Sleep patterns and behaviour in typically developing children and children with autism, Down syndrome, Prader-Willi syndrome and intellectual disability
Introduction
Aberrant sleep patterns commonly occur in children with an intellectual disability (ID), and include frequent daytime sleeping, daytime sleepiness, difficulties setting at bedtime, repeated nocturnal awakenings and early morning awakenings. Estimates of the prevalence of sleep difficulties in children with an ID range from 24% to 86% (Bartlett et al., 1985, Didden et al., 2002, Quine, 2001, Robinson and Richdale, 2004). Bedtime disturbances have been estimated to be as high as 50% in children with an intellectual disability (ID; Bartlett et al., 1985), with approximately 39% of the children having shortened sleep patterns (Poindexter & Bihm, 1994).
A problem with many of the studies of sleep in children with an ID is the heterogeneity of participant samples. There is often a lack of consideration of the aetiology of the ID with samples often comprising children with a variety of disorders such as autism spectrum disorders, Down syndrome (DS), cerebral palsy, fragile-X syndrome, and Prader-Willi syndrome (PWS) (Bartlett et al., 1985, Clements et al., 1986, Quine, 1991). It has been postulated that the nature and extent of sleep problems in such children may vary depending on the aetiology of the disorder that produces the ID (Stores, 1992). Indeed, there is some literature to support this notion (Cotton & Richdale, 2006).
Sleep problems are commonly reported in children with DS. Quine (1991) estimated that 44% of children with DS have a sleep problem. Sleep difficulties reported in children with DS include persistent problems with settling (Cunningham et al., 1986, Stores et al., 1996, Stores et al., 1998), frequent night-time waking (Cunningham et al., 1986, Stores et al., 1996, Stores et al., 1998), co-sleeping (Cunningham et al., 1986, Stores et al., 1998) and early morning waking (Stores et al., 1996). Behaviours associated with obstructive sleep apnoea syndrome (OSAS) occur in 30-50% of children with DS (Levanon et al., 1999, Stebbens et al., 1991, Stores et al., 1996, Stores et al., 1998). With nocturnal sleep, children with DS breathe through their mouth, are restless, snore loudly, extend their neck, and have apneoic episodes (Stores et al., 1996). OSAS adversely affects the child's sleep with frequent arousal and awakenings (Levanon et al., 1999). Daytime functioning can also be affected by OSAS as children can be overactive, have frequent daytime naps, and can suffer from excessive daytime sleepiness (EDS) (Stores et al., 1996). The sleep problems observed in children with DS tend to be neither as prevalent nor severe as for children with other disabilities (Cunningham et al., 1986, Stores and Stores, 1996, Stores et al., 1996, Stores et al., 1998).
Sleep disturbances in children with autism are pronounced and pervasive. Difficulties are generally observed with respect to bedtime settling, sleep onset, and sleep maintenance (Richdale & Schreck, 2009). Early morning waking also occurs in approximately 24% of autistic children (Hoshino, Watanabe, Yashima, Kaneko, & Kumashiro, 1984). A range of sleep onset difficulties have been observed or poor sleep habits such as being unable to sleep in a dark room, lengthy bedtime rituals, falling asleep other than in one's own bed, bedtime tantrums and being unable to sleep without the presence of their mother (Hoshino et al., 1984, Krakowiak et al., 2008, Patzold et al., 1998).
Several questionnaire-based studies have examined sleep in individuals with PWS (Cassidy et al., 1990, Helbing-Zwanenburg et al., 1993, Richdale et al., 1999). The frequency of sleep problems in individuals with PWS has been estimated to be 35.7% with the prevalence of problems increasing with age of the child (Richdale et al., 1999). EDS is a common complaint in individuals with PWS (Cassidy et al., 1990, Clarke et al., 1989, Helbing-Zwanenburg et al., 1993, Richdale et al., 1999), more so than children with DS (Helbing-Zwanenburg et al., 1993). Children with PWS are more likely to nap during that day, with sleep occurring mainly in boring or quiet environments (Cassidy et al., 1990, Vela-Bueno et al., 1984). Other prevalent sleep problems including snoring, frequent night-time waking, early morning waking, and enuresis are also observed (Cassidy et al., 1990, Richdale et al., 1999, Sarimski, 1994). Although not a sleep problem, children with PWS fall asleep easily at bedtime, as compared to children with Williams-Beuren syndrome (WBS; Sarimski, 1994) and typically developing (TD) children (Richdale et al., 1999).
A key problem associated with past research on sleep and ID is that there has been a heavy reliance on nocturnal sleep habits such as settling difficulties and frequent night-time waking (Bartlett et al., 1985, Clements et al., 1986). However while sleep and daytime behaviour problems are known to be related (Richdale, Francis, Gavidia-Payne, & Cotton, 2000) there has been little exploration of the relationship between children's sleep patterns and behaviour over a 24-h period.
This report builds upon our earlier work on parental reports of sleep problems in children with ID (Cotton & Richdale, 2006). Our main aim was to examine 24-h sleep patterns of children with DS, autism or PWS and children with intellectual impairments of unknown aetiology but presumed to be familial (FID). A secondary aim was to elucidate how 24-h sleep patterns relate to behaviour patterns across this period.
Section snippets
Participants
Sleep data were available for 115 children aged between 3 and 16 years of age (M = 7.9, SD = 3.0 years), which represents 75% of the sample previously reported in Cotton and Richdale (2006). Of these children, 82 had developmental and intellectual delays and 33 had no known impairments and were presumed to be typically developing (TD). Participants were all from three earlier studies conducted by one or both authors (Patzold et al., 1998, Richdale et al., 1999, Richdale et al., 2000). Of the
Daytime sleep and behaviour
For 14 days parents made daily ratings of their child's levels of excitement, energy, and general behaviour on 100-mm visual analogue scales (VAS). For the excitement scale 0 represented ‘very calm’ and 100 ‘very excited’. For the energy scale 0 indicated that the child was ‘very tired’ and 100 ‘very energetic’. For the behaviour rating scale a score of 0 represented ‘very well behaved’ and 100 represented ‘very difficult’. Average scores for the 14 days were then derived for each child and
Discussion
Disturbed sleep patterns are common in TD children (Armstrong, Quinn, & Dadds, 1994); however they can be more prevalent and prominent in children with developmental delays (Cotton & Richdale, 2006). In the current study we examined sleep patterns of children with autism, Down syndrome (DS), Prader-Willi syndrome (PWS), familial intellectual disability (FID), and typically developing (TD) children. Importantly we also examined whether the relationships between 24-h sleep patterns and behaviour
Acknowledgements
Dr Sue Cotton is supported by the Ronald Phillip Griffiths Fellowship from the Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne.
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