Sleep problems in children with neurological disorders

Investigating the association between the lunar cycle and sleep, physiological, cognitive, and physical performance in children with Down syndrome

BACKGROUND

Children with Down syndrome (DS) offer a compelling context within the fieldof human biology for examining potential lunar influences. While the exact mechanisms governing lunar effects are still under investigation, a growing body of scientific inquiry suggests possible connections between lunar phases and physiological, physical, and cognitive parameters. This investigation holds promise for uncovering the intricate interplay between lunar cycles (LCs) and the unique biology of children with DS. This study investigated the potential influence of the LC on physiological, physical, and cognitive parameters in children with DS, focusing on sleep patterns, physical performance, and cognitive abilities.

MATERIALS AND METHODS

Seventeen children with DS participated in this study. Sleep data, physical performance metrics, and cognitive test results were collected throughout the LC, including the new moon (NM), first quarter, full moon (FM), and third quarter. Statistical analyses were conducted to assess the differences in these parameters across lunar phases.

RESULTS

Significant differences were observed in sleep patterns, with reduced total sleep time (P < 0.01) and sleep efficiency (P < 0.001) during the FM phase. Heart rates (HRs) before (P < 0.001) and after (P < 0.01) exercise also displayed pronounced changes during LC. Additionally, the reaction time (RT) exhibited a significant difference (P < 0.01) across the lunar phases. However, physical performance metrics, including squat jump (SJ), sprint, and 6-minute walk distance (6MWD), did not show significant variations.

CONCLUSION

This study suggests that LC may have a moderating effect on sleep patterns, HR, and cognitive performance in children with DS. These findings have practical implications for caregivers and educators and highlight the importance of considering lunar-associated variations in planning schedules and interventions for children with DS.

Comparison of actigraphy with a sleep protocol maintained by professional caregivers and questionnaire-based parental judgment in children and adolescents with life-limiting conditions

BACKGROUND

Actigraphy offers a promising way to objectively assess pediatric sleep. Aim of the study was investigating the extent to which actigraphy used in children and adolescents with life-limiting conditions is consistent with two other measures of sleep diagnostics.

METHODS

In this monocentric prospective study N = 26 children and adolescents with life-limiting conditions treated on a pediatric palliative care unit were assessed. For three consecutive nights they wore an actigraph; the 24-hours sleep protocol documented by nurses and the Sleep Screening for Children and Adolescents with Complex Chronic Conditions (SCAC) answered by parents were analyzed. Patient characteristics and the parameters sleep onset, sleep offset, wake after sleep onset (WASO), number of wake phases, total sleep time (TST) and sleep efficiency (SE) were descriptively examined. Percentage bend correlations evaluated the three measures' concordance.

RESULTS

Descriptively, and except for the number of waking episodes, the different measures' estimations were comparable. Significant correlations existed between actigraphy and the sleep protocol for sleep onset (r = 0.83, p = < 0.001) and sleep offset (r = 0.89, p = < 0.001), between actigraphy and SCAC for SE (r = 0.59, p = 0.02).

CONCLUSION

Agreement of actigraphy with the focused sleep measures seems to be basically given but to varying degrees depending on the considered parameters.

Insights into the Frequency and Distinguishing Features of Sleep Disorders in Pediatric Palliative Care Incorporating a Systematic Sleep Protocol

Currently, no concrete figures on sleep disorders and sleep characteristics in children and adolescents with life-limiting conditions (LLC) and severe neurological impairment (SNI) based on pediatric palliative care professionals’ assessment and following an official classification system such as the International Classification of Sleep Disorders (ICSD-3) exist. The ICSD-3 sleep disorders of inpatient children and adolescents with LLC and SNI (N = 70) were assessed by professionals using a recording sheet (two-year recruitment period). A systematic sleep protocol was applied to identify patients’ sleep characteristics. Of these patients, 45.6% had sleep disorders, with the majority of them experiencing two different ones. Overall, the most frequently identified disorders were Chronic Insomnia and Circadian Sleep–Wake Disorder. Patients experiencing Chronic Insomnia showed more sleep phases during the daytime and more waking phases at nighttime than those unaffected. Patients with and without a Circadian Sleep–Wake Disorder additionally differed in the length of sleep phases during the daytime. Rapid changes between wakefulness and sleep were specifically characteristic of Hypersomnia. The study provides important insights into the prevalence and characteristics of individual ICSD-3 sleep disorders in pediatric palliative care. The findings may contribute to a targeted and efficient diagnosis and therapy of distressing sleep problems in seriously ill patients.

Unsupervised Sleep and Wake State Identification in Long-Term Electrocorticography Recordings

Studying the neural correlates of sleep can lead to revelations in our understanding of sleep and its interplay with different neurological disorders. Sleep research relies on manual annotation of sleep stages based on rules developed for healthy adults. Automating sleep stage annotation can expedite sleep research and enable us to better understand atypical sleep patterns. Our goal was to create a fully unsupervised approach to label sleep and wake states in human electro-corticography (ECoG) data from epilepsy patients. Here, we demonstrate that with continuous data from a single ECoG electrode, hidden semi-Markov models (HSMM) perform best in classifying sleep/wake states without excessive transitions, with a mean accuracy (n=4) of 85.2% compared to using K-means clustering (72.2%) and hidden Markov models (81.5%). Our results confirm that HSMMs produce meaningful labels for ECoG data and establish the groundwork to apply this model to cluster sleep stages and potentially other behavioral states.

A Review of Sleep Disturbances among Infants and Children with Neurodevelopmental Disorders

Sleep problems are common among children with neurodevelopmental disorders (NDDs). We review sleep disturbance in three major NDDs: autism spectrum disorder, Down syndrome, and fetal alcohol spectrum disorder (FASD). We review associations with functional impairment, discuss how patterns of sleep disturbance inform understanding of etiology, and theorize about mechanisms of impairment. Sleep disturbance is a transdiagnostic feature of NDDs. Caregivers report high rates of sleep problems, including difficulty falling or staying asleep. Polysomnography data reveal differences in sleep architecture and increased rates of sleep disorders. Sleep disturbance is associated with functional impairment and stress among families. Further research is needed to elucidate mechanisms of impairment and develop more effective interventions. Despite significant sleep disturbance in FASD, limited research is available.

Outcome domains and outcome measures used in studies assessing the effectiveness of interventions to manage non-respiratory sleep disturbances in children with neurodisabilities: a systematic review

OBJECTIVES

To assess whether a core outcome set is required for studies evaluating the effectiveness of interventions for non-respiratory sleep disturbances in children with neurodisabilities.

DESIGN

Survey of outcome measures used in primary studies identified by a systematic review.

DATA SOURCES

ASSIA, CENTRAL, Cochrane Database of Systematic Reviews, Conference Proceedings Citation Index, CINAHL, DARE, Embase, HMIC, MEDLINE, MEDLINE In-Process, PsycINFO, Science Citation Index, Social Care Online, Social Policy & Practice, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform and the UK Clinical Trials Gateway were searched up to February 2017.

ELIGIBILITY CRITERIA

Studies evaluating pharmacological or non-pharmacological interventions for children (≤18 years old) with a neurodisability and experiencing non-respiratory sleep disturbance.

DATA EXTRACTION AND SYNTHESIS

Outcome measures were listed from each study and categorised into domains.

RESULTS

Thirty-nine studies assessed five core outcome areas: child sleep, other child outcomes, parent outcomes, adverse events and process measures. There were 54 different measures of child sleep across five domains: global measures; sleep initiation; maintenance; scheduling; and other outcomes. Fifteen non-pharmacological (58%) and four pharmacological studies (31%) reported child outcomes other than sleep using 29 different measures.One pharmacological and 14 non-pharmacological (54%) studies reported parent outcomes (17 different measures). Eleven melatonin studies (85%) recorded adverse events, with variation in how data were collected and reported. One non-pharmacological study reported an explicit method of collecting on adverse events. Several process measures were reported, related to adherence, feasibility of delivery, acceptability and experiences of receiving the intervention.

CONCLUSIONS

There is a lack of consistency between studies in the outcome measures used to assess the effectiveness of interventions for non-respiratory sleep disturbances in children with neurodisabilities. A minimum core outcome set, with international consensus, should be developed in consultation with parents, children and young people, and those involved in supporting families.

PROSPERO REGISTRATION NUMBER

CRD42016034067.

Dendritic spines: Revisiting the physiological role

Dendritic spines are small, thin, specialized protrusions from neuronal dendrites, primarily localized in the excitatory synapses. Sophisticated imaging techniques revealed that dendritic spines are complex structures consisting of a dense network of cytoskeletal, transmembrane and scaffolding molecules, and numerous surface receptors. Molecular signaling pathways, mainly Rho and Ras family small GTPases pathways that converge on actin cytoskeleton, regulate the spine morphology and dynamics bi-directionally during synaptic activity. During synaptic plasticity the number and shapes of dendritic spines undergo radical reorganizations. Long-term potentiation (LTP) induction promote spine head enlargement and the formation and stabilization of new spines. Long-term depression (LTD) results in their shrinkage and retraction. Reports indicate increased spine density in the pyramidal neurons of autism and Fragile X syndrome patients and reduced density in the temporal gyrus loci of schizophrenic patients. Post-mortem reports of Alzheimer's brains showed reduced spine number in the hippocampus and cortex. This review highlights the spine morphogenesis process, the activity-dependent structural plasticity and mechanisms by which synaptic activity sculpts the dendritic spines, the structural and functional changes in spines during learning and memory using LTP and LTD processes. It also discusses on spine status in neurodegenerative diseases and the impact of nootropics and neuroprotective agents on the functional restoration of dendritic spines.

Pharmacological and non-pharmacological interventions for non-respiratory sleep disturbance in children with neurodisabilities: a systematic review

BACKGROUND

There is uncertainty about the most appropriate ways to manage non-respiratory sleep disturbances in children with neurodisabilities (NDs).

OBJECTIVE

To assess the clinical effectiveness and safety of NHS-relevant pharmacological and non-pharmacological interventions to manage sleep disturbance in children and young people with NDs, who have non-respiratory sleep disturbance.

DATA SOURCES

Sixteen databases, including The Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE, were searched up to February 2017, and grey literature searches and hand-searches were conducted.

REVIEW METHODS

For pharmacological interventions, only randomised controlled trials (RCTs) were included. For non-pharmacological interventions, RCTs, non-randomised controlled studies and before-and-after studies were included. Data were extracted and quality assessed by two researchers. Meta-analysis and narrative synthesis were undertaken. Data on parents' and children's experiences of receiving a sleep disturbance intervention were collated into themes and reported narratively.

RESULTS

Thirty-nine studies were included. Sample sizes ranged from 5 to 244 participants. Thirteen RCTs evaluated oral melatonin. Twenty-six studies (12 RCTs and 14 before-and-after studies) evaluated non-pharmacological interventions, including comprehensive parent-directed tailored (n = 9) and non-tailored (n = 8) interventions, non-comprehensive parent-directed interventions (n = 2) and other non-pharmacological interventions (n = 7). All but one study were reported as having a high or unclear risk of bias, and studies were generally poorly reported. There was a statistically significant increase in diary-reported total sleep time (TST), which was the most commonly reported outcome for melatonin compared with placebo [pooled mean difference 29.6 minutes, 95% confidence interval (CI) 6.9 to 52.4 minutes; p = 0.01]; however, statistical heterogeneity was extremely high (97%). For the single melatonin study that was rated as having a low risk of bias, the mean increase in TST was 13.2 minutes and the lower CI included the possibility of reduced sleep time (95% CI -13.3 to 39.7 minutes). There was mixed evidence about the clinical effectiveness of the non-pharmacological interventions. Sixteen studies included interventions that investigated the feasibility, acceptability and/or parent or clinician views of sleep disturbance interventions. The majority of these studies reported the 'family experience' of non-pharmacological interventions.

LIMITATIONS

Planned subgroup analysis was possible in only a small number of melatonin trials.

CONCLUSIONS

There is some evidence of benefit for melatonin compared with placebo, but the degree of benefit is uncertain. There are various types of non-pharmacological interventions for managing sleep disturbance; however, clinical and methodological heterogeneity, few RCTs, a lack of standardised outcome measures and risk of bias means that it is not possible to draw conclusions with regard to their effectiveness. Future work should include the development of a core outcome, further evaluation of the clinical effectiveness and cost-effectiveness of pharmacological and non-pharmacological interventions and research exploring the prevention of, and methods for identifying, sleep disturbance. Research mapping current practices and exploring families' understanding of sleep disturbance and their experiences of obtaining help may facilitate service provision development.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016034067.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Non-pharmacological interventions for non-respiratory sleep disturbance in children with neurodisabilities: a systematic review

AIM

To describe existing evidence on non-pharmacological interventions to manage sleep disturbance in children with neurodisabilities.

METHOD

We systematically reviewed non-pharmacological interventions aimed at improving non-respiratory sleep disturbance in children with neurodisability. Sixteen databases, grey literature, and reference lists of included papers were searched up to February 2017. Two researchers (B.B., C.M., G.S., A.S., A.P.) undertook screening, data extraction, and quality appraisal.

RESULTS

Twenty-five studies were included: 11 randomized controlled trials and 14 before-and-after studies. All studies were at high or unclear risk of bias. Parent-directed interventions were categorized as comprehensive tailored interventions (n=9), comprehensive non-tailored interventions (n=8), and non-comprehensive interventions (n=2). Six 'other' non-pharmacological interventions were included. Seventy-one child and parent sleep-related outcomes were measured across the included studies. We report the two most commonly measured outcomes: the Child Sleep Habits Questionnaire and sleep onset latency. Five studies reported significant improvements on at least one of these outcomes.

INTERPRETATION

Various types of non-pharmacological intervention for managing sleep disturbance have been evaluated. Clinical heterogeneity and poor study quality meant we could not draw definitive conclusions on the effectiveness of these interventions. Current clinical guidance recommends parent-directed interventions as the first approach to managing sleep disturbance; prioritizing research in this area is recommended.

WHAT THIS PAPER ADDS

Existing evidence on non-pharmacological interventions to manage sleep disturbance in children with neurodisabilities is predominately of poor quality. Most included studies evaluated parent-directed interventions of varying content and intensity. There was very little consistency between studies in the outcome measures used. There is some evidence that parent-directed interventions may improve child outcomes.

The Unfavorable Alliance of Pain and Poor Sleep in Children with Life-Limiting Conditions and Severe Psychomotor Impairment

A high prevalence of sleep problems exists in children and adolescents with life-limiting conditions (LLC) and severe psychomotor impairment (SPMI). This study aimed to compare the impacts of various child-related (pain, epilepsy, repositioning, medical care) and environment-related (light, noise, TV/radio, open door) factors on sleep in this vulnerable population. Data were obtained through the “Sleep Questionnaire for Children with Severe Psychomotor Impairment” (SNAKE) by proxy assessment. n = 212 children (mean age: 10.4 years) were included in the analyses. Logistic and linear regression models were used to compare child- and environment-related factors against the global rating of children’s sleep quality, five SNAKE scales, children’s sleep duration, and sleep efficacy. Pain increased the risk of sleeping poorly four-fold (OR (odds ratio) = 4.13; 95% CI (confidence interval): 1.87–9.13) and predicted four sleep problems as assessed by the SNAKE. Children who needed to reposition during the night were at three times greater risk of sleeping poorly (OR = 3.08; 95% CI: 1.42–6.69). Three of the five SNAKE scales were predicted through nocturnal repositioning. Repositioning and epilepsy predicted a reduced sleep duration and low sleep efficacy. None of the environment-related factors exhibited statistically significant results. This study emphasizes the urgent need for reliable pain detection in the context of sleep disturbances in severely ill children.

Sleep disturbances in Rett syndrome: Impact and management including use of sleep hygiene practices

Sleep disturbances are debilitating for individuals with Rett syndrome (RTT) and their families yet the evidence base for management is poor. We investigated management strategies and their relationships with sleep problems. Data were provided by 364/461 (79%) families with a child with RTT and registered with the International RTT Phenotype Database. Logistic regression models were used to investigate relationships between impacts of sleep problems on the child and family with age group, mutation type, medication type, and sleep hygiene score. Linear regression models were used to estimate the association of disorders of initiating and maintaining sleep (DIMS) with age group, mutation type, medication type, and sleep hygiene. Among those who ever had difficulty falling asleep or night waking, use of any medication was associated with higher odds of moderate/major impact sleep problems (relative to minor/no impact) for the affected child and the family, as well as higher DIMS scores, when compared with the no treatment/nonmedication group accounting for the effects of age, mutation type, and sleep hygiene score. Better use of sleep hygiene practices was associated with lower odds of moderate/major impact on the family (odds ratio 0.60, 95% confidence intervals [CIs] 0.37, 0.98) and lower DIMS scores (geometric mean ratio 0.86, 95%CI 0.80, 0.92) compared with poorer use after adjusting for covariates. Attention to sleep hygiene remains an important management strategy for sleep problems in RTT. Further prospective research is required to investigate efficacy of pharmaceutical treatments.

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

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

The humanistic and economic burden of Dravet syndrome on caregivers and families: Implications for future research

We reviewed the current literature with respect to the humanistic and financial burdens of Dravet Syndrome (DS) on the caregivers of children with DS, in order to (1) identify key unanswered questions or gaps in knowledge that need to be addressed and then, based on these knowledge gaps, (2) propose a research agenda for the scientific community to address in the coming decade. The findings support the conclusion that caring for a child with DS is associated with significant humanistic burden and direct costs. However, due in part to the paucity of studies, as well as the lack of measures of specific burden domains, there remains much that is not known regarding the burden of caregiving for children with DS. To address the significant knowledge gaps in this area, research is needed that will: (1) identify the specific domains of caregivers' lives that are impacted by caring for a child with DS; (2) identify or, if needed, develop measures of caregiving impact in this area; (3) identify the factors that influence DS caregiving burden; (4) develop and evaluate the efficacy of treatments for reducing the negative impact of DS and its comorbidities on DS caregivers; (5) quantify the direct medical costs associated with DS and DS comorbidities and identify the factors that influence these costs; and (6) quantify and fully explore the indirect costs of DS. Research that addresses these goals will provide the empirical foundation needed for improving the quality of life of children with DS and their families.

Reliability of parent report measures of sleep in children with Down syndrome

BACKGROUND

Behavioural sleep disturbances are common among children with Down syndrome (DS). However, tools used to detect and evaluate behavioural sleep disturbances were developed for typically developing children and have not been evaluated for use among children with DS. The current study evaluates the psychometric properties of three measures of behavioural sleep disturbances that are currently being used with children with intellectual and developmental disabilities, including children with DS.

METHOD

Caregivers of 30 children with DS rated their child's sleep with the Behavioral Evaluation of Disorders of Sleep (BEDS), Children's Sleep Habits Questionnaire (CSHQ) and Sleep Disturbances Scale for Children (SDSC). Caregivers also provided information on sleep diagnoses and completed a 7-night sleep and behaviour diary.

RESULTS

The study investigated the rate of detecting sleep problems, internal consistency, and convergent and concurrent validity of the BEDS, CSHQ and SDSC. Children with DS were reported to exhibit behavioural sleep disturbances at different rates depending on the measure used; 0% BEDS, 79.3% CSHQ and 17.2% SDSC. Internal consistency was comparable for all three measures for their total scores. However, when evaluating the internal consistency of subscale scores, those on the CSHQ and SDSC performed more strongly. The subscales of the CSHQ performed best when evaluating convergent and concurrent validity, with the SDSC subscales performing moderately well.

CONCLUSION

The study findings suggest that, among children with DS, the CSHQ and its subscales performed in a psychometrically sound and theoretically appropriate manner in relation to other measures of sleep, medical history of sleep problems, and daily reports of sleep and associated behaviours. The SDSC performed moderately well. When evaluating behavioural sleep disturbances among children with DS, the CSHQ is recommended based on its stronger psychometric properties.

The relationship between sleep and working memory in children with neurological conditions

The objective of this study is to investigate whether sleep problems might account for the increased working memory deficits observed in school-aged children with neurological conditions. A novel, transdiagnostic approach to the investigation was chosen, and sleep is treated as a process that can potentially account for working memory difficulties across a range of neurological conditions. Prevalence estimates of sleep problems are also examined. Archival data of 237 children aged 6 to 11 years were collected from a Western Australian statewide neuropsychological service for the period 26 July 2011 to 14 January 2014. Measures of parent-reported sleep quality, snoring, and daytime sleepiness were obtained, in addition to objective measures of verbal and spatial working memory, storage capacity, and processing speed. The results of the data analysis reveal that over one third of participants reported having clinically-significant levels of sleep problems and that poor sleep quality is significantly associated with verbal working memory difficulties. This association remains after partialling out the variance contributed to performance by storage capacity and processing speed, suggesting that sleep is impacting upon an executive component of working memory. No other significant associations are observed. The results suggest that poor sleep quality is associated with an executive component of verbal (rather than spatial) working memory in children with neurological conditions. This has implications for the biological mechanisms thought to underlie the relationship between sleep and cognition in children. The results also demonstrate the clinical utility of a transdiagnostic approach when investigating sleep and cognition in children with neurological conditions.

Determinants of sleep disturbances in Rett syndrome: Novel findings in relation to genotype

Rett syndrome is a rare but severe neurological disorder associated with a mutation in the methyl CpG binding protein 2 (MECP2) gene. Sleep problems and epilepsy are two of many comorbidities associated with this disorder. This study investigated the prevalence and determinants of sleep problems in Rett syndrome using an international sample. Families with a child with a confirmed Rett syndrome diagnosis and a MECP2 mutation registered in the International Rett Syndrome Phenotype Database (InterRett) were invited to participate. Questionnaires were returned by 364/461 (78.9%) either in web-based or paper format. Families completed the Sleep Disturbance Scale for Children and provided information on the presence, nature, and frequency of their child's sleep problems. Multivariate multinomial regression was used to investigate the relationships between selected sleep problems, age group, and genotype and linear regression for the relationships between sleep disturbance scales and a range of covariates. Night waking was the most prevalent sleep problem affecting over 80% with nearly half (48.3%) currently waking often at night. Initiating and maintaining sleep was most disturbed for younger children and those with a p.Arg294* mutation. Severe seizure activity was associated with poor sleep after adjusting for age group, mutation type, and mobility. We were surprised to find associations between the p.Arg294* mutation and some sleep disturbances given that other aspects of its phenotype are milder. These findings highlight the complexities of aberrant MECP2 function in Rett syndrome and explain some of the variation in manifestation of sleep disturbances. © 2016 Wiley Periodicals, Inc.

Ongoing daytime behavioural problems in university students following childhood mild traumatic brain injury

Sleep is often disrupted in traumatic brain injury (TBI) and may be related to persistent behaviour problems; however, little is known about this relationship in young adults. This study explored associations between TBI, behavioural problems and sleep disturbances in 247 university students (197 non-TBI, 47 mild TBI, two moderate TBI, one severe TBI) aged 18-25 years, who completed validated measures for behaviour, sleep quality and history of TBI. Because of small group numbers, participants reporting moderate to severe TBI were excluded from the analyses. Results indicated that students with mild TBI reported higher levels of daytime dysfunction, somatic complaints, withdrawal, other behavioural complaints and internalizing behaviours compared with students with no TBI history. A correlational analysis indicated a moderate relationship between the above significant variables. Our results suggest that university students with a history of mild TBI are more likely to experience certain ongoing daytime behavioural problems, which are likely to negatively influence their academic functioning in tertiary education. This study highlights the importance of research on long-term problems following mild TBI in young adults aged 18-25 years--an age group often overlooked within the literature.

Sleep concerns in children and young people with cerebral palsy in their home setting

AIMS

The aims were to identify in-home concerns about sleep in children and young people with cerebral palsy (CP) across age and Gross Motor Function Classification Scale (GMFCS) levels.

METHODS

This was a retrospective review of clinical notes of 154 children and young people with CP, aged 1-18 years (M = 7.8; standard deviation = 5.4) who received a home-based sleep service. Reported concerns were synthesised, for analysis according to age groups (1-5, 6-13, 14-18) and GMFCS levels.

RESULTS

Sixteen factors of concern were derived from the home-based assessment reports. Most children and young people had multiple factors of concern. These varied across age groups and GMFCS levels. Body position was of concern across all age groups, for over 90% at GMFCS levels IV and V, and for 10% at GMFCS level I. Settling routines were of concern for more than 90% at GMFCS levels I and II, but for less than 50% at GMFCS levels IV and V. Settling routines were of concern to over 65% of those under 6 years but less than 25% of those over 14 years. Conversely, pain and pressure care concerned less than 10% of children under 6, and more than 35% of those over 14 years.

CONCLUSIONS

Concerns about sleep vary across ages and GMFCS levels of children and young people with CP. Concerns relate to impairment of body structure and function, activity, environment, and personal supports. Multi-disciplinary, home-based assessment and interventions are recommended to address these concerns.

Molecular regulation of dendritic spine dynamics and their potential impact on synaptic plasticity and neurological diseases

The structure and dynamics of dendritic spines reflect the strength of synapses, which are severely affected in different brain diseases. Therefore, understanding the ultra-structure, molecular signaling mechanism(s) regulating dendritic spine dynamics is crucial. Although, since last century, dynamics of spine have been explored by several investigators in different neurological diseases, but despite countless efforts, a comprehensive understanding of the fundamental etiology and molecular signaling pathways involved in spine pathology is lacking. The purpose of this review is to provide a contextual framework of our current understanding of the molecular mechanisms of dendritic spine signaling, as well as their potential impact on different neurodegenerative and psychiatric diseases, as a format for highlighting some commonalities in function, as well as providing a format for new insights and perspectives into this critical area of research. Additionally, the potential strategies to restore spine structure-function in different diseases are also pointed out. Overall, these informations should help researchers to design new drugs to restore the structure-function of dendritic spine, a "hot site" of synaptic plasticity.

Replacing home visits with telephone calls to support parents implementing a sleep management intervention: findings from a pilot study and implications for future research

BACKGROUND

Resource constraints may inhibit the provision of appropriate interventions for children with neurodisabilities presenting with behavioural sleep problems. Telephone calls (TC), as opposed to home visits (HV), may be a more resource efficient means of supporting these families.

OBJECTIVE

To conduct a preliminary investigation exploring the feasibility and acceptability of replacing HV with TC to support parents implementing sleep management strategies and to gather evidence to inform the design and methods of a full trial.

METHODS

Parents referred to a sleep management intervention routinely delivered by a community paediatric team were alternately allocated to receive implementation support via HV (n = 7) or TC (n = 8). Activity logs recorded the frequency, duration and mode of support. Parents and practitioners were interviewed about their experiences of receiving/delivering the intervention.

RESULTS

Intervention drop-out was low, the frequency, number of contacts and intervention duration appeared comparable. Parents allocated TC received less contact time. Parents valued implementation support irrespective of delivery mode and practitioners reported that despite initial reservations, implementation support via TC appeared to work well.

CONCLUSIONS

TC appears an acceptable and convenient mode of delivering sleep support, valued by both parents and practitioners. We recommend a full-scale trial to investigate effectiveness.

Influence of sleep disorders on the behavior of individuals with autism spectrum disorder

The aim of this study was to investigate the correlation between sleep disorders and the behavior of subjects with autism spectrum disorder (ASD) and control subjects using specific questionnaires. A small percentage (1.8%) of the control subjects had symptoms indicative of sleep-breathing disorders (SBD) and nocturnal sweating. Fifty-nine percent of the subjects with ASD had symptoms indicative of at least one sleep disorder, with SBD the most commonly reported (38%). In the control group, the symptoms of SBD were correlated with social, thought, attentional, aggression, externalizing and behavioral problems. In the ASD group, disorders of arousal (DA) were correlated with thinking problems, and disorders of excessive somnolence were correlated with thinking and behavioral problems. These results suggest that children and adolescents with ASD have a high frequency of sleep disorders, which in turn correlate with some of the behavioral traits that they already exhibit. Furthermore, sleep disturbances, when present in the typically developing children, also correlated with behavioral problems.

The trajectories of sleep disturbances in Rett syndrome

Rett syndrome is a rare neurodevelopmental disorder usually affecting females, and is associated with a mutation in the MECP2 gene. Sleep problems occur commonly and we investigated the trajectories and influences of age, mutation and treatments. Data were collected at six time points over 12 years from 320 families registered with the Australian Rett Syndrome Database. Regression analysis was used to investigate relationships between sleep disturbances, age, mutation type and use of treatment, and latent class growth analysis was performed to identify sleep problem phenotypes and model the effect of mutation type. The age range of subjects was 2.0-35.8 years. The study showed that sleep problems occurred in more than 80% of individuals and the prevalence decreased with age. Night laughing and night screaming occurred in 77 and 49%, respectively, when younger. Those with a large deletion had a higher prevalence of night laughing, which often occurred frequently. Treatment was associated with a 1.7% reduction in risk of further sleep problems. High and low baseline prevalence groups were identified. Approximately three-quarters of girls and women with sleep disturbances were in the high baseline group and problems persisted into adulthood. Conversely, 57% with night laughing and 42% with night screaming in the high baseline group exhibited mild improvement over time. Mutation type was not found to be a significant predictor of group membership. In conclusion, the evolution of sleep problems differed between subgroups of girls and women with Rett syndrome, in part explained by age and genotype. Treatment was not associated with improvement in sleep problems.

Challenges in diagnosing narcolepsy without cataplexy: a consensus statement

BACKGROUND

Diagnosing narcolepsy without cataplexy is often a challenge as the symptoms are nonspecific, current diagnostic tests are limited, and there are no useful biomarkers. In this report, we review the clinical and physiological aspects of narcolepsy without cataplexy, the limitations of available diagnostic procedures, and the differential diagnoses, and we propose an approach for more accurate diagnosis of narcolepsy without cataplexy.

METHODS

A group of clinician-scientists experienced in narcolepsy reviewed the literature and convened to discuss current diagnostic tools, and to map out directions for research that should lead to a better understanding and more accurate diagnosis of narcolepsy without cataplexy.

RECOMMENDATIONS

To aid in the identification of narcolepsy without cataplexy, we review key indicators of narcolepsy and present a diagnostic algorithm. A detailed clinical history is mainly helpful to rule out other possible causes of chronic sleepiness. The multiple sleep latency test remains the most important measure, and prior sleep deprivation, shift work, or circadian disorders should be excluded by actigraphy or sleep logs. A short REM sleep latency (≤ 15 minutes) on polysomnography can aid in the diagnosis of narcolepsy without cataplexy, although sensitivity is low. Finally, measurement of hypocretin levels can helpful, as levels are low to intermediate in 10% to 30% of narcolepsy without cataplexy patients.

Children's sleep disturbance scale in differentiating neurological disorders

BACKGROUND

We use the Sleep Disturbance Scale for Children (SDSC) routinely as a tool for evaluating children's sleep quality in our pediatric neurology clinic. We analyzed at its ability to detect sleep disturbances distinctive to selected neurological disorders.

PATIENTS

One-hundred and eighty-six children (age range 2-18 years) who were evaluated by the SDSC questionnaire were divided into three groups according to their principal diagnosis: epilepsy, attention deficit hyperactivity disorder, or others. Their responses were analyzed.

RESULTS

The average frequency of abnormal total sleep score was 26.9%. The most frequent sleep disorders were excessive somnolence (25.3%), initiating and maintaining sleep (24.7%), and arousal/nightmares (23.1%). There were no significant group differences for total scores or sleep disorder-specific scores; although a sleep-wake transition disorder was more frequent among children with epilepsy (31%). A literature search revealed that the frequency of abnormal total scores in several neurological disorders (e.g., epilepsy, cerebral palsy) ranges between 20% and 30%.

CONCLUSIONS

The mechanism underlying sleep disturbances in many neurological disorders may be unrelated to that of the primary disease but rather originate from nonspecific or environmental factors (e.g., familial/social customs and habits, temperament, psychological parameters). Although the SDSC is noninformative for studying the effect of a specific neurological disorder on sleep, we still recommend its implementation for screening for sleep disturbances in children with neurological abnormalities.

Pediatric sleep difficulties after moderate-severe traumatic brain injury

The objective of this study is to systematically investigate sleep following moderate-severe pediatric traumatic brain injury (TBI). School-aged children with moderate-severe TBI identified via hospital records were invited to participate, along with a school-age sibling. Subjective reports and objective actigraphy correlates of sleep were recorded: Children's Sleep Habits Questionnaire (CSHQ), Sleep Self-Report questionnaire (SSR), and 5-night actigraphy. TBI participants (n = 15) and their siblings (n = 15) participated. Significantly more sleep problems were parent-reported (CSHQ: p = 0.003; d = 1.57), self-reported (SSR: p = 0.003; d = 1.40), and actigraph-recorded in the TBI group (sleep efficiency: p = 0.003; d = 1.23; sleep latency: p = 0.018; d = 0.94). There was no evidence of circadian rhythm disorders, and daytime napping was not prevalent. Moderate-severe pediatric TBI was associated with sleep inefficiency in the form of sleep onset and maintenance problems. This preliminary study indicates that clinicians should be aware of sleep difficulties following pediatric TBI, and their potential associations with cognitive and behavioral problems in a group already at educational and psychosocial risk.

Behaviour disorders in children with an intellectual disability

Behaviour disorders are frequent in children with an intellectual disability, regardless of the underlying etiology. They are often disabling, and can create problems in everyday life and can mask, or reveal, an organic or psychiatric illness. Such behaviours are often chronic and more than one may be present in the same individual. This is further complicated by the fact that parents often do not seek help for the problem, perhaps believing that it is due to the child's disability and cannot be treated. The present review describes some general concepts dealing with the management of behaviour disorders commonly seen in children and youth with an intellectual disability, and gives a high level overview of behaviours commonly problematic in this patient population including sleep disturbances, agitated and aggressive behaviours, and self-injury behaviour. In general, while pharmacological treatment is possible, behavioural intervention is a more effective and better tolerated form of treatment.

Sleep patterns in children with ADHD: a population-based cohort study from birth to 11 years

Associations between sleep duration and disturbance in infancy and early childhood and attention deficit hyperactivity disorder diagnoses were investigated. Data from the Avon Longitudinal Study of Parents and Children, a population-based prospective longitudinal birth-cohort study of children born in 1991–1992 in South-West England, were employed. Eight thousand, one hundred and ninety-five children were assessed using the Development and Well-Being Assessment. One hundred and seventy-three cases (2.1%) met criteria for attention deficit hyperactivity disorder. Parental report at eight time points showed children with attention deficit hyperactivity disorder slept less than peers. Absolute differences were small and mainly restricted to night-time sleep, with no strong evidence of differences from controls, except at 69 months {5 years 9 months; 12 min (95% CI: 5–19), P = 0.001}, at 81 months {6 years 9 months; 15 min (95% CI: 8–22), P < 0.001} and at 115 months {9 years 7 months; 11 min (95% CI: 4–18), P = 0.001}. The attention deficit hyperactivity disorder group had more night-waking at every age, significant from about 5 years. When tracking children’s sleep along a normative centiles chart, a shift in sleep duration from one centile to a lower centile was a useful predictor of attention deficit hyperactivity disorder. Age-specific decreases of >1SD in sleep duration across adjacent time points was a significant predictor of attention deficit hyperactivity disorder at 3–5 years (P = 0.047). In children with attention deficit hyperactivity disorder, shorter sleep duration and sleep disturbances appear early and predate the usual age of clinical diagnosis. The rate of change of sleep duration relative to an individual, rather than absolute sleep duration at any stage, may prove beneficial in identifying increased risk of attention deficit hyperactivity disorder.

Quality of life and behavioural adjustment in childhood hydrocephalus

The aim of the paper is to describe parent and teacher reported behavioural outcomes and quality of life in childhood hydrocephalus, and to consider the implications for future service planning. A community sample of 235 school-aged children with hydrocephalus (5-16 years) were identified via a database of service users, held by the Scottish Spina Bifida Association. Parent and teacher reports of behaviour on the Strengths and Difficulties Questionnaire (SDQ), and parent reports of quality of life on the Paediatric Quality-of-Life Generic Core (PedsQL Core) and Paediatric Quality-of-Life Fatigue (PedsQL Fatigue) were obtained, as were reports of service use and satisfaction.  In total, 35% (n = 76) of parents and 86% (n = 47) of teachers who were contacted participated in the study. Parents reported behavioural difficulties in 57% and teachers in 33% of children. Quality of life was significantly reduced in comparison to published norms. Children whose parents reported unmet needs had poorer psychosocial outcomes, but families rarely accessed appropriate specialist services. In conclusion, hydrocephalus is associated with high rates of behaviour problems and markedly reduced quality of life. It is important to increase professional awareness of psychological need in this chronic neurological condition, and to increase access to appropriate psychosocial services.

Sleep contributes to dendritic spine formation and elimination in the developing mouse somatosensory cortex

Sleep is maximal during early postnatal life when rapid and extensive synapse remodeling occurs. It remains unknown whether and how sleep affects synapse development and plasticity. Using transcranial two-photon microscopy, we examined the formation and elimination of fluorescently labeled dendritic spines and filopodia of Layer 5 pyramidal neurons in the barrel cortex of 3-week-old mice during wakefulness and sleep. We observed high turnover of dendritic protrusions over 2 h in both wake and sleep states. The formation rate of dendritic spines or filopodia over 2 h was comparable between the two states. The elimination rate of dendritic spines or filopodia was lower during 2-h wakefulness than during 2-h sleep. Similar results were observed on dendritic protrusion dynamics over 12-h light/dark cycle when mice spent more time asleep or awake. The substantial remodeling of dendritic protrusions during the sleep state supports the notion that sleep plays an important role in the development and plasticity of synaptic connections in the mouse cortex.

Sleep in children with cerebral palsy: a review

Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.

A brief primer on sleep for pediatric and child clinical neuropsychologists

Sleep problems are common in the children seen by pediatric and child clinical neuropsychologists, and these problems have the potential to significantly impact the child and his or her family. All are treatable to some degree, and some respond extremely well to existing treatments. This article provides a brief overview of the impact, nature, screening, and treatment for childhood sleep problems, with a particular emphasis on issues relevant to practicing neuropsychologists.

Long-term sleep disturbances in children: a cause of neuronal loss

Short-term sleep loss is known to cause temporary difficulties in cognition, behaviour and health but the effects of persistent sleep deprivation on brain development have received little or no attention. Yet, severe sleep disorders that last for years are common in children especially when they have neurodevelopmental disabilities. There is increasing evidence that chronic sleep loss can lead to neuronal and cognitive loss in children although this is generally unrecognized by the medical profession and the public. Without the restorative functions of sleep due to total sleep deprivation, death is inevitable within a few weeks. Chronic sleep disturbances at any age deprive children of healthy environmental exposure which is a prerequisite for cognitive growth more so during critical developmental periods. Sleep loss adversely effects pineal melatonin production which causes disturbance of circadian physiology of cells, organs, neurochemicals, neuroprotective and other metabolic functions. Through various mechanisms sleep loss causes widespread deterioration of neuronal functions, memory and learning, gene expression, neurogenesis and numerous other changes which cause decline in cognition, behaviour and health. When these changes are long-standing, excessive cellular stress develops which may result in widespread neuronal loss. In this review, for the first time, recent research advances obtained from various fields of sleep medicine are integrated in order to show that untreated chronic sleep disorders may lead to impaired brain development, neuronal damage and permanent loss of developmental potentials. Further research is urgently needed because these findings have major implications for the treatment of sleep disorders.

Consensus guidelines into the management of epilepsy in adults with an intellectual disability

BACKGROUND

Epilepsy has a pervasive impact on the lives of people with intellectual disability and their carers. The delivery of high-quality care is impacted on by the complexity and diversity of epilepsy in this population. This article presents the results of a consensus clinical guideline process.

RESULTS

A Delphi process identified a list of priority areas for the development of evidence-based guidelines. All guidelines were graded and consensus on scoring was achieved across the guideline group.

CONCLUSION

There is a dearth of high-quality evidence from well-constructed studies on which to base guidance. However, the development of internationally derived consensus guidelines may further support the management of epilepsy in adults with an intellectual disability.