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  • Updated 02.21.2023
  • Released 06.06.1994
  • Expires For CME 02.21.2026

Sleep and intellectual disability



Individuals with intellectual disability, including children with neurodevelopmental disorders, are commonly affected by sleep disturbances. These sleep issues may manifest as typical sleep-related symptoms of insomnia or daytime sleepiness or as the appearance or exacerbation of disruptive daytime behaviors. The diagnosis and management of these sleep disorders, including sleep-disordered breathing, insomnia, hypersomnia, and circadian disorders, is part of the multidisciplinary approach to treatment. This article illustrates various sleep disorders associated with intellectual disability, including their etiology, diagnosis, and management.

Key points

• Sleep issues are more common in patients with neurodevelopmental disorders than in the normal pediatric population.

• Patients with intellectual disorders and sleep issues may present with common sleep-related symptoms, impaired learning, or the development or exacerbation of disruptive daytime behaviors.

• Diagnosis of sleep issues requires careful history and judicious use of tools directed to identify the underlying sleep disorder.

• Some sleep disorders may be a direct result of the underlying neurologic process.

• Strategies for the management of sleep disorders in various syndromes associated with intellectual impairment vary depending on the etiology and manifestations.

• Hypnotics and sedating medications have little use in the treatment of sleep disorders in the intellectually impaired. However, melatonin is advantageous when there are disturbances of the sleep-wake cycle.

• Behavioral techniques for insomnia should be applied before medication in those with intellectual impairment.

• Obstructive sleep apnea may improve with continuous positive airway pressure. However, procedures such as adenotonsillectomy are commonly indicated in children with intellectual impairment.

Historical note and terminology

Individuals with intellectual impairment have long been known to have frequent sleep issues (114). Bartlett described frequent sleep issues in a cohort of children with neurodevelopmental issues (12). These individuals commonly have sleep disturbances, including insomnia, hypersomnia, parasomnia, and sleep-disordered breathing (10). Intellectual disability was previously referred to as mental retardation and defined as “a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. This disability originates before age 18” (American Association on Intellectual and Developmental Disabilities 2009). Criteria for the diagnosis of intellectual disability are described in The Diagnostic and Statistical Manual of Mental Disorders, TR, fifth edition (06).

Although sleep problems are recognized in children with intellectual disabilities, newer discoveries of sleep issues have uncovered more specific issues in each disorder. Various sleep disturbances are reported in disorders associated with intellectual disability and will be briefly described in the following conditions:

• Angelman syndrome

• Attention deficit and hyperactivity disorder

• Autism spectrum disorders

• Cerebral palsy

• Down syndrome

• Kleefstra syndrome

• MBD5 haploinsufficiency syndrome

• Mowat-Wilson syndrome

• Prader-Willi syndrome

• Rett syndrome

• Smith-Magenis syndrome

A study focusing on determinants of sleep problems in children with intellectual disability found that comorbidities, such as recurrent pain, frequent seizures, and prescription of sleep medications, rather than functional abilities, were associated with poorer sleep, raising the possible benefit of improving sleep as part of the management strategy (44). Epileptic encephalopathies, which include epilepsy with continuous spike-wave during slow sleep, eg, Landau-Kleffner syndrome, are beyond the scope of this article, but are described elsewhere in MedLink Neurology.

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