Behavioral Interventions for Sleep Disturbances in Children With Neurological and Neurodevelopmental Disorders: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Sleep. 2020 Mar 12;zsaa040. doi: 10.1093/sleep/zsaa040. Online ahead of print.

Abstract

Study objectives: Sleep disturbances are common and associated with negative functional and health consequences in children with neurological and neurodevelopmental disorders (NNDDs), and represent an important potential target for behavioral interventions. This systematic review examined the efficacy of behavioral sleep interventions (BSIs) for children with NNDDs and comorbid sleep disturbances.

Methods: A systematic search of MEDLINE, EMBASE, PsychINFO, and CENTRAL was conducted in April 2019. Randomized controlled trials (RCTs) of BSI for children with NNDDS were included. Meta-analysis and GRADE quality ratings were performed on sleep and secondary functional outcomes (cognition, academics, behavior).

Results: Nine RCTs were identified (n=690; Mage=8.39±2.64years; 71.11% male). Largely moderate level evidence for post-treatment improvements in sleep were found on (i) subjectively reported sleep disturbances (total sleep disturbance [SMD=0.89], night wakings [SMD=0.52], bedtime resistance [SMD=0.53], parasomnias [SMD=0.34], sleep anxiety [SMD=0.50]), subjectively reported sleep patterns (sleep duration [SMD=0.30], sleep onset duration [SMD=0.75]) and (ii) objectively measured actigraphic sleep patterns (total sleep time [MD=18.09 mins; SMD=0.32], sleep onset latency [MD=11.96 mins; SMD=0.41]). Improvements in sleep (subjective, not actigraphy) were maintained at follow-up, but few studies conducted follow-up assessments resulting in low quality evidence. Reduction in total behavioral problems (SMD=0.48) post-treatment, and attention/hyperactivity (SMD=0.28) at follow-up were found. Changes in cognition and academic skills were not examined in any studies.

Conclusions: BSIs improve sleep, at least in the short-term, in children with NNDDs. Benefits may extend to functional improvements in behavior. More rigorous RCTs involving placebo-controls, blinded outcome assessment, longer follow-up durations, and assessment of functional outcomes are required.

Keywords: Behavioral treatment; insomnia; meta-analysis; pediatric; sleep disturbance.