychiatrica Scandavia, 67, 361-370.AcknowledgementsThe authors would like to express their appreciation to Autism West-Midlands, the Down Syndrome Association, and Baljit Nhal from Birmingham Children’s Hospital for their help with the recruitment process. A special thanks is also extended to the parents caring for children with intellectual disabilities and the parents caring for typically developing children who made this research possible.Table 1. Demographic characteristics and child care responsibilities of parental groups Cases (N = 32)Controls (N = 29)Test of differenceSex (Female)24 (75%)20 (69%) χ2 (1) = 0.06, p = .81Marital Status (Partnered)28 (88%)20 (70%) χ2 (1) = 2.11, p = .15Ethnicity (Caucasian)29 (91%)26 (90%) χ2 (1) = 0.00, p = 1.00Occupational status (Professional)15 (47%)16 (55%) χ2 (1) = 0.15, p = .70Currently employed outside the home 23 (72%) 28 (100%) χ2 (1) = 7.19, p = .007Mean age ADDIN EN.CITE <EndNote><Cite ExcludeYear="1"><Author>SD</Author><record><rec-number>80</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McCurry, S. M.</author><author>Logsdon, R. G.</author><author>Teri, L.</author><author>Vitiello, M. V.</author></authors></contributors><auth-address>McCurry, SM&#xD;Univ Washington, Sch Nursing, Dept Psychosocial &amp; Community Hlth, 9709 3rd Ave NE,Ste 507, Seattle, WA 98115 USA&#xD;Univ Washington, Sch Nursing, Dept Psychosocial &amp; Community Hlth, Seattle, WA 98115 USA&#xA;Univ Washington, Dept Psychiat &amp; Behav Sci, Seattle, WA 98195 USA</auth-address><titles><title>Steep disturbances in caregivers of persons with dementia: Contributing factors and treatment implications</title><secondary-title>Sleep Medicine Reviews</secondary-title></titles><pages>143-153</pages><volume>11</volume><number>2</number><keywords><keyword>sleep</keyword><keyword>insomnia</keyword><keyword>caregivers</keyword><keyword>alzheimer&apos;s disease</keyword><keyword>dementia</keyword><keyword>depression</keyword><keyword>randomized controlled-trial</keyword><keyword>older-adults</keyword><keyword>alzheimers-disease</keyword><keyword>neuropsychiatric symptoms</keyword><keyword>cardiovascular health</keyword><keyword>physical-activity</keyword><keyword>chronic insomnia</keyword><keyword>risk-factors</keyword><keyword>nonpharmacologic treatment</keyword><keyword>clinical-significance</keyword></keywords><dates><year>2007</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1087-0792</isbn><accession-num>ISI:000245432500006</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000245432500006</url></related-urls></urls><language>English</language></record></Cite></EndNote>(SD) years42.8 (5.78) 39.9 (4.36) F (1,59) = 4.76, p = .03Mean age of main care recipient ADDIN EN.CITE <EndNote><Cite ExcludeYear="1"><Author>SD</Author><record><rec-number>80</rec-number><ref-type name="Journal Article">17</ref-type><contributors><authors><author>McCurry, S. M.</author><author>Logsdon, R. G.</author><author>Teri, L.</author><author>Vitiello, M. V.</author></authors></contributors><auth-address>McCurry, SM&#xD;Univ Washington, Sch Nursing, Dept Psychosocial &amp; Community Hlth, 9709 3rd Ave NE,Ste 507, Seattle, WA 98115 USA&#xD;Univ Washington, Sch Nursing, Dept Psychosocial &amp; Community Hlth, Seattle, WA 98115 USA&#xA;Univ Washington, Dept Psychiat &amp; Behav Sci, Seattle, WA 98195 USA</auth-address><titles><title>Steep disturbances in caregivers of persons with dementia: Contributing factors and treatment implications</title><secondary-title>Sleep Medicine Reviews</secondary-title></titles><pages>143-153</pages><volume>11</volume><number>2</number><keywords><keyword>sleep</keyword><keyword>insomnia</keyword><keyword>caregivers</keyword><keyword>alzheimer&apos;s disease</keyword><keyword>dementia</keyword><keyword>depression</keyword><keyword>randomized controlled-trial</keyword><keyword>older-adults</keyword><keyword>alzheimers-disease</keyword><keyword>neuropsychiatric symptoms</keyword><keyword>cardiovascular health</keyword><keyword>physical-activity</keyword><keyword>chronic insomnia</keyword><keyword>risk-factors</keyword><keyword>nonpharmacologic treatment</keyword><keyword>clinical-significance</keyword></keywords><dates><year>2007</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1087-0792</isbn><accession-num>ISI:000245432500006</accession-num><urls><related-urls><url>&lt;Go to ISI&gt;://000245432500006</url></related-urls></urls><language>English</language></record></Cite></EndNote>(SD) years11.5 (3.35) 8.8 (4.23) F (1,58) = 7.52, p = .008Mean depression score (SD)8.6 (3.92)3.2 (2.31)F (1,59) = 41.64, p <.001Mean anxiety score (SD) 11.0 (4.40)5.0 (2.44)F (1,59) = 43.12, p <.001Depression score ≥ 8 (%)20 (63%)2 (7%) χ2 (1) = 18.06, p <.001Anxiety score ≥ 8 (%)24 (75%) 3 (10%) χ2 (1) = 23.22, p <.001 ................
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