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Special Education and Rehabilitation



Arnela PASALIC1,

1Center “Vladimir Nazor”, Sarajevo, Bosnia and Herzegovina
2University of Sarajevo, Sarajevo, Bosnia and Herzegovina
Received: 09-June-2021
Revised: 04-July-2021
Accepted: 10-July-2021
Online first: 11-July-2021

1. Introduction

Sleep is one the most basic human needs and is universally regarded as a foundation of good health, well-being and quality of life (Matricciani et al., 2019). However, many children have sleep problems. Studies have reported that approximately 25-40% of children aged 1 to 5 years have some form of sleeping problems (Galland & Mitchell, 2010). Most common sleep problems include bedtime resistance, delayed sleep onset, short sleep duration, and frequent nocturnal awakening. Short sleep duration is associated with a number of negative physical, socio-emotional and cognitive outcomes (Matricciani et al., 2013). In addition to this, poor sleep has also been implicated as a potential causal factor of aggression and violence (Kamphuis et al., 2012; Schlieber & Han, 2018). Children with a developmental disability such as an intellectual disability (ID) or an autism spectrum disorder (ASD) are at an even higher risk of having sleeping problems than typically developing children (Bourke-Taylor et al., 2013; Keenan et al., 2007; Souders et al., 2017). Estimates of sleeping problems prevalence among individuals with developmental disabilities vary from 13% to 86% (Didden & Sigafoos, 2001). Research on children and adolescents with ASD has shown that sleep problems, especially insomnia, range from 40% to 80% in this population (Cortesi et al., 2010). These authors stress the importance of improving sleep patterns in children with disabilities as it will probably lead to better daytime behaviour and better overall family functioning. The most common sleep problems in children with an ID are settling difficulties, night waking, long sleep latencies and early morning waking (Richdale et al., 2000). It has long been shown that the chronic sleep problems of children with a developmental disability affect the whole family and add additional stress for family functioning (Hoare et al., 1998). The reasons of poor sleep in children with a developmental disability are manifold. Some of these factors contributing to poor sleep are inherent to central nervous factors, gastroesophageal reflux, pain, and epileptic seizures (Dodge & Wilson, 2001). It is evident that sleep problems in people with a developmental disability have multifactorial etiology with various contributions of neurologic, medical, and psychiatric factors (Angriman et al., 2015).
The behavioural reasons for poor sleep and sleeping problems involve long screen time, especially in bed, lack of physical activity and excessive sugar-sweetened beverages consumption (Morrissey et al., 2019). Screen time involves time spent using a device with a screen such as smartphone, tablet, laptop, TV, etc. Many researchers have examined the negative effects of screen time on sleep (Ghekiere et al., 2019; Janssen et al., 2020) Some researchers have also found a link between endocrine activity and sleep patterns (Hatzinger et al., 2008). Several studies have compared sleep problems in typically developing children and children with developmental disabilities (Buckley et al., 2010; Polimeni et al., 2005). Results of these studies have shown that children with developmental disabilities have more sleep problems than typically developing children. However, there are few studies that examined and compared parental experiences regarding their children’s sleep patterns.

1.1 Aim of the study
The goal of the present paper is to examine sleep patterns in children with an ID, children with an ASD, and typically developing children. Additionally, we wanted to examine what strategies parents use to settle their children for sleep and whether there are differences in supplements/medications that children use for sleeping. More specifically, the research questions we set to answer in this study were:

1. Are there differences in the mean sleep duration in children with an ID, children with an ASD and typically developing children?
2. Are there differences in the number of times children wake in the night with IDs, children with an ASD and typically developing children?
3. Are there differences in screen time between children with an ID, children with an ASD and typically developing children?
4. What is the effect of screen time on sleep duration?
5. Are there differences in time spent outdoors between children with an ID, children with an ASD and typically developing children?
6. What is the effect of time spent outdoors on sleep duration?
7. What supplements or medications do children use for sleep?
8. What strategies do parents use to settle their children for sleep?

    2. Method

    2.1. Participants
    The sample for this study consisted of parents of 114 children. Of those, there were parents of 40 children with an ID (29 boys, 11 girls), parents of 34 children with an ASD (26 boys, 8 girls), and parents of 40 typically developing children (23 boys, 17 girls). The children’s ages were between 2 to 14 years (mean age 6.4 years, SD- 3.0 years). All children attended pre-school and elementary schools in Canton Sarajevo, Bosnia and Herzegovina.

    2.2. Procedure
    Parents of children with developmental disabilities and parents of typically developing children were recruited through an online survey sent to different non-governmental organisations and parental preschool and elementary school associations. The total number of completed surveys was 34 for children with an ASD, 40 for children with an ID, and 260 for typically developing children. We also had 11 surveys completed for children with other disabilities (sensory and motor impairments), but these were not included in the analysis due to the small number. To reduce unequal variance between samples and to reduce Type I error, we randomly (through random number generator in Microsoft Excel) chose 40 parents of typically developing children to be included in this study.

    2.3. Instruments
    We created a survey form consisting of demographic data and sleep patterns data. Demographic data included information on child’s age, gender, and diagnosis and parent’s educational level. Sleep patterns data included eight questions:

    1. On average, how long does your child sleep during the night?
    2. Does your child wake up during the night? (rarely, often, always)
    3. How much screen time does your child have during the day?
    4. How much time does your child spend outside (play, walking)?
    5. What supplements/medications does your child use to fall asleep?
    6. How do you settle your child for sleep?
    7. If your child wakes up during the night, how do you settle him back to sleep?
    8. Any additional comments?

    The first four questions were numerical (quantitative) and could be statistically analyzed. Questions 5-8 were narrative (qualitative) in nature, but in cases where a few categories were present (as in question number 5), we presented data quantitatively.

    2.4. Statistical Analysis
    Data were presented descriptively through frequencies, mean scores, and standard deviations. One-way analysis of variance (ANOVA) was used to measure differences in mean sleep duration among the groups followed by Tukey’s test for comparison of groups. A chi-square test was used to evaluate the relationship between the number of times a child wakes in the night and the children’s group status, screen time and group status and outdoor activity and group status. An alpha level of .05 was set for all statistical tests. The statistical analysis was performed with the computer program SPSS v.27 for Windows (IBM, 2020)

    3. Results

    Results have been discussed as per each research question.
    The first research question was to compare the mean sleep duration time in children with an ID, children with an ASD and typically developing children. These results are shown in Table 1.
    As can be seen from Table 1. there is a statistically significant difference in the mean sleep duration between the groups. According to the Tukey’s HSD test, statistically significant difference was between typically developing children and children with an ID.

    Table 1
    Mean sleep duration time in children with an ID, an ASD, and typically developing children

    Children with an ASD did not statistically significantly differ from children with an ID and from typically developing children.
    The second research question was how often the child wakes up during the night in relation to a child’s diagnosis. These results are presented in Table 2.

    Table 2
    Contingency table of children waking up during a night’s sleep

    It is evident from Table 2 that the distribution of answers differs in relation to a child’s diagnosis which is confirmed by the results of Chi square test (ꭓ2 = 22.8; p<.01). Again, children with an intellectual disability seem to wake up more frequently during a nights’ sleep compared to the other two groups.
    The third research question was to examine differences in screen time in relation to the child’s group. These results are presented in Table 3.
    According to the results of Chi-square test, there were no statistically significant differences in screen time in relation to the child’s diagnosis (ꭓ2 = 4.2; p<.65).
    The fourth research question was to examine the relationship between screen time and sleep duration.
    These results are presented in Figure 1.
    From the Figure 1, we can see there is no linear relationship between screen time and sleep duration, however it is evident that children who had the most screen time tend to have the shortest sleep duration. However, according to the results of Tukey HSD test the only significant difference in mean sleep duration was between the groups of a) over 3h and b) 2h to 3h.
    The fifth and sixth research questions were related to outdoor activities. We first examined were there any differences in the amount of time spent outdoors between the groups. These results are shown in Table 4.

    Table 3
    Contingency table of children’s screen time


    Figure 1. Sleep duration in relation to screen time

    Table 4
    Contingency table of time children spend outside the home/school

    The Chi square test revealed statistically significant differences in the time spent outside the home in relation to child’s diagnosis (ꭓ2 = 10.3; p<.03). According to these results, it seems that children with an ID spend considerably less time outside of home than their peers with an ASD and typically developing children.
    For the sixth research question we examined how outdoor activities affected sleep duration. These results are shown in Figure 2.

    Figure 2. Sleep duration in relation to outdoor activities

    According to the one-way ANOVA, there were no statistically significant differences in sleep duration in relation to the amount of outdoor activities (F=0.41;p=.67).
    The seventh research question was what supplements / medications children used for their sleeping problems. These results are presented in Table 5.

    Table 5
    Supplements/medications children use for sleep problems

    It is obvious from Table 5. that children with an ASD were more likely to use melatonin as a sleep aid, while children with an ID were more likely to use other medication for sleep problems.
    The last research question was how the parents settled their children for sleep and back to sleep. To these questions, parents provided various responses. The most common answer was bedtime story reading, followed by lying together in bed and cuddling the child to sleep, music, and some parents reported that children fall asleep independently.

    In relation to the answers and comments provided to these questions (question number 6 and question number 7) in the survey, there were no systematic differences in the answers parents provided in relation to their child’s diagnostic status. That means that parents of all children use the same or similar strategies to settle their children for sleep.

    For the last question, several parents provided additional comments such as: “it is very important to establish a routine for sleep”, “my child has frequent nocturnal fears”, “my child is sensitive to weather changes and then has an exceptionally hard time falling asleep”, “stress caused by COVID 19 makes things worse as children cannot enjoy their childhood”.

    4. Discussion

    The results of this study show that people are prone to risk-taking behaviours in traffic. It is important to point out that not only risky behaviours in traffic may lead to traumatic brain injury. For example, traumatic brain injury may occur at home, at school or work, at the playground, etc., and risky behaviour may or may not be involved. This study examined few risky behaviours in traffic that can lead to traumatic brain injury. The study focuses on risky behaviours in traffic due to frequent traffic accidents, especially amongst young people. Traffic accidents are one of the most common causes of traumatic brain injury and are very often caused by risky behaviours. As assumed, this study showed that the most common risky behaviour is not wearing a crash helmet while cycling. Almost all participants have noted that they do not wear a crash helmet. According to the Road Traffic Safety Act, a crash helmet must be worn only by cyclists under the age of 16, and failure to wear the helmet is penalized (Official Gazette of the Republic of Croatia, 108/2017). Helmets have been found to reduce the risk of the traumatic brain injury by 63% to 88% for all ages (Thompson et al., 1999). There is a significant relationship between wearing a helmet and reducing the mortality and the morbidity associated with the traumatic brain injury (Dodds et al., 2019). The risk of developing a severe traumatic brain injury is 18 times higher for people who do not wear a crash helmet on a motorcycle (Javouhey et al., 2006). Thus, promoting and encouraging the wearing of a crash helmet seems to be a good preventive measure. According to the results, the second most common risk-taking behaviour is running across the road on a red light. This behaviour is dangerous because it is unexpected for other people in traffic. A car may suddenly appear, and the driver will not slow down if he/she sees a green light. At that moment, an unexpected run by a pedestrian can lead to accidents with fatal consequences. Running across the road may also cause falls. Crossing the road on a red light is considered a traffic violation. Most participants have noted that they do not wear a seat belt when sitting in the back seat, but nearly an equal percentage of participants noted that they wear a seat belt in the front seat of a car. The following example will show why not wearing a seat belt in the back seat can be dangerous. If the driver and the passenger in the front seat wear a seat belt, and if there is a sudden braking or impact, the seat belts will hold them. However, if the passengers in the back seat of a car do not wear seat belts, the force can push them forward and they may hit against the front seat. In this case, the passengers in the back seat may sustain serious head injuries, while the passengers in the front seats may suffer serious spinal injuries. Previous research has shown that child car safety seats reduce the risk of fatalities in accidents by about 70% in infants and about 55% in children aged 1-4 years. For the children over 8 years of age, the seat belts reduce the risk of an injury by about 50% (Karlo et al., 2011). More participants have noted that they have ridden with a driver who was under the influence of alcohol than that they have driven under the influence of alcohol. Driving under the influence of alcohol often leads to traffic accidents. The risk of being involved in a crash increases significantly at 0.05 BAC and above. The relative risk of being killed in a single ‐ vehicle crash with BACs of 0.05–0.079 is 7–21 times higher than for drivers at 0.00 BAC. In numerous countries lowering the BAC limit from 0.08 to 0.05 has been a proven effective countermeasure (Fell and Voas, 2013). Alcohol abuse is associated with the higher speed and not wearing a seat belt, resulting in larger and more serious accidents (Cunningham et al., 2002). Alcohol affects cognitive abilities, therefore it is dangerous to drive any vehicle under the influence of alcohol. The results show that the least frequent risk-taking behaviour was driving under the influence of psychoactive substances. The statistically significant differences between male and female participants were confirmed on certain statements where men always exhibited a higher propensity for risky behaviour in traffic. It is more likely that men will not wear a seat belt in the front seat, that they will drive more often under the influence of alcohol and/or psychoactive substances, or ride with a person under the influence of alcohol and/or psychoactive substances. There is no statistically significant difference in performance between male and female participants in not wearing a helmet while riding a bicycle, a motorcycle or a scooter, not wearing a seat belt in the back seat, and running across the road on the red light. It is important to note that the answers obtained by the subjective method (questionnaire), regardless of the anonymity of the respondents, as such do not have to be completely accurate.

    4.1. Limitations
    There are several important limitations in this study worth mentioning. First, as with any survey, there is a risk that the data collected might be subjective and we did not have the means to verify the answers. Secondly, we did not take into consideration some factors that might be linked to sleep such as obesity level. Next, we do not know how valid the diagnoses of ID and ASD are as they were only reported by the parents in the survey. It is highly likely that the sleep quality is related to the severity of ID and ASD symptoms and we did not collect information on symptom severity. Also, another interesting topic that deserves more attention is the relationship between sleep patterns and behaviour in the child the following day. Lastly, we should have collected more precise data for some questions such as “Does the child wake up during the night?”. The potential answers are rarely, often and always. However, rarely for one parent can mean once a night, while for the another parent it can mean once a week. We should have collected continual data for several other items such as questions regarding outdoor activity and screen-time.

    5. Conclusion

    Children with an ID had less sleep duration and more night waking than children with an ASD and typically developing children. Children who have more than 3 hours of screen time have shorter sleep duration. The amount of outdoor activity was not statistically correlated with sleep duration. The most commonly used supplement to aid a child’s sleep was melatonin (in children with  an ASD) and the most commonly used medication to aid sleep was diazepam (children with an ID). Parents have many cognitive and behavioural strategies to help their children sleep better.


    We would like to thank all the parents for providing valuable information for this study.

    Conflict of interests

    Authors declare no conflict of interests.


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    How to cite this article:Saletovic, A., Pasalic, A., Memisevic, H. Sleeping Patterns in Children with Developmental Disabilities. Journal for ReAttach Therapy and Developmental Diversities.

    Copyright ©2021Saletovic, A., Pasalic, A., Memisevic, H. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0)


    Survey form “Sleeping patterns in Children with Developmental Disabilities”

    Dear parents,

    The purpose of this survey is to find out more about sleeping patterns of children with developmental disabilities. Please complete the form to the best of your knowledge.

    1. Child’s age_______
    2. Child’s diagnosis___________________________________
    3. On average, how long does your child sleeps during the night?_________________________
    4. Does your child wake up during the night? Rarely  Often   Always
    5. How much screen time does your child have during the day? ___________________________
    6. How much time does your child spend outside (play, walking)? _____________________
    7. What supplements/medications does your child use to fall asleep? ______________________
    8. How do you settle your child for sleep? ______________________________________
    9. If your child wakes up during the night, how do you settle him back to sleep? _______________________________________________________________________
    10. Any additional comments?


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