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Daytime Sleep Problems Are Related to Fine Motor Function in Persons with Down Syndrome

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Title: Daytime Sleep Problems Are Related to Fine Motor Function in Persons with Down Syndrome
Language: English
Authors: C.-C. Chen (ORCID 0000-0001-6963-3795), S. D. R. Ringenbach (ORCID 0000-0001-7420-6683)
Source: International Journal of Disability, Development and Education. 2025 72(4):614-625.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 12
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Sleep, Down Syndrome, Psychomotor Skills, Predictor Variables, Adolescents, Adults, Correlation, Symptoms (Individual Disorders), Intelligence Tests, Verbal Ability, Vocabulary, Muscular Strength
Geographic Terms: Arizona
Assessment and Survey Identifiers: Peabody Picture Vocabulary Test
DOI: 10.1080/1034912X.2024.2379457
ISSN: 1034-912X
1465-346X
Abstract: Given the high prevalence of sleep problems and fine motor deficits that have been reported in persons with Down syndrome (DS), this study was to investigate the effect of sleep-related problems occurring during the day on fine motor function (i.e. manual dexterity and handgrip strength) in persons with DS. We also tested the moderating role of obstructive sleep apnoea (OSA) in the link between sleep-related problems occurring during the day and fine motor function. It was hypothesised that subtle sleep-related problems occurring during the day would significantly predict fine motor performance. Fifty-two persons with DS, aged 13-54, participated and caregivers completed a sleep questionnaire for their children with DS. Hierarchical multiple regression analyses indicated a greater frequency of sleep-related problems occurring during the day significantly predicted greater manual dexterity deficits. Results also suggested that OSA was the moderator for the association between sleep-related problems occurring during the day and manual dexterity. This study has highlighted the importance of exploring sleep problems that might impair fine motor performance for the DS population in their everyday lives. Additional studies are needed to develop effective interventions to promote sleep hygiene and fine motor development in this population.
Abstractor: As Provided
Entry Date: 2026
Accession Number: EJ1503865
Database: ERIC
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  Value: <anid>AN0184519112;54q01may.25;2025Apr18.03:24;v2.2.500</anid> <title id="AN0184519112-1">Daytime Sleep Problems Are Related to Fine Motor Function in Persons with Down Syndrome </title> <p>Given the high prevalence of sleep problems and fine motor deficits that have been reported in persons with Down syndrome (DS), this study was to investigate the effect of sleep-related problems occurring during the day on fine motor function (i.e. manual dexterity and handgrip strength) in persons with DS. We also tested the moderating role of obstructive sleep apnoea (OSA) in the link between sleep-related problems occurring during the day and fine motor function. It was hypothesised that subtle sleep-related problems occurring during the day would significantly predict fine motor performance. Fifty-two persons with DS, aged 13–54, participated and caregivers completed a sleep questionnaire for their children with DS. Hierarchical multiple regression analyses indicated a greater frequency of sleep-related problems occurring during the day significantly predicted greater manual dexterity deficits. Results also suggested that OSA was the moderator for the association between sleep-related problems occurring during the day and manual dexterity. This study has highlighted the importance of exploring sleep problems that might impair fine motor performance for the DS population in their everyday lives. Additional studies are needed to develop effective interventions to promote sleep hygiene and fine motor development in this population.</p> <p>Keywords: Daytime sleepiness; sleep apnoea; motor development; manual dexterity; grip force; intellectual disability</p> <p>Down syndrome (DS) is one of the most common neurodevelopmental disorders characterised by having three copies of chromosome 21. Abnormalities in chromosome numbers are usually associated with intellectual disabilities and lead to physical problems, including congenital heart defects, thyroid disease, and skeletal problems, and developmental challenges, such as cognitive and motor deficits and sleep disorders, in persons with DS. To date, the estimated life expectancy rates have increased from 26 years in 1950 to 53 years in 2010. The longer adulthood survival after 1950 is primarily due to the increased survival of children with DS. Thus, it can be expected the number of people living with DS has steadily increased from 1950 until 2010. In a recent study, De Graaf et al. ([<reflink idref="bib17" id="ref1">17</reflink>]) used and validated an alternative approach to estimate that the number of people with DS living in the United States has grown from 49,923 in 1950 to 206,366 in 2010. Such an impact has been especially salient for the families of children with DS due to the increased life expectancy and daily life dependencies. For example, children with Down syndrome have at least three times as many outpatient visits and are more frequently hospitalised than other children with special health care needs (CSHCN) (Boulet et al., [<reflink idref="bib8" id="ref2">8</reflink>]). Children with DS had significantly higher mean annual out‐of‐pocket costs than their matched children without DS within each age and cost category (Kageleiry et al., [<reflink idref="bib29" id="ref3">29</reflink>]). In particular, children with DS, compared with other CSHCN, are less likely to receive health care that meets quality standards specifically care coordination and having their health care service needs met (Phelps et al., [<reflink idref="bib38" id="ref4">38</reflink>]). Therefore, families of a child with DS and our society are facing challenges to support this population. Because of the prevalence and severity of biological and physical conditions in persons with DS, applying for more research work at the practical level and therapeutic intervention are needed in order to mitigate family and societal impacts.</p> <p>Individuals with DS generally show deficits in motor skills. In the past years, most studies have been much more interested in gross motor function in persons with DS, such as postural control (Eid et al., [<reflink idref="bib21" id="ref5">21</reflink>]; Jung et al., [<reflink idref="bib28" id="ref6">28</reflink>]) and locomotion (Anderson-Mooney et al., [<reflink idref="bib2" id="ref7">2</reflink>]; Corsi et al., [<reflink idref="bib16" id="ref8">16</reflink>]) since it is important to their overall physical health, and ability to perform workplace activities (Gupta et al., [<reflink idref="bib24" id="ref9">24</reflink>]). On the other hand, fine motor function is also a key point for activities of daily living in persons with DS. Dolva et al. ([<reflink idref="bib18" id="ref10">18</reflink>]) reported that 5-year-old children with DS have low capabilities to perform manipulative skills, such as tooth brushing, tying shoelaces, and toileting tasks. They noted only 11% and 0% of participants with DS in their study were able to perform tooth brushing and tying shoelaces respectively. To date, reduced manual dexterity has been considered as one of the factors that cause a higher prevalence of cavities in persons with DS (Kusumoto et al., [<reflink idref="bib30" id="ref11">30</reflink>]; Oredugba, [<reflink idref="bib37" id="ref12">37</reflink>]). Further, the association between grip strength and functional performance is also evident. Shields et al. ([<reflink idref="bib43" id="ref13">43</reflink>][<reflink idref="bib44" id="ref14">44</reflink>]) found that the increased upper-limb muscular strength and endurance through a community-based resistance training program can positively impact vocational tasks (e.g. grocery shelving task) of young adults with DS. Particularly, children with DS demonstrate lower levels of fine motor function (i.e. poor manual dexterity and grip force performance) than those with ID without DS and those without ID (Connolly & Michael, [<reflink idref="bib15" id="ref15">15</reflink>]; Priosti et al., [<reflink idref="bib40" id="ref16">40</reflink>]). Moreover, manual dexterity and grip strength are predictive of survival in older adults with ID, including DS (Oppewal & Hilgenkamp, [<reflink idref="bib36" id="ref17">36</reflink>]). Since the improvement of fine motor function might lead to a more productive and active lifestyle in adulthood and ageing with DS, however, scant data are available on fine motor function involving a substantial sample of older adults with DS.</p> <p>A growing body of research has supported the contention that sleep and fine motor function may have a biological and behavioural commonality. Due to the alterations in craniofacial and oral musculature development and low muscle tone, persons with DS are exceptionally vulnerable to obstructive sleep apnoea (OSA) since infancy, with estimates of the prevalence of the condition ranging from 30% to as high as 80% (Austeng et al., [<reflink idref="bib4" id="ref18">4</reflink>]; Breslin et al., [<reflink idref="bib9" id="ref19">9</reflink>]; Marcus, [<reflink idref="bib33" id="ref20">33</reflink>]; Trois et al., [<reflink idref="bib48" id="ref21">48</reflink>]). Ruberto et al. ([<reflink idref="bib42" id="ref22">42</reflink>]) indicated children with obstructive sleep apnoea (OSA) syndrome had significantly poor performance in manual dexterity, ball skills, and balance in the Movement Assessment Battery for Children evaluation compared to children without OSA. Ayalon and Friedman ([<reflink idref="bib5" id="ref23">5</reflink>]) reported that acute sleep deprivation has a deleterious effect on manual dexterity, measured as the Purdue Pegboard Test (PPT), in a group of obstetrics and gynaecology residents. Additionally, the organisation and consolidation of sleep also play a role in fine motor function in persons with ID. The reduced sleep efficiency (e.g. more sleep fragmentation and frequent awakenings,) has been suggested to limit learning capacity in a finger-tapping task for persons with William Syndrome (Berencsi et al., [<reflink idref="bib7" id="ref24">7</reflink>]). Since that, the persistence of fine motor deficits in persons with DS into adulthood raised a question of whether the fine motor function is also affected by their sleep-disordered breathing. Currently, Chen and Ringenbach ([<reflink idref="bib13" id="ref25">13</reflink>]) noted that sleep-related problems occurring during the day (e.g. excessive daytime sleepiness, drowsiness, or daytime napping) were one of the significant predictors of the variance in the performance of PPT in adolescents and young adults with DS. Maris et al. ([<reflink idref="bib34" id="ref26">34</reflink>]) indicated the symptoms of sleep-disordered breathing were related to more daytime sleepiness in persons with DS. Thus, the prevalence of OSA seems to play a moderating effect on fine motor development in persons with DS. However, there is a dearth of research on the association between OSA and fine motor function in the DS population.</p> <p>Taken together, the purpose of the current study was to examine the association between two common types of sleep problems (i.e. features associated with OSA and sleeping-related disorders occurring during the day) and fine motor function, as measured by PPT and handgrip strength, in adolescents, young and older adults with DS. The sleep questionnaire by Simonds and Parraga ([<reflink idref="bib45" id="ref27">45</reflink>]) was completed to assess sleep problems in persons with DS because it has been specifically designed and validated for ID and DS populations. In line with past literature, the current study was innovative in that it centred on the link between sleeping-related disorders occurring during the day and fine motor deficits in persons with DS. In addition, we assessed whether OSA would moderate the relationship between sleep-related problems occurring during the day and fine motor function in the DS population. To the best of our knowledge, this study would be one of the pioneering studies that examine the effect of sleep problems on fine motor function in persons with DS.</p> <hd id="AN0184519112-2">Methods</hd> <p></p> <hd id="AN0184519112-3">Participants</hd> <p>As shown in Table 1, a total of 52 participants (33 males, 19 females, aged 13–54 years) participated in this study. The researchers contacted the interested parents/guardians and participants with DS through local organisations (e.g. DS Network Arizona, Sharing Down Syndrome Arizona, Special Olympics) and scheduled a testing visit in the laboratory. First, the Peabody Picture Vocabulary Test-4<sups>th</sups> Edition (PPVT-IV) (Dunn & Dunn, [<reflink idref="bib19" id="ref28">19</reflink>]) was performed to measure receptive processing and verbal intelligence in standard American English vocabulary. It has been conducted in persons with ID and DS (Loveall et al., [<reflink idref="bib32" id="ref29">32</reflink>]; Phillips et al., [<reflink idref="bib39" id="ref30">39</reflink>]). PPVT-IV required participants to select one picture that best represented the meaning of the spoken word from a set of four numbered pictures. Since PPVT-IV is a standardised norm-referenced test that is appropriate for functioning levels equivalent to mental age (MA) to as young as 2.5 years old, the participant would be excluded if his/her MA was below 2.5 years old.</p> <p>Table 1. Descriptive statistics of participants (<emph>n</emph> = 52).</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>Mean</td><td>s.d.</td></tr></thead><tbody><tr><td>Demographic Information</td><td /><td /></tr><tr><td> Chronological Age (CA, years)</td><td>27.90</td><td>10.50</td></tr><tr><td> Mental Age (MA, years)</td><td>6.20</td><td>2.21</td></tr><tr><td> Height (cm)</td><td>149.15</td><td>12.25</td></tr><tr><td> Weight (kg)</td><td>73.60</td><td>21.86</td></tr><tr><td> Body Mass Index (BMI, kg/m<sup>2</sup>)</td><td>32.87</td><td>11.11</td></tr><tr><td>Sleep Problems</td><td /><td /></tr><tr><td> Features associated with OSA</td><td>14.88</td><td>6.73</td></tr><tr><td> Sleep-related Problems Occurring during the Day</td><td>11.13</td><td>5.79</td></tr><tr><td>Purdue Pegboard Test</td><td /><td /></tr><tr><td> Total Subtest</td><td>19.82</td><td>7.17</td></tr><tr><td> Assembly Subtest</td><td>8.72</td><td>3.55</td></tr><tr><td>Handgrip Test</td><td /><td /></tr><tr><td> Total Handgrip Strength (kg)</td><td>41.27</td><td>15.06</td></tr></tbody></table> </ephtml> </p> <p>Next, visual acuity, using a standard eye chart (i.e. Snellen) or a modified version that consists of letter E's pointing in different directions for participants who could not recognise letters, and hearing levels, using an audiometer (Model # MA 25, MAICO Diagnostics GmbH, Berlin, Germany) were tested to ensure participants had no physical and sensory limitations and would be able to follow the instructions. The sleep problems were rated by participants' caregivers on questionnaires to evaluate the severity of sleep problems among participants. Since there were multiple resources and methods applied for participant recruitment, we believe that the sample in the current study would be representative of the general DS population. All protocols were approved by the Institutional Review Board of the University.</p> <hd id="AN0184519112-4">Measures</hd> <p></p> <hd id="AN0184519112-5">Manual Dexterity Measure</hd> <p>The Purdue Pegboard Test (PPT) (Model # 32020A, Lafayette Instruments Company, Lafayette, IN, USA) was used to assess manual dexterity. There were four cups that contained 25 pegs, 20 collars, 40 washers, and 25 pegs on the top of the pegboard. The performance in the total and assembly subtests were recorded in this study. In the total subtest, participants were requested to complete a dominant hand condition, placing a pin one at a time with the dominant hand, and place it into a row of holes on the dominant hand side, a non-dominant hand condition, placing a pin with the non-dominant hand one at a time into a row of holes on the non-dominant hand side, and bimanual condition, placing pairs of pins at the same time in adjacent holes with both hands. Three 30-sec trials on each condition were performed. The total subtest score was the sum of the average number of pins placed in the dominant, non-dominant, and both hands conditions.</p> <p>In the assembly subtest, participants were asked to place a pin, washer, collar, and the second washer one at a time with alternating hands. It was recorded as the average of pieces placed in three 60-sec trials. The assembly subtest has been used to measure visuospatial construction ability along with executive functioning. Higher performance in the assembly subtest was significantly associated with shorter reaction times on the phasic alertness and divided attention tests (Strenge et al., [<reflink idref="bib47" id="ref31">47</reflink>]). Considering its uniqueness, the performance in the assembly subtest was recorded separately.</p> <p>The predictive validity of PPT for employability in adults with ID is 0.70 (Neeman, [<reflink idref="bib35" id="ref32">35</reflink>]), and the test-retest reliability of this methodology in adults with DS was reported to be.86 to.92 (Chen & Ringenbach, [<reflink idref="bib11" id="ref33">11</reflink>]).</p> <hd id="AN0184519112-6">Handgrip Strength Measure</hd> <p>The Jamar hydraulic dynamometer (Model #5030J1, Sammons Preston Rolyan, Clifton, NJ, USA) was used to assess the maximum grip strength. Participants were asked to stand with their shoulders adducted, neutrally rotated with elbows flexed approximately at a 90-degree angle, the forearm in a neutral position, and the wrist was between 0 and 30 degrees dorsiflexion and between 0 and 15 degrees deviation to grasp the dynamometer. The dominant hand condition was tested first. Participants were instructed to squeeze the handle as hard as they could for at least 5-sec. A 15-sec rest period was given between trials for reading and recording the performance. The device measured in kilograms. The average of three trials performed was the score for the dominant hand condition. Then, the non-dominant hand was tested by following the same procedure. The sum of the average score in the dominant hand and the non-dominant hand was calculated as their handgrip strength. Three participants did not perform the handgrip test. This testing procedure is recommended by the American Society of Hand Therapists (Fess, [<reflink idref="bib23" id="ref34">23</reflink>]) and the test-retest reliability in adults with ID was.94 (same-day interval) and.90 (two-week interval) (Hilgenkamp et al., [<reflink idref="bib25" id="ref35">25</reflink>]).</p> <hd id="AN0184519112-7">Sleep Problems Measure</hd> <p>The Sleep Questionnaire developed by Simonds and Parraga (SQ-SP; 1982) was collected in the current study. Caregivers were asked to report relevant sleep problems they observed in the past three months. It was a 7-point Likert-type scale and modified by Stores et al. ([<reflink idref="bib46" id="ref36">46</reflink>]) to explore sleep problems in children with ID and DS. The test-retest reliability for the total SQ-SP score ranged from, <emph>r</emph> =.83 to 1.00. Two types of sleep problems were derived from SQ-SP, including 1) Features associated with OSA, consisting of six items, rated snoring or gasping for breath; 2) Sleep-related problems occurring during the day, consisting of six items, rated daytime sleepiness, naps, or daytime overactivity. Higher scores represented a more severe sleep problem in that specific type.</p> <hd id="AN0184519112-8">Procedures</hd> <p>The caregivers completed an informed consent form, demographic (e.g. chronological age, behaviour checklist, and medical history), and sleep questionnaires. The demographic questionnaire was used to screen whether participants may have health issues that could impair their motor performance. Next, the participant performed PPVT-IV, vision test, and hearing test to confirm the capabilities in performing all the tests. No participant was excluded from the study. Lastly, each participant was asked to perform the PPT and handgrip test. The entire testing procedure lasted on average 30-min.</p> <hd id="AN0184519112-9">Statistical Analyses</hd> <p>Data were analysed with the Statistical Package for the Social Sciences, SPSS 27.0. The data followed a normal distribution. Violations of normality for all data, including skewness and kurtosis. There were no outliers present in the data, and no values needed to be deleted. A Pearson Product- Moment Correlation Coefficient was used to evaluate the strength of the relationships between the performance in the PPT and handgrip and four types of sleep problems (two-tailed). In addition, two moderated regressions tested whether sleep problems and behaviours during the day significantly predicted manual dexterity and handgrip strength. To test each fine motor function, the centred predictor variable of sleep-related problems occurring during the day was entered in Step 1 of the regression model for the main effect. Then, the mean-centred interaction variable of sleep-related problems occurring during the day and features associated with OSA were entered in Step 2 of the model to test the moderation effect.</p> <hd id="AN0184519112-10">Results</hd> <p></p> <hd id="AN0184519112-11">Associations Between Sleep Problems and Fine Motor Function</hd> <p>Pearson-product moment correlations revealed correlations between features associated with OSA, sleep-related disorder occurring during the day, PPT total subtest, PPT assembly subtest, and total handgrip strength (see Table 2). Sleep-related problems occurring during the day were negatively and significantly associated with the PPT assembly subtest (<emph>r</emph> = −.280, <emph>p</emph> <.001). Total handgrip strength was positively and significantly associated with the PPT assembly subtest (<emph>r</emph> =.294, <emph>p</emph> <.001). Features associated with OSA were positively and significantly correlated with sleep-related problems occurring during the day (<emph>r</emph> =.518, <emph>p</emph> =.036). PPT total subtest and total handgrip strength were not significantly related to features associated with OSA or sleep-related problems occurring during the day.</p> <p>Table 2. Intercorrelations between sleep problem and fine motor function (<emph>n</emph> = 54).</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>1</td><td>2</td><td>3</td><td>4</td><td>5</td></tr></thead><tbody><tr><td>1. Sleep<sup>1</sup></td><td>-</td><td /><td /><td /><td /></tr><tr><td>2. Sleep<sup>2</sup></td><td>.518*</td><td>-</td><td /><td /><td /></tr><tr><td>3. PPT Total Subtest</td><td>.071</td><td>−.118</td><td>-</td><td /><td /></tr><tr><td>4. PPT Assembly Subtest</td><td>−.097</td><td>−.280*</td><td>.822*</td><td>-</td><td /></tr><tr><td>5. Total Handgrip Strength</td><td>.083</td><td>−.022</td><td>.282*</td><td>.294*</td><td>-</td></tr></tbody></table> </ephtml> </p> <p>1 *<emph>p</emph> ≤.05.</p> <p>2 PPT = Purdue Pegboard Test; Sleep<sups>1</sups> = Features associated with OSA; Sleep<sups>2</sups> = Sleep-related problems occurring during the day.</p> <p>G*Power 3.1 (Faul et al., [<reflink idref="bib22" id="ref37">22</reflink>]) provided an a priori power analysis for the hierarchical multiple regression. With a power level of.80, medium effect size of 0.15, and α =.05, the minimum sample size needed was 43 participants; thus, our sample size of 54 was sufficient to detect medium effect sizes.</p> <hd id="AN0184519112-12">Moderating Effect of OSA</hd> <p>Three moderated regressions tested whether sleep-related problems occurring during the day predicted fine motor function (see Table 3). The only significant regression was evident in the PPT assembly subtest. The overall regression model for Step 1 was significant, <emph>F</emph> (<reflink idref="bib1" id="ref38">1</reflink>, 51) = 4.151, <emph>p</emph> =.044, and accounted for 7.8% of the variance (R<sups>2</sups> =.078). Sleep-related problems occurring during the day significantly predicted the performance of the PPT assembly subtest, β = −.280, <emph>t</emph> (<reflink idref="bib52" id="ref39">52</reflink>) = −2.062, <emph>p</emph> =.044. In Step 2, it was significant, <emph>F</emph> (<reflink idref="bib2" id="ref40">2</reflink>, 49) = 4.484, <emph>p</emph> =.016, and accounted for 15.5% of the variance (R<sups>2</sups> =.155). The interaction terms between sleep-related problems occurring during the day and features associated with OSA, ΔR<sups>2</sups> =.077, β =.298, <emph>t</emph> (<reflink idref="bib52" id="ref41">52</reflink>) = 2.104, <emph>p</emph> =.041, was statistically significant.</p> <p>Table 3. Moderating analyses predicting fine motor function from sleep-related problems occurring during the day and features associated obstructive sleep apnea (<emph>n</emph> = 52).</p> <p> <ephtml> <table><thead><tr><td>Predictors</td><td>Coefficient</td></tr><tr><td>B</td><td>SE<sub>B</sub></td><td><italic>t</italic></td><td>95% CI</td><td>ΔR<sup>2</sup></td></tr></thead><tbody><tr><td>Total Subtest</td><td /><td /><td /><td /><td /></tr><tr><td>Step 1</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.146</td><td>−.118</td><td>−.840</td><td>[−.496,.203]</td><td>.014</td></tr><tr><td>Step 2</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.291</td><td>−.235</td><td>−1.610</td><td>[−.655,.072]</td><td>.085</td></tr><tr><td> Sleep<sup>1</sup> x Sleep<sup>2</sup></td><td>.043</td><td>.314</td><td>2.150</td><td>[.003,.083]</td><td /></tr><tr><td>Assembly Subtest</td><td /><td /><td /><td /><td /></tr><tr><td>Step 1</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.171</td><td>−.280</td><td>−2.062*</td><td>[−.339, −.004]</td><td>.078</td></tr><tr><td>Step 2</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.240</td><td>−.391</td><td>−2.762*</td><td>[−.414, −.065]</td><td>.077</td></tr><tr><td> Sleep<sup>1</sup> x Sleep<sup>2</sup></td><td>.020</td><td>.298</td><td>2.104*</td><td>[.001,.039]</td><td /></tr><tr><td>Total Handgrip Strength</td><td /><td /><td /><td /><td /></tr><tr><td>Step 1</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.057</td><td>−.022</td><td>−.151</td><td>[−.881, 698]</td><td><.001</td></tr><tr><td>Step 2</td><td /><td /><td /><td /><td /></tr><tr><td> Sleep<sup>1</sup></td><td>−.150</td><td>−.058</td><td>−.368</td><td>[−.917, 671]</td><td>.008</td></tr><tr><td> Sleep<sup>1</sup> x Sleep<sup>2</sup></td><td>.027</td><td>.096</td><td>606</td><td>[−.063, 118]</td><td /></tr></tbody></table> </ephtml> </p> <ulist> <item>3 *<emph>p</emph> ≤.05.</item> <item>4 PPT = Purdue Pegboard Test; Sleep<sups>1</sups> = Features associated with OSA; Sleep<sups>2</sups> = Sleep-related problems occurring during the day.</item> </ulist> <hd id="AN0184519112-13">Discussion</hd> <p>The purpose of the current study was to examine the relationship between sleep-related problems occurring during the day and fine motor function among persons with DS. We also explored OSA as a moderator of the link between sleep-related problems occurring during the day and fine motor function. This research contributes to a growing body of literature, which has found that greater experiences of sleep-related problems occurring during the day are significantly associated with negative fine motor performance (Ayalon & Friedman, [<reflink idref="bib5" id="ref42">5</reflink>]; Cao et al., [<reflink idref="bib10" id="ref43">10</reflink>]). In addition, this study is one of the first to examine the potential moderating effect of OSA in the link between sleep-related problems occurring during the day and fine motor function in persons with DS.</p> <p>The first hypothesis was partially supported; sleeping-related disorders occurring during the day significantly predicted the performance of the PPT assembly subtest. Persons with DS have reported a greater frequency of sleeping-related disorders occurring during the day (Rosen et al., [<reflink idref="bib41" id="ref44">41</reflink>]) and showed greater manual dexterity deficits (Alesi & Battaglia, [<reflink idref="bib1" id="ref45">1</reflink>]). Our findings further add to existing research that has suggested a link between experiences of sleeping disorders and manual dexterity. In particular, our findings also complement previous research that has recognised the link between experiences of sleeping-related disorders occurring during the day and manual dexterity deficits for adolescents and young adults with DS (Chen & Ringenbach, [<reflink idref="bib13" id="ref46">13</reflink>]).</p> <p>The second research hypothesis was also supported; our preliminary findings indicated a statistically significant moderating effect between the features of OSA and fine manual dexterity in persons with DS. The PPT assembly subtest is a normative data test that highly emphasises motor speed and hand-eye coordination, including procedural memory and sequence learning, which occur primarily in the motor cortex, basal ganglia, and prefrontal cortex. Beebe and Gozal ([<reflink idref="bib6" id="ref47">6</reflink>]) proposed a model that sleep disruption may prevent sleep-related restorative processes, and further induce chemical and structural central nervous system damages. This, in turn, leads to dysfunction of prefrontal regions of the brain cortex, manifested behaviourally in executive function. Chen et al. ([<reflink idref="bib14" id="ref48">14</reflink>]) noted a relationship between OSA and executive function in persons with DS. Hence, Sleep disturbance is related to greater impairments in executive function in this population. In line with previous research, our findings supported the idea that OSA may exert an impact on fine motor dexterity in persons with DS. These findings reflect the increasing need for studies that utilise polysomnography or actigraphy measures to explore persons with Down syndrome's experiences with sleep problems and the potential moderating and mediating variables that contribute to the link to fine motor development and performance.</p> <p>On the other hand, the findings did not support the hypothesis; sleeping-related disorders occurring during the day predict the performance of handgrip strength. Besides sleep problems, the performance of handgrip strength in persons with DS may be primarily influenced by physical dysfunction. The handgrip test required participants to apply large muscle activations, rapid accelerations of movement, and precisely coordinated movements of the hand, wrist, elbow, and shoulder to respond to the task. Therefore, their small hand sizes with short fingers may cause some difficulties in manipulative activities (John et al., [<reflink idref="bib26" id="ref49">26</reflink>]; Jover et al., [<reflink idref="bib27" id="ref50">27</reflink>]). Reduced muscle mass and hypotonia may also result in a decrease in muscle strength (Dupre & Weidman-Evans, [<reflink idref="bib20" id="ref51">20</reflink>]). In addition, unlike typical populations, persons with Down syndrome may show simultaneous neural activation in both muscle pairs, which could be described as a coactivation pattern, during the handgrip test (Latash, [<reflink idref="bib31" id="ref52">31</reflink>]). Future studies should include hand anthropological variables and physical function measures to better understand the effects of OSA on handgrip strength and on the DS population.</p> <p>While this study contributes to a current gap in the literature on the link between sleep problems and fine motor function in persons with DS, there are some limitations. A major limitation of this study is the restricted responses available for the sleep problems measure. Caregivers were asked to report whether their children with DS had sleep problems within the past 90 days. However, other instruments, such as the Epworth Sleepiness Scale, The Pittsburgh Sleep Quality Index (PSQI), and the STOP-BANG questionnaire for OSA assessment should be considered in the future since they have been widely used in the sleep research community. In addition, future studies could employ a polysomnography or actigraphy measure that integrates a wider variety of questionnaires regarding the extent to which persons with DS experience the frequency of sleep problems in their lives. In samples of the DS population, frequent experience of sleep problems has been associated with lower levels of executive function and physical activity (Chen & Ringenbach, [<reflink idref="bib12" id="ref53">12</reflink>]; Chen et al., [<reflink idref="bib14" id="ref54">14</reflink>]). It may also be helpful to explore the potential roles of these variables in future research centred on physical activity and executive function outcomes as a result of sleep problems. Further, participants visited the laboratory at different times of the day. Future research should also account for time-of-day differences in their testing. Circadian variation of motor performance (e.g. sprint speed, bench press) can be high when comparing morning versus afternoon performance in the same individual (Atkinson & Reilly, [<reflink idref="bib3" id="ref55">3</reflink>]). For most people, performance is optimised in the late afternoon or early evening at the height of the core body temperature rhythm. Moreover, future studies should continue exploring the underlying mechanisms of how OSA exerts an influence on the relationship between sleep-related problems occurring during the day and fine motor function. Studies could also examine which specific types of physical activity could strengthen the association between sleep problems and fine motor performance.</p> <p>This study has practice implications for health professionals and parents to provide information regarding the fine motor deficits that may occur for persons with DS due to subtle sleep problems. The current research could assist health professionals and parents to take additional precautions to examine sleep disorder symptoms. Physicians might link a reported symptom of the frequency of sleep disorders from the caregivers to fine motor development and performance in their patients with DS. More studies would be needed to understand the relationship between sleep problems and fine motor function, and the variables that potentially mitigate this link could lead to more efficacious prevention and treatment approaches that help practitioners and families promote quality of life in the DS population.</p> <hd id="AN0184519112-14">Disclosure Statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <hd id="AN0184519112-15">Data Availability Statement</hd> <p>Research data are not shared.</p> <ref id="AN0184519112-16"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref38" type="bt">1</bibl> <bibtext> Present affiliation of C.-C. 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PubType: Academic Journal
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Daytime Sleep Problems Are Related to Fine Motor Function in Persons with Down Syndrome
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22C%2E-C%2E+Chen%22">C.-C. Chen</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-6963-3795">0000-0001-6963-3795</externalLink>)<br /><searchLink fieldCode="AR" term="%22S%2E+D%2E+R%2E+Ringenbach%22">S. D. R. Ringenbach</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7420-6683">0000-0001-7420-6683</externalLink>)
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22International+Journal+of+Disability%2C+Development+and+Education%22"><i>International Journal of Disability, Development and Education</i></searchLink>. 2025 72(4):614-625.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 12
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Sleep%22">Sleep</searchLink><br /><searchLink fieldCode="DE" term="%22Down+Syndrome%22">Down Syndrome</searchLink><br /><searchLink fieldCode="DE" term="%22Psychomotor+Skills%22">Psychomotor Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Predictor+Variables%22">Predictor Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Intelligence+Tests%22">Intelligence Tests</searchLink><br /><searchLink fieldCode="DE" term="%22Verbal+Ability%22">Verbal Ability</searchLink><br /><searchLink fieldCode="DE" term="%22Vocabulary%22">Vocabulary</searchLink><br /><searchLink fieldCode="DE" term="%22Muscular+Strength%22">Muscular Strength</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Arizona%22">Arizona</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Peabody+Picture+Vocabulary+Test%22">Peabody Picture Vocabulary Test</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/1034912X.2024.2379457
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1034-912X<br />1465-346X
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Given the high prevalence of sleep problems and fine motor deficits that have been reported in persons with Down syndrome (DS), this study was to investigate the effect of sleep-related problems occurring during the day on fine motor function (i.e. manual dexterity and handgrip strength) in persons with DS. We also tested the moderating role of obstructive sleep apnoea (OSA) in the link between sleep-related problems occurring during the day and fine motor function. It was hypothesised that subtle sleep-related problems occurring during the day would significantly predict fine motor performance. Fifty-two persons with DS, aged 13-54, participated and caregivers completed a sleep questionnaire for their children with DS. Hierarchical multiple regression analyses indicated a greater frequency of sleep-related problems occurring during the day significantly predicted greater manual dexterity deficits. Results also suggested that OSA was the moderator for the association between sleep-related problems occurring during the day and manual dexterity. This study has highlighted the importance of exploring sleep problems that might impair fine motor performance for the DS population in their everyday lives. Additional studies are needed to develop effective interventions to promote sleep hygiene and fine motor development in this population.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2026
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1503865
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1503865
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/1034912X.2024.2379457
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 614
    Subjects:
      – SubjectFull: Sleep
        Type: general
      – SubjectFull: Down Syndrome
        Type: general
      – SubjectFull: Psychomotor Skills
        Type: general
      – SubjectFull: Predictor Variables
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Correlation
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Intelligence Tests
        Type: general
      – SubjectFull: Verbal Ability
        Type: general
      – SubjectFull: Vocabulary
        Type: general
      – SubjectFull: Muscular Strength
        Type: general
      – SubjectFull: Arizona
        Type: general
      – SubjectFull: Peabody Picture Vocabulary Test
        Type: general
    Titles:
      – TitleFull: Daytime Sleep Problems Are Related to Fine Motor Function in Persons with Down Syndrome
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: C.-C. Chen
      – PersonEntity:
          Name:
            NameFull: S. D. R. Ringenbach
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          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1034-912X
            – Type: issn-electronic
              Value: 1465-346X
          Numbering:
            – Type: volume
              Value: 72
            – Type: issue
              Value: 4
          Titles:
            – TitleFull: International Journal of Disability, Development and Education
              Type: main
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