PART V: EP MAGAZINE SLEEP SERIES

THE ROLE SLEEP PLAYS IN PEOPLE WITH DISABILITIES AND THEIR FAMILIES

BY DR. EMILY SINGER

This article focuses on the important role sleep plays in people with disabilities and their families. As anyone that has had a bad night of sleep can relate, the consequences of poor sleep are often felt immediately the next day. Particularly, in families with a child with a disability, quality sleep can be elusive.

Children with developmental disabilities are more likely to have sleep problems compared to their typically developing peers.1 Many neurodevelopmental disorders are associated with certain pediatric sleep problems. Children with Down syndrome commonly have obstructive sleep apnea and screening for this disorder is important for their health.2 Children with autism spectrum disorder can have a wide variety of sleep problems, including problems falling asleep and staying asleep. Studies have shown that children with attention-deficit/hyperactivity disorder can have worsening of those symptoms around bedtime, which leads to increased bedtime resistance and trouble falling asleep.3 These sleep problems can have daytime consequences such as inattention, behavioral dysregulation and school difficulties.4 Frequently, these children have pre-existing difficulties with behavior or social interaction and a poor night's sleep exacerbates these issues.5 Thus, you can see the importance of screening children with disabilities for sleep problems. 

The effects of poor sleep can ripple out to the entire family. We know that sleep can have a large impact on an individual or families' overall sense of wellness.6,7 As discussed in an earlier article in this series, sleep is a restorative process that allows us to consolidate memory, regulate emotions and be alert during the day. Importantly, when we have disrupted or inadequate sleep there are effects on how we are able to process events and store memories. Studies have shown that poor sleep leads to more negative associations of memories. Furthermore, poor sleep can lead to emotional dysregulation, lowering our threshold to tolerate stressors.8 We can all recall a time when we became irrationally upset about a minor stressor in the face of sleep deprivation! This exemplifies how sleep problems can be a predictor of our daily mood, but even more importantly, chronic inability to sleep can lead to future depression.9 This finding underlies the importance of establishing better sleep to promote mental health.

Our sleep inevitably changes as we age. From the tendency to L wake up and go to sleep earlier to the amount of time spent in different sleep cycles, the differences abound when comparing children to older individuals.10 By studying people over age 85, researchers have made connections between regular, quality sleep and longevity.11 On the other hand, poor sleep habits can impact our physical health in myriad ways. Sleep problems have been linked to chronic medical problems like heart disease and diabetes, just to name a few.12 

So, in our busy, modern society, what can we do to mitigate these risks? Promoting healthy sleep throughout the entire family should be of utmost importance. Families should be encouraged to discuss their children's sleep issues with their health provider. Studies have shown that targeting poor sleep can lead to better daytime behaviors. For example, parents of children with autism reported improvements in hyperactivity and restricted behaviors after implementing strategies learned from sleep education workshops.13 Family-focused interventions can be most helpful when addressing pediatric sleep problems. This is especially true with younger children and children with developmental delay. Often, a family's attitudes and beliefs towards sleep need to be evaluated before changes to behavior can be undertaken.14 Parental education to common pediatric sleep problems can empower families to implement the changes necessary to find solutions. ✦ 

1. Reynolds et al., "Sleep Problems in 2- to 5-Year-Olds With Autism Spectrum Disorder and Other Developmental Delays." 2. Horne et al., "Sleep and Sleep Disordered Breathing in Children with down Syndrome." 3. Owens, "A Clinical Overview of Sleep and Attention-Deficit/Hyperactivity Disorder in Children and Adolescents." 4. Malow et al., "Characterizing Sleep in Children with Autism Spectrum Disorders." 5. Mazurek and Sohl, "Sleep and Behavioral Problems in Children with Autism Spectrum Disorder." 6. Varma et al., "Examining Sleep and Mood in Parents of Children with Sleep Disturbances." 7. Estrela et al., "Chronic Parenting Stress and Mood Reactivity." 8. Worley, "The Extraordinary Importance of Sleep."

9 Baglioni et al., "Insomnia as a Predictor of Depression"; Varma et al., "Examining Sleep and Mood in Parents of Children with Sleep Disturbances." 10. Edwards et al., "Aging and Sleep." 11. Mazzotti et al., "Human Longevity Is Associated with Regular Sleep Patterns, Maintenance of Slow Wave Sleep, and Favorable Lipid Profile." 12. Buysse, "Sleep Health." 13. Reed et al., "Parent-Based Sleep Education Workshops in Autism." 14. Tikotzky and Sadeh, "The Role of Cognitive–Behavioral Therapy in Behavioral Childhood Insomnia."

Bedtime resistance, a child's attempt at stalling the inevitable bedtime (one more book, another hug, a sip of water!) can be ameliorated by parents setting clear limits. A concrete way to do so is with a bedtime pass. Providing a child with a pass to get out of bed for one or two last "curtain calls" before being told that they are out of passes and must go to bed. Emphasis should be placed on the rewards that could be earned if a child keeps their pass for the night by staying in bed. Sleep-onset association is another common problem that children face when trying to fall asleep. Sleep-onset association occurs when children become dependent on the presence of a parent to fall asleep. Gradually promoting independent settling and ability to fall asleep can help children wake less frequently at night.15

When thinking about sleep problems, considering the developmental age of the child is important. In contrast to younger children, adolescents may need more active participation in their own sleep education. A study of adolescents with autism showed that an individualized sleep plan based on both the adolescent and parents' identified problems improved sleep and daytime behaviors like impulsivity and anxiety. The adolescents were engaged to complete sleep diaries and track rewards and roles for the adolescent and their parent were clearly defined.16

As you can see, there are many different ways to improve sleep for children of different developmental stages. We suggest families start with one or two interventions and expand from there. Making sleep a priority can provide lasting benefits for mood, health, and longevity! •

ABOUT THE AUTHOR: Dr. Emily Singer has research and clinic interests in pediatric neurology and sleep medicine, especially in children with neurodevelopmental disorders and epilepsy. 

15. Anders, Halpern, and Hua, "Sleeping Through the Night."

16. Loring et al., "Impact of a Brief Behavioral Intervention for Insomnia on Daytime Behaviors in Adolescents with Autism Spectrum Disorders.

References:

Anders, T. F., Halpern, L. F., & Hua, J. (1992). Sleeping Through the Night: A Developmental Perspective. Pediatrics, 90(4), 554–560. Baglioni, C., Battagliese, G., Feige, B., Spiegelhalder, K., Nissen, C., Voderholzer, U., Lombardo, C., & Riemann, D. (2011). Insomnia as a predictor of depression: A meta-analytic evaluation of longitudinal epidemiological studies. Journal of Affective Disorders, 135(1–3), 10–19. doi.org/10.1016/j.jad.2011.01.011 Buysse, D. J. (2014). Sleep Health: Can We Define It? Does It Matter? Sleep, 37(1), 9–17. doi.org/10.5665/sleep.3298 Edwards, B. A., O'Driscoll, D. M., Ali, A., Jordan, A. S., Trinder, J., & Malhotra, A. (2010). Aging and sleep: Physiology and pathophysiology. Seminars in Respiratory and Critical Care Medicine, 31(5), 618– 633. doi.org/10.1055/s-0030-1265902 Estrela, C. da, Barker, E. T., Lantagne, S., & Gouin, J.-P. (2018). Chronic parenting stress and mood reactivity: The role of sleep quality. Stress and Health, 34(2), 296–305. doi.org/10.1002/smi.2790 Horne, R. SC., Wijayaratne, P., Nixon, G. M., & Walter, L. M. (2019). Sleep and sleep disordered breathing in children with down syndrome: Effects on behaviour, neurocognition and the cardiovascular system. Sleep Medicine Reviews, 44, 1–11. doi.org/10.1016/j.smrv.2018.11.002 Loring, W. A., L. Johnston, R., Shui, A. M., & Malow, B. A. (2018). Impact of a Brief Behavioral Intervention for Insomnia on Daytime Behaviors in Adolescents with Autism Spectrum Disorders. Journal of Contemporary Psychotherapy, 48(3), 165–177. doi.org/10.1007/s10879-018-9381-3 Malow, B. A., Marzec, M. L., McGrew, S. G., Wang, L., Henderson, L. M., & Stone, W. L. (2006). Characterizing Sleep in Children with Autism Spectrum Disorders: A Multidimensional Approach. Sleep, 29(12), 1563–1571. doi.org/10.1093/sleep/29.12.1563

Mazurek, M. O., & Sohl, K. (2016). Sleep and Behavioral Problems in Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 46(6), 1906–1915. doi.org/10.1007/s10803-016-2723-7 Mazzotti, D. R., Guindalini, C., Moraes, W. A. dos S., Andersen, M. L., Cendoroglo, M. S., Ramos, L. R., & Tufik, S. (2014). Human longevity is associated with regular sleep patterns, maintenance of slow wave sleep, and favorable lipid profile. Frontiers in Aging Neuroscience, 6, 134. doi.org/10.3389/fnagi.2014.00134 Owens, J. A. (2009). A Clinical Overview of Sleep and Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 18(2), 92–102. Reed, H. E., McGrew, S. G., Artibee, K., Surdkya, K., Goldman, S. E., Frank, K., Wang, L., & Malow, B. A. (2009). Parent-Based Sleep Education Workshops in Autism. Journal of Child Neurology, 24(8), 936–945. doi.org/10.1177/0883073808331348 Reynolds, A. M., Soke, G. N., Sabourin, K. R., Hepburn, S., Katz, T., Wiggins, L. D., Schieve, L. A., & Levy, S. E. (2019). Sleep Problems in 2- to 5-Year-Olds With Autism Spectrum Disorder and Other Developmental Delays. Pediatrics, 143(3). doi.org/10.1542/peds.2018-0492 Tikotzky, L., & Sadeh, A. (2010). The role of cognitive–behavioral therapy in behavioral childhood insomnia. Sleep Medicine, 11(7), 686–691. doi.org/10.1016/j.sleep.2009.11.017 Varma, P., Conduit, R., Junge, M., & Jackson, M. L. (2020). Examining Sleep and Mood in Parents of Children with Sleep Disturbances. Nature and Science of Sleep, 12, 865–874. doi.org/10.2147/NSS.S271140 Worley, S. L. (2018). The Extraordinary Importance of Sleep. Pharmacy and Therapeutics, 43(12), 758–763.