Parental sleep-related practices and sleep in children aged 1-3 years: a systematic review

The current systematic review sought to identify the relationship between the range of different parental sleep-related practices that had been explored in relations to child sleep outcomes in children aged 1-3 years. A systematic literature review was carried out in CINAHL, The Cochrane Library, PsycArticles, PsycInfo, PubMed and Web of Science, as well as relevant grey literature in August 2022 using the terms; population (children, aged 1-3 years), exposure (parental sleep-related practice) and outcome (child sleep). Any quantitative study published between 2010 and 2022 that explored the relationship between parental sleep-related practices and the sleep of children aged 1-3 years were included. The Mixed Methods Appraisal Tool was employed to quality appraise included studies and results were narratively synthesised. In all, 16 longitudinal and cross-sectional quantitative studies met inclusion criteria. Parental presence or physical involvement, as well as broader parental practices including using screens or devices at bedtime and night-time breastfeeding were all related to poorer child sleep outcomes. Consistent and relaxing routines, sleeping in a cot, and spending all night in their own sleep location were associated with better child sleep outcomes. Acknowledging the plethora of diverse parental sleep-related practices, which may have varying relationships with child sleep outcomes, could be usefully considered in theoretical models and to inform clinical practice. Issues of definitional and measurement ambiguity are highlighted and discussed.

A cross-sectional survey of healthcare professionals supporting children and young people with epilepsy and their parents/carers: which topics are raised in clinical consultations and can healthcare professionals provide the support needed?

BACKGROUND AND PURPOSE

Children and young people (CYP) with epilepsy see healthcare professionals (HCPs) for management of their seizures but may require information, advice and support with a range of broader topics. The purpose of the survey was to identify from HCPs, which topics CYP with epilepsy and their parents/carers ask about other than seizure management, and how adequately HCPs feel able to support them with these topics.

METHOD

A cross-sectional online survey was used to collect data. Adverts which included a link to the survey were shared via social media channels, professional networks and United Kingdom (UK)-based epilepsy networks. Eighty-eight HCPs in the UK (who worked with CYP with epilepsy and their parents/carers) completed the survey. Quantitative data are presented descriptively. Qualitative data (free-text responses) were reflexively thematically analysed.

RESULTS

CYP with epilepsy and their parents/carers were reported to ask HCPs for information, advice and support about a range of topics, most commonly, cognition and mental health. CYP were reported as also frequently asking about aspects of their social life while parents/carers commonly asked about sleep. HCPs varied in how able they felt to adequately support families about these topics, as well as in their views about which resources could be most useful. Having insufficient time and a lack of suitable services and resources to refer to, or draw upon, were key barriers to HCPs being able to support CYP and their families.

DISCUSSION

Findings highlight the broad array of topics CYP with epilepsy and their families are reported as seeking support for. HCPs identified gaps in services and their abilities to meet those needs. There appeared to be a mismatch between the support that families were seeking and the ability of HCPs to meet these needs. Findings have implications for how HCPs could best be supported to deal with topics raised by CYP and families in clinic, highlighting the potential usefulness of informational resources on key topics for HCPs, parents/carers and CYP.

The relationship between parents' cognitions, bedtime behaviours and sleep-related practices with their child's sleep

Certain parental cognitions about child sleep and bedtime behaviours used with their child have been linked to poorer child sleep. However, previous research has focused on mothers and explored only a limited range of sleep-related cognitions and practices. The present study investigated whether parental cognitions and sleep-related practices (both in connection with their own sleep and their child's sleep), alongside the bedtime behaviours used with their child were associated with and/or were predictive of their child's sleep. Mothers and fathers from 44 families (with a child aged 12-24 months) separately completed questionnaires reporting (i) their cognitions (about their own sleep and their child's sleep), (ii) sleep-related practices (used in connection with their own and their child's sleep) and (iii) bedtime behaviours used with their child. Child sleep was assessed through parental report and actigraphy. Both parents' cognitions about their own sleep predicted cognitions about their child's sleep. Mothers' own sleep-related practices predicted the types of practices they used with their child. Different patterns of maternal and paternal variables influenced parental perceptions of their child having a sleep problem. The present findings highlight the importance of including mothers and fathers in child sleep research. Parents' dysfunctional cognitions (their own sleep) and broader sleep-related practices (their own and child sleep) should be considered when exploring influences on child sleep. Results have possible implications for targets of interventions for child sleep problems and also potential implications for theoretical models of child sleep.

'No one's ever said anything about sleep': A qualitative investigation into mothers' experiences of sleep in children with epilepsy

INTRODUCTION

Sleep problems in children with epilepsy (CWE) are common. However, little is known about parental experiences and feelings about managing sleep in their CWE. To provide the most appropriate services' provision, it is essential that the lived experience of parents of this patient group and the issues and problems that they face in managing their child's sleep is understood.

METHOD

In 2018, nine mothers of CWE (aged 5-15 years) were interviewed about their perceptions and experiences around their child's sleep, sleep problems and their management, the impact of sleep difficulties on the child and their family and available support.

RESULTS

Four themes were identified that represented the nature of the child's sleep problems, including settling and night-waking issues, parasomnias and child anxiety around sleep. Seven themes represented mothers' experiences of managing their child's sleep and any associated problems, including the longstanding challenging nature of child sleep issues, management strategies adopted, challenges related to managing sleep over time, the link between sleep and seizures, the negative impact of poor sleep on daytime functioning, role of antiseizure medication and maternal concerns about child sleep. One theme represented the perceived lack of information, help and support available.

CONCLUSIONS

Findings suggest there are unmet needs in supporting parents to deal with sleep, sleep problems and their management in CWE.

PATIENT OR PUBLIC CONTRIBUTION

This individual study was conducted under the umbrella of the CASTLE research programme (see https://castlestudy.org.uk/). Parents who have lived experience of parenting a child with epilepsy were co-applicants for the programme and were involved in the original conception, aims, design and funding application for the research programme (including the project reported in this paper) and advised on project design. Mothers of CWE who have lived experience of managing sleep and sleep problems in their child were participants who shared their experiences through the interviews, which formed the data of the current study.

Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E: a protocol for a randomised controlled trial comparing an online behavioural sleep intervention with standard care in children with Rolandic epilepsy

INTRODUCTION

Sleep and epilepsy have an established bidirectional relationship yet only one randomised controlled clinical trial has assessed the effectiveness of behavioural sleep interventions for children with epilepsy. The intervention was successful, but was delivered via face-to-face educational sessions with parents, which are costly and non-scalable to population level. The Changing Agendas on Sleep, Treatment and Learning in Epilepsy (CASTLE) Sleep-E trial addresses this problem by comparing clinical and cost-effectiveness in children with Rolandic epilepsy between standard care (SC) and SC augmented with a novel, tailored parent-led CASTLE Online Sleep Intervention (COSI) that incorporates evidence-based behavioural components.

METHODS AND ANALYSES

CASTLE Sleep-E is a UK-based, multicentre, open-label, active concurrent control, randomised, parallel-group, pragmatic superiority trial. A total of 110 children with Rolandic epilepsy will be recruited in outpatient clinics and allocated 1:1 to SC or SC augmented with COSI (SC+COSI). Primary clinical outcome is parent-reported sleep problem score (Children's Sleep Habits Questionnaire). Primary health economic outcome is the incremental cost-effectiveness ratio (National Health Service and Personal Social Services perspective, Child Health Utility 9D Instrument). Parents and children (≥7 years) can opt into qualitative interviews and activities to share their experiences and perceptions of trial participation and managing sleep with Rolandic epilepsy.

ETHICS AND DISSEMINATION

The CASTLE Sleep-E protocol was approved by the Health Research Authority East Midlands (HRA)-Nottingham 1 Research Ethics Committee (reference: 21/EM/0205). Trial results will be disseminated to scientific audiences, families, professional groups, managers, commissioners and policymakers. Pseudo-anonymised individual patient data will be made available after dissemination on reasonable request.

TRIAL REGISTRATION NUMBER

ISRCTN13202325.

The impact of parent treatment preference and other factors on recruitment: lessons learned from a paediatric epilepsy randomised controlled trial

BACKGROUND

In paediatric epilepsy, the evidence of effectiveness of antiseizure treatment is inconclusive for some types of epilepsy. As with other paediatric clinical trials, researchers undertaking paediatric epilepsy clinical trials face a range of challenges that may compromise external validity MAIN BODY: In this paper, we critically reflect upon the factors which impacted recruitment to the pilot phase of a phase IV unblinded, randomised controlled 3×2 factorial trial examining the effectiveness of two antiseizure medications (ASMs) and a sleep behaviour intervention in children with Rolandic epilepsy. We consider the processes established to support recruitment, public and patient involvement and engagement (PPIE), site induction, our oversight of recruitment targets and figures, and the actions we took to help us understand why we failed to recruit sufficient children to continue to the substantive trial phase. The key lessons learned were about parent preference, children's involvement and collaboration in decision-making, potential and alternative trial designs, and elicitation of stated preferences pre-trial design. Despite pre-funding PPIE during the trial design phase, we failed to anticipate the scale of parental treatment preference for or against antiseizure medication (ASMs) and consequent unwillingness to be randomised. Future studies should ensure more detailed and in-depth consultation to ascertain parent and/or patient preferences. More intense engagement with parents and children exploring their ideas about treatment preferences could, perhaps, have helped predict some recruitment issues. Infrequent seizures or screening children close to natural remission were possible explanations for non-consent. It is possible some clinicians were unintentionally unable to convey clinical equipoise influencing parental decision against participation. We wanted children to be involved in decisions about trial participation. However, despite having tailored written and video information to explain the trial to children we do not know whether these materials were viewed in each consent conversation or how much input children had towards parents' decisions to participate. Novel methods such as parent/patient preference trials and/or discrete choice experiments may be the way forward.

CONCLUSION

The importance of diligent consultation, the consideration of novel methods such as parent/patient preference trials and/or discrete choice experiments in studies examining the effectiveness of ASMs versus no-ASMs cannot be overemphasised even in the presence of widespread clinician equipoise.

UK parents' help-seeking for child sleep: A qualitative investigation into parental preferences and reservations about resources

Child sleep is a common parental concern and there is an array of resources available to parents. However, an exploration of UK parents' help-seeking behaviours around child sleep is lacking. This study sought to identify the resources parents use to seek information and help for child sleep, as well as to explore what factors parents prefer about certain sources and their reservations about using other resources. Parents of 6-36 month old children residing in the United Kingdom (UK) completed an online questionnaire between October 2015 and October 2016 about their use, opinions and experiences regarding resources for child sleep. Quantitative data were descriptively analysed and thematic analysis was conducted on parents' open-ended text responses. Participants were 266 UK parents (97% mothers). Parents' ages ranged from 21 to 45 years (M = 33.49 years, SD = 4.71) and all resided in the United Kingdom (UK). General Internet searches were the most commonly reported source used by 47% of parents with a range of other informal resources also frequently consulted. Health Visitors (HVs) were the most accessed healthcare professional reportedly consulted by 38% of parents. Seven themes represented parental preferences for their resource use. Most strongly endorsed included a desire for information from other parents, particularly those with practical experience and accessing information that aligned with their parenting values. Parents preferred sources that provided support and reassurance, as well as those that afforded parents the ability to select relevant elements from a range of information. Seven themes represented parents' reservations about resources. Most strongly endorsed were concerns about reliability, being judged and challenges associated with filtering vast amounts of information. Parents reported having reservations towards sources if they had a previous negative experience with the source. Possible implications of the findings and specific suggestions about how existing and future resources could be adapted to better meet parents' needs are highlighted.

The effects of Autonomous Sensory Meridian Response (ASMR) videos on arousal and mood in adults with and without depression and insomnia

BACKGROUND

Autonomous Sensory Meridian Response (ASMR) is a pleasant physiological tingling sensation induced by certain visual and auditory triggers. ASMR has been shown to reduce stress and increase positive mood, but its effects have not yet been studied in populations with clinically severe symptoms. The present study aimed to investigate whether the experience of ASMR improved mood and reduced arousal in people with and without insomnia and depression symptoms.

METHODS

1,037 participants (18-66 years) completed online questionnaires assessing insomnia and depression symptom severity followed by questionnaires on current mood and arousal levels before and after watching an ASMR video. The independent variables were the participant's group (insomnia, depression, insomnia and depression combined or control) and whether they experienced ASMR during the video. The dependent variables were the change in mood and arousal levels after watching the video.

RESULTS

As predicted, all participants showed significantly increased relaxation and improved mood after watching the video with the largest effects for participants who experienced ASMR and for participants in the combined and depression groups. No difference was found between the insomnia and control groups.

LIMITATIONS

It is not known how many participants were familiar with ASMR videos prior to taking part in the study (nor whether this is important). Also, the categorization of participants into the ASMR group was based on self-report and thus, not verified.

CONCLUSIONS

Results suggest that ASMR videos have the potential to be used to improve mood and reduce arousal with implications for alleviating symptoms of insomnia and depression.

Moral duty and equalization concerns motivate children's third-party punishment

Although children enact third-party punishment, at least in response to harm and fairness violations, much remains unknown about this behavior. We investigated the tendency to make the punishment fit the crime in terms of moral domain; developmental patterns across moral domains; the effects of audience and descriptive norm violations; and enjoyment of inflicting punishment. We tested 5- to 11-year-olds in the United Kingdom (N = 152 across two experiments, 55 girls and 97 boys, predominantly White and middle-class). Children acted as referees in a computer game featuring teams of players: As these players violated fairness or loyalty norms, children were offered the opportunity to punish them. We measured the type (fining or banning) and severity of punishment children chose and their enjoyment in doing so. Children only partially made the punishment fit the crime: They showed no systematic punishment choice preference for disloyal players, but tended to fine rather than ban players allocating resources unfairly-a result best explained by equalization concerns. Children's punishment severity was not affected by audience presence or perpetrators' descriptive norm violations, but was negatively predicted by age (unless punishment could be used as an equalization tool). Most children did not enjoy punishing, and those who believed they allocated real punishment reported no enjoyment more often than children who believed they pretended to punish. Contrary to predictions, retribution was not a plausible motive for the observed punishment behavior. Children are likely to have punished for deterrence reasons or because they felt they ought to. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Qualitative Investigation Into What Parents Want From an Online Behavioural Sleep Intervention for Children With Epilepsy

Many of the same sleep problems seen in typically developing (TD) children are frequently experienced by children with epilepsy (CWE). Behavioural sleep interventions (BSIs) are commonly and successfully used to treat these sleep problems in TD children and in some neurodevelopmental disorder populations. Therefore, BSIs should be effective in CWE, however, there are special seizure-related considerations for CWE and their parents which may be salient to consider in any future BSI development for this group. The current study sought to identify, from parents, if there were special considerations for the content and delivery of an online BSI for parents of CWE. Semi-structured interviews were conducted with nine mothers of CWE and thematic analysis was conducted on the interview data. Ten themes were apparent which represented what parents wanted from any online BSI for CWE. Parents wanted (i) other parents' views and real-life experiences to be included, (ii) recognition of how changes over time may influence the appropriateness of using various sleep-management options, (iii) to be presented with a range of sleep management options from which they could select, (iv) personalised information and suggestions for behaviour-change options, (v) help to address child anxiety around sleep, (vi) for the advice and behaviour-change options to be practical, (vii) general educational information about sleep and the relationship between sleep and epilepsy, (viii) for parental worries and concerns to be acknowledged, (ix) to receive help, support, and reassurance around children's sleep; and (x) to include the child in the intervention. It was clear that any online BSI would require specific adaptations and additions (to content and delivery format) to best meet the needs of parents of CWE. It is hoped that having identified what parents want from on online BSI for CWE will allow these factors to be acknowledged in future intervention development, with the intention to optimise parental engagement and intervention effectiveness. Practical suggestions for how these aspects could be integrated into any online BSI are suggested.

Development and Evaluation of the CASTLE Trial Online Sleep Intervention for Parents of Children with Epilepsy

Introduction: Many of the sleep problems experienced by children with epilepsy (CWE) have the same behavioural basis as common sleep problems seen in typically developing (TD) children. Behavioural sleep interventions (BSIs) are widely used to treat these sleep problems in TD children and are hypothesised to be effective for CWE. However, specific considerations need to be addressed and incorporated into a BSI for CWE to ensure the intervention is tailored to this population's needs. This paper details developing and tailoring an online BSI for parents of CWE, to be used in the CASTLE (Changing Agendas on Sleep, Treatment and Learning in Epilepsy) Sleep-E clinical trial. Method: In phase one, two existing theory-driven paediatric BSIs were adapted into a novel online behavioural sleep intervention (CASTLE Online Sleep Intervention or COSI) which specifically incorporated the needs and requirements reported by nine parents of CWE. Scoping their needs included conducting interviews with three CWE so that they could contribute to the overall intervention content. In phase two, six of these parents evaluated COSI, reviewing and feeding back on COSI until parental approval for content and functionality was achieved. Results: In phase one, a range of adaptations was made to the content and presentation of standardised intervention material to acknowledge and emphasise the key seizure-specific issues to ensure COSI best met parents of CWE's needs. Adaptations included embedding parent and child experiences in the intervention, including particular information requested by parents, such as the links between sleep and seizures and managing child and parental anxieties around sleep, as well as developing functionality to personalise the delivery of content. In phase two, parents confirmed that they found the final version of COSI to be functional and appropriate (after one round of review) for use by parents of CWE and that 100% would recommend it to other families who have CWE. Discussion: It is hoped that the use of evidence-based BSIs, adapted to consider salient epilepsy-specific factors, will increase parent-engagement, COSI's relevance for this particular patient group and overall efficacy in improving sleep in CWE. The effectiveness of COSI will be tested in the CASTLE Sleep-E clinical trial (https://castlestudy.org.uk/).

Parentally reported barriers to seeking help and advice for child sleep from healthcare professionals

BACKGROUND

Healthcare professionals (HCPs), largely doctors, paediatricians, health visitors, midwives, and practice nurses, are in a good position to provide information, help, advice, or guidance to parents for child sleep. However, evidence suggests that there is a gap between the number of parents who desire assistance from HCPs and those that make use of these sources, yet very little is known about the reason for this apparent disparity. The aim of this study was to understand the barriers reported by parents to consulting HCPs about child sleep.

METHODS

In this study, 266 U.K.-based parents of children aged 6-36 months old completed an online questionnaire (between October 2015 and October 2016) about their help-seeking behaviours in relation to child sleep. This included reporting perceived barriers to consulting HCPs for child sleep information and advice about problems.

RESULTS

Thematic analysis highlighted five themes, which parents reported acted as barriers to them consulting HCPs. Specifically, parents perceived HCPs to have a lack of knowledge or training around the topic of child sleep and that advice would be limited in terms of breadth of information or management options that would be offered. Parents were also concerned about wasting their own or HCPs' time, perceived there was a lack of continuity in the information they received, and held concerns about possible negative consequences for their family if they shared details about any child sleep difficulties.

CONCLUSIONS

Possible practical approaches to address the barriers reported by parents are highlighted. This includes improving training around the topic of child sleep for HCPs and adapting the content or manner in which the topic of child sleep and any associated issues are addressed with parents.

Parent Report and Actigraphically Defined Sleep in Children with and without Developmental Coordination Disorder; Links with Fatigue and Sleepiness

BACKGROUND

Impaired sleep is associated with negative effects on quality of life and daytime functioning. Higher rates of sleep disturbance are reported in children with various developmental disorders. However, little is known about sleep in children with developmental coordination disorder (DCD), a condition characterized by everyday movement difficulties. Previously, in a preliminary study, we found higher rates of parent-reported sleep disturbance in children with DCD compared to controls.

AIMS

To examine sleep in DCD using objective measures and to examine links with daytime fatigue and sleepiness.

METHODS

Two groups (primary and secondary school-aged) of 15 children with DCD, plus matched controls, participated. Parent-reported child sleep was assessed using the Children's Sleep Habits Questionnaire and actigraphy provided an objective measure of sleep-wake patterns over 1 week (including weekdays and weekend). Pediatric restless legs syndrome (RLS) semi-structured diagnostic interview was conducted with each child and parent to capture symptoms of RLS. Aspects of self-rated child functioning were assessed with questionnaires (Pre-sleep Arousal Scale, Pediatric Daytime Sleepiness Scale, PedsQL Multidimensional Fatigue Scale) and mothers' reported thoughts about child sleep with the Maternal Cognitions about Infant Sleep Questionnaire.

RESULTS

The DCD groups had greater parent-reported sleep disturbance. Actigraphy results suggested that for secondary aged children with DCD their sleep quality was impaired and there were differences in the timing of sleep compared to controls (including some differences in the variation between weekday and weekend sleep times). The actigraphy of the primary age group with DCD was unremarkable compared to controls. No child in the study met the criteria for RLS. Exploratory analyses suggested that daytime fatigue, aspects of pre-sleep arousal, and daytime sleepiness were reported as greater in the DCD groups and were particularly related to objective sleep parameters in the DCD groups. Maternal thoughts about sleep did not differ between the DCD and control groups.

CONCLUSION

The nature and underlying cause of sleep disturbance and how it might be linked with aspects of daytime functioning in adolescents with DCD requires further research. Meanwhile, clinical awareness of the risk of atypical sleep patterns/sleep problems in DCD is important to ensure early identification and implementation of appropriate support.

Definitions of sleeplessness in children with attention-deficit hyperactivity disorder (ADHD): implications for mothers' mental state, daytime sleepiness and sleep-related cognitions

BACKGROUND

Sleep disturbances are common in children with attention-deficit hyperactivity disorder (ADHD). Sleeplessness is frequently reported although results are inconsistent perhaps because different definitions for it are applied. This study looked at maternal functioning and child objective sleep patterns in relation to different definitions of sleeplessness in children with ADHD.

METHODS

The study included 45 children (aged 3-14 years) with ADHD and their mothers. Sleeplessness was defined according to: (i) yes/no report of whether mothers thought their children had a problem with sleeplessness (Maternal definition MD) and (ii) mothers' responses to a quantitative standardized questionnaire (Quantitative definition QD) designed to detect the frequency and duration of parent-reported problems with settling, night waking and early waking. Objective sleep patterns were also assessed by means of actigraphy. Maternal mental health, daytime sleepiness and cognitions related to child sleep were assessed by questionnaire.

RESULTS

Both definitions appeared to tap similar although slightly different constructs. There were no group differences in objective sleep patterns. Maternal mental health was found to be significantly worse in the mothers who considered their child to be sleepless (MD) (P < 0.025), but not in those mothers whose child was found to be sleepless according to the standardized criteria (QD). Maternal sleepiness did not differ between groups. For both categories of sleepless children (MD and QD), the mothers had significantly more doubts about their competency as a parent (P < 0.01 and P < 0.025, respectively) compared to mothers of children without sleeplessness.

CONCLUSIONS

Two different maternal assessments of child sleeplessness in children with ADHD may assess subtly different constructs, but both may provide useful information about potential problems across the family.

Weighted blankets and sleep in autistic children--a randomized controlled trial

OBJECTIVE

To assess the effectiveness of a weighted-blanket intervention in treating severe sleep problems in children with autism spectrum disorder (ASD).

METHODS

This phase III trial was a randomized, placebo-controlled crossover design. Participants were aged between 5 years and 16 years 10 months, with a confirmed ASD diagnosis and severe sleep problems, refractory to community-based interventions. The interventions were either a commercially available weighted blanket or otherwise identical usual weight blanket (control), introduced at bedtime; each was used for a 2-week period before crossover to the other blanket. Primary outcome was total sleep time (TST) recorded by actigraphy over each 2-week period. Secondary outcomes included actigraphically recorded sleep-onset latency, sleep efficiency, assessments of child behavior, family functioning, and adverse events. Sleep was also measured by using parent-report diaries.

RESULTS

Seventy-three children were randomized and analysis conducted on 67 children who completed the study. Using objective measures, the weighted blanket, compared with the control blanket, did not increase TST as measured by actigraphy and adjusted for baseline TST. There were no group differences in any other objective or subjective measure of sleep, including behavioral outcomes. On subjective preference measures, parents and children favored the weighted blanket.

CONCLUSIONS

The use of a weighted blanket did not help children with ASD sleep for a longer period of time, fall asleep significantly faster, or wake less often. However, the weighted blanket was favored by children and parents, and blankets were well tolerated over this period.

Behavioral parent training to address sleep disturbances in young children with autism spectrum disorder: a pilot trial

OBJECTIVES

A large percentage of children with autism spectrum disorders (ASD) have bedtime and sleep disturbances. However, the treatment of these disturbances has been understudied. The purpose of our study was to develop a manualized behavioral parent training (BPT) program for parents of young children with ASD and sleep disturbances and to test the feasibility, fidelity, and initial efficacy of the treatment in a small randomized controlled trial (RCT).

PARTICIPANTS AND METHODS

Parents of a sample of 40 young children diagnosed with ASD with an average age of 3.5years were enrolled in our study. Participants were randomized to either the BPT program group or a comparison group who were given nonsleep-related parent education. Each participant was individually administered a 5-session program delivered over the 8-week study. Outcome measures of feasibility, fidelity, and efficacy were collected at weeks 4 and 8 after the baseline time point. Children's sleep was assessed by parent report and objectively by actigraphy.

RESULTS

Of the 20 participants in each group, data were available for 15 participants randomized to BPT and 18 participants randomized to the comparison condition. Results supported the feasibility of the manualized parent training program and the comparison program. Treatment fidelity was high for both groups. The BPT program group significantly improved more than the comparison group based on the primary sleep outcome of parent report. There were no objective changes in sleep detected by actigraphy.

CONCLUSIONS

Our study is one of few RCTs of a BPT program to specifically target sleep disturbances in a well-characterized sample of young children with ASD and to demonstrate the feasibility of the approach. Initial efficacy favored the BPT program over the comparison group and suggested that this manualized parent training approach is worthy of further examination of the efficacy within a larger RCT.

Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial

OBJECTIVE

To assess the effectiveness and safety of melatonin in treating severe sleep problems in children with neurodevelopmental disorders.

DESIGN

12 week double masked randomised placebo controlled phase III trial.

SETTING

19 hospitals across England and Wales.

PARTICIPANTS

146 children aged 3 years to 15 years 8 months were randomised. They had a range of neurological and developmental disorders and a severe sleep problem that had not responded to a standardised sleep behaviour advice booklet provided to parents four to six weeks before randomisation. A sleep problem was defined as the child not falling asleep within one hour of lights out or having less than six hours' continuous sleep.

INTERVENTIONS

Immediate release melatonin or matching placebo capsules administered 45 minutes before the child's bedtime for a period of 12 weeks. All children started with a 0.5 mg capsule, which was increased through 2 mg, 6 mg, and 12 mg depending on their response to treatment.

MAIN OUTCOME MEASURES

Total sleep time at night after 12 weeks adjusted for baseline recorded in sleep diaries completed by the parent. Secondary outcomes included sleep onset latency, assessments of child behaviour, family functioning, and adverse events. Sleep was measured with diaries and actigraphy.

RESULTS

Melatonin increased total sleep time by 22.4 minutes (95% confidence interval 0.5 to 44.3 minutes) measured by sleep diaries (n=110) and 13.3 (-15.5 to 42.2) measured by actigraphy (n=59). Melatonin reduced sleep onset latency measured by sleep diaries (-37.5 minutes, -55.3 to -19.7 minutes) and actigraphy (-45.3 minutes, -68.8 to -21.9 minutes) and was most effective for children with the longest sleep latency (P=0.009). Melatonin was associated with earlier waking times than placebo (29.9 minutes, 13.6 to 46.3 minutes). Child behaviour and family functioning outcomes showed some improvement and favoured use of melatonin. Adverse events were mild and similar between the two groups.

CONCLUSIONS

Children gained little additional sleep on melatonin; though they fell asleep significantly faster, waking times became earlier. Child behaviour and family functioning outcomes did not significantly improve. Melatonin was tolerable over this three month period. Comparisons with slow release melatonin preparations or melatonin analogues are required.

TRIAL REGISTRATION

ISRCT No 05534585.

Comparison of sleep questionnaires in the assessment of sleep disturbances in children with autism spectrum disorders

BACKGROUND AND PURPOSE

The purpose of this study was to compare two parent completed questionnaires, the Modified Simonds & Parraga Sleep Questionnaire (MSPSQ) and the Children's Sleep Habits Questionnaire (CSHQ), used to characterize sleep disturbances in young children with autism spectrum disorders (ASD). Both questionnaires have been used in previous work in the assessment and treatment of children with ASD and sleep disturbance.

PARTICIPANTS AND METHODS

Parents/caregivers of a sample of 124 children diagnosed with ASD with an average age of six years completed both sleep questionnaires regarding children's sleep behaviors. Internal consistency of the items for both measures was evaluated as well as the correlation between the two sleep measures. A Receiver Operating Characteristics (ROC) curve analysis was also conducted to examine the predictive power of the MSPSQ.

RESULTS

More than three quarters of the sample (78%) were identified as poor sleepers on the CSHQ. Cronbach's alpha for the items on the CSHQ was 0.68 and Cronbach's alpha for items on the MSPSQ was 0.67. The total scores for MSPSQ and CSHQ were significantly correlated (r=.70, p<.01). After first identifying the poor sleepers based on the CSHQ, an area under the curve was 0.89 for the MSPSQ. Using a cut off score of 56 on the MSPSQ, sensitivity was .86 and specificity was .70.

CONCLUSIONS

In this sample of children with ASD, sleep disturbances were common across all cognitive levels. Preliminary findings suggest that, similar to the CSHQ, the MSPSQ has adequate internal consistency. The two measures were also highly correlated. A preliminary cut off of 56 on the MSPSQ offers high sensitivity and specificity commensurate with the widely used CSHQ.

Sleep behaviour in children with developmental co-ordination disorder

BACKGROUND

Children with developmental co-ordination disorder (DCD) experience significant difficulty in the performance of everyday movement skills in the absence of obvious neurological, sensory or intellectual impairment. They often underachieve academically and have higher rates of anxiety than their typically developing peers. Such factors are known to be associated with sleep problems in other clinical populations but the sleep patterns of children with DCD have not been examined. Information about the frequency and nature of sleep problems in DCD will aid our understanding of this developmental disorder. It may also be clinically helpful, alerting clinicians to potential difficulties so that these can be identified early and appropriate support offered.

OBJECTIVE

To examine sleep behaviour of children with DCD compared with typically developing control children.

METHODS

Two groups of 16 boys aged 8 to 12 years (M = 10.28, SD = 1.28) participated: (1) the DCD group had Movement ABC-2 Checklist scores below the 5th percentile; (2) an age-matched control group of typically developing children had Movement ABC-2 Checklist scores above the 15th percentile. Parents of children from both groups completed the Children's Sleep Habits Questionnaire.

RESULTS & DISCUSSION

The total sleep disturbance score was significantly higher for children with DCD compared with the control group (U= 24, P < 0.001). Subscale scores indicated particular problems with bedtime resistance (U= 77.5, P < 0.05), parasomnias (U= 28.5, P < 0.001) and daytime sleepiness (U= 58.00, P < 0.01). There were no differences between the groups for sleep onset delay, sleep duration, night wakings and sleep-disordered breathing. These preliminary results suggest that sleep patterns of children with DCD may be of clinical relevance and are worthy of further investigation.

Presleep arousal and sleep disturbances in children

STUDY OBJECTIVES

To determine if associations between presleep arousal and sleep disturbance reported in adults are also characteristic of children.

DESIGN

Linear regression analyses examined whether somatic and cognitive presleep arousal predicted sleep disturbances.

SETTING

Two inner city schools, London, U.K.

PARTICIPANTS

One hundred twenty-three children aged 8 to 10 years, 49% boys, from ethnically diverse backgrounds.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

Children completed the Sleep Self-Report and the Pre-sleep Arousal Scale (comprising somatic and cognitive subscales). Parents completed the Child Sleep Habits Questionnaire. In separate models, both somatic (beta = 0.44, P < 0.001, R2 = 0.19) and cognitive (beta = 0.48, P < 0.001, R2 = 0.23) presleep arousal predicted the Sleep Self-Report total score. Somatic (beta = 0.28, P <.01, R2 = 0.08) and cognitive (beta = 0.37, P < 0.001, R2 = 0.14) arousal also predicted Sleep Self-Report insomnia items in separate models. These results were partially replicated when using the parent report of the Child Sleep Habits Questionnaire. When somatic and cognitive items were included in the same models, cognitive but not somatic arousal significantly predicted (most definitions of) sleep disturbance.

CONCLUSIONS

Cognitive, and to a lesser extent somatic, presleep arousal appears to be associated with sleep disturbances in children. This suggests that further research into cognitive aspects of sleep disturbance in children is warranted-as incorporating this information into treatments may eventually prove fruitful.

Behavioural aspects of children's sleep

There is good empirical evidence that behavioural factors play a role in the onset/maintenance of many childhood sleeplessness problems and that behaviour therapy can be used as an effective form of management. There is a smaller, but growing, literature supporting the idea that behavioural interventions may also play a significant role in the management of other types of sleep disorder (eg, rhythmic movement disorders, arousal disorders, nightmares and circadian rhythm sleep disorders), and this is an area ripe with research possibilities. This review outlines the nature of behavioural aspects of children's sleep and how these might be addressed by behaviour therapy. Clinical considerations concerned with the use of behavioural therapy are also highlighted (eg, the role of behaviour therapy as an adjunct to other treatments, its use with special populations, and how it might be delivered to families).

The psychosocial problems of children with narcolepsy and those with excessive daytime sleepiness of uncertain origin

BACKGROUND

Narcolepsy is a predominantly rapid eye movement sleep disorder with onset usually in the second decade but often in earlier childhood. Classically it is characterized by combinations of excessive sleepiness especially sleep attacks, cataplexy, hypnagogic hallucinations, and sleep paralysis. The psychosocial effects of this lifelong condition are not well documented, especially in children. This study aims to describe the psychosocial profile of a large group of children with narcolepsy compared with other excessively sleepy children and controls.

METHODS

We used an international cross-sectional questionnaire survey of children aged from 4 to 18 years who had received from a physician a diagnosis of narcolepsy compared with age- and gender-matched controls. Assessments were made of behavior, mood, quality of life, and educational aspects.

RESULTS

Recruited children were separated into those who met conventional criteria for narcolepsy (n = 42) and those whose primary complaint was excessive daytime sleepiness without definite additional features of narcolepsy (excessive daytime sleepiness group; n = 18). Compared with controls, children with narcolepsy and also those with excessive daytime sleepiness alone showed significantly higher rates of behavioral problems and depression. Again, to a significant extent, their quality of life was poorer and they had more educational problems. The children with narcolepsy and the excessive daytime sleepiness group were indistinguishable from each other on these measures.

CONCLUSIONS

A range of psychosocial problems can be identified in children with narcolepsy. The origins of these problems are unclear. The similar profiles of difficulties in the narcolepsy and excessive daytime sleepiness groups suggest that excessive sleepiness is the main cause. Clinicians and others responsible for the care of such children need to be mindful of the importance of early detection, intervention, and, ideally, the prevention of these problems.

Actigraphic and Parent Reports of Sleep Patterns and Sleep Disorders in Children With Subtypes of Attention-Deficit Hyperactivity Disorder

STUDY OBJECTIVE

To describe parent-reported and actigraphically assessed sleep patterns and sleep disorders in stimulant-medication-free children with attention-deficit/hyperactivity disorder (ADHD), divided according to ADHD subtype.

PARTICIPANTS

Seventy-one stimulant-medication-free children with a clinical diagnosis of ADHD (8 girls; mean 8.8 years (SD 2.6), range 3-15 years) recruited from child psychiatry clinics.

MEASUREMENTS

ADHD: ADHD Rating Scale DSM IV- Home Version to subdivide children into those with predominantly attention deficit, mainly hyperactivity, and those with both aspects equally. Sleep: Parent-completed sleep diary, clinical history, and 5 nights of actigraphy.

RESULTS

Parents reported a wide range of frequently occurring sleep disturbances in their children. However, the objective sleep patterns were not abnormal and did not differ between the ADHD subtypes, and objective sleep patterns did not predict ADHD severity. There was poor correspondence between parent report and actigraphy. Careful clinical consideration of each case suggested that sleep disorders may be widespread in this group of children; only 8 of the 71 children had no discernable likely sleep disorder. Symptoms of sleep-disordered breathing, sleeplessness and reports of restless legs featured prominently.

CONCLUSIONS

Parents of children with ADHD may not be accurate reporters of their children's sleep pattern and/or the sleep disturbances that come to parents' attention are not best detected by actigraphy. Results highlight the prominence of parent-reported sleep disturbance in children with ADHD and the need for clinicians to routinely screen for the presence of sleep disorders and assess detailed sleep physiology where indicated.

Psychological disturbance and sleep disorders in children with neurofibromatosis type 1

The objective of this study was to explore the behaviour, including sleep patterns, of children with neurofibromatosis type 1 (NF1). For this purpose we designed a cross-sectional descriptive survey conducted by postal enquiry with telephone follow-up. Simonds and Parraga's sleep questionnaire and the Strength and Difficulties Questionnaire were used to screen sleep patterns and behaviours respectively. Information was obtained for 64 children (39 male, mean age 10 y 7 mo, SD 4 y 1 mo, range 3 to 18 y; 57% response rate). There were increased numbers of children with NF1 achieving scores in the borderline and abnormal range for ratings of peer problems (p < 0.001), hyperactivity (p < 0.001), emotional symptoms (p < 0.001), and conduct disorder (p < 0.05). Total difficulties score was also high (p < 0.001) in the NF1 group. Only one group of sleep problems, parasomnias (in particular sleepwalking and sleep terrors), had a higher occurrence (p < or = 0.05) in the NF1 group than in the general population. Within the NF1 group, conduct problems (p < or = 0.05), hyperactivity (p < or = 0.01), emotional problems (p < or = 0.01), and the total difficulties score (p < or = 0.01) were all significantly higher in children with frequent sleep disturbance. We conclude that NF1 is associated with sleep and behavioural problems in a high proportion of children. Psychiatric conditions, e.g. attention-deficit-hyperactivity disorder, may be underdiagnosed on a large scale in children with NF1, and the use of simple screening tools in clinical settings may prove beneficial.

Sleep patterns and sleep disorders in children with autistic spectrum disorders: insights using parent report and actigraphy

The present study sought to describe the profile of sleep disturbance reported in children with autistic spectrum disorders (ASDs) and to document any sleep disorders underlying reports of sleeplessness. Sixty-nine children aged 5 to 16 years (mean 9 years 4 months, SD 2 years 7 months; 14 females) with an ASD were assessed by detailed sleep histories taken from parents, the Simonds and Parraga Sleep Questionnaire, a 2-week sleep diary, and actigraphs worn by the child for five nights. Parent-reported sleeplessness featured prominently (64%). Sleep disorders underlying the sleeplessness were most commonly behavioural (i.e. to do with inappropriate sleep-related behaviours), although sleep-wake cycle disorders and anxiety-related problems were also seen. In addition, the sleeplessness patterns of a large minority of children could not be classified by conventional diagnostic criteria. Sleep patterns measured objectively did not differ between those children with or without reported sleeplessness, but the sleep quality of all children seemed to be compromised compared with normal values.

The relative efficacy of two brief treatments for sleep problems in young learning disabled (mentally retarded) children: a randomised controlled trial

BACKGROUND

Settling and night waking problems are particularly prevalent, persistent, and generally considered difficult to treat in children with a learning disability, although intervention trials are few. Scarce resources, however, limit access to proven behavioural treatments.

AIMS

To investigate the efficacy of a media based brief behavioural treatment of sleep problems in such children by comparing (1) face-to-face delivered treatment versus control and (2) booklet delivered treatment versus controls.

METHODS

The parents of 66 severely learning disabled children aged 2-8 years with settling and/or night waking problems took part in a randomised controlled trial with a wait-list control group. Behavioural treatments were presented either conventionally face-to-face or by means of a 14 page easy to read illustrated booklet. A composite sleep disturbance score was derived from sleep diaries kept by parents.

RESULTS

Both forms of treatment were almost equally effective compared with controls. Two thirds of children who were taking over 30 minutes to settle five or more times per week and waking at night for over 30 minutes four or more times per week improved on average to having such settling or night waking problems for only a few minutes or only once or twice per week (H = 34.174, df = 2, p<0.001). These improvements were maintained after six months.

CONCLUSIONS

Booklet delivered behavioural treatments for sleep problems were as effective as face-to-face treatment for most children in this population.

Psychological consequences of road traffic accidents for children and their mothers

BACKGROUND

Little is known about the psychological and behavioural consequences of road traffic accidents for children. The study aimed to determine the outcome of road traffic accidents on children and their mothers.

METHOD

A 1-year cohort study of consecutive child attenders aged 5-16 years at an Accident and Emergency Department. Data were extracted from medical notes and from interview and self-report at baseline, 3 months and 6 months.

RESULTS

The children had an excellent physical outcome. Fifteen per cent suffered acute stress disorder; 25% suffered post-traumatic stress disorder at 3 months and 18% at 6 months. Travel anxiety was frequent. Post-traumatic consequences for mothers were common.

CONCLUSION

Psychological outcome was poor for a minority of children and associated with disability, especially for travel. There were significant family consequences. There is a need for changes in clinical care to prevent, identify and treat distressing and disabling problems.

Behavioural treatment for sleep problems in children with severe intellectual disabilities and daytime challenging behaviour: effect on mothers and fathers

OBJECTIVES

The study aimed to assess the mental state of mothers and fathers following successful behavioural intervention for sleep problems in such children.

DESIGN

A randomized controlled trial of behavioural interventions for sleep problems.

METHODS

Parents of 15 children with severe intellectual disabilities, severe sleep problems, and challenging daytime behaviour received treatment for the child's sleep problem and were compared with 15 controls who received no treatment. Parental stress, sleepiness, locus of control, perceived control, and satisfaction with aspects of sleep were assessed.

RESULTS

Successful treatment benefited the mothers, reducing stress, increasing perceived control and making them more satisfied with their sleep, their child's sleep, and their ability to cope with their child's sleep. Positive effects in the fathers were limited to increased satisfaction with their own sleep and their child's sleep; fathers tended to feel less control following treatment. Maternal sleepiness and perceived control, and aspects of parental satisfaction showed improvements in both the treatment and control groups.

CONCLUSION

The effects of childhood sleep problems, and their resolution using behavioural interventions, may be different in mothers and fathers. This highlights the need to assess all family members in order to gain a greater understanding of how best to help families as a whole. The improvements in both control and treatment groups indicate that there may be non-specific effects of taking part in the study that played a therapeutic role.

Alterations in sleep physiology in young children with insulin-dependent diabetes mellitus: relationship to nocturnal hypoglycemia

OBJECTIVES

To examine the effect of diabetes per se and nocturnal hypoglycemia on sleep in children with insulin-dependent diabetes mellitus (IDDM).

DESIGN

Overnight polysomnography was performed on 3 occasions in 29 children with IDDM - twice during metabolic profiling. Sleep data were analyzed from 14 children (median [range], 8.7 [5.9 to 12.9] years) with a night of hypoglycemia and a nonhypoglycemic night. Seven children in the control group (9 [5.6 to 11.4] years) underwent 2 nights of polysomnography, once during metabolic profiling (to assess the effects of metabolic profiling), and 15 members of the control group had polysomnography only (to assess the effects of diabetes per se and to compare with the index group).

RESULTS

Children with IDDM had disrupted sleep compared with the control group (short wakes, percentage of sleep time, 0.8 [0.5 to 1.9] vs 0.0 [0.0 to 0.3], median [interquartile range], IDDM vs control group, respectively, P =.001; long wakes, 1.2 [0.7 to 3. 0] vs 0.0 [0.0 to 0.0], P =.033; total number of wakes, 6 [3.5 to 11. 5] vs 1 [0 to 2], P =.002). Blood sampling disrupted sleep with increased long wakes as percentage of sleep time (0.3 [0.0 to 3.8] vs 4.3 [3.1 to 16.9], nonsampling vs sampling night, respectively, P =.003). Episodes of hypoglycemia were profound, with a glucose nadir of 2.0 [1.4 to 3.3] mmol/L (35.0 [24.5 to 57.8] mg/dL) and prolonged, 308 [30 to 630] minutes, with no effect on sleep.

CONCLUSIONS

Children with diabetes had disrupted sleep compared with a control group, but there was no effect of profound nocturnal hypoglycemia on sleep quality. J Pediatr 2000;137:233-8)

Behavioural treatments for sleep problems in children and adolescents with physical illness, psychological problems or intellectual disabilities

Young people with physical, psychological or intellectual disabilities or disorders are reported to have more frequent and persistent problems with sleep than their peers without <<<<special needs>>>>. Sleep disorders affecting the quantity or quality of sleep have effects on a child's daytime functioning and the functioning of their families. Many children with special needs have learning and behaviour problems and their parents (particularly mothers) have increased levels of stress and poorer mental health. This relationship between sleep disorders and learning, and behaviour and family functioning makes it particularly important that children with special needs receive appropriate intervention for their sleep disorders. This may be one way of mitigating these other problems. This review considers the case reports and experimental trials which have used behavioural treatments for sleep problems in children and adolescents with special needs. Behavioural treatments for sleep-wake cycle disorders, sleeplessness, parasomnias and excessive sleepiness are reported. These preliminary reports do suggest that behavioural approaches can be rapidly successful for treating sleep problems, even where the sleep problems are long-standing, severe and associated with physical, psychological or intellectual problems. The parent and the clinician should not be deterred from treating the sleep problem in isolation using behavioural treatments. Methodological issues, however, highlight the importance of further and better research. Not all children responded to the behavioural interventions and some needed re-implementation of therapy to maintain improvements; the use of heterogeneous groups make the findings and choice of treatment for individuals difficult to interpret. Finally, there are few studies overall, and the majority are case studies rather than controlled studies using multiple baseline designs or randomization and a control group. Careful studies are required in order to establish the relative efficacy of the behavioural techniques and their suitability with homogeneous subgroups of children with special needs.

A systematic review of treatments for settling problems and night waking in young children

OBJECTIVES

To assess the efficacy of treatments for settling problems and night waking in young children.

DESIGN

A systematic review of randomised controlled trials of interventions for settling problems and night waking in young children.

SETTING

Electronic bibliographic databases and references on identified papers, hand searches, and personal contact with specialists.

SUBJECTS

Children aged 5 years or less who had established settling problems or night waking.

INTERVENTIONS

Interventions had to be described and a placebo, waiting list, or another intervention needed to have been used as a comparison. Interventions comprised drug trials or non-drug trials.

MAIN OUTCOME MEASURES

Number of wakes at night, time to settle, or number of nights in which these problems occurred.

RESULTS

Drugs seemed to be effective in treating night waking in the short term, but long term efficacy was questionable. In contrast, specific behavioural interventions showed both short term efficacy and possible longer term effects for dealing with settling problems and night waking.

CONCLUSIONS

Given the prevalence and persistence of childhood sleep problems and the effects they can have on children and families, treatments that offer long lasting benefits are appealing and these are likely to be behavioural interventions.

REVIEW ARTICLE: Behavioural and cognitive-behavioural interventions for sleep disorders in infants and children: A review

This review covers the literature on behavioural and cognitive-behavioural treatments for sleep disturbance in infants, pre-school, and school-age children. Treatment areas are dyssomnias (disorders of initiating, maintaining, or excessive sleep) and parasomnias (behaviours which occur predominantly during sleep). Interventions aimed at preventing sleep disorder through targeting infant sleep patterns are also examined. Controlled experimental studies are the main focus of this review but case studies and clinical reports are also included. It is concluded that, for families willing to undertake behavioural and cognitive-behavioural interventions, some treatments appear effective for some infant and child sleep problems, in the short term at least. The adequacy of current research is discussed, and suggestions for future research are given.

Sleep problems and daytime challenging behaviour in a community-based sample of adults with intellectual disability

The present study aimed to explore associations between sleep problems and daytime challenging behaviour in a community sample of adults with intellectual disability. Sleep and behaviour questionnaires were completed for 205 people aged 18 years or over living in health- or social-services-managed community housing. This sample represented an 86% return rate. The informants were carers and the individuals themselves where possible. Seventy-nine people with sleep problems were compared with 121 individuals without this difficulty; five people were excluded from the analysis. Individuals with sleep problems displayed significantly more daytime irritability, stereotypy and hyperactivity than those without sleep problems. Individuals displaying clinically significant aggression/temper, self-injury and screaming were significantly more likely to have a concurrent sleep problem, and these forms of challenging behaviour were significantly more severe in the sleep problem group. Associations between sleep problems and daytime challenging behaviour exist in this population, although the nature of any links remains unclear and should be the attention of future research.

Behavioural treatment for sleep problems in children with severe learning disabilities and challenging daytime behaviour: effect on daytime behaviour

The study aimed to investigate a group of children with severe learning disabilities, challenging daytime behaviour, and severe sleep problems to see if successful behavioural treatment of the children's sleep problems resulted in reduced daytime challenging behaviour as reported by mothers and teachers. A randomised controlled trial of behavioural interventions for the children's sleep problems was conducted (N = 30). The intervention group received an individually tailored behavioural programme and were supported by telephone calls from the therapist. Baseline assessments of the children's behaviour were made using the Aberrant Behavior Checklist and were repeated 1 month and 3 months after the start of intervention. There were no behavioural changes that were specific to children in the treatment group. However, improvements in some behaviours were seen in both the intervention and the control group at the 1-month and 3-month assessments and there was agreement between mothers' and teachers' reports for many of these changes. The results suggest that nonspecific effects of participating in the study (including an increased sleep duration, which was seen in both groups), rather than resolution of sleep problem per se, may have a beneficial effect on child behaviour and these factors need to be identified for therapeutic use.

Clinical services for sleep disorders

Children's sleep disorders are common and often harmful to development and well being. The clinical services available to affected children and their families need to be improved. At present, professional interest and expertise in sleep disorders medicine is severely limited by the paucity of appropriate teaching and training. The work of a mainly tertiary sleep disorders clinic was reviewed, which showed that accurate diagnosis of a wide range of sleep disorders is possible, and that treatment needs can be specified. Although families appreciated such assessment, the outcome was unsatisfactory in many cases, often because treatment recommendations were not implemented by referrers. Reasons for this appear to include poor communication between referrers and families, and unavailability of treatment resources. A three tier system of service provision is proposed to improve this situation, which rests essentially on better professional training in the sleep disorders field.

Home polysomnography norms for children

Home polysomnography (PSG) by means of ambulatory monitoring systems has distinct advantages over sleep laboratory recordings, especially for children. However, normative data have been lacking. Norms for conventional PSG variables were compiled for 60 children age 5-16 years using the Oxford Medilog ambulatory monitoring system. Recordings were confined to a single night in view of previous demonstrations that the sleep on the first night is not significantly affected by the recording procedure. The results are presented in 5 age subgroups. Broad comparisons with published laboratory PSG norms for children of the same ages suggest that in home recordings sleep duration is longer, and slow wave sleep is much more pronounced with a commensurate reduction in stage 2 NREM sleep. That is, sleep quality and quantity appears better at home even when adaptation to the laboratory situation has been promoted. These new normative data are considered valuable for both clinical and research purposes where physiological sleep studies in children are required.

Behavioural treatment for sleep problems in children with severe learning disabilities and challenging daytime behaviour: effect on sleep patterns of mother and child

Children with sleep problems present serious management problems to their parents. Such children are also more likely to have additional problems, behavioural disturbance being particularly common. This randomized controlled trial of behavioural interventions for the children's sleep problems was conducted to explore the efficacy and mechanisms of treatment in children with the most extreme forms of problems: severe learning disabilities, severe sleep problems and severe daytime challenging behaviour. Fifteen index families received behavioural advice for the child's sleep problem and compared with 15 matched controls who received no such advice. Repeat assessments of the children's and mothers' sleep were made by parental report as well as actometry. Objective changes in the children's sleep quality and quantity were not seen after treatment. However, mothers in the treatment group reported improvements in the children's sleep problems and had an increased sleeping time themselves following treatment. The results indicate that sleep problems can be successfully treated in this group of children, although the mechanisms of treatment may not be as direct as supposed. This has implications for understanding of sleep problems in children with learning disabilities and also for clinical practice, when considering ways of offering help to these highly 'challenged' families.

Sleep and psychological disturbance in nocturnal asthma

Subjective and objective sleep disturbance was studied in children with nocturnal asthma. Relations between such disturbance and daytime psychological function were also explored, including possible changes in learning and behaviour associated with improvements in nocturnal asthma and sleep. Assessments included home polysomnography, parental questionnaires concerning sleep disturbance, behaviour, and mood and cognitive testing. Compared with matched controls, children with asthma had significantly more disturbed sleep, tended to have more psychological problems, and they performed less well on some tests of memory and concentration. In general, improvement of nocturnal asthma symptoms by changes in treatment was followed by improvement in sleep and psychological function in subsequent weeks. The effects of asthma on sleep and the possible psychological consequences are important aspects of overall care.

A questionnaire survey of sleep and night-time behaviour in a community-based sample of adults with intellectual disability

Two hundred and five people with intellectual disability, aged 18 years or over, and living in health- or social-services-managed community housing, completed sleep and behaviour questionnaires. An 85.7% return rate was achieved. Settling problems were present in 26.8% and night waking in 55.6% of the subjects. Parasomnias were present in 14% of subjects and 15% of the sample showed some features associated with sleep-related breathing problems. Factors associated with sleep-related problems included gender, aetiology of intellectual disability, epilepsy, treatment with antiepileptic medication, evening caffeine consumption, nocturnal urinary incontinence and ability to communicate. Significant sleep-related problems were demonstrated in this population; some of these problems might be avoided by simple measures.