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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
Using Cochrane library—“sleep*” and “child*” Cochrane reviews: 0 relevant; Cochrane Database of Reviews of Effectiveness: two relevant; using Medline, Psychinfo: “sleep*” AND “developmental disabilities” limit to child and review articles: one relevant. See table 2.
Three reviews of evidence on this topic were located. Only one of these reviews searched the grey literature or included non-English language publications.1 The other reviews provided insufficient information on search procedure to be certain that they were systematic.2,3 Reviews of prevalence suggest that occurrence of sleep disorders among children with developmental disabilities is high.4,5
The evidence available would suggest that behavioural interventions are successful for young children without developmental disabilities. Caution should be used when considering the potential impact of intervention on sleep problems owing to the heterogeneity of the presenting problems, the subjects used, the changes measured, and the programmes implemented. These problems may be exacerbated when using children or infants as subjects. The definition and treatment strategies for a sleep disorder in a 6 month old baby cannot be assumed to be equivalent to definition and treatment strategies in a 6 year old child. In particular, it may be inappropriate to assume that findings from samples of younger, non-disabled children are necessarily applicable in this instance.
The review of behavioural interventions for sleep difficulties with young adults and children with learning difficulties would suggest that behavioural interventions are also efficacious in this group. However, because of the shortage of studies in this area, single case studies and non-controlled studies were included in the review, and size of effect could not reliably be assessed. These factors are likely to overestimate intervention effects. Particular problems with conducting research within this area were highlighted by this review. Treatment “overlap” seemed to be common; for instance, in some studies melatonin was used in conjunction with behavioural interventions, making it difficult to attribute cause to the observed effects on sleep. (But see Archimedes from September 2002 for more on this—Ed.) Families prefer behavioural interventions in the first instance. However, the success of such interventions will also depend on the parents’ ability and motivation to implement them. Studies do not appear to have evaluated adherence to behavioural programmes, which may be problematic for interventions that advocate not responding to crying or disruptive behaviour.
▸CLINICAL BOTTOM LINE
Families prefer behavioural therapy to drug therapy or surgical interventions for sleep problems children.
Behavioural interventions improve children’s sleep patterns, but evidence is insufficient to predict impact.
Children with developmental delays or disabilities also appear to benefit from behavioural programmes.
There is little evidence to favour one behavioural intervention over another.3 Alternative strategies are:
Sleep scheduling/scheduled awakening. Altering sleep pattern by instituting fixed bedtime and waking time. Sleep outside of scheduled times is avoided, although fixed naps during the daytime may also scheduled.
Combination of bedtime routine and gradual distancing from parents. Establishing positive bedtime routines. Parental involvement is gradually reduced; for example, sleeping in the same bed is gradually reduced by the parent moving from bed to sitting next to the bed until the child is asleep, then replaced with doll.
Bedtime fading with or without response cost. The retraining of bedtime habits by beginning bedtime at a relatively late time when child will fall asleep quickly, then gradually bringing bedtime forward until desired bedtime is achieved. Response cost involves the child being taken out of bed for a certain period if he or she doesn’t fall asleep within a specified time.
Extinction. Bedtime fading and gradual withdrawal of parental involvement. The parents re-enter the room, encouraging the child to sleep at intervals of 3–5 minutes; these intervals are increasingly extended.
No evidence was found which would suggest a behavioural intervention would do harm. In comparison, treatment of sleep breathing disorders, in the absence of infection, involves physical intervention (invasive treatments with poor evidence for efficacy6,7) or drug treatments, which may cause side effects. Nonetheless, the impact on the child and family of extinctions strategies should be considered.
We would like to acknowledge the contributions of Professor Tricia Sloper, at York University, for drawing our attention to this important problem, and Dr Paul Ramchandani, Oxford, for his comments.
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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