Sleep Characteristics of Youth With Functional Abdominal Pain and a Healthy Comparison Group

Edward D. Huntley, MA; John V. Campo, MD; Ronald E. Dahl, MD; Daniel S. Lewin, PhD

Disclosures

J Pediatr Psychol. 2007;32(8):938-949. 

In This Article

Abstract and Introduction

Abstract

Objective To describe sleep problems among youth with and without functional abdominal pain (FAP).
Methods Participants were 8-15 years of age diagnosed with FAP (n = 67) or healthy pain-free comparisons (n = 80). Parents and participants completed instruments assessing sleep, psychiatric status, and FAP symptoms. Parent and child reports of sleep problems were compared across groups and the association of FAP to behavioral sleep problems was assessed controlling for psychopathology.
Results Children with FAP were reported to have more symptoms of behavioral sleep disorders (BSD), as well as increased nightmares and daytime tiredness than the comparison group. There were no group differences in total sleep time. Logistic regression analysis indicated that FAP was associated with a significantly increased risk of BSD symptoms [Odds ratio (OR): 4.17] after controlling for psychopathology.
Conclusion Sleep problems in youth with FAP warrant clinical attention and future research should continue to explore sleep problems that co-occur with and independent of psychopathology.

Introduction

Sleep plays an important role in optimal physical and mental functioning. During the past decade there has been increasing awareness and interest in the role of adequate sleep and the impact of sleep disorders on health and behavior (Colten, Altevogt, & Institute of Medicine (U.S.). Committee on Sleep Medicine and Research, 2006). The roles of sleep-specific changes in neurohomones and endocrine factors have been implicated in the control of pain (Andersen et al., 2006; Moldofsky, 2001, 2002), metabolism (Spiegel et al., 2004; Spiegel, Leproult, & Van Cauter, 1999), and immune function (Kapsimalis, Richardson, Opp, & Kryger, 2005; Opp, 2006). Changes in cognition, attention, and affect regulation arising from sleep disorders or inadequate sleep, are less well understood, but may also play a significant role in individuals— ability to cope with pain associated with specific medical disorders. This study is a preliminary descriptive investigation of the sleep habits and prevalence of sleep disorder symptoms in children and adolescents diagnosed with functional abdominal pain (FAP).

FAP is a common disorder with symptoms that often persist into adulthood (Walker, Guite, Duke, Barnard, & Greene, 1998), and is associated with considerable functional impairment and increased utilization of healthcare services (Campo, Comer, Jansen-Mcwilliams, Gardner, & Kelleher, 2002; Zeltzer, Bush, Chen, & Riveral, 1997a, 1997b). It is estimated that the prevalence of FAP is between 9 and 25% in children and adolescents, with prevalence increasing with age into adolescence, particularly in females (Scharff, 1997). FAP is defined as at least three episodes of abdominal pain having no identified medical cause that occurs within a three-month period and is associated with use of healthcare services and/or disruptions in usual activities (e.g., school attendance) (Apley, 1967). Pain in patients with FAP is most commonly episodic, located in the periumbilical region, and described as sore, colicky, and/or sharp (Abu-Arafeh & Russell, 1995).

Sleep Disturbance in FAP. There are ~88 sleep disorders defined in the International Classification of Sleep Disorders, Diagnostic and Coding Manual (AASM, 2005). Common complaints arising from sleep disorders include objective and subjective reports of difficulty initiating and maintaining sleep, poor sleep quality, and various signs of daytime somnolence including difficulty waking in the morning and unplanned or increased need to sleep during the day. While research diagnostic criteria have been developed for most adult sleep disorders (Buysse, 2005; Buysse, Ancoli-Israel, Edinger, Lichstein, & Morin, 2006), comparable, reliable criteria have yet to be developed in children. This is the case the for behavioral sleep disorders (BSDs) of childhood, which may be particularity common among children with medical and psychiatric disorders. BSDs generally involve the child having difficulty initiating and maintaining sleep and place a significant burden on the parents who are required to spend significant time with the child at the beginning or in the middle of the night.

To date there have been few studies of sleep disturbance in pediatric patients with FAP (Haim et al., 2004), although there have been reports of subjective complaints of insufficient sleep, poor sleep quality, and daytime fatigue in affected individuals (Garber, Zeman, & Walker, 1990; Heitkemper, Charman, Shaver, Lentz, & Jarrett, 1998; Hyman & Fleisher, 1997). Haim and colleagues (2004) reported abdominal pain prior to sleep onset was a unanimous complaint among study participants with FAP and that 29% of these participants reported that abdominal pain had aroused them from sleep. FAP is suspected to be a precursor of irritable bowel syndrome (IBS) in adults (Walker, 1999T). IBS is characterized by FAP associated with bowel complaints such as changes in stool frequency or consistency, as well as relief with defecation (Hyams et al., 1995). The adult IBS literature suggests that associated complaints of subjective sleep problems are common. In the first of two studies of sleep in adults with IBS, participants experienced increased late night gastrointestinal disturbance and there was an objective decrease in the percentages of rapid-eye-movement sleep (Goldsmith & Levin, 1993). In the second study, participants with IBS reported a nighttime increase in pain symptoms and poor sleep quality (Orr, Crowell, Lin, Harnish, & Chen, 1997).

Pain. Pain has been shown to have a deleterious impact on the initiation and maintenance of sleep (Drewes, Nielsen, Arendt-Nielsen, Birket-Smith, & Hansen, 1997; Lewin & Dahl, 1999), and the combined effects of chronic pain and illness are likely to have an even greater negative impact on sleep continuity and sleep quality. Insufficient sleep has been shown to increase the perception of pain (Moldofsky & Scarisbrick, 1976) and the cognitive and affective deficits resulting from chronic sleep disturbance may interfere with an individual's ability to manage pain and other stressors associated with chronic illness. These effects may be amplified in pre-adolescents whose coping skills may be eroded by nascent and developing cognitive competencies and abilities to regulate affect and attention. An understanding of the reciprocal effects of pain and insufficient sleep is likely to have important implications for intervention strategies.

Sleep disturbances have been documented in clinical samples of youth with chronic childhood illnesses associated with chronic pain. For example, parents of children with juvenile rheumatoid arthritis (JRA) reported higher rates of nighttime wakings, parasomnias, sleep-disordered breathing, and daytime sleepiness (Bloom et al., 2002). In addition, based on overnight polysomnographic recordings youth with JRA had more nighttime arousals and were significantly sleepier on multiple sleep latency tests (a validated measures of daytime sleep propensity) the following day (Zamir, Press, Tal, & Tarasiuk, 1998). Children with migraine headaches took longer to fall asleep (Bruni, Russo, Violani, & Guidetti, 2004) and headache duration predicted sleep anxiety, parasomnias, and bedtime resistance based on parental reports comparing migraines to healthy children (Miller, Palermo, Powers, Scher, & Hershey, 2003). Female adolescents with chronic musculoskeletal pain took longer to fall asleep, exhibited more night awakenings, had more subjective reports of poor sleep quality and higher rates of daytime sleepiness compared to a normative sample (Meltzer, Logan, & Mindell, 2005). Taken together, youth with chronic pain have higher rates of sleep problems and increased daytime fatigue. Sleep plays an important if not a critical role in the maintenance of optimal physical and mental health. For example, inadequate sleep and greater weekend bedtime delay has been associated with academic difficulties in adolescents (Wolfson & Carskadon, 1998). In addition, specific deficits in cognitive performance and increased prevalence rates of psychiatric disorders have been associated with specific sleep disorders (Gozal, 1998; Picchietti et al., 1999).

Psychopathology and FAP. Psychiatric comorbidity with FAP is particularly relevant as sleep disturbance is often associated with anxiety and depressive disorders (Kirmil-Gray, Eagleston, Gibson, & Thoresen, 1984; Simonds & Parraga, 1984). Several studies have documented an association of FAP with anxiety and/or depressive symptoms and disorders in primary care (Campo et al., 2004) and specialty care samples (Garber, Zeman, & Walker, 1990; Liakopoulou-Kairis et al., 2002). One study found that patients with FAP have significantly higher rates of anxiety and internalizing symptoms (e.g., social withdrawal and sadness) than healthy controls, but that participants with FAP did not differ from patients with presumably "organic" gastrointestinal illness (e.g., inflammatory bowel disease) or psychiatric patients (Walker, Garber, & Greene, 1993). There is little data to support the notion that pain causes the associated emotional disturbance or that FAP is simply the consequence of emotional distress. One unconfirmed retrospective study suggests that anxiety may precede the development of FAP (Campo et al., 2004).

The goal of this study was to describe the sleep habits and prevalence of sleep problems in youth with FAP compared to a healthy pain-free comparison group, and to explore the extent to which FAP is associated with BSD symptoms while controlling for the presence of psychiatric disorders. We hypothesized that FAP would be associated with increased symptoms of sleep disorders, decreased sleep duration, and decrements in sleep quality.

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