Sleep disturbances and correlates of children with autism spectrum disorders

Sleep disturbance and other co-occurring conditions in autistic children: A network approach to understanding their inter-relationships

Autistic children frequently have one or more co-occurring psychological, behavioral, or medical conditions. We examined relationships between child behaviors, sleep, adaptive behavior, autistic traits, mental health conditions, and health in autistic children using network analysis. Network analysis is hypothesis generating and can inform our understanding of relationships between multiple conditions and behaviors, directing the development of transdiagnostic treatments for co-occurring conditions. Participants were two child cohorts from the Autism Treatment Network registry: ages 2-5 years (n = 2372) and 6-17 years (n = 1553). Least absolute-shrinkage and selection operator (LASSO) regularized partial correlation network analysis was performed in the 2-5 years cohort (35 items) and the 6-17 years cohort (36 items). The Spinglass algorithm determined communities within each network. Two-step expected influence (EI2) determined the importance of network variables. The most influential network items were sleep difficulties (2 items) and aggressive behaviors for young children and aggressive behaviors, social problems, and anxious/depressed behavior for older children. Five communities were found for younger children and seven for older children. Of the top three most important bridge variables, night-waking/parasomnias and anxious/depressed behavior were in both age-groups, and somatic complaints and sleep initiation/duration were in younger and older cohorts respectively. Despite cohort differences, sleep disturbances were prominent in all networks, indicating they are a transdiagnostic feature across many clinical conditions, and thus a target for intervention and monitoring. Aggressive behavior was influential in the partial correlation networks, indicating a potential red flag for clinical monitoring. Other items of strong network importance may also be intervention targets or screening flags.

Pattern of sleep disorders among children with autism spectrum disorder

BACKGROUND

Sleep disorders (SDs) are among many co-morbid medical conditions that affect children with autism spectrum disorder (ASD). Raising awareness and improving the standard of care for children diagnosed with ASD may result from identifying SDs among them. This study aims to evaluate patterns of SDs among Sudanese children diagnosed with ASD.

METHOD

Using the Childhood Sleep Habit Questionnaire (CSHQ) to gather data on sleep disorders and SPSS version 26.0 for data analysis, a descriptive cross-sectional study was carried out in the five main autistic centres in Khartoum state covering all registered patients with ASD between April and June 2022. Ninety-two children diagnosed with ASD were enrolled in this study after the purpose of the research was explained and consent was obtained from their guardians. A p-value < 0.05 was considered to indicate statistical significance.

RESULTS

The mean age was 6.90 (± 2.6) years with a boys-to-girls ratio of 2.17:1. The prevalence of SDs (at least one sleep condition almost daily) was 95.65%. Sleep onset 71 (77.2%), limit setting 32 (32.6%), resistant onset to sleep 48 (52.2%), and combined 52 (56.5%) insomnia affected the majority of children. Additionally, there were significant associations between sex and Limit-setting insomnia, advanced sleep phase disorder, and narcolepsy type 2 (P values = 0.033, 0.009, and 0.037, respectively). Additionally, there was a significant association between age and sleep-related breathing disorders-snoring (p value = 0.031).

CONCLUSION

The frequency of SDs is significant among children diagnosed with ASD from Sudan, and certain SDs are associated with age and sex. Subsequent studies are required to develop national guidelines for the prevalence, presentation, screening, and treatment of SDs in children diagnosed with ASD.

Hypnotic treatment improves sleep architecture and EEG disruptions and rescues memory deficits in a mouse model of fragile X syndrome

Fragile X syndrome (FXS) is associated with disrupted cognition and sleep abnormalities. Sleep loss negatively impacts cognitive function, and one untested possibility is that disrupted cognition in FXS is exacerbated by abnormal sleep. We tested whether ML297, a hypnotic acting on G-protein-activated inward-rectifying potassium (GIRK) channels, could reverse sleep phenotypes and disrupted memory in Fmr1-/y mice. Fmr1-/y mice exhibit reduced non-rapid eye movement (NREM) sleep and fragmented NREM architecture, altered sleep electroencephalogram (EEG) oscillations, and reduced EEG coherence between cortical areas; these are partially reversed following ML297 administration. Treatment following contextual fear or spatial learning restores disrupted memory consolidation in Fmr1-/y mice. During memory recall, Fmr1-/y mice show an altered balance of activity among hippocampal principal neurons vs. parvalbumin-expressing interneurons; this is partially reversed by ML297. Because sleep disruption could impact neurophysiological phenotypes in FXS, augmenting sleep may improve disrupted cognition in this disorder.

The intersection of sleep and synaptic translation in synaptic plasticity deficits in neurodevelopmental disorders

Individuals with neurodevelopmental disorders experience persistent sleep deficits, and there is increasing evidence that sleep dysregulation is an underlying cause, rather than merely an effect, of the synaptic and behavioral defects observed in these disorders. At the molecular level, dysregulation of the synaptic proteome is a common feature of neurodevelopmental disorders, though the mechanism connecting these molecular and behavioral phenotypes is an ongoing area of investigation. A role for eIF2α in shifting the local proteome in response to changes in the conditions at the synapse has emerged. Here, we discuss recent progress in characterizing the intersection of local synaptic translation and sleep and propose a reciprocal mechanism of dysregulation in the development of synaptic plasticity defects in neurodevelopmental disorders.

Sleep problems and circadian rhythm functioning in autistic children, autism with co-occurring attention deficit hyperactivity disorder, and typically developing children: A comparative study

LAY ABSTRACT

Sleep problems are common in autism spectrum disorder (ASD) and different factors can contribute to its occurrence in this population. Misalignment of the biological clock (our circadian system) has been described as one possible explanation. While there is a body of research on sleep problems, relatively less is known about circadian functioning and the specific population of autistic children with co-occurring attention deficit hyperactivity disorder (ADHD). Using an ambulatory circadian monitoring (ACM) system, which resembles a common watch, we gathered sleep parameters and the different rhythms obtained from measuring motor activity, light exposure and distal temperature in 87 autistic children and adolescents, 27 of whom were diagnosed with co-occurring ADHD, and 30 neurotypical children and adolescents as a comparison group. Autistic children and, especially, those with co-occurring ADHD showed greater motor activity during sleep which would be worth studying in future projects which could better define this restless sleep. Of note, we observed an atypical pattern of wrist temperature, with higher values in neurotypical children, followed by autistic children and, ultimately, those with co-occurring ADHD. Temperature is one of the most valuable factors evaluated here as it is closely connected to sleep-wakefulness and the hormone melatonin. Its special pattern during day and nighttime would support the hypothesis of an atypical secretion of melatonin in autistic individuals which would also link with the higher presence of sleep problems in this neurodevelopmental condition.

Sleep and Activity Patterns in Autism Spectrum Disorder

Background

Autism spectrum disorder (ASD) is a highly heritable and heterogeneous neurodevelopmental disorder characterized by impaired social interactions, repetitive behaviors, and a wide range of comorbidities. Between 44-83% of autistic individuals report sleep disturbances, which may share an underlying neurodevelopmental basis with ASD.

Methods

We recruited 382 ASD individuals and 223 of their family members to obtain quantitative ASD-related traits and wearable device-based accelerometer data spanning three consecutive weeks. An unbiased approach identifying traits associated with ASD was achieved by applying the elastic net machine learning algorithm with five-fold cross-validation on 6,878 days of data. The relationship between sleep and physical activity traits was examined through linear mixed-effects regressions using each night of data.

Results

This analysis yielded 59 out of 242 actimetry measures associated with ASD status in the training set, which were validated in a test set (AUC: 0.777). For several of these traits (e.g. total light physical activity), the day-to-day variability, in addition to the mean, was associated with ASD. Individuals with ASD were found to have a stronger correlation between physical activity and sleep, where less physical activity decreased their sleep more significantly than that of their non-ASD relatives.

Conclusions

The average duration of sleep/physical activity and the variation in the average duration of sleep/physical activity strongly predict ASD status. Physical activity measures were correlated with sleep quality, traits, and regularity, with ASD individuals having stronger correlations. Interventional studies are warranted to investigate whether improvements in both sleep and increased physical activity may improve the core symptoms of ASD.

The Connection Between Sleep Problems and Emotional and Behavioural Difficulties in Autistic Children: A Network Analysis

The interactions between sleep problems, autism symptoms and emotional and behavioural difficulties were explored using network analysis in 240 autistic children (mean age: 8.8 years, range 5-13 years) with moderate to severe sleep problems. Findings revealed a highly connected and interpretable network, with three separate clusters identified of the modelled variables. Depression, anxiety and behavioural difficulties were the most central variables of the network. Depression, anxiety and restricted repetitive and stereotyped patterns behaviours (RRBs) were the strongest bridging variables in the network model, transmitting activation both within and between other symptom clusters. The results highlight that depression and anxiety were highly connected symptoms within the network, suggesting support in these areas could be helpful, as well as future research.

Autism Spectrum Disorder and Sleep

Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.

Incidence of Otolaryngological Manifestations in Individuals with Autism Spectrum Disorder: A Special Focus on Auditory Disorders

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by stereotyped and repetitive behavior patterns. In addition to neurological and behavioral problems, individuals with ASD commonly experience otolaryngological comorbidities. Individuals with ASD often have auditory disorders including hearing loss and auditory processing disorders such as central auditory processing disorder (CAPD), as well as both chronic and recurrent otitis media. These challenges negatively impact a person's ability to effectively communicate and may further impact their neurological functioning, particularly when not appropriately treated. Individuals diagnosed with ASD also have difficulty sleeping which contributes to increased irritability and may further aggravate the core behavioral symptoms of autism. The individuals with ASD also have a higher rate of sinusitis which contributes to the worsening of the autism behavior phenotype. The high prevalence of otolaryngological comorbidities in individuals with ASD warrants a better collaboration between their various healthcare providers and otolaryngologists with expertise in auditory, sleep, and sinus disorders in pursuit of improving the quality of life of affected individuals and their families/caregivers.

Children with Autism Spectrum Disorder and Abnormalities of Clinical EEG: A Qualitative Review

Over the last decade, the comorbidity between Autism Spectrum Disorder (ASD) and epilepsy has been widely demonstrated, and many hypotheses regarding the common neurobiological bases of these disorders have been put forward. A variable, but significant, prevalence of abnormalities on electroencephalogram (EEG) has been documented in non-epileptic children with ASD; therefore, several scientific studies have recently tried to demonstrate the role of these abnormalities as a possible biomarker of altered neural connectivity in ASD individuals. This narrative review intends to summarize the main findings of the recent scientific literature regarding abnormalities detected with standard EEG in children/adolescents with idiopathic ASD. Research using three different databases (PubMed, Scopus and Google Scholar) was conducted, resulting in the selection of 10 original articles. Despite an important lack of studies on preschoolers and a deep heterogeneity in results, some authors speculated on a possible association between EEG abnormalities and ASD characteristics, in particular, the severity of symptoms. Although this correlation needs to be more strongly elucidated, these findings may encourage future studies aimed at demonstrating the role of electrical brain abnormalities as an early biomarker of neural circuit alterations in ASD, highlighting the potential diagnostic, prognostic and therapeutic value of EEG in this field.

UBE3A: The Role in Autism Spectrum Disorders (ASDs) and a Potential Candidate for Biomarker Studies and Designing Therapeutic Strategies

Published reports from the CDC's Autism and Development Disabilities Monitoring Networks have shown that an average of 1 in every 44 (2.3%) 8-year-old children were estimated to have ASD in 2018. Many of the ASDs exhibiting varying degrees of autism-like phenotypes have chromosomal anomalies in the Chr15q11-q13 region. Numerous potential candidate genes linked with ASD reside in this chromosomal segment. However, several clinical, in vivo, and in vitro studies selected one gene more frequently than others randomly and unbiasedly. This gene codes for UBE3A or Ubiquitin protein ligase E3A [also known as E6AP ubiquitin-protein ligase (E6AP)], an enzyme involved in the cellular degradation of proteins. This gene has been listed as one of the several genes with a high potential of causing ASD in the Autism Database. The gain of function mutations, triplication, or duplication in the UBE3A gene is also associated with ASDs like Angelman Syndrome (AS) and Dup15q Syndrome. The genetic imprinting of UBE3A in the brain and a preference for neuronal maternal-specific expression are the key features of various ASDs. Since the UBE3A gene is involved in two main important diseases associated with autism-like symptoms, there has been widespread research going on in understanding the link between this gene and autism. Additionally, since no universal methodology or mechanism exists for identifying UBE3A-mediated ASD, it continues to be challenging for neurobiologists, neuroscientists, and clinicians to design therapies or diagnostic tools. In this review, we focus on the structure and functional aspects of the UBE3A protein, discuss the primary relevance of the 15q11-q13 region in the cause of ASDs, and highlight the link between UBE3A and ASD. We try to broaden the knowledge of our readers by elaborating on the possible mechanisms underlying UBE3A-mediated ASDs, emphasizing the usage of UBE3A as a prospective biomarker in the preclinical diagnosis of ASDs and discuss the positive outcomes, advanced developments, and the hurdles in the field of therapeutic strategies against UBE3A-mediated ASDs. This review is novel as it lays a very detailed and comprehensive platform for one of the most important genes associated with diseases showing autistic-like symptoms. Additionally, this review also attempts to lay optimistic feedback on the possible steps for the diagnosis, prevention, and therapy of these UBE3A-mediated ASDs in the upcoming years.

Autism Traits and Cognitive Performance: Mediating Roles of Sleep Disturbance, Anxiety and Depression

Theories about autism spectrum disorder (ASD) have addressed cognitive deficits however few have examined how comorbid diagnoses, including sleep disturbance, anxiety and depression contribute to the underlying deficits. We investigated potential mediations of common ASD comorbidities in the relationship between sub-clinical autism traits and cognitive performance using an international community sample. Cognitive tasks assessed working memory [executive functioning (EF) theory], mental state attribution [theory of mind (ToM)], and global/local visual processing [weak central coherence (WCC) theory]. Structural equation modelling (SEM) demonstrated sleep disturbance and anxiety mediated the relationship of autism traits on measures of EF, but not WCC and ToM. This suggests that treating the symptoms of sleep disturbance and anxiety may lead to improvements in working memory.

Assessment of autonomic symptom scales in patients with neurodevelopmental diagnoses using electronic health record data

Background

Sleep disturbances, gastrointestinal problems, and atypical heart rate are commonly observed in patients with autism spectrum disorder (ASD) and may relate to underlying function of the autonomic nervous system (ANS). The overall objective of the current study was to quantitatively characterize features of ANS function using symptom scales and available electronic health record (EHR) data in a clinically and genetically characterized pediatric cohort.

Methods

We assessed features of ANS function via chart review of patient records adapted from items drawn from a clinical research questionnaire of autonomic symptoms. This procedure coded for the presence and/or absence of targeted symptoms and was completed in 3 groups of patients, including patients with a clinical neurodevelopmental diagnosis and identified genetic etiology (NPD, n=244), those with an ASD diagnosis with no known genetic cause (ASD, n=159), and age and sex matched controls (MC, n=213). Symptoms were assessed across four main categories: (1) Mood, Behavior, and Emotion; (2) Secretomotor, Sensory Integration; (3) Urinary, Gastrointestinal, and Digestion; and (4) Circulation, Thermoregulation, Circadian function, and Sleep/Wake cycles.

Results

Chart review scores indicate an increased rate of autonomic symptoms across all four sections in our NPD group as compared to scores with ASD and/or MC. Additionally, we note several significant relationships between individual differences in autonomic symptoms and quantitative ASD traits.

Conclusion

These results highlight EHR review as a potentially useful method for quantifying variance in symptoms adapted from a questionnaire or survey. Further, using this method indicates that autonomic features are more prevalent in children with genetic disorders conferring risk for ASD and other neurodevelopmental diagnoses.

Predicting future sleep problems in young autistic children

LAY ABSTRACT

Sleep problems are common in autistic children and negatively impact daytime functioning. A method for predicting sleep problems could help with treatment and prevention of such problems. This study aimed to determine predictors of sleep problems among young autistic children. Study participants consisted of autistic children aged 2-5 years who did not have sleep problems at a first visit (Autism Treatment Network Registry) and had sleep data available at a subsequent visit (Registry Call-Back Assessment study). Sleep problems for five study cohorts of children were defined by different methods, including parent questionnaires and parent- or clinician-report of sleep problems. We found that self-injurious behavior, sensory issues, dental problems, and lower primary caregiver education level were significant risk factors of future sleep problems. These predictors may help clinicians provide prevention or earlier treatment for children who are at risk of developing sleep problems.

A longitudinal study of the relationships between sleep problems in autistic children and maternal mental health

LAY ABSTRACT

Autistic children experience increased the rates of sleep problems. These sleep problems have been associated with mother's mental health symptoms. However, the direction of these relationships is not well understood. This study investigated the relationships between autistic children's sleep problems and mothers' mental health over a 12-year period using data collected as part of the Longitudinal Study of Australian Children. Data from 397 autistic children and their mothers were included in this study. Mothers completed a questionnaire about their own mental health and common childhood sleep problems at four time points from 4-5 years to 14-15 years. The results showed important relationships between mothers' mental health symptoms and child sleep problems at two time points. Specifically, (1) mothers' mental health symptoms when the child was aged 4 to 5 years predicted child sleep problems at age 6 to 7 years; and (2) child sleep problems at age 12-13 years predicted mothers' mental health symptoms when the child was aged 14 to 15 years. Interestingly, these significant relationships also coincide with key developmental transition time points, when the child is transitioning in and out of primary school. These findings highlight the need for increased support for both the child and mother at these times to optimise outcomes for both.

Sleep in 22q11.2 Deletion Syndrome: Current Findings, Challenges, and Future Directions

PURPOSE OF REVIEW

To summarize current literature available on sleep in 22q11.2 Deletion Syndrome (22q11.2DS; Velocardiofacial or DiGeorge Syndrome), a neurogenetic disorder caused by a hemizygous deletion in a genomic region critical for neurodevelopment. Due to the greatly increased risk of developmental psychiatric disorders (e.g., autism and schizophrenia) in 22q11.2DS, this review focuses on clinical correlates of sleep disturbances and potential neurobiological underpinnings of these relationships.

RECENT FINDINGS

Sleep disturbances are widely prevalent in 22q11.2DS and are associated with worse behavioral, psychiatric, and physical health outcomes. There are reports of sleep architecture and sleep neurophysiology differences, but the literature is limited by logistical challenges posed by objective sleep measures, resulting in small study samples to date. Sleep disturbances in 22q11.2DS are prevalent and have a substantial impact on well-being. Further investigation of sleep in 22q11.2DS utilizing multimodal sleep assessments has the potential to provide new insight into neurobiological mechanisms and a potential trans-diagnostic treatment target in 22q11.2DS.

Natural Course of IQSEC2-Related Encephalopathy: An Italian National Structured Survey

Pathogenic loss-of-function variants in the IQ motif and SEC7 domain containing protein 2 (IQSEC2) gene cause intellectual disability with Rett syndrome (RTT)-like features. The aim of this study was to obtain systematic information on the natural history and extra-central nervous system (CNS) manifestations for the Italian IQSEC2 population (>90%) by using structured family interviews and semi-quantitative questionnaires. IQSEC2 encephalopathy prevalence estimate was 7.0 to 7.9 × 10-7. Criteria for typical RTT were met in 42.1% of the cases, although psychomotor regression was occasionally evidenced. Genetic diagnosis was occasionally achieved in infancy despite a clinical onset before the first 24 months of life. High severity in both the CNS and extra-CNS manifestations for the IQSEC2 patients was documented and related to a consistently adverse quality of life. Neurodevelopmental delay was diagnosed before the onset of epilepsy by 1.8 to 2.4 years. An earlier age at menarche in IQSEC2 female patients was reported. Sleep disturbance was highly prevalent (60 to 77.8%), with mandatory co-sleeping behavior (50% of the female patients) being related to de novo variant origin, younger age, taller height with underweight, better social interaction, and lower life quality impact for the family and friends area. In conclusion, the IQSEC2 encephalopathy is a rare and likely underdiagnosed developmental encephalopathy leading to an adverse life quality impact.

Sleep disturbances are associated with irritability in ASD children with sensory sensitivities

BACKGROUND

Parent reports suggest that 44-84% of children with ASD exhibit sleep disturbances that are of clinical concern. Previous studies have reported that, in children with ASD, the severity of sleep disturbances is associated with the severity of either sensory problems or aberrant behaviors, but none have performed combined analyses with measures of both sensory and aberrant behaviors symptom domains from the same children.

METHODS

We examined parent reports of 237 children with ASD, 1.4-8.7 years old, using the child sleep habits questionnaire (CSHQ), sensory profile (SP), and aberrant behaviors checklist (ABC).

RESULTS

The analyses revealed that sleep disturbances were most strongly associated with SP sensory sensitivity and ABC irritability scores. Together these scores explained 35% of the variance in total CSHQ scores. Moreover, sensory sensitivity scores moderated the association between irritability and sleep disturbances, indicating that sleep disturbances were significantly associated with irritability only in children with moderate to severe sensory sensitivities.

CONCLUSION

We suggest that the three symptom domains may interact and exacerbate each other such that successful intervention in one symptom domain may have positive impact on the others. Further intervention studies testing this hypothesis are highly warranted.

Hypnotic treatment reverses NREM sleep disruption and EEG desynchronization in a mouse model of Fragile X syndrome to rescue memory consolidation deficits

Fragile X syndrome (FXS) is a highly-prevalent genetic cause of intellectual disability, associated with disrupted cognition and sleep abnormalities. Sleep loss itself negatively impacts cognitive function, yet the contribution of sleep loss to impaired cognition in FXS is vastly understudied. One untested possibility is that disrupted cognition in FXS is exacerbated by abnormal sleep. We hypothesized that restoration of sleep-dependent mechanisms could improve functions such as memory consolidation in FXS. We examined whether administration of ML297, a hypnotic drug acting on G-protein-activated inward-rectifying potassium channels, could restore sleep phenotypes and improve disrupted memory consolidation in Fmr1 -/y mice. Using 24-h polysomnographic recordings, we found that Fmr1 -/y mice exhibit reduced non-rapid eye movement (NREM) sleep and fragmented NREM sleep architecture, alterations in NREM EEG spectral power (including reductions in sleep spindles), and reduced EEG coherence between cortical areas. These alterations were reversed in the hours following ML297 administration. Hypnotic treatment following contextual fear or spatial learning also ameliorated disrupted memory consolidation in Fmr1 -/y mice. Hippocampal activation patterns during memory recall was altered in Fmr1 -/y mice, reflecting an altered balance of activity among principal neurons vs. parvalbumin-expressing (PV+) interneurons. This phenotype was partially reversed by post-learning ML297 administration. These studies suggest that sleep disruption could have a major impact on neurophysiological and behavioral phenotypes in FXS, and that hypnotic therapy may significantly improve disrupted cognition in this disorder.

Sleep disturbances in autism spectrum disorder: Animal models, neural mechanisms, and therapeutics

Sleep is crucial for brain development. Sleep disturbances are prevalent in children with autism spectrum disorder (ASD). Strikingly, these sleep problems are positively correlated with the severity of ASD core symptoms such as deficits in social skills and stereotypic behavior, indicating that sleep problems and the behavioral characteristics of ASD may be related. In this review, we will discuss sleep disturbances in children with ASD and highlight mouse models to study sleep disturbances and behavioral phenotypes in ASD. In addition, we will review neuromodulators controlling sleep and wakefulness and how these neuromodulatory systems are disrupted in animal models and patients with ASD. Lastly, we will address how the therapeutic interventions for patients with ASD improve various aspects of sleep. Together, gaining mechanistic insights into the neural mechanisms underlying sleep disturbances in children with ASD will help us to develop better therapeutic interventions.

Impact of sleep disorders on behavioral issues in preschoolers with autism spectrum disorder

Background

Sleep disorders are one of the most common problems in children with Autism Spectrum Disorder (ASD). However, they often tend to be underdiagnosed and incorrectly treated in clinical practice. This study aims to identify sleep disorders in preschool children with ASD and to explore their relationship with the core symptoms of autism, the child's developmental and cognitive level as well as the psychiatric comorbidities.

Methods

We recruited 163 preschool children with a diagnosis of ASD. The Children's Sleep Habits Questionnaire (CSHQ) assessed sleep conditions. Multiple standardized tests were used to evaluate intellectual abilities, the presence of repetitive behaviors (through the Repetitive Behavior Scale-Revised), as well as the emotional-behavioral problems and the psychiatric comorbidities (through the Child Behavior Checklist -CBCL 11/2-5).

Results

The results showed that poor disorders had consistently higher scores in all areas assessed by the CSHQ and on the CBCL across all domains. The correlational analysis showed that severe sleep disorders were associated with higher scores in internalizing, externalizing, and total problems at the CBCL syndromic scales, and in all DSM-oriented CBCL subscales. Moreover, we found that the association between sleep disorders and restricted and repetitive behaviors (RRBs) is explained by the anxiety-related symptoms.

Conclusion

Based on these findings, the study recommends that screening for sleep problems followed by early intervention should constitute a routine part of clinical practice for children with ASD.

Efficacy of Melatonin for Insomnia in Children with Autism Spectrum Disorder: A Meta-analysis

AIM

 This study aimed to evaluate the effectiveness of melatonin in treating insomnia in children with autism spectrum disorder (ASD).

METHODS

 Comprehensive searches were conducted in the PubMed, EMBASE, and Web of Science databases from their inception to April 20, 2022. Data were extracted and assessed for quality by two researchers. Statistical analysis was performed using the Stata 15.0 software.

RESULTS

 Four studies including 238 patients were included. The results showed that compared with the control group, melatonin could shorten the sleep-onset latency (standardized mean difference [SMD] = - 1.34, 95% CI: -2.19 to -0.48), reduce the number of awakenings (SMD = -2.35, 95% CI: -4.62 to -0.08), and prolong the total sleep time (SMD = 1.42, 95% CI: 0.5-2.33) in children with ASD.

CONCLUSION

 Melatonin has a certain effect on relieving sleep disturbances in children with ASD, which can shorten sleep latency, reduce the number of awakenings, and prolong total sleep time. Larger studies are required to verify this hypothesis.

Sleep problems in autism: Sex differences in the school-age population

Clinically significant sleep problems affect up to 86% of the autistic population in school-age. Sleep problems can have negative impacts on child cognition, behavior, and health. However, sex differences in the prevalence and types of sleep problems are not well understood in autism. To evaluate sex differences in sleep problems in the school-age autistic population, we obtained parent-report of sleep problems on the Children's Sleep Habits Questionnaire and conducted direct assessments to establish diagnosis and intellectual ability in 6-12-year-old children (autism n = 250; typical development [TD] n = 114). Almost 85% of autistic females demonstrated sleep problems compared to 65.8% of autistic males, 44.8% of TD females, and 42.4% of TD males; a statistically significant increase for autistic females. Autistic females demonstrated increased bedtime resistance, sleep anxiety, and sleepiness, and decreased sleep duration, but did not differ in sleep onset delay, night wakings, parasomnias, or disordered breathing compared with autistic males. Intellectual ability was not related to increased sleep problems. Higher anxiety scores were associated with more sleep problems for males but not females. In one of the first studies to evaluate sex differences in sleep in the school-age, autistic population, autistic females demonstrated increased sleep problems compared to autistic males, TD females, and TD males. Current autism assessment and intervention practices may benefit from increased attention to sleep problems in autistic school-age females and to anxiety in autistic males to enhance well-being and behavioral and health outcomes.

Sleep mediates the relationship between having an autistic child and poor family functioning

Sleep is an important biological necessity, a lack of which can have many cognitive, psychological, social, and physical impacts. Children with autism are known to present with sleep difficulties more frequently than their typically developing peers but despite this, there is relatively little research looking at the impact of sleep on the family. To investigate the effect of sleep on families of autistic and typically developing (TD) children, we conducted a study of sleep disturbances among children, sleep quality of their parents in association with their family function. In our study, 239 parents of autistic children and 227 parents of TD children participated. These parents completed a survey about their child's sleep disturbances, their own sleep quality, and their family function, along with a series of demographic questions. Analyses indicated that autistic children experience more sleep difficulties than TD peers, that children's sleep disturbances are associated with parental sleep quality and that parents of autistic children report decreased sleep quality compared to parents of TD children. Parental sleep quality, and child sleep quality were both found to partially mediate the relationship between autism diagnosis and family function.

Higher scores on autonomic symptom scales in pediatric patients with neurodevelopmental disorders of known genetic etiology

INTRODUCTION

Features of underlying autonomic dysfunction, including sleep disturbances, gastrointestinal problems, and atypical heart rate, have been reported in neurodevelopmental conditions, including autism spectrum disorder (ASD). The current cross-sectional, between-groups study aimed to quantify symptoms of autonomic dysfunction in a neurodevelopmental pediatric cohort characterized by clinical diagnoses as well as genetic etiology.

METHOD

The Pediatric Autonomic Symptom Scales (PASS) questionnaire was used to assess autonomic features across a group of patients with clinical neurodevelopmental diagnoses (NPD; N = 90) and genetic etiologies. Patients were subdivided based on either having a clinical ASD diagnosis (NPD-ASD; n = 37) or other non-ASD neurodevelopmental diagnoses, such as intellectual disability without ASD, speech and language disorders, and/or attention deficit hyperactivity disorder (NPD-OTHER; n = 53). Analyses focused on characterizing differences between the NPD group compared to previously published reference samples, as well as differences between the two NPD subgroups (NPD-ASD and NPD-OTHER).

RESULTS

Our results indicate higher PASS scores in our NPD cohort relative to children with and without ASD from a previously published cohort. However, we did not identify significant group differences between our NPD-ASD and NPD-OTHER subgroups. Furthermore, we find a significant relationship between quantitative ASD traits and symptoms of autonomic function.

CONCLUSION

This work demonstrates the utility of capturing quantitative estimates of autonomic trait dimensions that may be significantly linked with psychosocial impairments and other core clinical features of ASD.

Parasympathetic functioning and sleep problems in children with autism spectrum disorder

Respiratory sinus arrhythmia (RSA), an index of parasympathetic nervous system activity, has been linked with sleep quality among children with neurotypical development. The current study extended examination of these processes to children with autism spectrum disorder (ASD), a group at considerable risk for sleep problems. Participants included 54 children with ASD (aged 6-10 years, 43% Hispanic). RSA data were collected via a wired MindWare system during a 3-min baseline and a 3-min challenge task. Parents reported on their children's sleep problems and sleep duration using the Children's Sleep Habits Questionnaire, Abbreviated. Although no significant correlations emerged between RSA indices and parent-reported child sleep, baseline RSA and RSA reactivity interacted in the prediction of sleep problems. For children with higher RSA reactivity, higher baseline RSA was associated with fewer sleep problems, but for children with lower RSA reactivity, baseline RSA was not predictive. No main effects or interactions of RSA predicted sleep duration. Findings suggest resilience against sleep problems for children with ASD presenting with higher baseline RSA and higher RSA reactivity. Implications of these results center upon directly targeting psychophysiology (i.e., parasympathetic nervous system regulation) as a possible mechanism to improve sleep in children with ASD, and developing personalized interventions based on physiological markers of risk and resilience.

Patterns of sleep disturbances and associations with depressive symptoms in autistic young adults

Autistic individuals are at an increased risk for both sleep disturbances and depression. While studies in the general population and in autistic adults have drawn general links between sleep disturbances and mental health, few studies have examined the extent to which specific sleep problems may be implicated in the extremely high rates of depression among autistic adults. This study aimed to describe the patterns of sleep disturbances in autistic young adults, and their associations with depressive symptoms while controlling for relevant demographic factors. A sample of 304 legally independent adults (age 18-35 years old) with a childhood diagnosis of autism spectrum disorder self-reported on their average sleep behaviors during the past week and depressive symptoms on the Beck Depressive Inventory-II. A significant proportion (86.01%) of autistic young adults experienced at least one of the primary sleep disturbances of interest, including short total sleep time (39.59%), poor sleep efficiency (60.07%), and delayed sleep phase (36.18%). Additionally, lower sleep efficiency and delayed sleep phase were both associated with higher depressive symptoms. The associations between sleep and depressive symptoms identified in our study suggest that sleep treatments may hold potential for ameliorating depressive symptoms in autistic adults who also experience sleep problems. Further research using daily sleep diaries and objective measures of sleep behaviors, as well as longitudinal studies, are needed to understand how changes in sleep may relate to changes in depressive symptoms in autistic adults.

Sleep Problems in Children With Neurocutaneous Syndromes: A Cross-Sectional Study

Introduction: The prevalence and patterns of sleep disturbances in neurocutaneous syndromes are variable and understudied. Methods: Cross-sectional study for 18 months at a tertiary care pediatric hospital, involving 100 children with neurocutaneous syndromes aged between 4 and 10 years using the Children's Sleep Habits Questionnaire-Abbreviated. Results: In 100 children with neurocutaneous syndromes, 47 (47%) had significant sleep problems. In subgroup analysis, 7 of 17 children with neurofibromatosis 1, 24 of 63 children with tuberous sclerosis complex, 10 of 12 children with Sturge-Weber syndrome, 2 of 3 children with linear nevus sebaceous syndrome, and each of the children with hypomelanosis of Ito, McCune-Albright syndrome, megalencephaly-capillary malformation syndrome, and unclassified neurocutaneous syndrome had significant sleep problems. Conclusion: The prevalence of sleep problems in our study population was not more than that observed in the general pediatric population. Prospective multicentric studies are needed to comprehend sleep problems in children with neurocutaneous syndromes.

A cross-cultural comparison of sleep patterns between typically developing children and children with ASD living in Saudi Arabia and the United Kingdom

BACKGROUND

Sleep is crucial for child development, especially for children with ASD. While it is known that children with ASD experience more severe sleep problems and that these problems tend to persist compared to their typically developing counterparts, these findings tend to come from only Western countries. A cross-cultural study is important to understand if the prevailing understanding of sleep in children with ASD can be extended to different cultural backgrounds.

AIM

A cross-cultural study is conducted, involving typically developing children and children with ASD aged 5-12 across two countries: Saudi Arabia and the United Kingdom.

METHODS AND PROCEDURES

Using a combination of questionnaires measuring ASD severity (CARS-2), sleep quality (CSHQ), sociodemographic and lifestyle variables and sleep diaries, 244 children were sampled using a mixture of snowball and convenience sampling methods.

OUTCOMES AND RESULTS

Children with ASD experience more sleep problems compared to typically developing children in Saudi Arabia, and these problems similarly persist across time. Specifically, it was found that children with ASD in Saudi Arabia experience greater sleep onset latency and a greater number of night awakenings. Additionally, across the ASD groups, it was found that children from Saudi Arabia generally experienced poorer sleep than children in the United Kingdom in terms of shorter sleep duration, although children in the United Kingdom tended to report more instances of sleep anxiety and parasomnias.

CONCLUSIONS AND IMPLICATIONS

Several reasons such as parental education about sleep hygiene, cultural influences and social hours were put forward as potential explanations for cross-cultural differences. Findings served to emphasise the importance of culturally-appropriate interventions and public education regarding child sleep.

Eating and sleep problems, related factors, and effects on the mental health of the parents in children with autism spectrum disorder

This study aimed to evaluate the frequency of sleep and eating problems in children with autism spectrum disorder (ASD), the factors associated with these problems, and the relationship with the risk of developing depression and anxiety in their parents. In the study, 156 children with ASD and their parents were included. The Brief Autism Mealtime Behavior Inventory (BAMBI), the Children's Sleep Habits Questionnaire (CSHQ), the Hospital Anxiety Depression Scale (HADS) were completed by the parents. The Childhood Autism Rating Scale (CARS) was administered by the researchers to evaluate the severity of ASD in children. The mean age of children was 8.08 ± 2.84, and 87.2% of the children were male. The mean score of CARS was 41.25 ± 6.16, the mean score of BAMBI was 45.67 ± 11.87, and the mean score of CSHQ was 51.67 ± 10.17. According to the CSHQ, 83.3% of the children had sleep problems. The response rate above the cut-off point in the HAD-A subscale was 59.6%, whereas it was 67.3% in the HAD-D subscale. There was a positive correlation between CARS and BAMBI, CSHQ, HAD-A, and HAD-D subscales. There was a positive correlation between BAMBI and CHSQ, HAD-A, and HAD-D subscales. There was a positive correlation between the CSHQ, HAD-A, and HAD-D subscales. There was a negative correlation between the age of the child with ASD, food refusal, and resistance to bedtime. As sleeping and eating problems affect a large portion of children diagnosed with ASD and their caregivers, large population-based studies evaluating both these problems must be designed and carried out to understand factors affecting the prevalence, development, and persistence of sleeping and eating problems and to determine interventions to reduce these issues.

Meeting the 24-h movement guidelines and health-related outcomes among youth with autism spectrum disorder: a seven-country observational study

BACKGROUND

Meeting daily guidelines for physical activity, screen time, and sleep duration is associated with a host of health indicators for youth. In this cross-sectional observational study, we investigated the associations between adherence to the movement guidelines and health-related outcomes among youth with autism spectrum disorder (ASD).

METHODS

Parents of youth with ASD (10-17 years) from seven countries and regions were invited to provide online proxy-reports for child's movement behaviors (i.e., physical activity, sleep and screen time), and health-related outcomes (i.e., body mass index [BMI], general health, and quality of life). A series of multiple linear regression analyses were used to examine the associations between meeting movement guidelines and health-related outcomes, adjusted for covariates.

RESULTS

The final sample consisted of 1165 youth with ASD. Compared with youth meeting all three guidelines, a higher BMI z-score was observed in those who met no guidelines (B = 0.62, P = 0.04), "sedentary time only" (B = 0.60, P = 0.047), and "physical activity plus sleep only" (B = 0.85, P = 0.04). Compared with meeting all three guidelines, meeting no guidelines was associated with poorer general health (B = - 0.46, P = 0.02). Further, compared with youth meeting all three guidelines, a lower quality of life score was observed in those who met no guidelines (B = - 0.47, P = 0.02) and "physical activity only" (B = - 0.62, P = 0.03). Lastly, there were dose-response associations between the number of guidelines met and all three health-related outcomes (all P_trend < 0.05).

CONCLUSIONS

In conclusion, meeting more 24-h movement guidelines was generally associated with more favorable health-related outcomes in youth with ASD. The low level of adherence to all three guidelines (2.0%) suggests the urgent need to promote the adoption of all the guidelines in this group.

Clinical and behavioral attributes leading to sleep disorders in children on the autism spectrum

Sleep disorders are a common comorbid condition in children diagnosed with autism spectrum disorder ("autism"). However, the relationship between the clinical features of autism and sleep disorders remains unclear. A better understanding of the inherent autism-related characteristics linked to comorbid sleep disorders would improve comprehensive assessment and management. This study examined the relationship between sociodemographics, autism symptoms, sleep problems, cognitive status, behavioral attributes, and sensory profiles. Using data from 1268 participants who took part in the Australian Autism Biobank, sleep-related measurements using the Child Sleep Habits Questionnaire (CSHQ) were compared between autistic children aged 2 to 17 (N = 969), their siblings (N = 188), and unrelated children without an autism diagnosis (N = 111). The known relationship between sleep problems and autism was further explored by including scores from the Autism Diagnostic Observation Schedule-2, Mullen Scales of Early Learning, Vineland Adaptive Behavioral Scale-II and the Short Sensory Profile-2; which were included in analyses for autistic participants who had a completed CSHQ. Multiple regression models were used to identify clinical/behavioral variables associated with CSHQ subscales. The autism group had a significantly higher total CSHQ score than the sibling and comparison groups (p < 0.001), indicating worse sleep quality. Within the autism group, lower adaptive behaviors (i.e., VABS-II) and sensory issues (i.e., SSP-2 subclass scores) were positively associated with the severity of sleep problems (i.e., the CSHQ subclass scores) (p < 0.001). The significant functional impact of poor sleep on autistic children warrants an assessment of sleep as a critical part of a holistic approach to supporting autistic children and their families. LAY SUMMARY: Autistic children generally have co-occurring conditions. Sleep disorders impact approximately 50%-80% of autistic children. The impact on the quality of life for both the children and their families can be significant. This study compares sleep problems in autistic children and adolescents with their siblings and children without a diagnosis of autism, and investigates the relationship between specific autistic traits, daily life behaviors and sleep problems. The findings highlight the importance of a holistic assessment for autistic children and matching appropriate sleep intervention and supports where indicated.

Attention-Deficit/Hyperactivity Disorder Symptoms, Gastrointestinal Symptoms, Sleep Problems, Challenging Behavior, Adaptive Behavior, and Quality of Life in Children and Adolescents with Autism Spectrum Disorder

This study investigated the relationship between sleep, gastrointestinal symptoms, challenging behavior, adaptive behavior, and quality of life between children and adolescents with autism spectrum disorder (ASD), with and without attention-deficit/hyperactivity disorder (AD/HD) symptoms. Parents of 118 children and adolescents with ASD completed the Conners Early Childhood Rating Scale-Parent Short Form or the Conners 3-Parent Short Form, Children's Sleep Habits Questionnaire, Gastrointestinal Symptom Inventory, Behavior Problems Inventory-Short Form, Pediatric Quality of Life Inventory and the Vineland Adaptive Behavior Scales, Second Edition. The ASD group and the ASD with AD/HD groups differed significantly in sleep problems, gastrointestinal symptoms, and quality of life. Regressions indicated that AD/HD symptoms accounted for a small proportion of the variance for the differences in sleep problems and quality of life. AD/HD symptoms contribute to the complex needs of individuals with ASD. Research is necessary to investigate how these symptoms exacerbate comorbidities.

Characterizing sleep disorders in an autism-specific collection of electronic health records

OBJECTIVE/BACKGROUND

Sleep problems are common in people on the autism spectrum. This study reviews one detailed approach to querying the electronic health record (EHR) in a large tertiary care center.

PATIENTS/METHODS

We developed methods for identifying people on the autism spectrum and defined their sleep problems using the key words, "sleep" or "melatonin", or International Classification of Diseases (ICD) codes. We examined treatment responses of these individuals to melatonin supplementation.

RESULTS

Sleep problems were documented in 86% of patients with ages ranging from 6 to 30 years old. Our specific keyword search yielded more patients with sleep diagnoses than ICD codes alone. About two-thirds of patients who received melatonin supplementation reported benefit from its use.

CONCLUSIONS

Our study provides a framework for using deidentified medical records to characterize sleep, a common co-occurring condition, in people on the autism spectrum. Using specific keywords could be helpful in future work that queries the EHR.

Sleep and social-emotional problems in preschool-age children with developmental delay

Sleep problems and social-emotional (SE) problems are common in preschooler children and may be affected by culture. However, little is known about the link between sleep and social-emotional problems in non-Western countries. This study aims to compare sleep problems and their association with SE problems in Turkish children with either typical development (TD) or neurodevelopmental delay (NDD). In this case-control study, children with NDD (n = 126) and children with TD (n = 102) were included. Parents completed the Children's Sleep Habits Questionnaire (CSHQ), and the Ages and Stages Questionnaire: Social-Emotional (ASQ:SE). More than half of the TD and NDD groups had sleep problems when assessed by CSHQ (54.4%, 72.2%, respectively). The correlation between CSHQ and ASQ:SE scores in the NDD and TD groups was r = 0.44 and r = 0.352, respectively (both p < 0.001). Children who slept less than 9 h had lower ASQ:SE scores in the NDD (p = 0.003) and TD group (p = 0.023). In the TD group, those who slept after 23:01 h had lower ASQ:SE scores compared to early sleepers (p = 0.04). Multivariate analysis revealed associations between SE problems and male gender, lower family income, bedtime resistance, and shorter sleep duration in the NDD group. In the TD group, male gender, sleep onset delay, sleep duration of CSHQ subscale were found to be associated with SE problems. Sleep problems were identified in more than half of all preschooler children, regardless of developmental delay, and were associated with increased SE problems. Interventions to correct sleep problems may have a positive impact on children's emotional development.

Sleep deficiency as a driver of cellular stress and damage in neurological disorders

Neurological disorders encompass an extremely broad range of conditions, including those that present early in development and those that progress slowly or manifest with advanced age. Although these disorders have distinct underlying etiologies, the activation of shared pathways, e.g., integrated stress response (ISR) and the development of shared phenotypes (sleep deficits) may offer clues toward understanding some of the mechanistic underpinnings of neurologic dysfunction. While it is incontrovertibly complex, the relationship between sleep and persistent stress in the brain has broad implications in understanding neurological disorders from development to degeneration. The convergent nature of the ISR could be a common thread linking genetically distinct neurological disorders through the dysregulation of a core cellular homeostasis pathway.

Association of 3-hydroxy-3-methylglutaryl-coenzyme A reductase gene polymorphism with obesity and lipid metabolism in children and adolescents with autism spectrum disorder

The prevalence of obesity among children and adolescents with autism spectrum disorder (ASD) is higher than that among typically developing children and adolescents. However, very few studies have explored the genetic factors associated with obesity in children and adolescents with ASD. Thus, the aim of this study was to examine the associations between 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) gene polymorphisms and obesity among children and adolescents with ASD. The study participants consisted of 33 children and adolescents with ASD and 271 age- and sex-matched typically developing controls. We compared the metabolic traits (body mass index, blood pressure, triglyceride, high-density lipoprotein, and fasting glucose levels) between the ASD and control group. Furthermore, we assessed the genotypes of rs12654264 in the HMGCR gene within the participants with ASD, and compared metabolic traits among the different allele subgroups. The mean body mass index (BMI) and triglyceride level of the ASD group were significantly higher than those of the control group. Within the ASD group, the triglyceride level of participants with rs12654264-T alleles was significantly higher than that of participants with A-alleles. A pattern of increasing values in the BMI and fasting glucose was also observed in participants with T allele. This is the first study to show that obesity in children and adolescents with ASD is associated with the cholesterol synthesis pathway. Future studies are needed to further clarify the molecular mechanisms by which the HMGCR gene influences metabolic traits.

Effects of exercise on sleep, melatonin level, and behavioral functioning in children with autism

LAY ABSTRACT

This study examined the impact of physical exercise on sleep and behavioral functioning in children (aged 8-12 years) with autism spectrum disorders. It also investigated whether exercise would alter endogenous melatonin level among the population. Participants were divided into two groups: exercise group (12-week, 30-min morning jogging intervention) and a control group (i.e. did not receive any physical exercise intervention during the study period). Significant improvements on sleep and behavioral functioning were found in the exercise group, but not in the control group Moreover, a significant increase in melatonin level was also shown in the exercise group. Findings of this study reconfirmed the sleep and behavioral benefits of exercise in children with autism spectrum disorder. Melatonin-mediated mechanism should be further explored to develop an effective treatment intervention.

Sufficient sleep duration in autistic children and the role of physical activity

LAY ABSTRACT

Higher levels of physical activity may be associated with improved sleep in children, but this relationship is still being determined, especially in autistic children. In this study, we used existing data from the 2018 National Survey of Children's Health. Caregivers of children 6-17 years old, including caregivers of autistic children, completed a questionnaire that included questions about physical activity (days active in the past week) and sleep duration. We then determined if children were obtaining the recommended hours of sleep for their age (i.e. sufficient sleep). We found that higher physical activity levels were associated with sufficient sleep duration, but this finding was weaker in autistic children. In particular, this association was not observed in autistic children with more severe autism spectrum disorder, female autistic children, and autistic children 6-12 years old. In conclusion, physical activity is a promising approach to help children obtain sufficient sleep duration. However, more personalized approaches to improving sleep may be needed for certain groups of autistic children.

Sleep Disturbances in Children Affected by Autism Spectrum Disorder

BACKGROUND

Sleep disturbances are common in children affected by Autism Spectrum Disorder (ASD). The aim of our study was to describe sleep characteristics and disturbances in children with ASD, to evaluate possible related factors, and to assess parental stress.

METHODS

Hundred children with a diagnosis of ASD (mean age: 66.7 months, SD: 27.4, range: 24.7-152.1 months, n = 79 males) were included in the study. We collected data on sociodemographic, clinical, genetic and instrumental variables as well as comorbid conditions. Parents filled out the Questionnaire on sleep behavior in the first years of life, the BEARS questionnaire, and the Parenting Stress Index Short Form. From the analysis on sleep characteristics, we excluded 25 children treated with melatonin.

RESULTS

Fifty-seven (57%) out of 100 children met the criteria for insomnia. Sleep disorders were associated with developmental or cognitive delay, emotional and behavioral problems (such as anxiety problems and aggressive behaviors) and absence of strategies for inducing sleep after nocturnal awakenings. From parents' reports, sleep disorders had diurnal repercussions on their offspring; however, we found no statistical correlation between disturbances and family stress. Also, no significant correlation was found between sleep disturbances and epilepsy. Finally, a statistical correlation was found between the regular intake of melatonin and the resolution of insomnia.

CONCLUSIONS

Multifactorial variables may be associated to insomnia that could have an impact on the children' behavior. Clinicians need to be aware of the value of screening for sleep disturbance in children with ASD to integrate sleep interventions in the treatment plan.

Sleep in Children with Autism Spectrum Disorder: A Narrative Review and Systematic Update

Purpose of Review

Sleep problems are a common comorbidity for children with autism spectrum disorder (ASD), and research in this area has a relatively long history. Within this review, we first outline historic patterns in the field of sleep and ASD. Second, we conducted a systematic update and coded these studies based on their alignment with historic patterns. Research on ASD and sleep over the past two decades has primarily focused on four principal areas: (1) documenting the prevalence and types of sleep problems; (2) sleep problem treatment options and efficacy; (3) how sleep problems are associated with other behavioral, contextual, or biological elements; and (4) the impact of child sleep problems on families and care providers. The systematic update in this paper includes empirical studies published between 2018 and 2021 with terms for sleep and ASD within the title, keywords, or abstract.

Recent Findings

In sum, 60 studies fit the inclusion/exclusion criteria and most fit within the historic patterns noted above. Notable differences included more global representation in study samples, studies on the impacts of COVID-19, and a growing body of work on sleep problems as an early marker of ASD. The majority of studies focus on correlates of sleep problems noting less optimal behavioral, contextual, and biological elements are associated with sleep problems across development for children with ASD.

Summary

Recommendations for future directions include continued expansion of global and age representation across samples, a shift toward more treatment and implementation science, and studies that inform our mechanistic understanding of how sleep and ASD are connected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40675-022-00234-5.

The relationship between autism spectrum and sleep-wake traits

Autistic children and adults often have sleep disturbances, which may affect their and their family's quality of life. Yet, the relationship between sleep-wake patterns and autism spectrum traits is understudied. Identifying such relationships could lead to future research elucidating common mechanistic underpinnings. Thus, we aimed to determine whether sleep-wake patterns, specifically related to sleep, physical activity, and the daily sleep-wake rhythm (i.e., circadian rhythm), are associated with autism spectrum-related traits. Accelerometer-derived sleep-wake parameters were estimated in individuals with autistic spectrum traits and their family members (N = 267). We evaluated autism spectrum traits using the Social Responsiveness Scale (SRS) to assess the presence and severity of social impairment and the Behavior Rating Inventory of Executive Function (BRIEF) to assess executive function. The linear multivariate regression analysis (using SOLAR-Eclipse) showed that in adults, increased core autism spectrum traits and executive dysfunction were associated with disruption of several sleep-wake parameters, particularly related to the daily sleep-wake rhythm, and that executive dysfunction was associated with disrupted sleep quality and level of physical activity. We highlight the interplay between daytime function and disrupted sleep-wake patterns, specifically related to the daily sleep-wake rhythm, that could guide future research into common mechanisms.

Autonomic Nervous System Neuroanatomical Alterations Could Provoke and Maintain Gastrointestinal Dysbiosis in Autism Spectrum Disorder (ASD): A Novel Microbiome-Host Interaction Mechanistic Hypothesis

Dysbiosis secondary to environmental factors, including dietary patterns, antibiotics use, pollution exposure, and other lifestyle factors, has been associated to many non-infective chronic inflammatory diseases. Autism spectrum disorder (ASD) is related to maternal inflammation, although there is no conclusive evidence that affected individuals suffer from systemic low-grade inflammation as in many psychological and psychiatric diseases. However, neuro-inflammation and neuro-immune abnormalities are observed within ASD-affected individuals. Rebalancing human gut microbiota to treat disease has been widely investigated with inconclusive and contradictory findings. These observations strongly suggest that the forms of dysbiosis encountered in ASD-affected individuals could also originate from autonomic nervous system (ANS) functioning abnormalities, a common neuro-anatomical alteration underlying ASD. According to this hypothesis, overactivation of the sympathetic branch of the ANS, due to the fact of an ASD-specific parasympathetic activity deficit, induces deregulation of the gut-brain axis, attenuating intestinal immune and osmotic homeostasis. This sets-up a dysbiotic state, that gives rise to immune and osmotic dysregulation, maintaining dysbiosis in a vicious cycle. Here, we explore the mechanisms whereby ANS imbalances could lead to alterations in intestinal microbiome-host interactions that may contribute to the severity of ASD by maintaining the brain-gut axis pathways in a dysregulated state.

Sleep disorders and neuropsychiatric disorders in a pediatric sample of tuberous sclerosis complex: a questionnaire-based study

OBJECTIVE AND BACKGROUND

Sleep disorders (SD) are very common in childhood, especially in certain genetic syndromes. Tuberous Sclerosis Complex (TSC) is a genetic syndromesassociated with a high rate of SD, although these are still under-recognized. The aim of this study was to assess the prevalence of SD in TSC, and to evaluate the relationship between sleep, epilepsy and TSC-associated neuropsychiatric disorders (TAND).

METHODS

We administered the Sleep Disturbance Scale for Children (SDSC) and the Epworth Sleepiness Scale for Children and Adolescents (ESS-CHAD) to parents of 177 children with TSC referring to different Italian centers. We also collected information on epilepsy and TAND.

RESULTS

SDSC score was positive in 59.3% of patients, being positive in 30.4% of patients without and in 63.6% of those with epilepsy (p = 0.005). However, in a multivariate logistic model considering antiseizure medications and nocturnal seizures, epilepsy ceased to be a significant risk factor for positive SDSC (OR = 2.4; p = 0.17). As for TAND, SDSC was positive in 67.9% of patients with and in 32.5% of those without TAND (p < 0.001). After adding in a multivariate logistic model active epilepsy, age, and pharmacotherapies, TAND continued to be a significant risk factor for positive SDSC (p = 0.01, OR = 1.11).

CONCLUSIONS

Our results revealed a high prevalence of SD in children with TSC. Epilepsy didn't increase the risk for SD, while a very strong association was found with TAND. An early detection of SD is of utmost importance in order to plan an individualized treatment, that in some cases might also ameliorate behavior and attention.

Sex differences in childhood sleep and health implications

CONTEXT

Sleep is critical for optimal childhood metabolic health and neurodevelopment. However, there is limited knowledge regarding childhood sex differences in sleep, including children with neurodevelopmental disorders, and the impact of such differences on metabolic health.

OBJECTIVE

To evaluate if sex differences in childhood sleep exist and if sleep associates with metabolic health outcomes equally by sex. Using autism spectrum disorder (ASD) as a case study, we also examine sleep sex differences in children with a neurodevelopmental disorder.

METHODS

A narrative review explored the literature focussing on sex differences in childhood sleep.

RESULTS

Sex differences in sleep were not detected among pre-adolescents. However, female adolescents were more likely to report impaired sleep than males. Childhood obesity is more common in males. Shorter sleep duration may be associated with obesity in male pre-adolescents/adolescents; although findings are mixed. ASD is male-predominant; yet, there was an indication that pre-adolescent female children with ASD had more impaired sleep.

CONCLUSION

Sex differences in sleep appear to emerge in adolescence with more impaired sleep in females. This trend was also observed among pre-adolescent female children with ASD. Further research is needed on sex differences in childhood sleep and metabolic health and the underlying mechanisms driving these differences.

Practitioner's review: medication for children and adolescents with autism spectrum disorder (ASD) and comorbid conditions

Alleviating the multiple problems of children with autism spectrum disorder (ASD) and its comorbid conditions presents major challenges for the affected children, parents, and therapists. Because of a complex psychopathology, structured therapy and parent training are not always sufficient, especially for those patients with intellectual disability (ID) and multiple comorbidities. Moreover, structured therapy is not available for a large number of patients, and pharmacological support is often needed, especially in those children with additional attention deficit/hyperactivity and oppositional defiant, conduct, and sleep disorders.

Sleep problems in children with autism spectrum disorder: a multicenter survey

BACKGROUND

High prevalence of sleep problems have been reported in children with Autism Spectrum Disorder (ASD). This study aims to investigate the sleep conditions of ASD children in China, and explore the relationship between the common sleep problems and core symptoms and developmental levels.

METHODS

Using a cross-sectional design, we included 2 to 7-year-old children from 13 cities in China: 1310 with ASD and 1158 with typically-developing (TD) children. The neurodevelopmental level was evaluated with the revised Children Neuropsychological and Behavior Scale (CNBS-R2016). ASD were diagnosed with DSM-5 and Child Autism Rating Scale (CARS). the Social Responsiveness Scale (SRS), the Autism Behavior Checklist (ABC) and the communication warning behavior sub-scale in CNBS-R2016 valued autism behaviors. The children' s sleep habits questionnaire (CSHQ) assessed sleep conditions.

RESULTS

The prevalence of sleep disorders in ASD children was significantly higher than that in TD (67.4% vs. 51%, p < 0.01), and among them the four dimensions with the highest prevalence of sleep problems were bedtime resistance (25.6%), sleep anxiety (22.7%), sleep onset delay (17.9%) and daytime sleepiness (14.7%). ASD children with sleep onset delay or sleep anxiety had higher ABC, SRS scores and higher scores on communication warning behavior with sleep anxiety, with daytime sleepiness had higher ABC, SRS and CARS scores, and with bedtime resistance had higher SRS total scores. Differences in the neurodevelopmental level were not significant.

CONCLUSION

Children with ASD have a higher prevalence of sleep problems. Bedtime resistance, anxiety, sleep onset delay and daytime sleepiness may be related to the core symptoms, but not be related to the developmental level in ASD children. In the clinic, sleep assessment should be included in the routine of ASD visits, and during the intervention, sleep hygiene education is as important as the treatment of biological factors.

TRIAL REGISTRATION

The study was approved by the ethics committee of the Children's Hospital of Chongqing Medical University, Approval Number: (2018) IRB (STUDY) NO. 121, and registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2000031194 ).

Abnormal sleep physiology in children with 15q11.2-13.1 duplication (Dup15q) syndrome

BACKGROUND

Sleep disturbances in autism spectrum disorder (ASD) represent a common and vexing comorbidity. Clinical heterogeneity amongst these warrants studies of the mechanisms associated with specific genetic etiologies. Duplications of 15q11.2-13.1 (Dup15q syndrome) are highly penetrant for neurodevelopmental disorders (NDDs) such as intellectual disability and ASD, as well as sleep disturbances. Genes in the 15q region, particularly UBE3A and a cluster of GABA_A receptor genes, are critical for neural development, synaptic protein synthesis and degradation, and inhibitory neurotransmission. During awake electroencephalography (EEG), children with Dup15q syndrome demonstrate increased beta band oscillations (12-30 Hz) that likely reflect aberrant GABAergic neurotransmission. Healthy sleep rhythms, necessary for robust cognitive development, are also highly dependent on GABAergic neurotransmission. We therefore hypothesized that sleep physiology would be abnormal in children with Dup15q syndrome.

METHODS

To test the hypothesis that elevated beta oscillations persist in sleep in Dup15q syndrome and that NREM sleep rhythms would be disrupted, we computed: (1) beta power, (2) spindle density, and (3) percentage of slow-wave sleep (SWS) in overnight sleep EEG recordings from a cohort of children with Dup15q syndrome (n = 15) and compared them to age-matched neurotypical children (n = 12).

RESULTS

Children with Dup15q syndrome showed abnormal sleep physiology with elevated beta power, reduced spindle density, and reduced or absent SWS compared to age-matched neurotypical controls.

LIMITATIONS

This study relied on clinical EEG where sleep staging was not available. However, considering that clinical polysomnograms are challenging to collect in this population, the ability to quantify these biomarkers on clinical EEG-routinely ordered for epilepsy monitoring-opens the door for larger-scale studies. While comparable to other human studies in rare genetic disorders, a larger sample would allow for examination of the role of seizure severity, medications, and developmental age that may impact sleep physiology.

CONCLUSIONS

We have identified three quantitative EEG biomarkers of sleep disruption in Dup15q syndrome, a genetic condition highly penetrant for ASD. Insights from this study not only promote a greater mechanistic understanding of the pathophysiology defining Dup15q syndrome, but also lay the foundation for studies that investigate the association between sleep and cognition. Abnormal sleep physiology may undermine healthy cognitive development and may serve as a quantifiable and modifiable target for behavioral and pharmacological interventions.

Vitamin a deficiency and sleep disturbances related to autism symptoms in children with autism spectrum disorder: a cross-sectional study

Background

Vitamin A deficiency (VAD) and sleep disturbances have been reported in children with autism spectrum disorder (ASD). The influence of vitamin A (VA) levels on sleep regulation and sleep disturbances in ASD has garnered concern. The present study aimed to characterize the association of VA levels with sleep disturbances in children with ASD.

Methods

This cross-sectional study compared children with ASD (n = 856) to typically developing children (TDC; n = 316). We used the Children’s Sleep Habits Questionnaire to assess sleep disturbances, Childhood Autism Rating Scale to evaluate the severity of autism symptoms, and Autism Behavior Checklist and Social Responsiveness Scale to assess autism behaviors. Serum VA levels were estimated using high-performance liquid chromatography. Multivariable linear regression and two-way analysis of variance were performed to investigate if VAD was related to sleep disturbances in children with ASD.

Results

Children with ASD had lower serum VA levels and a higher prevalence of sleep disturbances than TDC did. The incidence of VAD in ASD children with sleep disturbances was higher, and the symptoms more severe than those without sleep disturbances and TDC. Interestingly, the interaction between VAD and sleep disturbances was associated with the severity of autism symptoms.

Conclusion

VAD and sleep disturbances are associated with the core symptoms of ASD in children. Regular monitoring of sleep and VA levels may be beneficial for children with ASD.

Trial registration

Chinese Clinical Trial Registry, registration number: ChiCTR-ROC-14005442, registration date: December 9th 2014.

Links between parent-reported measures of poor sleep and executive function in childhood autism and attention deficit hyperactivity disorder

OBJECTIVES

This study sought to assess whether poor sleep is associated with aspects of executive function (EF) among children with autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), or typical development (TD), after adjusting for demographic variables, stimulant medications, intelligence, anxiety, inattention, and hyperactivity.

DESIGN

Cross-sectional.

SETTING

Children recruited through ongoing studies at the Kennedy Krieger Institute.

PARTICIPANTS

We studied 735 children (323 TD; 177 ASD; 235 ADHD) aged 8 to 12 years.

MEASUREMENTS

We investigated associations of parent-reported sleep measures from the Children's Sleep Habits Questionnaire (CSHQ) with parent-report measures of EF and performance-based processing speed with each clinical population. EF was measured using 8 clinical T scores that fall under 2 domains (behavioral regulation and metacognition) from the Behavior Rating Inventory of EF (BRIEF) and the processing speed index from the Wechsler Intelligence Scale for Children-IV or -V.

RESULTS

Higher CSHQ scores were associated with poorer EF on all BRIEF scales, across all child groups, after adjustment for demographic factors, stimulant medications, and IQ. Among children with ADHD, these associations largely remained after adjusting for anxiety. Among those ASD, anxiety partially accounted for these associations, especially for behavioral regulation EF outcomes. Co-occurring symptoms of inattention and hyperactivity/impulsivity further accounted for the associations between sleep and EF. Poor sleep was not significantly associated with processing speed.

CONCLUSIONS

Strong links exist between parent-reported poor sleep and executive dysfunction in children with typical development. Targeting anxiety may alleviate executive dysfunction, especially among children with ASD.