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A mother brings her 7 year old son with Down’s syndrome to clinic complaining of sleep difficulties. He won’t go to sleep alone, frequently wakes in the night, and will not be settled unless transferred to his parents’ bed. His parents are exhausted, and his mother believes his lack ofsleep is also disrupting his daytime behaviour. He has always been difficult to settle and seldom slept through the night without waking. The child is overweight, but not obese, and on enquiry his mother tells you that he does not usually snore, or suffer from nocturnal enuresis (bedwetting), which makes obstructive sleep apnoea an unlikely cause. His mother tells you, “I’m sure he’s just waking up out of stubbornness and not because anything’s wrong, but we’re all worn out. I don’t know what to do.” You wonder if a behavioural treatment programme might be able to help in this situation.
Structured clinical question
Can behavioural programmes [intervention] work to tackle sleep difficulties [outcome] for children with Down’s syndrome [patient] where there is no clear physical cause for the sleep problems?
Search strategy and outcome
Table 2 Behavioural treatments for sleep disorders in Down’s syndrome
Citation Study group Study type (level of evidence) Outcome Key results Comments
Ramchandani et al (2000) 9 controlled trials, 132 children randomised to drug treatments, 235 children randomised to psychological treatments. All children aged 5 years and under with a sleeping problem Systematic review, narrative synthesis (level 1a) Parent report (number of night awakenings, time to settle, number of nights disturbed) Effect sizes not reported. Drug trials showed short term benefits, but no effects were seen at two months follow up. Behavioural treatments produced both short and long term (6–12 weeks), but the loss of control groups at follow up was noted Conclusions are undermined by poor quality of trials Drug trials were assessed as of better quality than non-drug trials Mindell (1999) 39 studies, 1697 children aged 5 years and under with bedtime refusal or night waking problems Review, narrative synthesis (level 4) Parent report (sleep diaries, questionnaires) Effects sizes not reported. Interventions rated according to the number and quality of trials that showed effects. Extinction was considered "well established". Graduated extinction and scheduled awakenings "probably efficacious" No studies were excluded due to poor study methodology Lancioni et al (1999) 21 studies, 258 young people aged 4–23 years with a range of developmental disabilities with sleeping problems Review, narrative synthesis (level 4) Findings dichotomised into improvement or no improvement in sleep pattern 100% of those treated using bedtime fading with or without response cost improved Degree of sleep improvement not assessed. No assessment of study quality was used, nor were any studies excluded on the basis of their methodology 82% of those treated using bedtime routine plus gradual distancing of parents improved
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