Pediatric sleep difficulties after moderate-severe traumatic brain injury

Different trajectories of post-concussive symptom subscales after pediatric mild traumatic brain injury: Data from a prospective longitudinal study

PURPOSE

The aim of this study was to investigate the trajectory of parent-rated post-concussive symptoms (PCS), attentional performance and participation within 6 months in children after mild traumatic brain injury (mTBI).

METHODS

For this prospective longitudinal study, we included data on 64 children after mTBI and 57 healthy control children (age 8-16 years). Parents rated PCS using the Post-Concussion Symptom Inventory (PCSI) immediately (T0), 1 week (T1), and 3-6 months after injury (T2). Attentional performance (alertness, selective and divided attention) was measured using the Test of Attentional Performance (TAP) at T1 and T2 and participation was measured using the Child and Adolescent Scale of Participation (CASP) at T2.

RESULTS

Friedman tests showed different trajectories of PCS subscales over time: Compared to pre-injury level, the amount of somatic and cognitive PCS was still elevated at T1, while emotional PCS at T1 were already comparable to pre-injury level. The rating of sleep-related PCS at T2 was significantly elevated compared to the pre-injury rating. Quade ANCOVAs indicated group differences in PCS subscales between patients and controls at T1, but not at T2. Patients and controls showed a similar performance in tests of attention at T1 and T2, but parental rating of participation at school was significantly reduced. Although cognitive PCS and attention were not correlated, there were significantly negative Spearman correlations between participation at home and pre-injury and concurrent PCS at T2.

CONCLUSIONS

Our data imply that sleep-related PCS are still elevated weeks after injury and are thus a target for interventions after mTBI.

Childhood sleep: assessments, risk factors, and potential mechanisms

BACKGROUND

Sleep problem is a highly prevalent health issue among pediatric populations across the world. In this review, we aimed to identify risk factors contributing to sleep deficiency and poor sleep hygiene in children. Potential biological, psychosocial, and environmental mechanisms as well as research gaps in the literature are also discussed.

DATA SOURCES

A comprehensive search for relevant English language full-text, peer-reviewed publications was performed focusing on pediatric sleep studies from prenatal to childhood and adolescence in a variety of indexes in PubMed, SCOPUS, and Psych Info. Both relevant data based and systematic reviews are included.

RESULTS

This paper summarizes many risk factors for childhood sleep problems, including biological (e.g., genetics, gender, age and puberty, prenatal factors, postnatal factors); nutritional (e.g., macronutrients, micronutrients, omega-3 fatty acids, obesity); environmental (e.g., heavy metals, noise, light, air pollution); interpersonal (e.g., family, exposure to violence, screen media use, physical injury); and community/socioeconomic variables (e.g., racial/ethnicity and cultural factors, neighborhood conditions and socioeconomic status, school factors, public health disasters/emergencies), to better understand the development of sleep problems in children.

CONCLUSIONS

Poor childhood sleep is a multifactorial issue affected by a wide range of prenatal and early-life biological, environmental, and psychosocial risk factors and contributors. A better understanding of these risk factors and their mechanisms is an important first step to develop future research and prevention programs focusing on pediatric sleep problems.

Sleep disturbances in infants and young children following an acquired brain injury

STUDY OBJECTIVES

Sleep disturbances impact over half of older children and teens with acquired brain injury (ABI) following critical care hospitalization but are underevaluated in infants and young children. Given the importance of sleep in brain development and healing after injury, we hypothesized sleep disturbances would be associated with worse neurodevelopmental outcomes in infants with ABI.

METHODS

We performed a retrospective cohort study of 68 children aged 2-32 months following critical care hospitalization for ABI. The Brief Infant Sleep Questionnaire assessed sleep disturbances. Bayley Scales of Infant and Toddler Development, third edition and Adaptive Behavior Assessment System, third edition assessed developmental and adaptive functioning outcomes, respectively. t tests compared sleep characteristics in infants with ABI to historical healthy controls. Spearman's correlation evaluated relationships among sleep and outcomes. Multiple linear regression investigated relationships controlling for demographic and ABI characteristics.

RESULTS

Compared to healthy controls, children with ABI had shorter nighttime sleep duration (P = .01), longer daytime sleep duration (P < .001), and longer duration of nighttime awakenings (P < .001). Duration of night awakenings negatively correlated with Bayley Cognitive scores (Spearman's correlation = -.40). Night awakenings negatively correlated with worse Adaptive Behavior Assessment System, third edition General Adaptive Composite scores (Spearman's correlation = -.42). When controlling for demographic and ABI characteristics, ≥ 3 awakenings was significantly associated with worse Adaptive Behavior Assessment System, third edition General Adaptive Composite (β = -11.3; 95% confidence interval = -19.2, -3.5).

CONCLUSIONS

Sleep disturbances are associated with poorer outcomes in infants and toddlers after ABI. Sleep is vital to recovery and a potentially modifiable target to improve outcomes.

CITATION

Klapp JM, Hall TA, Riley AR, Williams CN. Sleep disturbances in infants and young children following an acquired brain injury. J Clin Sleep Med. 2022;18(10):2387-2395.

Convergent validity of the child behavior checklist sleep items in children with moderate to severe traumatic brain injury

AIM

The Child Behavior Checklist (CBCL) includes several sleep items. We aimed to examine the convergent validity of CBCL sleep scores with validated sleep measures, and to explore their functional correlates.

METHODS

This cross-sectional study included 44 children with moderate to severe TBI, aged 6-15 years. Parents completed the CBCL and Sleep Disturbance Scale for Children (SDSC), and children wore actigraphy watches.

RESULTS

We found significant, albeit differential, associations between CBCL and SDSC sleep scores. Specifically: (i) "trouble sleeping" with SDSC total score, (ii) "trouble sleeping" and "nightmares" with SDSC initiating and maintaining sleep, (iii) "talks/walks in sleep" with SDSC arousal, and (iv) "overtired," "sleeps more" and CBCL sleep composite with SDSC excessive somnolence. The CBCL item "sleeps less" was the only significant predictor of functioning; children who slept less had lower social competence. No associations were found between CBCL sleep scores and actigraphy.

CONCLUSIONS

The CBCL does not provide a comprehensive assessment of sleep disturbances in children with moderate to severe TBI. Nevertheless, certain CBCL sleep items demonstrate initial convergent validity with subscales of the SDSC assessing select types of sleep disturbances. The CBCL may be useful in research and clinical situations when administration of more comprehensive assessment sleep tools is not viable.

Examining the Use of a Rest-Activity Ratio in a Pediatric Rehabilitation Setting

OBJECTIVE

To examine the relationship between an estimate of sleep/wake regulation derived from actigraphy would be sensitive to neurocognitive dysfunction associated with acquired brain injury (ABI) in a pediatric rehabilitation sample.

DESIGN

cross-sectional design SETTING: Inpatient pediatric rehabilitation facility PARTICIPANTS: A sample of 31 males (72.1%) and 12 females (27.9%) admitted to a pediatric rehabilitation hospital wore an actigraph (wrist accelerometer) for one week. Ages ranged from 8 to 17 years (M=13.1, SD=2.7).

INTERVENTIONS

not applicable MAIN OUTCOME MEASURE(S): Raw actigraphy activity counts in 1-minute epochs were used to derive a rest-activity ratio over each 24-hour period and a 5-day average value was calculated covering Monday through Friday. Brain injury status was derived through medical record review and three groups were formed: traumatic brain injury (n=14), non-traumatic brain injury (n=16), and a non-ABI control group (n=13). Functional status was measured using WeeFIM Cognitive and Motor scores extracted from the medical records.

RESULTS

Unadjusted models showed a significant main group effect for brain injury status (p=0.012). Compared with controls, the rest-activity ratio was significantly lower in both the traumatic brain injury (p = 0.005), and non-traumatic brain injury (p = 0.023) groups. However, the main group effect was no longer significant in an adjusted model controlling for WeeFIM Cognitive and WeeFIM Motor scores at admission. In the context of the adjusted model, there was a significant relationship between the rest-activity ratio and WeeFIM Cognitive scores at admission.

CONCLUSIONS

Individuals with lower functional status at admission, especially in the cognitive domain, had lower rest-activity ratios, suggesting poorer sleep/wake regulation. Similar to findings in adults with acquired brain injury, this ratio may have utility in tracking sleep/wake regulation in the pediatric rehabilitation setting. Future studies should investigate sensitivity to change over the course of recovery and responsiveness to clinical interventions to improve sleep.

Sleep disturbances after pediatric traumatic brain injury: a systematic review of prevalence, risk factors, and association with recovery

STUDY OBJECTIVES

Sleep is vital for brain development and healing after injury, placing children with sleep-wake disturbances (SWD) after traumatic brain injury (TBI) at risk for worse outcomes. We conducted a systematic review to quantify SWD after pediatric TBI including prevalence, phenotypes, and risk factors. We also evaluated interventions for SWD and the association between SWD and other posttraumatic outcomes.

METHODS

Systematic searches were conducted in MEDLINE, PsychINFO, and reference lists for English language articles published from 1999 to 2019 evaluating sleep or fatigue in children hospitalized for mild complicated, moderate, or severe TBI. Two independent reviewers assessed eligibility, extracted data, and assessed risk of bias using the Newcastle-Ottowa Score for observational studies.

RESULTS

Among 966 articles identified in the search, 126 full-text articles were reviewed, and 24 studies were included (11 prospective, 9 cross-sectional, and 4 case studies). Marked heterogeneity was found in study populations, measures defining SWD, and time from injury to evaluation. Studies showed at least 20% of children with TBI had trouble falling or staying asleep, fatigue, daytime sleepiness, and nightmares. SWD are negatively correlated with posttraumatic cognitive, behavioral, and quality of life outcomes. No comparative intervention studies were identified. The risk of bias was moderate-high for all studies often related to lack of validated or objective SWD measures and small sample size. Heterogeneity precluded meta-analyses.

CONCLUSIONS

SWD are important morbidities after pediatric TBI, though current data are limited. SWD have implications for TBI recovery and may represent a modifiable target for improving outcomes after pediatric TBI.

The persistence of sleep disturbance and its correlates in children with moderate to severe traumatic brain injury: A longitudinal study

OBJECTIVES

The primary aim was to examine whether sleep disturbances persist in children in the chronic stage of recovery from moderate or severe traumatic brain injury (TBI). The secondary aim was to examine whether memory difficulties and/or other previously identified factors relate to sleep disturbances in children with moderate to severe TBI.

METHODS

This longitudinal study included 21 children with moderate to severe TBI, 8-18 years old, recruited from an urban tertiary paediatric specialised brain injury rehabilitation unit. Participants were seen 5 years and again 7 years post-injury, on average. Sleep disturbances were assessed with Sleep Disturbance Scale for Children (SDSC). Correlates that were considered included indicators of TBI severity, and questionnaires assessing everyday memory, fatigue, internalizing and externalizing behaviors and pain intensity.

RESULTS

The SDSC scores of children with moderate to severe TBI indicated greater disturbances in initiating and maintaining sleep, arousal, sleep-wake transition, and excessive somnolence relative to the norms, at follow-up. The mean SDSC scores and the number of participants with subclinical to clinical sleep disturbances on the SDSC remained unchanged from baseline to follow-up. At follow-up, the SDSC initiating and maintaining sleep, and excessive somnolence scales were associated with poorer everyday memory and greater fatigue.

CONCLUSIONS

Children with moderate to severe TBI experience ongoing sleep disturbances for years post-injury. Greater sleep disturbances are associated with worse functional outcomes. Further research into sleep disturbances and development of treatments is important, as it could improve the outcomes of children with TBI.

Children who sustained traumatic brain injury take longer to fall asleep compared to children who sustained orthopedic injuries: actigraphy findings

Objective: Primary: to examine objective sleep outcomes in children who sustained moderate to severe traumatic brain injury (TBI). Secondary: to examine the relation of objective sleep with subjective sleep, fatigue, and injury variables.Setting: A single tertiary brain injury unit.Participants: Children (5-15 years) with moderate to severe TBI (n = 23) or orthopedic injury (OI; n = 13).Design: Cohort study.Measures: Primary: objective sleep measure (actigraphy watch). Secondary: subjective sleep measure (questionnaire), fatigue questionnaire, and injury variables.Results: On actigraphy, children with TBI had longer sleep onset latency compared to children with OI. On the sleep questionnaire, children with TBI obtained higher scores for total sleep disturbance, initiating and maintaining sleep, and excessive somnolence. On the fatigue questionnaire, greater difficulties were found for total, sleep/rest, and cognitive fatigue for the TBI group. In the TBI group, actigraphy data did not correlate with sleep questionnaire, fatigue, or injury variables.Conclusion: Our study showed evidence of objective and subjective sleep disturbance in children with moderate to severe TBI, but these two types of sleep measures were not related. It is possible that distinct mechanisms underpin objective and subjective sleep disturbance, which may require different interventions.

Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life

OBJECTIVE

This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI.

PARTICIPANTS

We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI.

METHODS

Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy.

RESULTS

At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups.

CONCLUSIONS

These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.

Pediatric traumatic brain injury and abusive head trauma

Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.

Sleep and stress in the acute phase of concussion in youth

This study sought to address the complex interplay between both biological and psychological perceptions of stress and sleep in the acute stages following a mild traumatic brain injury. A secondary goal was to identify potential targets for intervention. Eleven acutely injured youth (mean age 12 years) were studied at home with overnight actigraphy, salivary cortisol and melatonin assays, and subjective ratings of stress and fatigue (injured group). Nine matched control youth also were assessed (control group). Results suggested longer sleep latencies (time to fall asleep) and higher levels of fatigue in the injured group exist (p = 0.025 and p = 0.004, respectively). In the injured group, stress and sleep onset were significantly related with most subjects meeting criteria for Acute Stress Disorder. Melatonin levels were lower at bedtime in the injured group. Saliva samples were collected via passive drool at three time points: ∼1 h before bed ("bedtime" or T1), immediately upon waking (time 2: T2), and 30 min post-waking (time 3: T3). Overnight increases in cortisol (T1 to T2) were greater for the injured group; however, post-sleep changes in cortisol (T2 to T3) were reversed with control concentrations increasing. These findings are unique in using actigraphy and salivary hormone levels in an acutely injured youth while in their homes. The differences in sleep latency and the presence of injury-related stress point to potential treatment targets in acute concussion.

Sleep Parameters and Overnight Urinary Melatonin Production in Children With Persistent Post-concussion Symptoms

BACKGROUND

Sleep disturbance is common after a mild traumatic brain injury (mTBI) in children, yet its biology is poorly understood. We aimed to explore sleep-related problems (SRPs), sleep-activity patterns, and endogenous melatonin production in children with different recovery trajectories following mTBI. We hypothesized that children with delayed recovery would have more SRPs and abnormal sleep-activity patterns, which would correlate with lower overnight melatonin production.

METHODS

In this prospective controlled cohort study, we enrolled 83 children with persistent symptoms, 26 children who had clinically recovered following mTBI, and 25 healthy controls. SRPs were evaluated using the sleep subscale of the Post-Concussion Symptom Inventory. Sleep actigraphy was performed for five to seven days at 37 (S.D. 7) days post-injury. Health-related quality of life and mood disturbance was assessed using the Child Health Questionnaire and the Behavior Assessment System for Children, respectively. Endogenous melatonin production was assessed using overnight urine collection.

RESULTS

The groups were similar in age (13.9 [S.D. 2.6] years) and sex (52% female). Regression analysis demonstrated increased SRP in the symptomatic group (9.0; 95% confidence interval: 7.6, 11.1) compared with the recovered group (1.6; 95% confidence interval: 1.0, 2.4) and controls (2.0; 95% confidence intervals: 1.2, 3.2). Actigraphy parameters and urinary melatonin levels were not significantly different between groups. Neither SRPs nor actigraphy parameters correlated with anxiety and depression scores.

CONCLUSIONS

Although children with persistent post-concussion symptoms reported more SRPs, this was not related to actigraphy sleep parameters or melatonin production. Further research is warranted to understand the pathophysiology of post-traumatic sleep disturbance.

Sleep-Wake Disturbances After Acquired Brain Injury in Children Surviving Critical Care

BACKGROUND

Sleep-wake disturbances are underevaluated among children with acquired brain injury surviving critical care. We aimed to quantify severity, phenotypes, and risk factors for sleep-wake disturbances.

METHODS

We performed a prospective cohort study of 78 children aged ≥3 years with acquired brain injury within three months of critical care hospitalization. Diagnoses included traumatic brain injury (n = 40), stroke (n = 11), infectious or inflammatory disease (n = 10), hypoxic-ischemic injury (n = 9), and other (n = 8). Sleep Disturbances Scale for Children standardized T scores measured sleep-wake disturbances. Overall sleep-wake disturbances were dichotomized as any total or subscale T score ≥60. Any T score ≥70 defined severe sleep-wake disturbances. Subscale T scores ≥60 identified sleep-wake disturbance phenotypes.

RESULTS

Sleep-wake disturbances were identified in 44 (56%) children and were classified as severe in 36 (46%). Sleep-wake disturbances affected ≥33% of patients within each diagnosis and were not associated with severity of illness measures. The most common phenotype was disturbance in initiation and maintenance of sleep (47%), although 68% had multiple concurrent sleep-wake disturbance phenotypes. One third of all patients had preadmission chronic conditions, and this increased risk for sleep-wake disturbances overall (43% vs 21%, P = 0.04) and in the traumatic brain injury subgroup (52% vs 5%, P = 0.001).

CONCLUSIONS

Over half of children surviving critical care with acquired brain injury have sleep-wake disturbances. Most of these children have severe sleep-wake disturbances independent of severity of illness measures. Many sleep-wake disturbances phenotypes were identified, but most children had disturbance in initiation and maintenance of sleep. Our study underscores the importance of evaluating sleep-wake disturbances after acquired brain injury.

A feasibility and acceptability study of cognitive behavioural treatment for insomnia in adolescents with traumatic brain injury: A-B with follow up design, randomized baseline, and replication across participants

Difficulties falling asleep or staying asleep (symptoms of insomnia) are common following paediatric traumatic brain injury (TBI). Yet, interventions to treat insomnia in this population have not yet been reported. This single-case series examined the feasibility and acceptability of cognitive behavioral treatment for insomnia (CBT-I) for adolescents (n = 5, aged 11-13 years) with TBI, and explored changes in sleep and fatigue post-treatment. Adolescents were randomly assigned to two conditions: a 7- or 14-days baseline, followed by 4 weeks of manualised CBT-I delivered individually. To assess feasibility and acceptability we compared recruitment and retention rates, and questionnaire scores to a-priori set criteria. We explored treatment efficacy and functional gains in sleep and fatigue from baseline to follow-up using structured visual analysis of time-series graphs, and reliable change indices or changes in clinical classification. Feasibility and acceptability indicators met a-priori criteria, but therapists noticed limited adolescent engagement in sessions. Clinically significant improvements were found in sleep, in 3 out of 4 cases, and fatigue, in all cases. Our study provides preliminary evidence that CBT-I is feasible for insomnia treatment in adolescents with TBI and provides directions for development of future treatment studies.

Sleep disturbances and internalizing behavior problems following pediatric traumatic injury

OBJECTIVE

This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury.

METHOD

Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes.

RESULTS

Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury.

CONCLUSIONS

Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record

Objective sleep outcomes 20 years after traumatic brain injury in childhood

Purpose: To assess objective sleep outcomes and correlates in young adults with a history of childhood traumatic brain injury.Materials and methods: Participants included 45 young adults who sustained brain injury in childhood (mild = 12, moderate = 22, and severe = 11) and 13 typically developing control participants. Sleep was assessed with actigraphy and sleep diaries recorded over 14 consecutive days. Rates of good sleep (sleep efficiency ≥ 85%) and poor sleep (sleep efficiency < 85%) were also evaluated.Results: At 20-years postinjury, participants with traumatic brain injury and controls presented with similar outcomes across the objective sleep parameters (all p > 0.050) and rates of poor sleepers were also similar between these groups (p = 0.735): 67% and 77%, respectively. However, moderate and severe traumatic brain injury and female sex were associated with longer sleep duration.Conclusions: These findings provide preliminary insights into objective sleep outcome and associated factors in the very-long-term after childhood brain injuries. They also indicate the need to monitor sleep outcomes in young adults with and without traumatic brain injury.Implication for rehabilitationSustaining traumatic brain injury in childhood can impact on several functional domains including sleep.Sleep disturbances, particularly insomnia-related symptoms, are common in this population, with evidence of poor outcomes reported until adolescence postinjury, while outcomes beyond adolescence remain unexplored.In this first investigation of objective sleep outcomes in young adults with a history of childhood traumatic brain injury, we showed that insomnia-related symptoms are highly prevalent in both young adults with traumatic brain injury (67%) and healthy controls (77%).These findings suggest the need to routinely evaluate and treat sleep problem in young adults in general, irrespective of history of childhood traumatic brain injury.

The Relationship Between Sleep and Cognition in Children Referred for Neuropsychological Evaluation: A Latent Modeling Approach

Children with conditions affecting cognitive processes experience high levels of sleep disturbance, which may further compound the cognitive ramifications of their disorders. Despite this, existing studies in this area have been primarily confined to only particular diagnostic groups and/or a limited scope of sleep and cognitive parameters. The current study characterized the nature of sleep problems and examined the relationship between a wide range of sleep-related problems and cognitive functioning in a large (N = 103) diagnostically heterogeneous sample of youth (aged 6–16) referred for neuropsychological assessment. Structural equation modeling was used to examine the relationship between sleep-related problems (i.e., daytime sleepiness, sleep onset latency, sleep fragmentation, sleep time variability, sleep debt) and cognitive performance (i.e., executive functioning, sustained attention, memory, processing speed). Sleep fragmentation emerged as the most prominent sleep-related problem in the present sample. Structural equation modeling demonstrated a negative association between sleep-related problems and cognition that did not reach statistical significance (β = −0.084, p = 0.629). The current statistical approach may be used as a conceptual framework for future work examining these multi-dimensional constructs in a parsimonious fashion.

Post-Concussive Syndrome: a Focus on Post-Traumatic Headache and Related Cognitive, Psychiatric, and Sleep Issues

PURPOSE OF REVIEW

Post-traumatic headache (PTH) is a secondary headache disorder following traumatic brain injury. We sought to examine the recent literature on PTH and associated cognitive, psychiatric, and sleep conditions to understand the latest findings about the associated conditions and available screening tools, and to understand the available treatment options for PTH.

RECENT FINDINGS

Up to one third of PTH patients may have depression and about one quarter may have insomnia. Anxiety and cognitive issues are also common. While there are few studies examining abortive medications for PTH, recent studies of preventive medications examine the efficacy of topiramate, and topiramate may be better than other oral preventive medications. Other currently investigated treatments include nerve blocks, onabotulinum toxin A, transmagnetic stimulation, and behavioral therapy (biofeedback). Due to an expanded focus on and knowledge of concussion and PTH, comorbid psychiatric, cognitive, and sleep issues have become more widely acknowledged and studied. However, more high-quality studies must be conducted to examine the underlying pathophysiology of PTH and associated symptoms and to determine the most effective abortive and preventive treatment options.

Sleep-Wake Disturbances After Traumatic Brain Injury: Synthesis of Human and Animal Studies

Sleep-wake disturbances following traumatic brain injury (TBI) are increasingly recognized as a serious consequence following injury and as a barrier to recovery. Injury-induced sleep-wake disturbances can persist for years, often impairing quality of life. Recently, there has been a nearly exponential increase in the number of primary research articles published on the pathophysiology and mechanisms underlying sleep-wake disturbances after TBI, both in animal models and in humans, including in the pediatric population. In this review, we summarize over 200 articles on the topic, most of which were identified objectively using reproducible online search terms in PubMed. Although these studies differ in terms of methodology and detailed outcomes; overall, recent research describes a common phenotype of excessive daytime sleepiness, nighttime sleep fragmentation, insomnia, and electroencephalography spectral changes after TBI. Given the heterogeneity of the human disease phenotype, rigorous translation of animal models to the human condition is critical to our understanding of the mechanisms and of the temporal course of sleep-wake disturbances after injury. Arguably, this is most effectively accomplished when animal and human studies are performed by the same or collaborating research programs. Given the number of symptoms associated with TBI that are intimately related to, or directly stem from sleep dysfunction, sleep-wake disorders represent an important area in which mechanistic-based therapies may substantially impact recovery after TBI.

Sleep outcomes following sleep-hygiene-related interventions for individuals with traumatic brain injury: A systematic review

BACKGROUND

Sleep disturbance is commonly reported following traumatic brain injury (TBI) and can adversely impact health and wellbeing and interfere with the rehabilitation process. As such, effective treatment of sleep disturbance is critical for overall recovery. Sleep hygiene, which is non-invasive, low cost, and low risk, could serve as a suitable first line of treatment for individuals experiencing sleep disturbance post-TBI.

OBJECTIVE

To assess the efficacy of sleep hygiene on sleep outcomes post-TBI.

DESIGN

PsycINFO, Medline and EMBASE databases were systematically searched using mesh terms and keywords related to 'traumatic brain injury', 'sleep' and 'treatment'. Studies that met inclusion criteria were assessed on their methodological quality using validated assessment tools.

RESULTS

Ten studies met inclusion criteria, none of which contained a child or adolescent population. Their methodological quality varied. The following interventions were shown to improve sleep outcomes amongst adults with TBI: Cognitive Behaviour Therapy for Insomnia, blue light therapy, Problem Solving Treatment and combined sleep hygiene and Prazosin. There was mixed evidence for the efficacy of exercise on sleep outcomes.

CONCLUSION

Preliminary findings suggest that some sleep-hygiene-related interventions, either in isolation or in combination with other treatments, may reduce sleep difficulties post-TBI.

Sleep and quality of life in children with traumatic brain injury and ADHD

Objective Attention problems are common in children who sustain a traumatic brain injury (TBI). The differential features of TBI-related Attention Deficit Hyperactivity Disorder (ADHD) and primary ADHD are largely unknown. This study aimed to compare sleep problems and quality of life between children with TBI and ADHD and children with primary ADHD. Methods Twenty children with TBI (mean age = 12.7 ± 3.1 years) who had clinically significant ADHD symptoms according to the structured diagnostic interview and rating scales and a control group with primary ADHD (n = 20) were included. Parents completed Children's Sleep Habits Questionnaire (CSHQ) and Kinder Lebensqualitätsfragebogen: Children's Quality of Life Questionnaire-revised (KINDL-R). Neurology clinic charts were reviewed for TBI-related variables. Results When compared to children with primary ADHD, the Total Score and Sleep Onset Delay, Daytime Sleepiness, Parasomnias, and Sleep Disordered Breathing subscores of CSHQ were found to be higher in children with TBI and ADHD. The Total Score and Emotional Well-Being and Self-Esteem subscores of the KINDL-R were found to be low (poorer) in children with TBI and ADHD. The Total Score and certain subscores of KINDL-R were found to be lower in TBI patients with a CSHQ > 56 (corresponds to significant sleep problems) when compared to those with a CSHQ < 56. CSHQ Total Score was negatively correlated with age. Conclusion Children with TBI and ADHD symptoms were found to have a poorer sleep quality and quality of life than children with primary ADHD. ADHD in TBI may be considered as a highly impairing condition which must be early diagnosed and treated.

Sleep Quantity and Quality during Acute Concussion: A Pilot Study

STUDY OBJECTIVES

A number of subjective and objective studies provide compelling evidence of chronic post-concussion changes in sleep, yet very little is known about the acute effects of concussion on sleep quality and quantity. Therefore, the purpose of this prospective pilot study was to use actigraphy to examine the changes in sleep quality and quantity acutely following concussion at home rather than in a hospital or sleep laboratory.

METHODS

Seventeen young adults (7 with acute concussion, 10 controls) were recruited for this study. All participants completed two 5-day testing sessions separated by 30 days from intake (controls) or day of injury (concussion). Participants wore actigraphs and kept a sleep journal. Sleep parameter outcomes included nighttime total sleep time (nTST), 24-h total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE). The coefficient of variation (CV) for each sleep parameter was computed for each session.

RESULTS

nTST and TST CV was significantly greater in the concussion group. There is the additional indication that individuals with a concussion may require and obtain more sleep shortly after injury and subsequently have a shorter duration of sleep at 1 mo post-injury. This pattern was not seen in the measures of sleep quality (WASO, SE).

CONCLUSIONS

Individuals with a concussion demonstrated increased nighttime sleep duration variability. This increase persisted at 1 mo post-injury and may be associated with previously documented self-reports of poor sleep quality lasting months and years after a concussion. Additionally, this increase may predispose individuals to numerous negative health outcomes if left untreated.

Evaluation of actigraphy-measured sleep patterns among children with disabilities and associations with caregivers' educational attainment: results from a cross-sectional study

OBJECTIVES

To use wrist-actrigrphy to collect objective measures of sleep and to characterise actigraphy-measured sleep patterns among children with disabilities. We also assessed the extent to which, if at all, caregivers' education is associated with children's sleep disturbances.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation centre in the Patagonia region, Chile.

METHODS

This study was conducted among 125 children aged 6-12 years with disabilities (boys: 55.2%) and their primary caregivers in Chile. Children wore ActiSleep monitors for 7 days. A general linear model was fitted to generate least-square means and SEs of sleep efficiency (proportion of the sleep period spent asleep) across caregivers' education levels adjusting for children's age, sex, disability type, caregiver-child relationship and caregivers' age. Multivariable logistic regression analyses were conducted to estimate ORs and 95% CIs of longer sleep latency (≥ 30 min) and longer wake after sleep onset (WASO) (≥ 90 min) (a measure of sleep fragmentation) in relation to caregivers' educational attainment.

RESULTS

Median sleep latency was 27.3 min, WASO 88.1 min and sleep duration 8.0 h. Mean sleep efficiency was 80.0%. Caregivers' education was positively and significantly associated with children's sleep efficiency (p trend<0.001). Adjusted mean sleep efficiency was 75.7% (SE=1.4) among children of caregivers high school education. Compared to children whose caregivers had >high school, children of caregivers with

CONCLUSIONS

Children with disabilities experience difficulties initiating sleep (prolonged sleep latency) and maintaining sleep (long WASO, low sleep efficiency). Among children with disabilities, lower level of caregivers' education is associated with more sleep disturbances.

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Key Words

• EPIDEMIOLOGY
• PUBLIC HEALTH
• SLEEP MEDICINE

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MESH Headings

• Actigraphy/instrumentation
• Actigraphy/methods
• Adult
• Caregivers/education
• Caregivers/psychology
• Child
• Chile/epidemiology
• Cross-Sectional Studies
• Disabled Children/psychology
• Educational Status
• Female
• Humans
• Male
• Sleep Wake Disorders/epidemiology
• Sleep Wake Disorders/etiology
• Sleep Wake Disorders/psychology
• Surveys and Questionnaires

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Grants

• T37 MD001449 NIMHD NIH HHS
• UL1 TR000170 NCATS NIH HHS
• 8UL1TR000170-07 NCATS NIH HHS
• T37-MD001449 NIMHD NIH HHS

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Affiliation(s)

Xiaoli Chen Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
Juan Carlos Velez Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Clarita Barbosa Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Micah Pepper Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Bizu Gelaye Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
Susan Redline Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
Michelle A Williams Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA

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Sleep-wake disturbances after traumatic brain injury

Sleep-wake disturbances are extremely common after a traumatic brain injury (TBI). The most common disturbances are insomnia (difficulties falling or staying asleep), increased sleep need, and excessive daytime sleepiness that can be due to the TBI or other sleep disorders associated with TBI, such as sleep-related breathing disorder or post-traumatic hypersomnia. Sleep-wake disturbances can have a major effect on functional outcomes and on the recovery process after TBI. These negative effects can exacerbate other common sequelae of TBI-such as fatigue, pain, cognitive impairments, and psychological disorders (eg, depression and anxiety). Sleep-wake disturbances associated with TBI warrant treatment. Although evidence specific to patients with TBI is still scarce, cognitive-behavioural therapy and medication could prove helpful to alleviate sleep-wake disturbances in patients with a TBI.

Sleep problems and their relationship to cognitive and behavioral outcomes in young children with traumatic brain injury

This study examined the effect of traumatic brain injury (TBI) in young children on sleep problems and the relationship of sleep problems to neuropsychological and psychosocial functioning. Participants were drawn from an ongoing longitudinal study of injury in young children recruited from 3 to 6 years of age. They constituted three groups: orthopedic injury (OI; n=92), complicated mild/moderate TBI (mTBI; n=55); and severe TBI (sTBI; n=20). Caregivers completed the Children's Sleep Habits Questionnaire (CSHQ), as well as ratings of behavioral adjustment, adaptive functioning, and everyday executive function at 1, 6, 12, and 18 months postinjury. Retrospective ratings of preinjury sleep and psychosocial functioning were obtained at the initial assessment. Children completed neuropsychological testing at all occasions. Children with complicated mTBI demonstrated more total sleep problems than children with OI at 6 months postinjury, but not at 12 or 18 months. Children with sTBI displayed more bedtime resistance and shorter sleep duration than those with complicated mTBI or OI at several occasions. Across groups, total sleep problems predicted more emotional and behavioral problems and worse everyday executive function as rated by parents across follow-up occasions. In contrast, sleep problems were generally not related to neuropsychological test performance. The results suggest that young children with TBI demonstrate more sleep problems than children with injuries not involving the head. Sleep problems, in turn, significantly increase the risk of poor psychosocial outcomes across time, but are not associated with worse neuropsychological test performance.