DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY LETTER TO THE EDITOR
Sleep difficulties after paediatric traumatic brain injury
Ruth E Sumpter1, Liam Dorris2, Thomas Kelly3, Thomas MMcMillan4
1 Royal Hospital for Sick Children, NHS Lothian – Paediatric Psychology andLiaison Service, Edinburgh; 2 Royal Hospital for Sick Children, NHS GreaterGlasgow and Clyde – Fraser of Allander Neurosciences Unit, Glasgow;3 Newcastle General Hospital, Newcastle & Tyne NHS Trust – Department ofPsychology, Newcastle; 4 University of Glasgow – Institute of Health andWellbeing, Glasgow, UK.
Correspondence to: [email protected]
doi: 10.1111/dmcn.12291
SIR–We read with interest the review by Stores andStores,1 outlining concerns about sleep problems after pae-diatric traumatic brain injury (TBI) and the lack of clinicaland research attention this topic has received. We stronglyagree that the literature from adult TBI research and preli-minary studies in paediatric TBI populations indicates theimportance of increasing the evidence base in this area.
The paediatric research literature is indeed limited, andStores and Stores review a number of papers, mostly inmild TBI samples via parent-proxy report of sleep prob-lems. Only two studies in Stores and Stores’ review exam-ined sleep after mild TBI using objective measurementtools (actigraphy or polysomnography). Kaufman et al.2
found poorer sleep efficiency and more night-wake-timeon polysomnography and 5-night actigraphy in mild paedi-atric TBI compared with healthy controls. However, thedesign of this study meant that the sleep difficulties identi-fied in the index group could not be attributed to braininjury.
Milroy et al.3 compared mild TBI with orthopaedicinjury controls on standardized sleep report (self andproxy) measures and with 5-night actigraphy. Contrary toStores and Stores’ summary of the study, no differenceswere found on actigraphy parameters for sleep efficiency,total-wake-time for measures of night-to-night variabilityor in the proportion defined with sleep problems by par-ent-report. Taken together with group comparison studiesof post-concussional symptoms, the current evidence sug-gests that sleep difficulties do not occur more often follow-ing mild paediatric TBI when compared with injurycontrols; but that mild TBI and injury control groups mayboth have elevated rates of sleep problems. At present,there is no evidence to support a view that sleep difficultiesare specifically associated with mild TBI.
More severe TBI can be associated with greater sleepdisruption, but evidence here is extremely limited. Parent-report studies, as reviewed by Stores and Stores, indicateincreased parent-report of sleep difficulties after moderate–severe TBI. Recently, Sumpter et al.4 found that moder-ate–severe paediatric TBI was associated with significantlymore parent and self-report of sleep problems and actigra-phy-measured sleep inefficiency in the form of sleep onsetand maintenance problems in comparison with siblings(a control for psychosocial, family, and demographic factors).Future research adopting objective measures of sleep qual-ity and quantity after moderate–severe TBI is warranted tobetter understand relationships between emotional, cogni-tive, and behavioural symptoms and sleep problems) in agroup already at risk of poor psychosocial adjustment.
REFERENCES
1. Stores G, Stores R. Sleep disorders in children with
traumatic brain injury: a case of serious neglect. Dev
Med Child Neurol 2013; 55: 797–805.
2. Kaufman Y, Tzischinsky O, Epstein R, Etzioni A, La-
vie P, Pillar G. Long-term sleep disturbances in ado-
lescents after minor head injury. Pediatr Neurol 2001;
24: 129–34.
3. Milroy G, Dorris L, McMillan TM. Sleep disturbances
following mild traumatic brain injury. J Pediatr Psychol
2008; 33: 242–7.
4. Sumpter RE, Dorris L, Kelly T, McMillan TM. Pediat-
ric sleep difficulties after moderate–severe traumatic
brain injury. J Int Neuropsychol Soc 2013; 19: 829–34.
Stores and Stores reply
Gregory Stores1, Rachel Stores2
1 Department of Psychiatry, University of Oxford, Oxford; 2 University ofBirmingham Medical School, Birmingham, UK.
Correspondence to: [email protected]
doi: 10.1111/dmcn.12286
SIR–We are grateful for the comments by Sumpter et al.on our review of sleep disorders in children with traumaticbrain injury (TBI)1 and are pleased that they agree that thesubject deserves more clinical and research attention thanit has received so far. We also thank them for drawing our
194 © 2013 Mac Keith Press
attention to their recent article,2 published after our ownwas written.
With the limited information currently available we feelit would be appropriate to suspend judgment on the issueof mild TBI possibly being associated with sleep problems.As we said in our review, ‘The counter-intuitive recurrenttheme that mild TBI particularly seems to predispose tosleep disturbance is one of the many current impondera-bles in this area of enquiry.’ Apropos the report by Kaufmanet al.3 (and the subsequent report by Pillar et al.4), we can-not help but re-emphasize the need for more methodologi-cally discerning studies of TBI and sleep disturbance.
We quoted the findings by Milroy et al.5 because theyincluded parents’ reports that their children’s sleep wasdisturbed, although their complaints were not matched byobjective findings. This raises the long-standing issue ofinconsistent relationships between (mainly parental) subjec-tive reports and objective measures of sleep disturbance.
Clearly, in everyday clinical practice when objectiveassessments may well not be feasible for whatever reason,parental reports are usually the only information availableand deserve to be taken at face value and acted upon ratherthan dismissed. They can have their own validity, includingas an indicator of families who are in need of support.6
When objective comparisons are available and do not tallywith parents’ complaints, it is possible that traditionalobjective measures might be relatively insensitive to moresubtle aspects of sleep physiology such as cyclic alternatingpattern rates which, if abnormal, might explain somesubjective sleep complaints.7
At present, the information on TBI and sleep distur-bance is essentially provisional and best viewed as raisingimportant clinical possibilities (rather than providing defin-itive accounts) for revision in the light of further findingsfrom appropriate research.
REFERENCES
1. Stores G, Stores R. Sleep disorders in children with
traumatic brain injury: a case of serious neglect. Dev
Med Child Neurol 2013; 55: 797–805.
2. Sumpter RE, Dorris L, Kelly T, McMillan TM. Pediat-
ric sleep difficulties after moderate–severe traumatic
brain injury. J Int Neuropsychol Soc 2013; 19: 829–34.
3. Kaufman Y, Tzischinsky O, Epstein R, Etzioni A, Lavie
P, Pillar G. Long-term sleep disturbances in adolescents
after minor head injury. Pediatr Neurol 2001; 24: 129–
34.
4. Pillar G, Averbooch E, Katz N, Peled N, Kaufman Y,
Shahar E. Prevalence and risk of sleep disturbances in
adolescents after minor head injury. Pediatr Neurol 2003;
29: 131–5.
5. Milroy G, Dorris L, McMillan TM. Sleep disturbances
following mild traumatic brain injury. J Pediatr Psychol
2008; 33: 242–7.
6. Wiggs L. Are children getting enough sleep? Implica-
tions for parents. Sociol Res Online 2007; 12: 13.
7. Parrino L, Ferri R, Bruni O, Terzano MG. Cycling
alternating pattern (CAP): the marker of sleep instabil-
ity. Sleep Med Rev 2012; 16: 27–45.
Book Review: Life Quality Outcomes in Children andYoung People with Neurological and DevelopmentalConditions: Concepts, Evidence, and PracticeClinics in Developmental MedicineEdited by Gabriel M Ronen, Peter L RosenbaumLondon: Mac Keith Press, 2013£95.00 (Hardback), pp 391.ISBN: 978-1-908316-58-5
This book brings together recent developments in thinkingabout the lives of children and young people with neurode-velopmental conditions.
The editors’ introductory chapter is instructive and setsout well the objectives for the book. The book has threemain sections: Concepts and Perspectives, Methods andMeasurement, and Opportunities for Intervention, eachsplit into a number of chapters. The authors are largelyfrom Ontario or have worked with Ontario groups. Muchis about development of Canadian Policy, but no lessrelevant for that. The twenty-seven chapters have differentauthors and the style and quality is maintained in eachchapter. However, it is inevitable in a multi-author book
that there is not always a natural flow – each author writesabout what they know best.
Researchers need to take a theoretical position, defineconcepts, and follow through their research plan if theireffort is to be worthwhile. However, those necessary con-straints may restrict understanding; therefore a researchermust at times stand back, reflect on other approaches andlisten to other ideas. Lucyna Lach’s chapter (‘The FamilyDoes Matter!’) was useful for this reason. She argues thatfamilies are complex, data only capture certain things, epi-demiology rarely provides definitive answers, and statisticsmay mislead. Understanding of child disability and meth-odologies has improved over the last 15 years; but remainsonly partial understanding. I expect that even the conceptof Participation, which has been so helpful over the lastdecade, will need to be revisited when we are ready for asuccessor to the International Classification of Functioning,Disability and Health.
There is a tension in the book which is identified byVeronica Smith and Kim Schonert-Reichl in their chapter,‘Contextural Facilitators: Resilience, Sense of Coherence,and Hope’. On the one hand, the book adopts a strength-
Book Review 195
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