Clinical reviewA systematic review to explore the feasibility of a behavioural sleep intervention for insomnia in children with neurodevelopmental disorders: A transdiagnostic approach
Introduction
Neurodevelopmental disorders (NDD) are a group of conditions that often manifest during the developmental period and are the result of developmental deficits of the central nervous system that impact one or more areas of functioning. NDD produce impairments across social, academic, personal, or occupational functioning [1]. Evidence suggests children with NDD have higher rates of sleep problems and may be more vulnerable to the impact of poor sleep than their typically developing (TD) peers [2]. Poor sleep is associated with a range of daytime consequences including cognitive impairments (e.g., memory and attention difficulties), lower academic performance, and more difficulties with behavioural and emotional regulation [3], [4], [5], areas in which children with NDD have existing impairments [1]. Moreover, poor sleep may result in increased symptom presentation of the NDD [6], ∗[7], ∗[8].
Insomnia (i.e., difficulties falling asleep, staying asleep, or early morning waking) is the most common sleep problem in children with NDD, with more than 85% reported meeting criteria [9]. Despite this commonality, NDD as a group are quite varied in how they manifest and in etiology [1]. In the interest of developing transdiagnostic treatment approaches, there is a desire to determine whether similar interventions can be effective for the shared problems (e.g., insomnia) across a variety of disorders with shared characteristics (e.g., atypical brain development). To address this need, we identified four highly prevalent NDD (namely, Attention Deficit Hyperactivity Disorder [ADHD], Autism Spectrum Disorder [ASD], Cerebral Palsy [CP], and Fetal Alcohol Spectrum Disorder [FASD]) as the focus for this systematic review of the literature. Despite their different manifestations and etiologies, ADHD, ASD, CP, and FASD are all associated with higher than typical rates of insomnia ∗[7], ∗[10]. Children with NDD are more likely to have bedtime resistance, anxiety, and sensory processing issues that interfere with settling to sleep ∗[11], [12], [13], [14]. As well, delayed sleep onset ∗[7], ∗[10], ∗[11], [15], night waking, and restless sleep ∗[10], ∗[11], [12], [16] are also common for children with ADHD, ASD, CP, and FASD.
There are currently no published clinical guidelines for treating sleep problems in children with NDD. However, guidelines recommended for TD children are often recommended for implementation with NDD populations. A number of authors [17], [18] have argued for the following course of treatment in both TD children and children with NDD: 1) provide psychoeducation about “normal” sleep; 2) teach/implement healthy sleep practices; 3) implementation of behavioural interventions (see Table 1 for description of behavioural interventions); and lastly, 4) initiate pharmacological treatment. Despite pharmacological treatments being the final recommendation, many children, especially children with NDD, are prescribed medications to aid sleep. A survey of US child psychiatrists found that 96% had prescribed at least one medication for sleep problems in the past month [19]. Moreover, a longitudinal study found that over 12 y, 81% of children evaluated in an ambulatory setting with insomnia had been prescribed medication [20], [21].
As of 2017, there are no US Food and Drug Administration approved sleep medications for children [22]. A recent review of the management of sleep disorders in children with NDD reported a lack of robust data supporting the use of pharmacological treatments for children with sleep problems [23]. More studies are needed to evaluate whether, and under what circumstances, pharmacological treatments are safe and efficacious [23]. Pediatric sleep experts recommend that medication should be considered only when education and behavioural interventions fail to produce adequate improvement, and/or these interventions are not feasible [14], [24], [25]. Additionally, parents view behavioural interventions as preferable to, and as effective as, medication [26], [27].
Behavioural intervention is utilized less than medication, with research showing that only 20% of cases receive this type of treatment [21]. Barriers to evidence-based behavioural treatment occur at multiple levels, including limited parental knowledge as well as lack of training of health professionals in pediatric sleep [28]. When behavioural treatments are available, they are typically provided within a traditional service delivery framework, which can be difficult for families to access due to incidental costs, such as travel to specialty health centres [28]. One way to overcome these barriers is by increasing parental knowledge and skills, and by training parents to implement a range of behavioural strategies with their children.
While a substantive body of literature demonstrates the effectiveness of behavioural interventions in TD children with insomnia [29], [30], there is very little research in children with NDD. A recent systematic review by Meltzer and Mindell [31] focused on behavioural interventions for pediatric insomnia; however, their review included only three studies that focused on children with special needs (two on ASD and one on Down syndrome). For these three studies [24], [25], [26], [27], [28], [29], [30], ∗[31], [32], significant improvement in sleep efficiency, as measured by actigraphy, was found after meta-analysis. The only study to include a follow-up assessment was the study of children with Down syndrome, which found behavioural sleep problems were improved at six-month follow-up [34]. Given the limited state of the literature, Meltzer and Mindell [31] concluded that future research evaluating the effectiveness of these interventions with children with NDD was needed.
Brown and colleagues [35] conducted a review focusing on the quality of non-pharmacological interventions for sleep problems in youth with chronic health conditions, encompassing NDD as well as conditions such as diabetes, migraines, and obsessive compulsive disorder. Of these 31 studies, 23 included at least one participant with either ADHD, ASD, or CP. None included participants with FASD [35]. All but one of the 31 studies demonstrated improvement in children's sleep following intervention, which led to the conclusion that behavioural intervention shows promise. Brown and colleagues concluded that more rigorous, high quality, large-scale studies are needed in this population. An important factor outlined in this publication was that behavioural treatments for sleep problems are not exclusive to specific health conditions, but rather have similar effects across children with a range of mental health and physical health conditions, as well as NDD [35]. This suggests that sleep problems in children with NDD may respond to a transdiagnostic treatment approach, in which the same basic treatment principles are applied across disorders, without tailoring the intervention to each diagnosis [36].
The aim of the current study was to conduct a systematic review of the literature to identify and evaluate the efficacy of parent-delivered behavioural interventions implemented to reduce sleep problems, with the focus solely on children with NDD (specifically ADHD, ASD, CP, and FASD). This review will help to determine whether a transdiagnostic approach to treating sleep problems in NDD populations may be feasible.
Section snippets
Information sources and search strategy
Published studies were identified through electronic database searches, including Cochrane, EBSCOHost (both CINAHL and PsycInfo), Informit, Ovid (both Embase and Medline), PubMed, and Scopus. The search strategy focused on four semantic groups, the Boolean operator ‘OR’ concatenated terms within each group and the Boolean operator ‘AND’ concatenated the four groups. The first group identified the target population, the second group identified the outcome variables, the third group identified
Results
A total of 10,363 articles were identified in the broad search, which was reduced to 5602 articles after the removal of duplicates. Following title and abstract screening 5436 articles were excluded, resulting in 166 articles being reviewed in full-text. One of the 166 studies was written in French. After the full-text review 33 studies remained to be included in the final review. The primary reason articles were excluded at the full-text review was not being original research (n = 97), with
Discussion
The purpose of this systematic review was to identify commonalities, trends in outcomes, and the methodological quality of the evidence for parent-delivered behavioural sleep interventions for children with NDD (specifically ADHD, ASD, CP, and FASD), and to determine whether a transdiagnostic approach to treating sleep problems in NDD is feasible. The current review extends the findings from two previous reviews that had assessed behavioural sleep interventions in pediatric populations with and
Conclusion
We believe this to be the first study systematically reviewing parent-delivered behavioural sleep interventions to children with a range of NDD diagnoses. Findings suggest that behavioural sleep interventions can be effective in NDD populations. However, the overall methodological quality of current research as well as the few or non-existent studies on certain NDD limits the ability to draw definitive conclusions about the effectiveness of these behavioural sleep interventions in ADHD, ASD,
Conflicts of interest
The authors have no conflicts of interest to declare.
Acknowledgements
This research is funded by Kids Brain Health Network (formerly NeuroDevNet), a Centre of Excellence of Canada. The authors would like to thank Ms. Sydney Dale-McGrath for her help as the Better Nights, Better Days for Children with Neurodevelopmental Disorders project manager. We would also like to thank Mr. Joshua Mugford and Mr. Derek Van Voorst for their assistance with formatting.
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