Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders

Objective. The purpose of this study was: 1) to examine both bedtime sleep behaviors and daytime behaviors associated with daytime sleepiness in a group of children with a primary medical sleep disorder (obstructive sleep apnea syndrome [OSAS]) compared with a group of children with a primary behavioral sleep disorder (BSD) (limit setting sleep disorder or sleep onset association disorder); and 2) to investigate the impact of a comorbid BSD on sleep and daytime behavioral consequences of OSAS. Methods. Children referred to a pediatric sleep disorders clinic during a 3-year period with a primary diagnosis of either polysomnographically-confirmed OSAS (n = 100) or a BSD (n = 52) were compared on several parent report measures assessing the following domains: symptoms of sleep disordered breathing, other sleep behaviors (primarily parasomnias), bedtime behaviors, and externalizing daytime behavior problems. The OSAS sample was then divided into a pure OSAS group (n = 78) and an OSAS plus a behavioral sleep diagnosis group (n = 22) based on the presence or absence of delayed sleep onset and/or prolonged nightwakings and compared on the parent-report symptom domains. Results. Almost one-quarter of the OSAS group had clinically significant behavioral sleep problems, primarily bedtime resistance, in addition to OSAS. Bedtime resistance was associated with a significantly shortened sleep duration in both the BSD and OSAS-BSD groups. Although the OSAS-BSD group had less severe disease, as defined by polysomnographic variables, than the pure OSAS group, they were rated by their parents as having more daytime externalizing behavior problems associated with daytime sleepiness. Conclusions. The results of this study suggest that evaluation for comorbid BSD should be done in all children presenting with symptoms of OSAS. The coexistence of such BSDs may contribute significantly to sleep deprivation, and thus to behavioral manifestations of daytime sleepiness in these children.