The Learning Implications for Children and Adolescents with Hypersomnolence

Abstract

The quantity and quality of sleep can impact behaviour, memory, cognition, executive function, attention, mood, and overall quality of life. Sleep disorders in children and adolescents range from behavioural insomnias, sleep breathing disorders, and sleep-wake transition disorders, through to disorders of excessive somnolence. Excessive daytime sleepiness (EDS) or hypersomnolence is one of the main symptoms reported in each of these disorders.Measuring sleepiness in children and adolescents has challenges. Subjective measures of sleepiness such as the Pediatric Daytime Sleepiness Scale (PDSS) are often used in a clinical setting. One concern with subjective measures of sleepiness is that children may manifest their sleepiness differently to adults who demonstrate overt somnolence. Children who are sleepy often deal with their sleepy state through hyperactive behaviours, inattention, and problematic behaviour. An additional concern with subjective measures of sleepiness is the vocabulary used in the questions: much of the sleep-associated vocabulary is not in common use by children and adolescents. This could influence the accuracy of responses by children and adolescents completing these measures.Identifying the prevalence of EDS in the general population is challenging due to the variety of sleepiness surveys used, the variability of questions within those surveys, the subjectiveness of responses, and the cultural setting. Project One of this research program focused on exploring the learning implications for children and adolescents with a central disorder of hypersomnolence. These participants had either gained a diagnosis of narcolepsy type 1 or idiopathic hypersomnia or were awaiting diagnosis. Ten participants, ranging in age from 4 years 8 months through to 18 years 6 months, were administered a range of standardised assessments to identify their neuropsychological, neurobehavioural and emotional functioning. Six of those participants were assessed over two time periods, initially without their wakefulness-promoting medication and when their medication had been resumed for more than one year. Despite the low participant numbers for Project One, it appears the EDS associated with narcolepsy and idiopathic hypersomnia impacts aspects of executive functioning, behaviour and mental health, particularly depression.Project Two was a community-based study with students in a large regional primary school, that used a cross-sectional design aiming to identify the prevalence’s of EDS amongst a population of children (4–12 years) from three perspectives: parent report, self-report, and teacher report. This study utilised a naturalistic approach; that is, identification of EDS in the context of a school day. The study also aimed to explore the association between perceived EDS using a standardised measure, the PDSS and formal academic outcomes in children.With a response from 365 students in Project Two, the prevalence’s of EDS identified by parents (12.5%), the children themselves (24%), and their teachers (8%), were quite different amongst the three respondent groups. Although parent and child PDSS scores were strongly correlated, the teacher scores did not correlate with either the parents’ or the child’s scores. When the associations between PDSS scores and academic outcomes were explored, a significant association was found between the teacher’s PDSS scores and the children’s outcomes. It was found that EDS, as identified using the PDSS, explained 10.6% of the variance associated with academic outcomes. This has implications for educating parents and teachers on the importance of sleep and the impact of daytime sleepiness.Two smaller projects embedded within Project Two explored how well children understand the vocabulary of sleep and the reasons children delay sleep-time. Exploring children’s understanding of sleep-associated vocabulary developed into a research article that has been published The second smaller study, exploring reasons children delay sleep-time, yielded detailed information not previously found in similar studies. The final study associated with Project Two focused on exploring the learning implications for the sleepiest children identified in the school community. With only six children participating in that study, the findings cannot be generalised; however, similar trends to those of the narcolepsy and idiopathic hypersomnolence group were identified. It appears EDS may impact behaviour and mental health in children with EDS of unknown origin.Previous research has focussed on the impact of hypersomnolence through specifically diagnosed disorders such as primary sleep apnoea or narcolepsy. This research project attempted to broaden the investigation into the impact of hypersomnolence through expanding the diagnostic categories to include participants with a diagnosis of Idiopathic Hypersomnia and children with no diagnosis but an identification of EDS using a standardised measure. Both Project One and Project Two identified a number of possible learning implications of hypersomnolence, particularly in areas associated with executive functioning, behaviour, and mental health. Project Two further identified a strong impact of EDS on academic outcomes. Further research using standardised assessment instruments and with larger groups may more clearly identify the specific impacts of EDS associated with central disorders of hypersomnolence and of EDS of unknown origin.