Investigation of the Sleep Quality of Children Ages 4 to 6 Yr With Cerebral Palsy and Cerebral Visual Impairment and Their Caregivers’ Sleep Quality and Levels of Depression and Anxiety

Abstract

Importance:

Sleep disturbances are common in children with cerebral palsy (CP) and may worsen with cerebral visual impairment (CVI). Understanding CVI’s impact on children and caregiver mothers is essential for holistic care planning.

Objective:

To compare the sleep quality of children with CP with and without CVI and their caregiver mothers. Secondary objectives included comparing maternal anxiety and depression levels and examining associations between children’s visual function and both child and maternal well-being.

Design:

Cross-sectional comparative study conducted between November 2023 and April 2024.

Setting:

Special education and rehabilitation center.

Participants:

Eighty-four children ages 4 to 6 yr with CP (42 with CVI, 42 without CVI) and their primary caregiver mothers.

Outcomes and Measures:

Children’s sleep quality was assessed using the Child Sleep Habits Questionnaire (CSHQ) and visual functioning with the Visual Function Classification System (VFCS). Mothers’ sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI), and their anxiety and depression was assessed with the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI).

Results:

Children with CVI had significantly higher CSHQ scores (p < .05). Their mothers also reported significantly higher PSQI, BAI, and BDI scores (p < .05). VFCS score correlated with all child and maternal outcomes. Children’s sleep quality was the main predictor of maternal anxiety and depression (p < .05).

Conclusions and Relevance:

CVI in children with CP has been associated with poorer sleep in both children and caregivers, as well as higher psychological burden in caregivers. A strong relationship has been found between children’s sleep quality and mothers’ mental health.

Plain-Language Summary

This study found that children with cerebral palsy and cerebral visual impairment had poorer sleep quality, and their mothers exhibited lower sleep quality and higher levels of psychological distress. The children’s reduced visual functioning was found to be associated with poorer sleep quality and higher psychological distress. Children’s sleep quality emerged as the primary factor influencing maternal mental health. It is recommended that visual and sleep issues for children with cerebral palsy and cerebral visual impairment be addressed together in the rehabilitation process. Further studies are needed to translate these findings into clinical practice.

Cerebral visual impairment (CVI) is one of the most common visual disorders in children with cerebral palsy (CP) and CVI is reported to occur in approximately 60% to 70% of children with CP (Philip et al., 2020). CVI, which is caused by primary and secondary visual center damage, can negatively affect children’s daily life patterns and routines (Cemali et al., 2023).

Beyond its impact on functional skills, loss of visual function may also lead to disturbances in biological rhythms, especially in the sleep–wake cycle. It has been reported that sleep problems are more common in people with visual impairment because of changes in melatonin secretion patterns and circadian rhythm disturbances (Hayton et al., 2021). Inadequate perception of the day–night cycle in people with reduced photosensitivity may lead to prolonged falling asleep, disruption of sleep patterns, and an increase in sleep problems (Atan et al., 2023).

In a study conducted in visually impaired people, the prevalence of sleep disorders was reported to vary between 28.7% and 33.1% (Tamura et al., 2021). However, although there is increasing evidence of an association between vision loss and sleep problems in the general population, studies that directly examine the effects on sleep quality in children with CP and CVI are limited (Ingram et al., 2022). When the literature was reviewed, it was determined that most of the studies on children with CP and CVI focused on areas such as motor skills, sensory processing, and emotional development, but there were no direct studies investigating the effects on children’s sleep quality and on caregivers’ sleep quality and mental health (Cemali et al., 2022, 2023; Chokron et al., 2021; Kılıç et al., 2025). It is predicted that loss of visual function in children with CP and CVI may have an impact on the sleep patterns of children and caregivers and the psychological state of caregivers. Understanding this relationship is important for both the sleep health of children and their caregivers and the mental well-being of the caregivers. Accordingly, the primary aim of this study was to compare the sleep quality of children who have CP and CVI with the sleep quality of children who have CP without CVI, as well as the sleep quality of their mothers; the second aim was to compare the anxiety and depression levels of their mothers; and the third aim was to examine the relationship between visual function level and sleep quality of children with CP and CVI and their mothers’ sleep quality, anxiety levels, and depression levels.

Method

Study Design

This prospective cross-sectional study was approved by the Lokman Hekim University Scientific Research Ethics Committee (Decision no. 2023/100) on June 13, 2023. This study was conducted in accordance with the Declaration of Helsinki. We followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) initiative’s checklist instructions in writing the article (Von Elm et al., 2007). All participants received detailed information before the study, and we obtained consent from the participants who stated that they were willing to participate in the study.

This study was carried out between November 2023 and April 2024 in a special education and rehabilitation center in Ankara, Turkey, where children who have CP with and without CVI were receiving rehabilitation. The two participant groups consisted of children who have CP, with and without CVI, and their caregivers. We evaluated children’s sleep habits and caregivers’ sleep quality, anxiety levels, and depression levels using caregiver-reported and self-reported questionnaires. We evaluated the children in each group using the Children’s Sleep Habits Questionnaire (CSHQ), and we evaluated their caregivers using the Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). All questionnaires used in the evaluation—the CSHQ for children and the PSQI, BDI, and BAI for caregivers—were completed by the caregivers under the guidance of the researchers. All results were compared between the two groups, and the relationship between these parameters was examined. Completion of the questionnaires took an average of 35 min.

Participants

For all children included in the study, both CP and CVI diagnoses were made by pediatric neurologists and ophthalmologists, respectively, and were based on clinical examination and brain MRI findings, with lesion localization considered for diagnostic confirmation. Children with lesions involving the visual centers received a CVI diagnosis in addition to having CP, whereas those with brain lesions outside the visual centers were classified as only having CP. All children had official hospital reports, and the inclusion process was carried out on the basis of these reports. Children were excluded from the study if they had surgery in the past 6 mo, if they used any medication that could affect sleep quality, or if they had cancer; rheumatologic, neurological, cardiopulmonary, or cardiovascular diseases; or uncontrolled epileptic seizures with diagnoses other than CP and CVI. We defined the caregivers’ ability to clearly understand the assessment questions and provide consistent, meaningful answers during the evaluation as an inclusion criterion. In addition, caregivers with chronic health conditions (orthopedic, cardiopulmonary, cardiopulmonary, neurological, oncological, rheumatological, or psychiatric diagnoses) or those using psychiatric medications were excluded from the study.

The required sample size was calculated using the G*Power 3.1.9.6 program (Heinrich-Heine-Universität Düsseldorf). We conducted an a priori power analysis for independent two-group comparisons using a (two-tailed) t test. On the basis of the primary outcome measure (CSHQ total score), assuming a medium effect size (Cohen’s d = .6), an α level of .05 (95% confidence interval), and a power of .80 (80% probability of detecting a true effect; β = Type 2 error probability), the minimum required sample size was determined to be 70 participants in total (35 children with CP and CVI, 35 children with CP without CVI).

The study included a total of 100 children ages 4 to 6 yr: 52 had CP and CVI, and 48 had CP without CVI. Ten children with CP and CVI and six children with CP without CVI were excluded from the study, because their evaluations could not be completed. The study was completed with 84 children, 42 with CP and CVI and 42 with CP without CVI. One hundred caregivers (mothers) ages 26–38 who met the initial inclusion criteria were invited to participate. However, because the assessments of 16 children could not be completed, the mothers of those children were also excluded from the final analysis. Consequently, the total number of caregivers included in the study was 84 (Figure 1).

Figure 1.

Participant flowchart.

Data Collection

We collected descriptive data on the children and caregiver mothers using a general assessment form created by the researchers. This form included the age and gender of the children, CP type (diparetic or quadriparetic), epilepsy diagnosis, clinical information about the medications used, and the age of the mothers. In addition, we used the Gross Motor Function Classification System (GMFCS) to determine whether the groups were homogeneous in terms of gross motor function levels, and we used the Visual Function Classification System (VFCS) to describe the visual functional status of children in the CVI group. We used the CSHQ to assess children’s sleep quality. Caregivers’ sleep quality, anxiety, and depression levels were evaluated with the PSQI, BDI, and BAI, and all questionnaires were completed by the caregivers. Recording of descriptive information, as well as the GMFCS and VFCS assessments, was carried out by a physiotherapist who specialized in vision rehabilitation, who completed undergraduate training in physiotherapy, and who holds both a master’s degree and a doctoral degree in occupational therapy. We conducted the GMFCS and VFCS assessments strictly in accordance with the official guidelines, through direct observation of the children during evaluation sessions at the rehabilitation center. The CSHQ, PSQI, BDI, and BAI completed by the caregivers were administered under the guidance of the same researcher.

GMFCS

We evaluated the gross motor function levels of children with CP using the GMFCS, which consists of five levels. The GMFCS classifies gross motor skills of children such as sitting, walking, and moving according to the level of independence. Level 1 is the level at which the child can move independently; Level 5 is the level at which motor skills are most restricted, with the child requiring significant physical support. In this system, as the level increases from 1 to 5, the child’s gross motor functioning decreases (Palisano et al., 1997).

VFCS

To evaluate visual function level, we used the VFCS, a five-level system that classifies the level at which children with CP can use their visual abilities in daily life. Level 1 indicates that the child uses visual functioning easily and effectively in daily life; Level 5 indicates that visual functioning is severely impaired and cannot be used even in highly adapted environments. An increase in levels from 1 to 5 on the VFCS indicates a decrease in visual functioning (Baranello et al., 2020).

CSHQ

We assessed children’s sleep quality with the 33-item CSHQ. The scale consists of eight subscales, and total scores range between 33 and 99. An increase in the total score obtained indicates a decrease in sleep quality. CSHQ total scores of 41 and higher indicate the presence of clinically significant sleep problems. Scores lower than 41 indicate normal sleep patterns (Owens et al., 2000).

PSQI

We assessed caregivers’ sleep quality with the PSQI, which consists of 19 questions and is scored between 0 and 21 in total, covering seven subdimensions. Sleep quality is considered to decrease as the score increases. A total score higher than 5 indicates poor sleep quality, and a score lower than 5 indicates good sleep quality (Ağargün et al., 1996; Buysse et al., 1989).

BAI

We assessed the anxiety levels of caregivers with the BAI, which consists of 21 items in total. Each item is evaluated between 0 and 3 points, and the total scores range between 0 and 63. As the score increases, the anxiety level is considered to increase: 0–7 points indicate minimal, 8–15 points indicate mild, 16–25 points indicate moderate, and 26 or more points indicate severe anxiety (Beck et al., 1988).

BDI

To evaluate the caregivers’ depression levels, we used the BDI. The scale consists of 21 items, with total scores ranging between 0 and 63. As the score increases, the severity of depression increases: 0–9 points indicate minimal, 10–16 points indicate mild, 17–29 points indicate moderate, and 30–63 points indicate severe depression (Beck et al., 1961).

Statistical Analysis

For statistical analyses, we used IBM SPSS Statistics (Version 26.0). We used the Kolmogorov–Smirnov test to evaluate whether the variables were normally distributed. It was determined that the numerical variables were normally distributed and the categorical variables were not normally distributed. Numerical variables were defined as means and standard deviations, and categorical variables were defined as frequency (n) and percentage. We used the χ² test to compare gender; medication use; presence of epilepsy; and GMFCS, VFCS, CSHQ, BAI, and BDI classifications between the groups, and we used the independent samples t test to compare the total and subscale scores of the CSHQ, PSQI, BAI and BDI. We calculated effect size (Cohen’s d) using the means and standard deviations of the groups. Effect size benchmarks were determined as <.30, .30–.80, and >.80 and were considered small, moderate, and strong, respectively. In the group of children with CP and CVI, we analyzed the relationship between children’s CSHQ and VFCS scores and caregivers’ PSQI, BAI, and BDI scores using the Pearson correlation test (Cohen, 1992). For correlation coefficients (rs), we determined .00–.19 as indicating a very weak correlation; .20–.39 as weak; .40–.69 as moderate; .70–.89 as strong, and .90–1.00 as very strong. We performed multiple linear regression analysis to determine the predictive effects of the children’s CSHQ total score and the caregivers’ PSQI total score variables on the caregivers’ BAI and BDI scores. In all analyses, the significance level was accepted as p < .05.

Results

The comparison of the age, gender, CP type, epilepsy diagnosis, medication used, and the age data of the caregivers of children who had CP with and without CVI is presented in Table 1. There was no statistically significant difference between the groups in terms of descriptive variables (p > .05).

Table 1.

Descriptive Characteristics of Groups and Differences Between Groups

Characteristic	Children With CP, n (%)		p
Characteristic	With CVI	Without CVI	p
Gender			.659 a
Male	19 (45.2)	17 (40.5)
Female	23 (54.8)	25 (59.5)
Type of CP			.661 a
Diparetic	18 (42.9)	20 (47.6)
Quadriparetic	24 (57.1)	22 (52.4)
Diagnosed as having epilepsy			.637 a
Yes	14 (33.3)	12 (28.6)
No	28 (66.7)	30 (71.4)
Taking medication for epilepsy			.637 a
Yes	14 (33.3)	12 (28.6)
No	28 (66.7)	30 (71.4)
Taking medication for spasticity			.693 a
Yes	3 (7.1)	4 (9.5)
No	39 (92.9)	38 (90.5)
Child’s age, mo, M (SD)	59.16 (6.70)	59.16 (7.87)	.485 b
Caregiver’s age, yr, M (SD)	31.00 (2.21)	31.76 (2.42)	.137 b

Note. In both groups of children, n = 42. CP = cerebral palsy; CVI = cerebral visual impairment.

The p value of the χ² test.

p < .05 for the independent-samples t test.

Data regarding the comparison of GMFCS, VFCS, CSHQ, PSQI, BAI, and BDI scores between the groups are presented in Table 2. A statistically significant difference was found between the groups in all outcome measures except GMFCS level (p < .05).

Table 2.

Comparison of GMFCS, VFCS, CSHQ, PSQI, BAI, and BDI Findings Between Groups

Measure	Children With CP, n (%)		p
Measure	With CVI	Without CVI	p
Findings for children
GMFCS level			.785
1	—	—
2	12 (28.6)	13 (31.0)
3	14 (33.3)	16 (38.0)
4	16 (38.1)	13 (31.0)
5	—	—
VFCS level			<.001
1	—	42 (100.0)
2	14 (33.3)	—
3	13 (31.0)	—
4	15 (35.7)	—
5	—	—
CSHQ classification			.023
Have sleeping problems (over 41 points)	20 (47.6)	10 (23.8)
No sleep problems (0–41 points)	22 (52.4)	32 (76.2)
Findings for caregivers
PSQI sleep quality level			.016
Poor (>5 points)	24 (57.1)	13 (31.0)
Good (0–5 points)	18 (42.9)	29 (69.0)
BAI anxiety level			.045
Minimal (0–7 points)	5 (11.9)	15 (35.7)
Mild (8–15 points)	11 (26.1)	12 (28.5)
Moderate (16–25 points)	13 (31.0)	8 (19.1)
Severe (>26 points)	13 (31.0)	7 (16.7)
BDI depression level			.047
Minimal (0–9 points)	5 (11.9)	15 (35.7)
Mild (10–16 points)	10 (23.8)	11 (26.1)
Moderate (17–29 points)	14 (33.3)	9 (21.5)
Severe (>30 points)	13 (31)	7 (16.7)

Note. n = 42 for both groups of children. For the χ² test, p < .05. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CVI = cerebral visual impairment; CP = cerebral palsy; CSHQ = Children’s Sleep Habits Questionnaire; PSQI = Pittsburgh Sleep Quality Index; GMFCS = Gross Motor Function Classification System; VFCS = Visual Function Classification System.

The data comparing the CSHQ and PSQI total and subscale scores and the total scores on the BAI and BDI between the groups are presented in Table 3. Statistically significant differences were found between the groups in all outcome measures except for the “sleep-disordered breathing” subdomain of the CSHQ and the “use of sleeping medications” subdomain of the PSQI (p < .05).

Table 3.

Comparison of CSHQ and PSQI Levels and Scores on Their Subcategories, the BAI, and the BDI Between Groups

Measure	Children With CP, M (SD)		p	Effect Size (d)
Measure	With CVI	Without CVI	p	Effect Size (d)
Findings for children
CSHQ total	40.21 (15.02)	32.16 (14.35)	.014	.548
Bedtime resistance	6.61 (2.49)	5.33 (3.15)	.041	.541
Sleep onset delay	2.28 (0.74)	1.95 (0.76)	.046	.440
Sleep duration	3.57 (1.97)	2.45 (1.51)	.002	.638
Sleep anxiety	4.47 (2.41)	3.42 (1.86)	.029	.488
Night wakings	3.50 (1.97)	2.45 (1.23)	.005	.639
Parasomnias	8.33 (2.67)	6.83 (3.08)	.020	.520
Sleep-disordered breathing	2.28 (0.74)	2.52 (1.68)	.405	.185
Daytime sleepiness	9.14 (2.75)	7.19 (2.65)	.001	.722
Findings for caregivers
PSQI total	8.52 (5.13)	5.64 (4.71)	.009	.585
Subjective sleep quality	1.28 (0.70)	0.88 (0.86)	.021	.510
Sleep latency	1.28 (0.77)	0.88 (0.73)	.016	.533
Sleep duration	1.40 (0.98)	0.90 (0.93)	.019	.523
Habitual sleep activity	1.28 (0.89)	0.80 (0.86)	.015	.548
Sleep disturbance	1.40 (0.96)	0.97 (0.98)	.028	.443
Use of sleeping medications	0.40 (0.70)	0.19 (0.50)	.112	.345
Daytime dysfunction	1.45 (0.99)	1.00 (0.91)	.032	.473
BAI score	21.90 (12.84)	15.04 (10.40)	.009	.587
BDI score	22.09 (12.12)	15.78 (10.12)	.011	.565

Note. n = 42 for both groups of children. For the independent-samples t test, p < .30. Effect sizes were assessed as follows: <.30, small; .30–.80, moderate; and >.80, strong; p < .05. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CP = cerebral palsy; CSHQ = Children’s Sleep Habits Questionnaire; CVI = cerebral visual impairment; PSQI = Pittsburgh Sleep Quality Index; VFCS = Visual Function Classification System.

Table 4 presents the data on the relationships between VFCS, CSHQ, PSQI, BAI and BDI outcome measures in the group of children with CP with CVI and their caregivers. Statistically significant relationships were found between all outcome measures (p < .001; rs = .884–.915).

Table 4.

Relationship Between Findings on the CSHQ, PSQI, VFCS, BAI, and BDI

Measure	Correlations for Children With CP and CVI and Their Caregivers
	CSHQ (Children)		PSQI (Caregivers)		VFCS (Children)
	r	p	r	p	r	p
Findings for children
CSHQ	—	—	.946	.000	.915	.000
VFCS	.915	.000	.884	.000	—	—
Findings for caregivers
BAI	.983	.000	.936	.000	.888	.000
BDI	.984	.000	.942	.000	.897	.000

Note. For each group, n = 42. For the Pearson test, p < .05. Correlations were assessed as follows: .00–.19, very weak; .20–.39, weak; .40–.69, moderate; .70–.89, strong; and .90–1.00, very strong. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CP = cerebral palsy; CSHQ = Children’s Sleep Habits Questionnaire; CVI = cerebral visual impairment; PSQI = Pittsburgh Sleep Quality Index; VFCS = Visual Function Classification System.

A multiple linear regression analysis performed on children with CP who have CVI revealed that 96.5% (R ² = .965, p = .000) of the variance in BAI scores and 96.7% (R ² = .967, p = .000) of the variance in BDI scores were explained by the CSHQ and PSQI. According to regression analysis, the sleep quality of children with CP and CVI had a significant negative effect on their mothers’ levels of anxiety (β = .977, p = .000) and depression (β = .928, p = .000). According to regression analysis, it was found that the sleep quality of the mothers of children with CP and CVI had no significant effect on the status of the mothers’ anxiety (β = .007, p = .946) and depression (β = .059, p = .525; Table 5).

Table 5.

Results of Regression Analysis Between CSHQ and PSQI and Beck Anxiety and Depression

Measure	Coefficients for Caregivers of Children With CP and CVI
	BAI a				BDI b
	B	SE	β	p	B	SE	β	p
CSHQ (children)	.835	.081	.977	.000	.749	.074	.928	.000
PSQI (caregivers)	.016	.238	.007	.946	.139	.217	.059	.525

Note. For the multiple linear regression test, p < .05. β = standardized coefficient; B = unstandardized coefficient; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CP = cerebral palsy; CSHQ = Children’s Sleep Habits Questionnaire; CVI = cerebral visual impairment; PSQI = Pittsburgh Sleep Quality Index.

^aAdjusted R ² = .965, p = .000.

^bAdjusted R ² = .967, p = .000.

Discussion

In this study, we found that the sleep quality of children with CP and CVI was lower than that of children with CP without CVI and that mothers of children with CP and CVI had lower sleep quality and higher levels of depression and anxiety. In addition, decreased visual ability and decreased sleep quality of children with CP and CVI were significantly associated with decreased sleep quality and increased levels of depression and anxiety in their mothers. Moreover, regression analysis revealed that children’s sleep quality was a determinant of their mothers’ mental health.

In the literature, it has been reported in various studies that vision loss negatively affects sleep quality by leading to decreased light penetration and disruption of the sleep–wake cycle (Alexander et al., 2014; An & Joo, 2016). Sleep problems have been reported as being common in children ages 1 to 16 yr who are totally blind, and these problems should be managed with strategies that support sleep routines (Ingram et al., 2022). In a comparative study with children ages 10 to 36 mo with early vision loss, dysfunctions in the sleep physiology of visually impaired children have been shown to affect sleep quality negatively (Fazzi et al., 2008). In the present study, we found that children with CP and CVI had lower sleep quality and had a higher proportion of children with sleep problems compared with children with CP without CVI. This may be related to the possibility that visual dysfunction caused by CVI limits light perception and the processing of environmental stimuli, which may, in turn, be associated with poorer sleep quality (Ingram et al., 2022). In the literature, it has been reported that because children with CP are unable to meet their own needs independently, especially at night, caregivers may need to check on their children, and this has been associated with poorer maternal sleep quality (Hulst et al., 2021). In addition, frequent nighttime awakenings due to spasticity, pain, seizures, risk of aspiration and other health problems have also been shown to reduce caregivers’ sleep quality (Petersen et al., 2020). As reported elsewhere, the addition of visual impairment to CP symptoms further decreases children’s independence and increases the need for care (Salavati et al., 2014). In our study, we found that mothers of children with CP and CVI had both lower sleep quality and a higher proportion of people with poor sleep quality compared with mothers of children with CP without CVI. These findings suggest that CVI may be associated with increased caregiving demands by limiting children’s functional independence, which, in turn, may be linked to poorer maternal sleep patterns.

It has been reported that the difficulties of children with CVI in perceiving environmental stimuli and communicating can lead caregivers to experience difficulties in meeting their children’s needs and an increased risk of emotional burnout (McDowell, 2021). Another study concluded that decreased visual ability in children with CVI increases children’s dependency on activities of daily living, increases their communication and sensory-processing problems, increases caregivers’ stress levels, and negatively affects their quality of life (Lupón et al., 2023). Researchers have found that parents of children with disabilities need to devote more time to the daily care of their children, which creates additional social, economic, and psychological burdens (Liu et al., 2023). Another study determined that restricting parents’ rest periods increased chronic stress levels by increasing physical and mental fatigue and that this was associated with burnout, anxiety, and depression (Abdullah et al., 2021). In another study, chronic care burden and lack of social support were found to increase anxiety and depression levels in mothers (Ren et al., 2020). In our study, we found the depression and anxiety levels of the mothers of children with CP and CVI and the number of people with moderate or higher levels were higher compared with those of the mothers of children with CP without CVI. These results suggest that visual impairment caused by CVI may be associated with increased care needs in children with CP and with higher levels of anxiety and depression in the caregivers of children with CVI, which may, in turn, be linked to poorer psychological health. For better understanding of this situation, qualitative studies that focus on the factors contributing to depression and anxiety in the caregivers of children with CVI would be beneficial.

Vision loss may disrupt the functioning of the circadian rhythm cycle (Atan et al., 2023). On the other hand, children with CP and CVI have been reported to experience more social and emotional problems compared with children with CP without CVI (Kılıç et al., 2025). As stated in another article, these symptoms constitute a risk factor for sleep disorders (Ogundele & Yemula, 2022). Another study found that the presence of CVI may reduce the child’s capacity to adapt to environmental stimuli, leading to frequent awakenings during the night (Ingram et al., 2022). In the literature, it has been reported that sleep problems in children directly affect the sleep patterns of caregivers and have negative consequences on mental health (Lang et al., 2021). In our study, a decrease in the visual skills level of children with CP and CVI was associated with a decrease in the sleep quality for both children and mothers and an increase in the anxiety and depression levels of mothers. Furthermore, decreased sleep quality in children with CP and CVI was associated with lower caregiver sleep quality and higher caregiver anxiety and depression. Moreover, according to the results of regression analysis in our study, the most important factor affecting the level of depression and anxiety of the mother was the sleep quality of children with CP and CVI. These findings suggest that visual function loss in children with CP and CVI may be not only related to children’s sleep patterns but also indirectly associated with the sleep quality and mental health of caregivers. In addition, the reciprocal decline in the sleep quality of children with CVI and their mothers may contribute to a cycle that could be linked to psychological well-being. Regression analysis further suggested that children’s sleep quality was the strongest explanatory factor for maternal depression and anxiety, showing that mothers’ mental health was more closely associated with their children’s sleep status than with their own sleep quality. This may reflect mothers’ tendency to view their children’s health and nighttime sleep status as a primary concern or to be related to anxieties about these issues (Serdengeçti et al., 2024). However, for a better understanding of this relationship, studies are needed that are designed to examine all factors that may influence maternal depression and sleep quality in combination.

Limitations of this study include that children with CP did not have a single CP type and that mothers of children with CP in both groups used sleeping pills. In addition, all assessments were based on parent-report measures, which may have introduced reporting bias, despite the use of validated and widely used instruments. Future studies should be planned to include mothers of children with CP and CVI who have a single CP type and who have not yet received pharmacologic or intervention approaches to sleep and to complement parent reports with observational or objective assessments.

Implications for Occupational Therapy Practice

The findings of this study indicate that sleep quality in children with cerebral palsy and cerebral visual impairment is closely associated with caregivers’ sleep quality and psychological well-being. In line with the Occupational Therapy Practice Framework: Domain and Practice (4th ed.; American Occupational Therapy Association, 2000), these findings suggest that not only addressing sleep-related assessments at the child level but also considering the child and caregiver together within a family-centered perspective may be clinically important. This study has the following implications for occupational therapy practice:

Occupational therapists may consider incorporating the assessment of sleep quality into routine occupational therapy evaluation processes, particularly for children with cerebral palsy and cerebral visual impairment.

When addressing sleep-related difficulties, it may be beneficial to assess children and caregivers together, taking into account the relationship between children’s sleep quality and caregivers’ sleep quality, anxiety, and depression levels.

Because reduced visual functioning may limit children’s ability to perceive environmental cues related to the day–night cycle, visual factors may be considered when examining sleep routines and the organization of daily life.

Occupational therapists may identify daily life and routine-related challenges associated with sleep difficulties and share these findings with the rehabilitation team, thereby contributing to strengthened interdisciplinary care.

Although this study did not evaluate intervention effectiveness, addressing sleep-related factors in occupational therapy evaluation and clinical planning processes may support a more holistic rehabilitation approach for children with cerebral palsy and cerebral visual impairment.

Conclusion

In this study, the sleep quality of children with CP and CVI was found to be lower than that of children with CP without CVI. At the same time, the mothers of children with CP and CVI were found to have poorer sleep quality and higher levels of depression and anxiety. Reduced visual abilities and poorer sleep quality in children were significantly associated with poorer sleep quality and higher levels of depression and anxiety in their mothers. Regression analysis showed a strong association between the sleep quality of children with CP and CVI and the mental health of their mothers. In addition to the visual function and sleep quality of children with CP and CVI, the sleep status and mental health of their caregiver mothers should also be included in routine evaluation processes. Where necessary, intervention programs covering these domains should be implemented for both children and caregivers. Future studies should examine in detail the factors that contribute to sleep problems in children with CP and CVI and the factors that affect sleep and mental health in caregivers. Furthermore, conducting randomized controlled intervention trials in this area will contribute to a clearer understanding of these associations and to the development of effective support strategies for both children and their families.

Footnotes

Acknowledgments

We thank the children and their mothers who participated in the study.

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