Sleep problems in children with Down syndrome: A summary report
Rebecca Stores
This article presents a summary of the findings of the first part of a research programme being carried out at The Sarah Duffen Centre in Portsmouth. The findings will be published in full in the future. It follows an article published in the last edition of the journal entitled A preliminary study of sleep disorders and daytime behaviour problems in children with Down syndrome. The first stage of the current research programme has been an extensive survey of sleep problems in a group of children with Down syndrome compared with other children with learning disabilities and non-disabled children.The daytime behaviour of all these children and their mothers' stress levels have also been investigated. This information, as well as associations between sleep disorders, daytime behaviour problems and maternal stress will be reported in future publications.
Stores R. Sleep problems in children with Down syndrome: A summary report. Down Syndrome Research and Practice. 1993;1(2);72-74.
doi:10.3104/reports.13
Background
Sleep problems are very common in children. For example, 20% of two year olds still
wake regularly during the night (Richman, 1981)
and some studies even suggest that up to 20% of children continue to have various
sleeping problems at 12 years of age (Rutter
et al, 1970).
The vast majority of sleep studies have focused on ordinary children. There have
been very few studies concerned with children with learning difficulties. However,
the few studies in the literature have shown sleep disturbance to be more common
in these children and also more likely to persist (Bartlett
et al 1985, Clements et al
1986, Quine 1991).
Even fewer studies have been carried out on children with specific forms of learning
difficulties. It is important to obtain information on the prevalence of sleep problems
and behaviours in children with these specific forms of learning difficulties for
two reasons: firstly, it will provide a better understanding of sleep problems and
secondly, it will allow intervention strategies to be developed.
Aims
- To investigate the occurrence and range of sleep disorders in children with Down
syndrome.
- To compare these findings with those of their non-handicapped brothers and sisters,
a group of other non-handicapped children and a group of children with mixed forms
of learning difficulties excluding Down syndrome.
The three control groups have been included to investigate (a) the effects of parental
style on sleep and daytime behaviour difficulties (b) the effects of children with
Down syndrome on the sleep of their brothers and sisters and (c) the specific effects
of Down syndrome on sleep and daytime behaviour problems as opposed to the effect
of learning disability in general.
Methodology
Procedure
Parents were sent a letter via schools explaining the nature of the research and
inviting them to take part. A questionnaire was forwarded to those parents agreeing
to take part and this was returned by post once completed.
Subject samples and design
The largest group was the group with Down syndrome (n=91), followed by the ordinary
group (n=78), the group with learning difficulties (n=71) and the Siblings (n=54).
Each group contained more boys than girls. The mean ages were between 9 and 11 years
and the age range was 4 to 19 years. The majority of the children with Down syndrome
and the children with learning difficulties attended schools for children with severe
learning difficulties (group with Down syndrome=81% and group with learning difficulties=85%).
13% of the group with Down syndrome and 15% of the group with learning difficulties
attended schools for children with moderate learning difficulties. 6% of the group
with Down syndrome attended mainstream schools. All the children in the sibling
and ordinary groups attended mainstream primary and secondary schools.
Measures
Sleep questionnaire
The questionnaire used was an adaptation of a questionnaire developed in the United
States by Simonds and Parraga
(1982). Section 1 consisted of 23 items concerned with general sleep habits of the
child. Section 2 contained 26 items concerned with the frequency of occurrence of
a range of sleep disorders and behaviours which fall under the following general
headings: disorders of initiating and maintaining sleep; disorders/behaviours associated
with obstructive sleep apnoea (obstructive sleep apnoea refers to the repeated obstruction
during the night of the child's upper airway causing pauses in breathing); other
disorders and behaviours occurring during sleep; sleep related disorders and behaviours
occurring during the day. For each item in this section, parents were asked to circle
one of the following: never, less than once a month, about once a month, about once
a week, several times a week or daily.
Results
Table 1 shows the percentage of children in each group showing frequent sleep problems
and behaviours i.e. those occurring daily or several times a week.
Table 1. Percentage of children showing frequent sleep problems and behaviours
|
|
D.S.
|
SIBS
|
ORD
|
L.D
|
|
Settling
|
20
|
2
|
9
|
29
|
|
Waking
|
32
|
10
|
10
|
44
|
|
Early waking
|
17
|
4
|
6
|
30
|
|
Reluctant to go to bed
|
26
|
26
|
22
|
34
|
|
Insists on sleeping with someone
|
9
|
0
|
3
|
10
|
|
Reluctant to go to bed due to fears
|
3
|
2
|
4
|
0
|
|
Breathes through mouth
|
73
|
33
|
33
|
54
|
|
Restless sleeper
|
60
|
22
|
26
|
52
|
|
Snores loudly
|
43
|
16
|
10
|
27
|
|
Sleeps with head tipped right back
|
30
|
4
|
5
|
10
|
|
Apnoeic episodes
|
12
|
0
|
1
|
6
|
|
Gags or chokes
|
7
|
0
|
1
|
7
|
|
Sleep talks
|
19
|
15
|
8
|
15
|
|
Teeth grinds
|
17
|
4
|
8
|
10
|
|
Wets bed
|
16
|
0
|
2
|
28
|
|
Head bangs
|
7
|
0
|
3
|
13
|
|
Nightmares
|
0
|
0
|
1
|
3
|
|
Sleep walks
|
3
|
0
|
1
|
0
|
|
Night terrors
|
0
|
2
|
0
|
2
|
|
Tongue biting
|
4
|
0
|
0
|
0
|
|
Daytime overactivity
|
29
|
6
|
13
|
46
|
|
Daytime naps
|
9
|
0
|
1
|
14
|
|
Excess daytime sleepiness
|
8
|
0
|
2
|
15
|
|
Irresistible sleep attacks
|
3
|
2
|
1
|
15
|
|
Floppy attacks
|
8
|
0
|
0
|
9
|
|
Attacks of inability to move
|
1
|
0
|
0
|
1
|
Overall the children with Down syndrome and the children with other forms of learning
difficulties showed a greater number of sleep disorders and behaviours than the
sibling and the ordinary groups. However, the patterns of sleep disorders seen in
the children with Down syndrome and the other children with learning difficulties
were very different, whereas the siblings and the ordinary groups showed very similar
patterns of sleep problems.
Regardless of age, the group with Down syndrome and the group with learning difficulties
were significantly more likely than the sibling and ordinary groups to show settling
problems and wake during the night. The group with Down syndrome was significantly
more likely than the sibling and ordinary groups to show early waking but the group
with learning difficulties was significantly more likely to show this problem than
all three other groups. The group with Down syndrome was significantly more likely
than the siblings to insist on sleeping with someone.
The group with Down syndrome was significantly more likely than all three other
groups to show the disorders and behaviours associated with obstructive sleep apnoea
syndrome ie. breathing through mouth rather than nose during sleep, loud snoring,
sleeping with head tipped right back, apnoeic episodes. The group with Down syndrome
and the group with learning difficulties were significantly more likely to show
restlessness and gag or choke during sleep.
Other disorders and behaviours occurring during sleep were generally less common
than disorders of initiating and maintaining sleep and disorders/behaviours associated
with obstructive sleep apnoea in all groups of children. However, the group with
Down syndrome was significantly more likely to show teeth grinding, bedwetting and
head banging than the sibling and the ordinary groups. The group with learning difficulties
was significantly more likely to wet the bed than all three other groups.
The group with Down syndrome was significantly more likely to show daytime overactivity
and irresistible sleep attacks than all three other groups and the group with Down
syndrome was also significantly more likely to show these behaviours than the sibling
and ordinary groups. The group with Down syndrome and the group with learning difficulties
were significantly more likely to have daytime naps, show excess daytime sleepiness
and floppy attacks (of an uncertain nature) than the sibling and ordinary groups.
Some age differences existed, mainly with disorders of initiating and maintaining
sleep. Where these occurred, younger children were more likely to show problems
than older children. The children were therefore improving with age.
Further analysis of the sleep information showed that the different types of sleep
problems, i.e. behavioural type sleep problems of settling, waking and early waking,
and the physical problems associated with obstructive sleep apnoea, were not associated
with each other. In other words, a child with a physical sleep problem was not more
likely to have a behavioural sleep problem than a child without. Both types of sleep
problem showed strong associations with daytime behavioural disturbance and excess
daytime sleepiness.
Summary
The present findings are of both clinical and theoretical interest. The finding
that children with Down syndrome score highest on those items associated with obstructive
sleep apnoea syndrome suggest that the sleep problems of these children are predominantly
physical in origin. This indicates the need for a more detailed investigation of
the problem of obstructive sleep apnoea in children with Down syndrome and the need
to consider further the effects of this problem, and associated sleep disturbance,
on daytime processes such as behaviour and basic attention and concentration. This
has not been the subject of any systematic research although possible associations
have been mentioned e.g.
Stebbens et al, 1991. The author is currently planning a project to investigate
these issues.
Acknowledgements
This research programme is being funded by the Portsmouth Down Syndrome Trust. The
author wishes to thank the Hampshire schools and the parents for all their help
with this project.
References
- Bartlett, L.B., Rooney,
V. and Spedding, S. (1985) Nocturnal difficulties in a population of mentally
handicapped children. British Journal of Mental Subnormality, 31, 54-59.
- Clements, J., Wing, L. and Dunn,
G.(1986) Sleep problems in handicapped children: A preliminary study. Journal
of Child Psychology and Psychiatry and Allied Disciplines, 27, 399-407.
- Quine, L. (1991) Sleep problems in children with
severe mental handicap. Journal of Mental Deficiency Research, 35, 269-290.
- Richman, N. (1981) A community survey of the characteristics
of one to two year olds with sleep disruptions. Journal of the American Academy
of Child Psychiatry, 20, 281-291.
- Rutter, M., Tizard, J.
and Whitmore, K. (1970) Education, Health and Behaviour. London, Longman.
- Simonds, J.F. and Parraga,H. (1982)
Prevalence of sleep disorders and sleep behaviors in children and adolescents. Journal
of the American Academy of Child Psychiatry, 21, 383-388.
-
Stebbens,V.A., Dennis, J., Samuels, M.P., Croft, C.B. and Southall, D.P. (1991)
Sleep related upper airway obstruction in a cohort with Down syndrome. Archives
of Disease in Childhood, 66, 1333-1338.
- Stores, R. (1993) A preliminary study of sleep disorders
and daytime behaviour problems in children with Down syndrome. Down Syndrome: Research
and Practice, 1(1) 29-33. [Open
Access Full Text
]