J R Soc Med 2001;94:177-179
© 2001 Royal Society of Medicine
Sleep problems in children with developmental disorders
Luci Wiggs DPhil CPsychol
University Section, Park Hospital for Children, Old Road, Headington,
Oxford OX3 7LQ, UK
E-mail:
lucinda.wiggs{at}psych.ox.ac.uk
 |
INTRODUCTION
|
|---|
In 1905 Clement Dukes, a school doctor, made the following observation
about
the effects of sleep loss upon the children in his
care
1:
`...younger pupils are allotted the same number of hours as the seniors for
sleep. What this means to the children is lowered vitality, apathy,
bloodlessness, diminished growth of the body and brain. It renders the child
an easy prey to disease [and] causes slight fainting attacks resembling these
cases of epilepsy...'
Although the tone of his remarks may seem over-dramatic it is now well
recognized that impaired sleep quantity or quality can have profound effects
on daytime mood, behaviour, cognition, general performance and
physiology2. When
sleep disturbance is present in children it impacts not only upon the child's
daytime functioning but also on that of the parents and the family at large;
associations between childhood sleep problems and maternal stress, depression,
poor marital relationships and even child abuse have been
reported3,4.
The negative associations with childhood sleep problems are of particular
concern in view of the high prevalence of sleep difficulties. Figures of about
25% of preschool
children5, 43% of
school-age prepubescent
children6 and 33% of
adolescents7 are
given, and these are likely to be understimates. The reported rates of sleep
disorders in children with developmental disorders are even higher. Rates vary
depending upon the criteria used to define a `sleep problem' but examples
reported are 49-89% of children with autistic spectrum
disorders8, 25-50%
of children with attention deficit hyperactivity disorder
(ADHD)9 and 34-86%
of children with intellectual
disabilities10.
The sleep problems of children with developmental disorders deserve
particular attention not least because of their prevalence but also because of
their persistence and severity, the additional stress that they place upon
carers, the contribution that sleep disturbance might be making to daytime
difficulties with behaviour and cognition and the parents' ability to cope
with them and, fortunately, the improvements in child and parent functioning
that can follow successful
treatment11.
|
SLEEP DISTURBANCE IN CHILDREN WITH DEVELOPMENTAL DISORDERS
|
|---|
The reported sleep abnormalities can be classified into three
basic groups:
(i) physiological sleep irregularities, such as
rapid eye movement (REM) sleep
abnormalities, which have been
identified across a range of conditions (the
clinical significance
of these anomalies is often uncertain); (ii) sleep
disorders
which are more prevalent in particular groups of children, often
resulting
from their underlying condition—for instance, sleep related
breathing
disorders are common in children with Down syndrome because
of
congenitally narrow airways, reduced muscle tone and increased
tonsil and
adenoid size; (iii) sleep `problems' of unspecified
origin which are commonly
reported across a range of conditions—notably,
difficulty in settling to
sleep, night waking, irregular sleep
patterns, short-duration sleep and
daytime sleepiness. There
is also a possible fourth group, in which a sleep
disorder is
causing or contributing to the `primary' condition. A substantial
minority
of children with ADHD are reported to have periodic limb movement
disorder
(PLMD)
12,
a condition characterized by stereotypic and repetitive
limb movements during
sleep which are accompanied by physiological
arousal. Sleep quality in PLMD is
impaired to such a degree
that it shows in daytime behavioural manifestations
of sleep
disruption—poor concentration, overactive behaviour and
impulsivity.
After treatment for the PLMD, ADHD symptoms have been reported
to
diminish or even resolve completely in these
cases
13.
|
LIMITATIONS OF EXISTING DATA
|
|---|
There are sizeable gaps in our knowledge of sleep disturbance
in children
with developmental disorders. First, too little
attention has been paid to
coexisting conditions such as
epilepsy
14,15—common
in
certain groups with developmental disorders—that might
affect sleep.
Secondly, the studies have often been poorly controlled,
if controlled at all,
for other factors such as age, IQ and
current medication that can impact upon
sleep patterns. Thirdly,
the methods for assessing sleep have varied, ranging
from physiological
sleep studies conducted in a sleep laboratory to parent
report
questionnaires. Although the different methods are all useful
and taken
together provide more complete understanding, the
comparison of results can be
difficult. Lastly, very few studies
have done more than describe the symptoms
or `sleep problems',
when what is needed is analysis of the sleep disorder
that underlies
the symptoms. This distinction is important since very
different
sleep disorders can present with similar symptoms, and treatment
needs
to be based on the disorder. There are just three broad categories
of
presenting symptoms—sleeplessness, excessive sleepiness
and episodic
disturbances of behaviour associated with sleep
(parasomnias)—but the
International Classification of
Sleep
Disorders
16 lists
over eighty underlying sleep disorders
each of which can produce one or more
of these symptoms. For
example, sleeplessness taking the form of difficulty
getting
to sleep at night may, amongst other things, result from disturbance
of
the body clock, failure to learn appropriate bedtime behaviour
or anxiety.
The treatments for these will differ greatly.
|
WHAT HELP IS BEING PROVIDED TO FAMILIES?
|
|---|
When children with developmental disorders have sleep disturbance,
they are
far from certain to receive treatment. Wiggs and
Stores
17 report
that of 124 children with severe intellectual disabilities
and current or past
sleep problems only 47% had received treatment
and the percentage was only
slightly higher (54%) in 61 children
with autism and sleep problems
(unpublished). These figures,
of course, say nothing about the quality or
success of the treatment.
Why is treatment not routinely provided? One reason
is that
doctors
18
and
psychologists
19,20
lack professional training
in sleep disorders; such training as they do
receive is limited
in time and scope. Secondly, parents of children with
associated
conditions may hesitate to seek advice. Among reasons suggested
by
parents are that sleep problems are
longstanding
17 and
thus
part of `normal' life, that parents (and professionals) view
them as an
inevitable and insoluble aspect of the underlying
condition
3 and that
previous experience has been negative—the offer
of hypnotic medication
when this was not wanted, or inappropriately
devised behavioural
programmes
17,21.
Professionals involved
in the care of these children must be capable of
assessing,
recognizing and diagnosing sleep disorders. This should be with
a
view to implementing treatment themselves or guiding the parents
of affected
children to other agencies providing treatment.
|
ASSESSMENT OF SLEEP PATTERNS
|
|---|
Stores provides a helpful framework for structuring the assessment
of sleep
in young people
22.
He emphasizes the importance of
a careful sleep history along with the
developmental, medical,
psychological and family history. Detailed review of
the child's
24 hour sleep—wake pattern is recommended to identify
factors
that are causing or perpetuating sleep problems. Options for
further
investigation
23
then include the use of sleep diaries
in which parents systematically record
information, questionnaires
(for screening purposes or to provide detailed
information about
specific aspects of sleep), video recordings, monitoring of
body
movements (which can detect basic sleep—wake patterns)
and
polysomnography (PSG), either in a laboratory or in the
child's home.
Objective recordings may be helpful when information
is lacking or of doubtful
veracity, and also for assessment
of the few sleep disorders where features of
the PSG form part
of the formal diagnostic requirement (e.g. narcolepsy,
obstructive
sleep apnoea). However, clinical enquiries and systematic sleep
diary
information will in many instances be sufficient for basic
assessment.
|
TREATMENT
|
|---|
Treatments for sleep disorders include adjustment of environmental
and
lifestyle factors, behavioural techniques to help the child
learn good sleep
habits or unlearn bad ones, cognitive therapy,
chronotherapy (altering sleep
timing to re-set the body clock),
physical measures such as use of bright
light to alter sleep
times or nasal continuous positive airways pressure to
aid breathing
during sleep, surgery (e.g. removal of tonsils and adenoids
if
they are causing obstruction) and pharmacological approaches
(such as
sedatives, stimulants and melatonin). Detailed advice
can be found elsewhere:
Stores
23 provides
an overview of management
strategies, and other reviews advise on specific
disorders such
as
autism
8,
ADHD
9 and
intellectual
disabilities
24.
Wiggs and
France
11
also review behavioural treatments for sleep problems
in children with
coexisting physical, psychological and intellectual
disabilities.
Although detailed management guidelines cannot be offered here, some
general conclusions can be drawn. First, there is much need for further
research, not only because of the deficiencies outlined earlier but also
because much of the existing work focuses on sleeplessness while other types
of sleep problem are neglected.
Secondly, various behavioural treatments and chronotherapy have been
reported successful across a range of conditions, even where the sleep problem
is longstanding and severe. A gradual approach, where the new behaviour is
taught in small steps, may be more practical and acceptable to parents than an
acute intervention, especially in children with developmental disorders. In
the absence of studies addressing relative efficacy, the choice of technique
should generally be guided by parental preference.
Thirdly, pharmacological management may have a place in the management of
some sleep disorders. For example, clonidine and imipramine have been reported
useful in children with ADHD, and melatonin has been found helpful for
children with disorders of the sleep—wake cycle (although the
uncertainties and concerns surrounding the use of melatonin in children must
be weighed up carefully in each
case25). In
general, sedative medication has a very limited role in the management of
children's sleeplessness since the clinical effects are slight and not well
maintained; hangover daytime effects are common and parents are often
resistant26.
Lastly, an argument for treating sleep problems in children with
developmental disorders is that the benefits apply not only to the affected
child but also to the family as a whole.
|
THE FUTURE
|
|---|
The high rate of sleep problems in these `special' populations
suggests
that enquiries about basic sleep—wake patterns
should form part of
routine history-taking, especially where
features of the child's daytime
behaviour or mood are suggestive
of disturbed sleep. Where appropriate,
extended assessment should
be performed with a view to diagnosing and treating
the underlying
sleep disorder. Treatment decisions need to be based not only
on
the type of sleep disorder but also, within reason, on the family's
preferences
and abilities.
Undeniably, randomized controlled trials of interventions (or combinations
of interventions) are needed. Ideally these would include homogeneous groups
of children whose sleep disorder and basic condition are tightly defined.
Confounders would be controlled for, or at least documented. To achieve
sufficient numbers, such trials might have to be multicentre. Until data from
such studies are available the most practical and quickest way to gain
treatment efficacy data may be carefully designed and well documented single
case experiments.
In view of the widespread nature of the sleep disorders and the good
response to behavioural treatments, another aspect to consider is prevention.
A potentially useful area for future research is evaluation of advice to new
parents on how to encourage good sleep habits and deal with the most common
sleep disorders. If effective methods could be identified the development of
longstanding and severe sleep disorders might be prevented and so too the
alarming negative factors with which they are associated.
|
REFERENCES
|
|---|
-
Dukes C. Sleep in relation to education. J R Sanit
Inst 1905;26:41
-4
-
Bonnet M. Sleep deprivation. In: Kryger MH, Roth T, Dement WC, eds.
Principles and Practice of Sleep Medicine 2nd edn.
Philadelphia: Saunders, 1994:50
-67
-
Quine L. Severity of sleep problems in children with severe
learning difficulties: description and correlates. J Community Appl
Soc Psychol 1992;2:247
-68
-
Chavin W, Tinson S. Children with sleep difficulties.
Health Visit1980; 53:477
-80[Medline]
-
Mindell J. Sleep disorders in children. Health
Psychol 1993;12:151
-62[Medline]
-
Kahn A, Van de Merckt C, Rebuffat E, Morzin M, Sottiaux M, Blum D,
Hennart P. Sleep problems in healthy preadolescents.
Pediatrics1989; 84:542
-6[Abstract/Free Full Text]
-
Morrison DN, McGee R, Stanton WR. Sleep problems in adolescence.
J Am Acad Child Adolesc Psychiatry1992; 31:94
-9[Medline]
-
Richdale AL. Sleep problems in autism: prevalence, cause and
intervention. Dev Med Child Neurol1999; 41:60
-6[Medline]
-
Corkum P, Tannock R, Moldofsky H. Sleep disturbance in children
with attention-deficit/hyperactivity disorder. J Am Acad Child
Adolesc Psychiatry1998; 37:637
-46[Medline]
-
Stores G. Annotation: sleep studies in children with a mental
handicap. J Child Psychol Psychiatry1992; 33:1303
-17[Medline]
-
Wiggs L, France K. Behavioural treatments for sleep problems in
children and adolescents with physical illness, psychological problems or
intellectual disabilities. Sleep Med Rev2000; 4:299
-314[Medline]
-
Pichietti D, Walters A. Attention-deficit hyperactivity disorder
and periodic limb movement disorder in childhood. Sleep
Res 1994;23:303
-
Pichietti D, Walters A. Restless legs syndrome and periodic limb
movement disorder in children and adolescents: comorbidity with
attention-deficit hyperactivity disorder. Child Adol Psychiatric
Clin Am 1996;5:729
-40
-
Bourgeois B. The relationship between sleep and epilepsy in
children. Semin Pediatr Neurol1996; 3:29
-35[Medline]
-
Devinsky O, Ehrenberg B, Barthlen GM, Abramson HS, Luciano D.
Epilepsy and sleep apnea syndrome. Neurology1994; 44:2060
-4[Abstract/Free Full Text]
-
American Sleep Disorders Association. International
Classification of Sleep Disorders, Revised: Diagnostic and Coding
Manual. Rochester, Minnesota: American Sleep Disorders
Association, 1997
-
Wiggs L, Stores G. Sleep problems in children with severe
intellectual disabilities: what help is being provided? J Appl Res
Intellec Dis 1996;9:160
-5
-
Stores G, Crawford C. Medical student education in sleep and its
disorders. J R Coll Physicians Lond1998; 32:149
-53[Medline]
-
Wiggs L, Stores R. Sleep education in undergraduate psychology
degree courses in the UK. Psychol Teach Rev1996; 5:40
-6
-
Stores R, Wiggs L. Sleep education in clinical psychology courses
in the UK. Clin Psychol Forum1998; 119:14
-18
-
Bartlett LB, Rooney V, Spedding S. Nocturnal difficulties in a
population of mentally handicapped children. Br J Ment
Subnormality 1985;31:54
-9
-
Stores G. Practitioner review: assessment and treatment of sleep
disorders in children and adolescents. J Child Psychol
Psychiatry 1996;37:907
-25[Medline]
-
Wiggs L, Stores G. Children's sleep: how should it be assessed?
Assoc Child Psychol Psychiatry Rev Newsl1995; 17:153
-7
-
Lancioni GE, O'Reilly MF, Basili G. Review of strategies for
treating sleep problems in persons with severe or profound mental retardation
or multiple handicaps. Am J Ment Retard1999; 104:170
-86[Medline]
-
Zhdanova IV. The role of melatonin in sleep and sleep disorders.
In: Culebras A, ed. Sleep Disorders and Neurological
Disease. New York: Marcel Dekker, 2000:137
-57
-
Richman N. A double-blind drug trial of treatment in young children
with waking problems. J Child Psychol Psychiatry1985; 26:591
-8[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
P. Lucas, K. Liabo, and H. Roberts
Do behavioural treatments for sleep disorders in children with Down's syndrome work?
Arch. Dis. Child.,
November 1, 2002;
87(5):
413 - 414.
[Full Text]
[PDF]
|
|
|
TOP
INTRODUCTION
SLEEP DISTURBANCE IN CHILDREN...
