Efficacy of Cognitive Behavioural Therapy for Insomnia and Bright Light Therapy in Adolescents With ADHD, Insomnia, and Evening Chronotype

Remission of insomnia is measured by Insomnia Severity Index (ISI), possible scores range from 0 to 20, with a score less than 9 (ISI <9) defined as remission of insomnia.

Treatment response for insomnia is defined as by a reduction of Insomnia Severity Index (ISI) score from baseline ≧ 6. ISI scores range from 0-20.

Pre-Sleep Arousal Scale (PSAS) is a 16-item self-rated scale measuring pre-sleep arousal. There are two subscales on the cognitive and somatic manifestations of arousal, with eight items in each subscale (possibly scored from 8 to 40). In both cases, a higher score indicates higher pre-sleep arousal.

Subjective sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). The Pittsburgh Sleep Quality Index is a 19-item self-rated scale assessing sleep quality and sleep disturbances over the past month. Possible global scores range from 0 to 21, with higher scores indicating a worse outcome.

Dysfunctional Beliefs and Attitudes about Sleep (DBAS) is a 16-item self-rated scale measuring the respondent's sleep-related beliefs, more specifically, their expectations and attitudes regarding the causes, consequences, and potential treatments of sleep issues. A total score is calculated by averaging score of all items, possibly scored 0 to 10, with a higher score indicating more dysfunctional beliefs and attitudes about sleep.

Arousal predisposition measured by the Arousal Predisposition Scale (APS). Possible scores range from 1 to 48. Arousal Predisposition Scale is a self-rated scale assessing an individual's tendency to become aroused in response to internal or external stimuli. Higher scores indicate greater arousal predisposition.

Sleep Hygiene Practice Scale (SHPS) is a 30-item self-rated scale measuring sleep hygiene behaviors, ranging in total scores from 30 to 180, with higher scores indicating lower levels of sleep hygiene.

Daily sleep diary for consecutive seven days. Sleep parameter estimated by daily sleep diary: total sleep time (TST) in hours.

Daily sleep diary for consecutive seven days. Sleep parameter estimated by daily sleep diary: sleep onset latency (SOL) in mins.

Daily sleep diary for consecutive seven days. Sleep parameter estimated by daily sleep diary: wake after sleep onset (WASO) in mins.

Daily sleep diary for consecutive seven days. Sleep parameter estimated by daily sleep diary: sleep efficiency (SE), which is calculated by total sleep time divided by total time in bed, possible value range from 0-100%.

The Morningness-Eveningness Questionnaire (MEQ) is a 19-item self-report rating scale measuring circadian preference (typology). Possible scores range from 16 to 89, with lower scores indicating preference towards eveningness. Based on the conventional cut off, having a Morningness-Eveningness Questionnaire score of 16-41 is considered eveningness.

Munich Chronotype Questionnaire (MCTQ) is a self-report measures of sleeping patterns during weekdays and weekends separately. The Mid-Sleep Time (MSF/MSFsc) are used to as an indicator of chronotype, where individuals with earlier mid-sleep time reflect a morning chronotype and later mid-sleep time reflect an evening chronotype.

The Adult ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklist is an 18-item self-administered questionnaire to screen for ADHD symptoms in both community surveys and clinical settings based on criteria of the DSM-IV-TR. The questionnaire asks participants to rate how often a symptom of inattention or hyperactivity has occurred during the past 6 months using a scale from 0 (never) to 4 (very often). The total score on this scale can range from 0 to 72, with higher scores indicating more ADHD symptomology.

Subjective awareness of neuropsychological difficulties measured by the Subjective Awareness of Neuropsychological Deficits Questionnaire for Children (SAND-C). This self-rated measure assesses perceived cognitive difficulties in daily life. The possible score ranges from 1-4. Higher scores indicate a worse outcome, reflecting greater perceived neuropsychological difficulties.

Hospital Anxiety and Depression Scale (HADS) is a self-assessed scale for detecting states of depression and anxiety. The depression subscale range in scores from 0 to 21, with higher scores indicating severer states of depression. Similarly, the anxiety subscale range in scores from 0-21 with higher scores indicating severer states of anxiety. No additional computation will be made with the two subscores.

Depression Anxiety Stress Scales (DASS-21) consists of three self-report scales designed to measure the emotional states of depression, anxiety and stress. Each of the three Depression Anxiety Stress Scales contains 14 items. Scale score ranges from 0 to 42. Higher scores suggest more depression, anxiety and stress, respectively.

Impulsive behaviour traits measured by the Short UPPS-P Impulsive Behavior Scale (SUPPS-P). This self-rated scale assesses multiple facets of impulsive behaviour. The Short UPPS-P Impulsive Behavior Scale (SUPPS-P) features a subscale score range of 4 to 16 for each of its five distinct impulsivity traits. Higher scores indicate a higher level of impulsive behavior.

Impulsiveness measured by the Barratt Impulsiveness Scale, Version 11 (BIS-11). This self-rated scale assesses attentional, motor, and non-planning impulsiveness. Possible total scores range from 30 to 120, with higher scores indicating higher impulsivity.

Multidimensional Fatigue Inventory (MFI) is a 20-item self-rated scale on fatigue symptoms. There are three subscales, measuring the physical (possibly scored from 7 to 35), mental (possibly scored from 6 to 30), and spiritual (possibly scored from 7 to 35), dimensions of fatigue. A grand total score can be calculated by summing up the three sub scores. A higher score represents a higher level of fatigue symptoms.

Paediatric Daytime Sleepiness Scale (PDSS) is an 8-item self-rated scale measuring daytime sleepiness, ranging in total scores from 0 to 32 with higher scores indicating more sleepiness.

Clinical Global Impression (CGI) Scale is a clinician-rated scale, comprised of two one-item subscales: Severity of Illness (CGI-S) subscale evaluates the severity of psychopathology. The score is given on a seven-point scale, with score ranging from 0-7, and higher values indicating higher severity of illness.

Clinical Global Impression (CGI) Scale is a clinician-rated scale, comprised of two one-item subscales: Clinical Global Improvement Scale (CGI-I) evaluates change from the initiation of treatment. Clinician rated treatment response score ranges from 0-7 and is defined as Clinical Global Improvement Scale score ≦ 2.

Children's Depression Rating Scale (CDRS-R) is a 17-item rating scale based on a semistructured interview with children. Possible scores range from 17 to 113, with higher scores indicating severer depressive symptoms.

Actigraphic assessment for consecutive seven days. Sleep parameter estimated by wrist actigraphy: time in bed (TIB) in hours

Actigraphic assessment for consecutive seven days. Sleep parameter estimated by wrist actigraphy: total sleep time (TST) in hours

Actigraphic assessment for consecutive seven days. Sleep parameter estimated by wrist actigraphy: sleep onset latency (SOL) in mins

Actigraphic assessment for consecutive seven days. Sleep parameter estimated by wrist actigraphy: wake after sleep onset (WASO) in mins

Actigraphic assessment for consecutive seven days. Sleep parameter estimated by wrist actigraphy: sleep efficiency (SE), which is calculated by total sleep time divided by total time in bed, range from 0-100%

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the nonparametric circadian rhythm analysis method - start times and average activity of L5 (i.e. five hours with least activity).

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the nonparametric circadian rhythm analysis method - start times and average activity of M10 (i.e. 10 h with maximal activity).

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the nonparametric circadian rhythm analysis method - relative amplitude (RA), which is calculated using L5 and M10 to give a nonparametric description of amplitude.

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the cosinor analysis method - acrophase (the peak of the sine wave).

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the cosinor analysis method - amplitude (the difference between the wave peak and trough).

Actigraphic assessment for consecutive seven days. Circadian parameters computed by the cosinor analysis method - mesor.

Dim-light melatonin onset (express as time value hh:mm) is determined by 10-hours salivary melatonin collected at 30-minutes interval. Melatonin is assayed by gas chromatography-mass spectrometry. Data will be collected in a subset of sample.

Neural sensitivity to light measured by pupillary light response (PLR). PLR is based on change in pupil diameter in response to standardized light stimuli.

Impulsive decision-making measured by the Delay Discounting Task (DDT). This behavioural task assesses preference for smaller immediate rewards over larger delayed rewards. Greater preference for larger delayed rewards indicates a better outcome, whereas steeper delay discounting indicates a worse outcome.

Decision-making under uncertainty measured by the Beads Task. This behavioural task assesses probabilistic reasoning and decision-making under uncertainty. More adaptive evidence gathering before decision-making generally indicates a better outcome.

Information sampling and reflection impulsivity measured by the Information Sampling Task (IST). This behavioural task assesses the amount of information gathered before making a decision. Greater adaptive information sampling generally indicates a better outcome.

Working memory measured by the Digit Span Task. This test assesses verbal short-term memory and working memory capacity. Higher scores indicate a better outcome.

Sustained attention measured by the Continuous Performance Task (CPT). This test assesses the ability to maintain attention to target stimuli over time. Better accuracy and fewer omission and commission errors indicate a better outcome.

The ERP components including CNV, NoGo N2, and NoGo P3 will be examined between the treatment group and control, in baseline, post-treatment and followup sessions.

The ERP components including feedback-related negativity (FRN) and P300 amplitudes to both negative and positive feedback will be examined on the Balloon Analogue Risk Task.

The ERP components, including N2 and P3 will be examined on the Stop Signal Task.