Parent-based sleep education for children with autism spectrum disorders

Assessment of Sleep in Children with Autism Spectrum Disorder

Sleep disturbances in children with autism spectrum disorder (ASD) are significantly more prevalent than found in typically developing (TD) children. Given the detrimental impact of poor sleep on cognitive, emotional, and behavioral functioning, it is imperative to screen and assess for sleep disturbances in this population. In this paper, we describe the screening and assessment process, as well as specific measures commonly used for assessing sleep in children with ASD. Advantages and limitations for use in children with ASD are discussed. While subjective measures, such as parent-report questionnaires and sleep diaries, are the most widely used, more objective measures such as actigraphy, polysomnography, and videosomnography provide additional valuable information for both diagnostic purposes and treatment planning. These objective measures, nonetheless, are limited by cost, availability, and feasibility of use with children with ASD. The current review provides an argument for the complementary uses of both subjective and objective measures of sleep specifically for use in children with ASD.

Sleep in Children with Autism Spectrum Disorder

The purposes of this paper are to provide an overview of the state of the science of sleep in children with autism spectrum disorder (ASD), present hypotheses for the high prevalence of insomnia in children with ASD, and present a practice pathway for promoting optimal sleep. Approximately two thirds of children with ASD have chronic insomnia, and to date, the strongest evidence on promoting sleep is for sleep education, environmental changes, behavioral interventions, and exogenous melatonin. The Sleep Committee of the Autism Treatment Network (ATN) developed a practice pathway, based on expert consensus, to capture best practices for screening, identification, and treatment for sleep problems in ASD in 2012. An exemplar case is presented to integrate key constructs of the practice pathway and address arousal and sensory dysregulation in a child with ASD and anxiety disorder. This paper concludes with next steps for dissemination of the practice pathway and future directions for research of sleep problems in ASD.

Insomnia, parasomnias, and narcolepsy in children: clinical features, diagnosis, and management

Sleep problems are frequently encountered as presenting complaints in child neurology clinical practice. They can affect the functioning and quality of life of children, particularly those with primary neurological and neurodevelopmental disorders, since coexisting sleep problems can add substantially to neurocognitive and behavioural comorbidities. Additionally, symptoms of some sleep disorders such as parasomnias and narcolepsy can be confused with those of other neurological disorders (eg, epilepsy), posing diagnostic challenges for paediatric neurologists. The understanding of the neurophysiology of sleep disorders such as insomnia, parasomnias, and narcolepsy is still evolving. There is a complex relation between the sleeping brain and its waking function. The interplay among genetic factors, alterations in neurotransmitters, electrophysiological changes, and environmental factors potentially contribute to the genesis of these sleep disorders.

Fathers experiences of sleeping problems in children with autism

Purpose

The purpose of this paper is to explore the role of fathers in the management of sleeping problems in children with autism and their perspectives of the impact of these difficulties on family life.

Design/methodology/approach

Semi-structured interviews with 25 UK-based fathers of children with autism were undertaken.

Findings

Two-thirds of fathers reported that their children experienced severe sleeping problems in the areas of bed-time resistance, sleep onset and night-time waking. Fathers were significantly involved in the management of these difficulties and reported a range of associated deleterious impacts on the family, including significant negative effects on paternal and maternal health, father’s employment, couple relationship and sibling experiences.

Research limitations/implications

The interview sample cannot be said to be representative of all fathers of children with autism since the backgrounds of those taking part were relatively homogeneous in respect of ethnicity, marital status and level of education.

Practical implications

Improvements in effective, family-centred provision are urgently needed which employ a co-parenting, gender-differentiated methodology.

Social implications

Given the severity and frequency of difficulties, sleeping problems in children with autism should be viewed as a significant public health concern.

Originality/value

This is one of the first studies, qualitative or quantitative, to explore the role and perspectives of fathers of children with autism in the important area of sleep management.

A Randomized, Crossover Trial of a Novel Sound-to-Sleep Mattress Technology in Children with Autism and Sleep Difficulties

STUDY OBJECTIVES

This preliminary study investigated the tolerability and efficacy of a novel mattress technology-the Sound-To-Sleep (STS) system-in the treatment of sleep problems in children with autism.

METHODS

After screening, 45 children, ages 2.5 to 12.9 years, were randomized to order of mattress technology use (On-Off vs. Off-On). Treatment conditions (On vs. Off) lasted two weeks with immediate crossover. Tolerability, including study discontinuation and parent-report of mattress tolerance and ease of use, was tracked throughout the study. Efficacy assessments were obtained at baseline, prior to crossover, and end of study and included measures of autism traits, other psychopathology symptoms, sensory abnormalities, communication difficulties, quality of life, sleep diary parameters, and single-blinded actigraphy-derived sleep parameters. Statistical analyses evaluated differences in tolerability and efficacy when the STS system was on versus off.

RESULTS

STS system use was well tolerated (n = 2, 4.4% dropout) and resulted in parent-reported sleep quality improvements (STS off mean = 4.3, 95% CI = 4.05-4.54 vs. on mean = 4.9, 95%CI = 4.67-5.14). The technology was described by parents as very easy to use and child tolerance was rated as good. Parent-diary outcomes indicated improvements in falling asleep and reduced daytime challenging behavior. Actigraphy-derived sleep parameters indicated improved sleep duration and sleep efficiency. Improvements in child and family quality of life were identified on parent questionnaires.

CONCLUSIONS

A future large sample phase 2 trial of the STS system is warranted and would benefit from extended study duration, an objective primary efficacy outcome, and careful attention to methodological issues that promote compliance with the intervention and study procedures.

Recommendations for Identifying Sleep Problems and Treatment Resources for Children with Autism Spectrum Disorder

Many young children experience sleep problems that may influence their daytime functioning. These sleep problems are especially prevalent in young children with autism spectrum disorder (ASD). Therefore, general recommendations for identifying and treating sleep problems in children with ASD are needed for behavior analysts to identify potential sleep problems and make empirically informed decisions regarding treatment options. The current paper seeks to provide behavior analysts, who work with children with ASD, with informative research on pediatric sleep problems, sleep measures, and options for behavioral sleep treatment.

Risks and Protective Factors for Stress Self-Management in Parents of Children With Autism Spectrum Disorder: An Integrated Review of the Literature

PROBLEM

Stress in parents of children with autism spectrum disorder (ASD) has been reported to be very high. However, little is known about what risk and protective factors influence parental stress self-management in this population. Accordingly, this manuscript is a synthesis of the risk and protective factors that impact self-management of stress in these parents. The concepts in the individual and family self-management theory context domain were used as a framework to guide data collection and analysis.

ELIGIBILITY CRITERIA

Searches were conducted using CINAHL, MedLine and PsychInfo. Studies were included if they addressed context factors in parents of children with ASD and were written in English.

SAMPLE

Ninety-eight studies met review criteria.

RESULTS

This review highlighted risk factors to parental stress self-management within the context of condition-specific factors, physical and social environment, and individual and family. The most concerning of these findings is that parents struggle accessing a diagnosis and services for their child and are frustrated with health care providers' knowledge of ASD and lack of communication.

CONCLUSIONS

The risks parents experience as they care for their child with ASD far outweigh the protective factors for self-management of parental stress.

IMPLICATIONS

Nurses who are aware of these issues can make important changes to their practice and have a significant impact on parental stress self-management and the care of children with ASD.

Sleep Problems in Young Children with Autism Spectrum Disorders: A Study of Parenting Stress, Mothers' Sleep-Related Cognitions, and Bedtime Behaviors

INTRODUCTION

Disrupted sleep is common among children with autism spectrum disorder (ASD).

AIMS

Our goal was to (1) examine the contribution of sleep problems to parenting stress in children with ASD as compared to typically developing (TD) and (2) to address maternal sleep-related cognitions and behaviors in both groups.

METHODS

Mothers of 34 ASD (mean age = 39.29 months, SD = 5.22) and 31 TD children (mean age = 36.23 months, SD = 5.75) completed questionnaires measuring maternal stress, sleep-related cognitions and settling to sleep interactions, and the child's sleep problems; mothers in the ASD group completed a symptom severity questionnaire.

RESULTS

In accord with previous research, children with ASD had more sleep problems compared to the TD group, and their mothers reported higher levels of stress. In the ASD group, sleep problems contributed to the experience of maternal stress, over and above symptom severity. Across groups, maternal cognitions and bedtime interactions were significantly associated with children's sleep problems.

CONCLUSION

The results highlight the interplay between sleep-related cognitions, bedtime interactions, and sleep problems and underscore the contribution of disrupted sleep to mothers' experience of parenting stress. As sleep problems in ASD children are common, clinicians are advised to include sleep in consultations with parents.

Promoting Sleep Health Among Families of Young Children in Head Start: Protocol for a Social-Ecological Approach

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

The Pediatric Sleep Clinical Global Impressions Scale-A New Tool to Measure Pediatric Insomnia in Autism Spectrum Disorders

OBJECTIVE

To pilot a clinician-based outcome measure that provides complementary information to objective measures and parent-based questionnaires for insomnia in children with autism spectrum disorders (ASD).

METHOD

The authors developed a Pediatric Sleep Clinical Global Impressions Scale (CGI). Questions included (1) the child's ability to fall asleep and remain sleeping independently (i.e., apart from parents); (2) bedtime resistance; (3) sleep onset delay; (4) night awakening; (5) parental satisfaction with their child's current sleep patterns; (6) family functioning as affected by their child's current sleep patterns; and (7) clinician's overall concern with the child's sleep. After refining the instrument through the evaluation of vignettes by ASD and sleep experts, the authors piloted the Pediatric Sleep CGI in a 12-week randomized trial of iron supplementation in children with ASD. Clinicians completed Pediatric Sleep CGIs and structured sleep histories, parents completed the Children's Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches.

RESULTS

In repeated measures models, the Pediatric Sleep CGI and CSHQ were correlated for sleep onset delay (r = .66, p < .001), night wakings (r = .40, p < .001), and total score (r = .29, p < .001). The CGI-S sleep onset delay and actigraphy sleep onset delay scores (r = .75, p = .0095) were also correlated. The overall CGI-S showed improvement with therapy (p = .047).

CONCLUSION

The Pediatric Sleep CGI shows promise in measuring clinician-rated outcomes in pediatric insomnia in children with ASD. Larger samples will be necessary to examine reliability, validity, and measure to change, as well as applicability to other populations with pediatric insomnia.

Treatment for Sleep Problems in Children with Autism and Caregiver Spillover Effects

Sleep problems in children with autism spectrum disorders (ASD) are under-recognized and under-treated. Identifying treatment value accounting for health effects on family members (spillovers) could improve the perceived cost-effectiveness of interventions to improve child sleep habits. A prospective cohort study (N = 224) was conducted with registry and postal survey data completed by the primary caregiver. We calculated quality of life outcomes for the child and the primary caregiver associated with treatments to improve sleep in the child based on prior clinical trials. Predicted treatment effects for melatonin and behavioral interventions were similar in magnitude for the child and for the caregiver. Accounting for caregiver spillover effects associated with treatments for the child with ASD increases treatment benefits and improves cost-effectiveness profiles.

Management of sleep disorders in neurodevelopmental disorders and genetic syndromes

PURPOSE OF REVIEW

Sleep disorders in individuals with developmental difficulties continue to be a significant challenge for families, carers, and therapists with a major impact on individuals and carers alike. This review is designed to update the reader on recent developments in this area.

RECENT FINDINGS

A systematic search identified a variety of studies illustrating advances in the regulation of circadian rhythm and sleep disturbance in neurodevelopmental disorders. Specific advances are likely to lead in some disorders to targeted therapies. There is strong evidence that behavioural and sleep hygiene measures should be first line therapy; however, studies are still limited in this area. Nonpharmacological measures such as exercise, sensory interventions, and behavioural are reported. Behavioural regulation and sleep hygiene demonstrate the best evidence for improved sleep parameters in individuals with neurodisability.

SUMMARY

Although the mainstay of management of children with sleep problems and neurodevelopmental disability is similar to that of typically developing children, there is emerging evidence of behavioural strategies being successful in large-scale trials and the promise of more targeted therapies for more specific resistant disorders.

Counting Sheep: Sleep Disorders in Children With Autism Spectrum Disorders

INTRODUCTION

This article will discuss the prevalence and types of sleep disorders experienced by children with autism spectrum disorders (ASDs), the risk factors for the development of sleep disorders among children with ASDs, the impact of sleep disorders on children with ASDs, and the role of the primary care provider (PCP) in diagnosing and treating sleep disorders among children with ASDs.

METHOD

Review of published literature on the topic.

RESULTS

Children with ASDs are at risk for the development of chronic sleep disorders, which can have a negative impact on behavior. Both behavioral and pharmacological interventions exist for the treatment of sleep disorders among children with ASDs, with supplemental melatonin being the most widely studied and proven treatment.

DISCUSSION

PCPs will care for children with ASDs. Therefore, it is vital for PCPs to be knowledgeable about this topic and to promptly assess for and manage sleep disorders among children with ASDs.

The Autism Speaks Autism Treatment Network Registry Data: Opportunities for Investigators

OBJECTIVE

Patient registries can effectively collect data over a long period of time to provide a better understanding of the typical presentation of specific conditions. The autism spectrum disorders (ASDs) have experienced a marked increase in reported prevalence over the past 20 years for reasons that are not completely clear. The Autism Treatment Network (ATN) Registry was established to facilitate investigations into a variety of questions critical to expanding our understanding of ASDs. Here we describe the establishment of the registry, its components, some of its findings to date, and opportunities for further use of this data.

METHODS

Participants are eligible for enrollment into the ATN registry if they are between the ages of 2.0 and 17.6 years at the time of enrollment and meet criteria for ASD as determined by clinical consensus on the basis of specific diagnostic measures (Autism Diagnostic Observation Schedule/Autism Diagnostic Observation Schedule, Second Edition; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). Baseline measures include demographics, autism assessment, cognitive assessment data, behavioral data, sleep habits, quality of life, sensory data, and treatments. Several of the measures are collected at annual follow-up visits.

RESULTS

More than 6800 children with ASD have been enrolled in the Autism Speaks ATN registry. Data from the registry have been reported at numerous scientific meetings and in several publications and have led to new recommendations for best practices in the management of ASD.

CONCLUSIONS

A patient registry for children and adolescents with ASD has had and will continue to have a significant impact on care for this population. Investigators are encouraged to query this database to further its impact by testing novel hypotheses and conducting preliminary proof-of-concept analyses.

Sleep Difficulties and Medications in Children With Autism Spectrum Disorders: A Registry Study

OBJECTIVES

Sleep difficulties are common in children with autism spectrum disorders, with wide-ranging effects on the child's daytime behavior. We reviewed data within our Autism Speaks Autism Treatment Network Registry to determine the prevalence of sleep difficulties and patterns of medication use.

METHODS

Data from 1518 children ages 4 to 10 years were analyzed to determine the number of children documented to have sleep difficulties by parent-completed questionnaires and clinician-completed forms and how these findings related to the use of sleep medications.

RESULTS

The Children's Sleep Habits Questionnaire total score was ≥41 (associated with clinically significant sleep problems in past research) in 71% of children. The prevalence of sleep diagnoses was less frequent (30% of children aged 4-10 years; P < .0001). Medications for sleep were prescribed in 46% of 4- to 10-year-olds given a sleep diagnosis. The most common medication used for sleep was melatonin followed by α-agonists, with a variety of other medications taken for sleep (anticonvulsants, antidepressants, atypical antipsychotics, and benzodiazepines). Children taking medications for sleep had worse daytime behavior and pediatric quality of life than children not taking sleep medications.

CONCLUSIONS

Parent concerns about sleep may not be reflected in the information gathered during a clinic visit, supporting the need to develop screening practice pathways for sleep in autism spectrum disorders. Furthermore, many medications taken for sleep have adverse effects, supporting the need for evidence-based interventions in this population.

Stress and Parents of Children with Autism: A Review of Literature

The purpose of this review is twofold. The first is to synthesize factors that impact parents' experiences of caring for a child with autism spectrum disorder (ASD); the second is to identify factors that impact parental stress and parental decision-making to use autism services or not. Parents of children with ASD score higher on levels of stress than other groups of parents. The daily challenges of caring for the child are endless and effect all aspects of the child's care as well as the parent's mental health and ability to manage the needs of the child and family. Understanding more about the challenges parents face will provide direction for research, intervention development, and practice. Accordingly, a search was conducted using CINAHL and Medline. Inclusion criteria included articles available in full text, published in English, and focused on children with ASD distinct from other diagnoses, as well as parental experiences of caring for a child with ASD. Articles (N = 132) that met the inclusion criteria were summarized. Challenging aspects of the child's diagnosis and care are discussed, as well as the factors that impact parental stress and decision-making to use autism services. Recommendations for research and practice include interventional development related to early diagnosis, disparity, access to care, parental decision-making to use autism services, and parental stress management.

Sleep Disturbances in Neurodevelopmental Disorders

Sleep disturbances are extremely prevalent in children with neurodevelopmental disorders compared to typically developing children. The diagnostic criteria for many neurodevelopmental disorders include sleep disturbances. Sleep disturbance in this population is often multifactorial and caused by the interplay of genetic, neurobiological and environmental overlap. These disturbances often present either as insomnia or hypersomnia. Different sleep disorders present with these complaints and based on the clinical history and findings from diagnostic tests, an appropriate diagnosis can be made. This review aims to provide an overview of causes, diagnosis, and treatment of sleep disturbances in neurodevelopmental disorders that present primarily with symptoms of hypersomnia and/or insomnia.

Sleep in Neurodevelopmental Disorders

Individuals with intellectual and developmental disabilities (IDD) experience sleep problems at higher rates than the general population. Although individuals with IDD are a heterogeneous group, several sleep problems cluster within genetic syndromes or disorders. This review summarizes the prevalence of sleep problems experienced by individuals with Angelman syndrome, Cornelia de Lange syndrome, Cri du Chat syndrome, Down syndrome, fragile X syndrome, Prader-Willi syndrome, Smith-Magenis syndrome, Williams syndrome, autism spectrum disorder, and idiopathic IDD. Factors associated with sleep problems and the evidence for sleep treatments are reviewed for each neurodevelopmental disorder. Sleep research advancements in neurodevelopmental disorders are reviewed, including the need for consistency in defining and measuring sleep problems, considerations for research design and reporting of results, and considerations when evaluating sleep treatments.

Sleep in Children With Autism Spectrum Disorders: How Are Measures of Parent Report and Actigraphy Related and Affected by Sleep Education?

Sleep disturbance is common in children with autism, resulting in a great need for effective treatments. To evaluate treatments for sleep disturbance in this population, it is critical to understand the relationship between measures of sleep captured by parent report and objective measures. The Children's Sleep Habits Questionnaire (CSHQ) and actigraphy-measured data from 80 children with autism and sleep-onset delay were evaluated. Reported problems with sleep-onset delay were concurrent with sleep duration problems in 66% of children, night wakings in 72% of children, and bedtime resistance in 66% of children; 38% of children were reported to have problems with all CSHQ insomnia domains. Actigraphy-measured sleep duration was correlated with estimates using CSHQ-reported bed and wake times.

Evaluation of actigraphy-measured sleep patterns among children with disabilities and associations with caregivers' educational attainment: results from a cross-sectional study

OBJECTIVES

To use wrist-actrigrphy to collect objective measures of sleep and to characterise actigraphy-measured sleep patterns among children with disabilities. We also assessed the extent to which, if at all, caregivers' education is associated with children's sleep disturbances.

DESIGN

Cross-sectional study.

SETTING

A rehabilitation centre in the Patagonia region, Chile.

METHODS

This study was conducted among 125 children aged 6-12 years with disabilities (boys: 55.2%) and their primary caregivers in Chile. Children wore ActiSleep monitors for 7 days. A general linear model was fitted to generate least-square means and SEs of sleep efficiency (proportion of the sleep period spent asleep) across caregivers' education levels adjusting for children's age, sex, disability type, caregiver-child relationship and caregivers' age. Multivariable logistic regression analyses were conducted to estimate ORs and 95% CIs of longer sleep latency (≥ 30 min) and longer wake after sleep onset (WASO) (≥ 90 min) (a measure of sleep fragmentation) in relation to caregivers' educational attainment.

RESULTS

Median sleep latency was 27.3 min, WASO 88.1 min and sleep duration 8.0 h. Mean sleep efficiency was 80.0%. Caregivers' education was positively and significantly associated with children's sleep efficiency (p trend<0.001). Adjusted mean sleep efficiency was 75.7% (SE=1.4) among children of caregivers high school education. Compared to children whose caregivers had >high school, children of caregivers with

CONCLUSIONS

Children with disabilities experience difficulties initiating sleep (prolonged sleep latency) and maintaining sleep (long WASO, low sleep efficiency). Among children with disabilities, lower level of caregivers' education is associated with more sleep disturbances.

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Key Words

• EPIDEMIOLOGY
• PUBLIC HEALTH
• SLEEP MEDICINE

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MESH Headings

• Actigraphy/instrumentation
• Actigraphy/methods
• Adult
• Caregivers/education
• Caregivers/psychology
• Child
• Chile/epidemiology
• Cross-Sectional Studies
• Disabled Children/psychology
• Educational Status
• Female
• Humans
• Male
• Sleep Wake Disorders/epidemiology
• Sleep Wake Disorders/etiology
• Sleep Wake Disorders/psychology
• Surveys and Questionnaires

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Grants

• T37 MD001449 NIMHD NIH HHS
• UL1 TR000170 NCATS NIH HHS
• 8UL1TR000170-07 NCATS NIH HHS
• T37-MD001449 NIMHD NIH HHS

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Affiliation(s)

Xiaoli Chen Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
Juan Carlos Velez Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Clarita Barbosa Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Micah Pepper Centro de Rehabilitación Club de Leones Cruz del Sur, Punta Arenas, Chile
Bizu Gelaye Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
Susan Redline Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
Michelle A Williams Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA

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Genetic variation in melatonin pathway enzymes in children with autism spectrum disorder and comorbid sleep onset delay

Sleep disruption is common in individuals with autism spectrum disorder (ASD). Genes whose products regulate endogenous melatonin modify sleep patterns and have been implicated in ASD. Genetic factors likely contribute to comorbid expression of sleep disorders in ASD. We studied a clinically unique ASD subgroup, consisting solely of children with comorbid expression of sleep onset delay. We evaluated variation in two melatonin pathway genes, acetylserotonin O-methyltransferase (ASMT) and cytochrome P450 1A2 (CYP1A2). We observed higher frequencies than currently reported (p < 0.04) for variants evidenced to decrease ASMT expression and related to decreased CYP1A2 enzyme activity (p ≤ 0.0007). We detected a relationship between genotypes in ASMT and CYP1A2 (r(2) = 0.63). Our results indicate that expression of sleep onset delay relates to melatonin pathway genes.

Non-pharmacological management of problematic sleeping in children with developmental disabilities

AIM

Sleep is important for underlying neural plasticity, and children with developmental disabilities suffer behavioural, emotional, cognitive, and sensory-motor issues that affect their wake and sleep states. Problematic sleeping can be hypothesized to have adverse effects on both of these areas in children with developmental disabilities. With this review, we aim to provide a benchmark in managing problematic sleeping in children with developmental disabilities.

METHOD

A literature search was conducted and data on the study descriptives, patient characteristics, study design, study-related factors, criteria applied to operationalize sleep and developmental disability, and sleep 'management' were collected. Each management strategy was tabulated and analysed.

RESULTS

We identified 90 studies involving 1460 children with developmental disabilities, of whom 61.6% were male. The highest proportion of studies, almost half, were in children with syndromes (44.4%), followed by studies in children with intellectual disabilities (18.9%). Non-pharmacological sleep management was primarily aimed at improving sleep quality (86.7%), followed by sleep-wake schedules and, to a certain extent, sleep regularity (42.2%). About 56.7% of the studies reported more than one approach. Studies mostly focused on disorders of initiating and maintaining sleep through a diversity of strategies and relied heavily on subjective measures to identify and monitor problematic sleeping. Sleep management approaches were primarily delivered at the level of the individual in the home setting. The number of management approaches per study was unrelated to the number of sleep problems discussed.

INTERPRETATION

Modifying sleep management strategies to meet the specific needs of children with developmental disabilities is encouraged, and studies that look beyond sleep quality or sleep quantity are required. It is also advocated that modifications to sleep hygiene, sleep regularity, and sleep ecology in a population with developmental disabilities are rigorously investigated. Finally, daytime somnolence should not be overlooked when aiming to optimize sleep in children with developmental disabilities across the ages and stages of their lives. There were several limitations in the research findings of problematic sleep in children with developmental disabilities. In general, the sleep problems and the developmental disabilities investigated were multicomponent in nature. It is likely that management approaches impacted those problems on multiple levels or through diverse 'therapeutic' pathways. There is a need for randomized controlled trials and more objective measures that quantify improved sleep or wake states.

The relationship between sleep and behavior in autism spectrum disorder (ASD): a review

Although there is evidence that significant sleep problems are common in children with autism spectrum disorder (ASD) and that poor sleep exacerbates problematic daytime behavior, such relationships have received very little attention in both research and clinical practice. Treatment guidelines to help manage challenging behaviors in ASD fail to mention sleep at all, or they present a very limited account. Moreover, limited attention is given to children with low-functioning autism, those individuals who often experience the most severe sleep disruption and behavioral problems. This paper describes the nature of sleep difficulties in ASD and highlights the complexities of sleep disruption in individuals with low-functioning autism. It is proposed that profiling ASD children based on the nature of their sleep disruption might help to understand symptom and behavioral profiles (or vice versa) and therefore lead to better-targeted interventions. This paper concludes with a discussion of the limitations of current knowledge and proposes areas that are important for future research. Treating disordered sleep in ASD has great potential to improve daytime behavior and family functioning in this vulnerable population.

MBD5 haploinsufficiency is associated with sleep disturbance and disrupts circadian pathways common to Smith-Magenis and fragile X syndromes

Individuals with autism spectrum disorders (ASD) who have an identifiable single-gene neurodevelopmental disorder (NDD), such as fragile X syndrome (FXS, FMR1), Smith-Magenis syndrome (SMS, RAI1), or 2q23.1 deletion syndrome (del 2q23.1, MBD5) share phenotypic features, including a high prevalence of sleep disturbance. We describe the circadian deficits in del 2q23.1 through caregiver surveys in which we identify several frequent sleep anomalies, including night/early awakenings, coughing/snoring loudly, and difficulty falling asleep. We couple these findings with studies on the molecular analysis of the circadian deficits associated with haploinsufficiency of MBD5 in which circadian gene mRNA levels of NR1D2, PER1, PER2, and PER3 were altered in del 2q23.1 lymphoblastoid cell lines (LCLs), signifying that haploinsufficiency of MBD5 can result in dysregulation of circadian rhythm gene expression. These findings were further supported by expression microarrays of MBD5 siRNA knockdown cells that showed significantly altered expression of additional circadian rhythm signaling pathway genes. Based on the common sleep phenotypes observed in del 2q23.1, SMS, and FXS patients, we explored the possibility that MBD5, RAI1, and FMR1 function in overlapping circadian rhythm pathways. Bioinformatic analysis identified conserved putative E boxes in MBD5 and RAI1, and expression levels of NR1D2 and CRY2 were significantly reduced in patient LCLs. Circadian and mTOR signaling pathways, both associated with sleep disturbance, were altered in both MBD5 and RAI1 knockdown microarray data, overlapping with findings associated with FMR1. These data support phenotypic and molecular overlaps across these syndromes that may be exploited to provide therapeutic intervention for multiple disorders.