Sleep Problems and Their Correlates in Children with Autism Spectrum Disorder: An Indian Study

Factors associated with sleep disturbances in children and adolescents with Angelman Syndrome

BACKGROUND

Angelman Syndrome (AS) is a rare genetic disorder characterised by hyperactivity, overexcitability, developmental delays, and lack of speech.

METHODS

This study used secondary data analysis to investigate sleep disturbances in children and adolescents (n = 212) who are enrolled in the Global Angelman Syndrome Registry. Participants were divided into two groups based on the presence or absence of sleep disturbance. The cut-off score of 40 on the Sleep Disturbance Scale for Children was used to indicate the presence or absence of sleep disturbances. Sleep disturbances and their association with co-occurring conditions were examined regarding challenging behaviour, language and communication, infancy history, gastrointestinal symptoms, and epilepsy. Multiple regression was then conducted to investigate possible predictors for sleep disturbances.

RESULTS

Children and adolescents with AS, with and without sleep disturbances, differed considerably regarding anxiety. Sleep disturbances were significantly associated with an ability to use spoken words and computerised communication devices, and anxiety was a predictor of sleep disturbances.

CONCLUSION

Future research is necessary to replicate this novel research, and to advance the clinical treatment of sleep disturbances in children and adolescents with AS.

Subjective and objective sleep alterations in medication-naïve children and adolescents with autism spectrum disorder: a systematic review and meta-analysis

AIMS

This study aimed to summarize the evidence on sleep alterations in medication-naïve children and adolescents with autism spectrum disorder (ASD).

METHODS

We systematically searched PubMed/Medline, Embase and Web of Science databases from inception through March 22, 2021. This study was registered with PROSPERO (CRD42021243881). Any observational study was included that enrolled medication-naïve children and adolescents with ASD and compared objective (actigraphy and polysomnography) or subjective sleep parameters with typically developing (TD) counterparts. We extracted relevant data such as the study design and outcome measures. The methodological quality was assessed through the Newcastle-Ottawa Scale (NOS). A meta-analysis was carried out using the random-effects model by pooling effect sizes as Hedges' g. To assess publication bias, Egger's test and p-curve analysis were done. A priori planned meta-regression and subgroup analysis were also performed to identify potential moderators.

RESULTS

Out of 4277 retrieved references, 16 studies were eligible with 981 ASD patients and 1220 TD individuals. The analysis of objective measures showed that medication-naïve ASD patients had significantly longer sleep latency (Hedges' g 0.59; 95% confidence interval [95% CI] 0.26 to 0.92), reduced sleep efficiency (Hedges' g -0.58; 95% CI -0.87 to -0.28), time in bed (Hedges' g -0.64; 95% CI -1.02 to -0.26) and total sleep time (Hedges' g -0.64; 95% CI -1.01 to -0.27). The analysis of subjective measures showed that they had more problems in daytime sleepiness (Hedges' g 0.48; 95% CI 0.26 to 0.71), sleep latency (Hedges' g 1.15; 95% CI 0.72 to 1.58), initiating and maintaining sleep (Hedges' g 0.86; 95% CI 0.39 to 1.33) and sleep hyperhidrosis (Hedges' g 0.48; 95% CI 0.29 to 0.66). Potential publication bias was detected for sleep latency, sleep period time and total sleep time measured by polysomnography. Some sleep alterations were moderated by age, sex and concurrent intellectual disability. The median NOS score was 8 (interquartile range 7.25-8.75).

CONCLUSION

We found that medication-naïve children and adolescents with ASD presented significantly more subjective and objective sleep alterations compared to TD and identified possible moderators of these differences. Future research requires an analysis of how these sleep alterations are linked to core symptom severity and comorbid behavioural problems, which would provide an integrated therapeutic intervention for ASD. However, our results should be interpreted in light of the potential publication bias.

Sleep disturbances and emotional dysregulation in young children with autism spectrum, intellectual disability, or global developmental delay

OBJECTIVE

Sleep disturbance and emotional dysregulation (ED) are common and often functionally impairing in young children with neurodevelopmental disorders (NDD). This study investigated the relationship between sleep disturbance and ED in a sample of preschoolers with ASD, intellectual disability, or global developmental delay, and examined possible predictors of their persistence over time.

METHODS

All children under 6 years of age clinically referred between July 2018 and May 2022 to two neuropsychiatric specialized centers for NDD received a comprehensive diagnostic evaluation, including the Child Behavior Checklist 1.5-5 (CBCL), the Autism Diagnostic Observation Schedule-2 (ADOS-2), and standardized tests of cognitive and global development. Sleep disturbances were assessed with the CBCL-sleep score, and ED with the CBCL Attention, Aggression, and Anxious/Depressed scales (CBCL-AAA). A reassessment of sleep and ED was conducted after 6 months or longer, including the Child Sleep Habits Questionnaire (CSHQ). Multivariate analyses and mixed linear regression models were conducted.

RESULTS

A total of 136 children, 75.7% male, median age 38.27 months, IQR 15.39, 41.2% with global developmental disorder (GDD) or intellectual disability (ID) participated in the study. Of them, 64.7% were diagnosed with autism spectrum disorder (ASD) and 35.3% with other NDD (w/o ASD). Sleep disturbances (CBCL-Sleep) and ED (CBCL-AAA) were positively correlated (p < 0.001), after accounting for age, ID/GDD and autism symptom severity, in both the entire sample and separately in each diagnostic group (ASD and NDD w/o ASD). Seventy-five children (55%) were reassessed a mean 17.2 months afterwards. There was persistence of the positive correlation between sleep problems and ED (p < 0.001) in both the entire sample and each diagnostic group. The longitudinal mixed linear model showed that ED at follow-up was predicted by baseline sleep problems (p = 0.008), ED (p < 0.001), and ASD severity (p = 0.015).

CONCLUSIONS

Sleep disturbances are significantly associated with ED in young children with NDD, either with or without ASD, both cross-sectionally and prospectively over time. Sleep problems represent an important comorbidity and a potential treatment target for improving emotional stability in NDD.

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.

Children with neurodevelopmental disorders: how do they sleep?

PURPOSE OF REVIEW

In this review we summarized the available evidence on sleep disorders in children with neurodevelopmental disorders (NDDs) in particular: intellectual disability (including some genetic conditions such as Prader-Willi Syndrome, Smith-Magenis Syndrome), Autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD), Developmental Coordination Disorder, language disorders, and specific learning disorders.

RECENT FINDINGS

Children with NDDs frequently suffer from sleep disturbances, with a higher prevalence than that of the general pediatric population.

SUMMARY

These problems tend to be chronic and may cause additional cognitive and behavioral difficulties, often affecting the whole family's well-being. Sleep behaviors are also related to other important developmental skills, such as attention and listening. Investigating sleep disorders in children with NDDs is therefore crucial in clinical practice. For a systematic approach in clinical practice, we propose the use of a short and easy to remember sleep screening tool.

The Effect of Sleep-Wake Routines on the Negative Emotional States and Aggressive Behaviors in Adults with Autism Spectrum Disorders (ASD) during the COVID-19 Outbreak

Disruption in routine may be related to experiencing negative emotional states and to aggressive behaviors in individuals with Autism Spectrum Disorder (ASD). The lockdown because of COVID-19 contributed to the disruption of individuals’ routines, including the sleep−wake cycle. The current study tested a relationship between the adherence to the sleep−wake routine and aggressive behaviors via the mediation role of negative emotional states (i.e., anxiety and anger). Forty-three parents of adults with ASD completed a web-based questionnaire about their life condition during the first lockdown (April−May 2020). Preliminary analyses showed a worsening in the adults’ aggressive behaviors during the lockdown in comparison to before it (Z = −3.130; p = 0.002). In the mediation models, the relationship between the adherence to the sleep−wake routines and aggressive behaviors was significant. The models showed the hypothesized mediated relationships among the adherence to the sleep−wake routines, negative emotional states, and aggressive behaviors (Model 1: F (1, 41) = 10.478, p < 0.001; Model 2: F(1, 41) = 9.826, p = 0.003). The findings confirmed the potential protective role of the adherence to the sleep−wake routines for the emotional and behavioral adjustment of adults with autism. Theoretical and practical contributions of the study were discussed; indeed, our results may inform parent-coaching as well as intervention programs for individuals with ASD given that adequate sleep hygiene may contribute to improvements in internalizing/externalizing behaviors.

Examining the Relationship Between Sleep Quality, Social Functioning, and Behavior Problems in Children with Autism Spectrum Disorder: A Systematic Review

Over forty percent of autistic children experience poor sleep quality, and social interaction difficulties are a core characteristic of autism. However, the relationship between sleep quality and social functioning and behavior remains poorly understood. This systematic review examined the evidence concerning the impact of sleep quality on the social functioning and behavior problems in autistic children and adolescents. It also identified key related factors and evaluated how this issue has been researched to date. Seven key journals were hand-searched and five databases were systematically searched, using keywords. Titles and abstracts of 4123 items were screened against eligibility criteria by two researchers. Relevant studies were retained if they were peer-reviewed empirical papers, published in English between 2000 and 2021. Then, the full text of 97 papers was screened and if they met the eligibility criteria, their reference lists were hand-searched. Forty-six studies were included in the final review. Data were systematically extracted and two authors critically appraised the strengths and weaknesses of studies using Critical Appraisal Skills Programme tools. Key themes were identified, because a meta-analysis was not possible due to the studies' heterogeneity. The review identified that sleep quality and social functioning are associated with one another and there is a small amount of evidence that a bi-directional causal relationship may exist. Evidence suggests that several nights of suboptimal sleep duration and a lack of deep continuous sleep negatively impact externalizing and internalizing behavior. Sleep quality is also reduced by anxiety and sensory sensitivity. However, longitudinal studies with larger samples are needed to establish causality. Future research needs to examine confounding factors and to develop consensus regarding best-practice processes for the objective measurement of sleep with autistic children. Additional research also needs to further examine the consequences of poor sleep quality on internalizing behavior, and the impact of socio-cultural practices.

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.

Subjective and Electroencephalographic Sleep Parameters in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review

Background: Sleep problems have commonly manifested in children and adolescents with autism spectrum disorder (ASD) with a complex and multifactorial interaction between clinical and etiological components. These disorders are associated with functional impairment, and provoke significant physical and mental affliction. The purpose of this study is to update the existing literature about objective and subjective sleep parameters in children and adolescents with ASD, extrapolating information from polysomnography or sleep electroencephalography, and sleep related questionnaires. Methods: We have conducted a systematic review of case-control studies on this topic, performing a web-based search on PubMed, Scopus and the Web of Science databases according to the Preferred Reporting items for Systematic Review and Meta-analyses (PRISMA) guidelines. Results: Data collected from 20 survey result reports showed that children and adolescents with ASD experienced a higher rate of sleep abnormalities than in typically developing children. The macrostructural sleep parameters that were consistent with subjective parent reported measures unveil a greater percentage of nighttime signs of insomnia. Sleep microstructure patterns, in addition, pointed towards the bidirectional relationship between brain dysfunctions and sleep problems in children with ASD. Conclusions: Today’s literature acknowledges that objective and subjective sleep difficulties are more often recognized in individuals with ASD, so clinicians should assess sleep quality in the ASD clinical population, taking into consideration the potential implications on treatment strategies. It would be worthwhile in future studies to examine how factors, such as age, cognitive level or ASD severity could be related to ASD sleep abnormalities. Future research should directly assess whether sleep alterations could represent a specific marker for atypical brain development in ASD.

Attention-deficit/hyperactivity disorder symptoms and sleep problems in preschool children: the role of autistic traits

BACKGROUND

Sleep problems are elevated in children with attention-deficit/hyperactivity disorder (ADHD). However, until now there has been comparatively little research on the role of autistic traits in this association. The current study examined the association between ADHD symptoms and sleep problems in Japanese preschool children and whether autistic traits might also be important for this relationship.

METHODS

Data were analyzed from 1053 children (average age 64.14 months, range 58-71; 50.3% male) that were drawn from the Tama Children's Survey (TCS). Parent-reported information was obtained on ADHD symptoms using the Strengths and Difficulties Questionnaire (SDQ) and autistic traits with the Social Responsiveness Scale Second Edition (SRS-2). Parents also provided information on three different categories of sleep problems experienced by their children - parasomnias, sleep disordered breathing and awakening/daytime problems. Ordinal logistic regression analysis was used to examine the associations.

RESULTS

In analyses adjusted for sociodemographic factors, the mother's mental health and child's emotional problems, compared to children with no ADHD symptoms or autistic traits, children with only ADHD symptoms had significantly increased odds for only one of 11 individual sleep problems - waking in a negative mood. In contrast, children with comorbid ADHD symptoms and autistic traits had elevated odds for five sleep problems with odds ratios ranging from 2.10 (takes time to become alert in the morning) to 3.46 (excessive body movement while sleeping).

CONCLUSIONS

Sleep problems may be especially elevated in children with comorbid ADHD symptoms and autistic traits.

Sleep Assessment for Sleep Problems in Children

The breadth of childhood sleep problems is broad and can be associated with biologic, psychiatric, behavioral, social, and environmental processes. Unrecognized childhood sleep problems may threaten daytime behaviors and negatively impact school and psychosocial functioning. Left unattended, overall child biopsychosocial development may be impaired. Thus, identifying and addressing sleep problems has potential to optimize childhood health, development, and overall well-being. Nurses need to be cognizant of detrimental impacts of child sleep deprivation and advocate for appropriate sleep assessments while offering sleep education to parents and children.

Sleep Disorders in Autism Spectrum Disorder Pre-School Children: An Evaluation Using the Sleep Disturbance Scale for Children

Background and Objectives: Sleep disorders are common in children with Autism Spectrum Disorder (ASD). The aims of this study were to describe the incidence and characteristics of sleep disorders using a questionnaire completed by the caregiver in a sample of preschool-aged children with ASD and to identify possible differences in a control group of peers. Materials and Methods: Sleep disorders were investigated with the Sleep Disturbance Scale for Children (SDSC) in a population of pre-school-aged (3–5 years) ASD children and in a control group. The Autism Diagnostic Observation Schedule—second ed. (ADOS-2) was further used to assess autism symptom severity. A total of 84 children (69 males; mean age 3.9 ± 0.8 years) with a diagnosis of ASD and 84 healthy controls (65 males; mean age of 3.7 ± 0.8 years) that were matched for age and sex were enrolled. Results: ASD children reported significantly higher (pathological) scores than the control group on the SDSC total scores and in some of the factor scores, such as Difficulty in Initiating and Maintaining Sleep (DIMS), disorders of excessive somnolence (DOES), and sleep hyperhidrosis. A total of 18% of ASD children had a pathological SDSC total T-score, and 46% had an abnormal score on at least one sleep factor; DIMS, parasomnias, and DOES showed the highest rates among the sleep factors. Younger children (3 years) reported higher scores in DIMS and sleep hyperhidrosis than older ones (4 and 5 years). No specific correlation was found between ADOS-2 and SDSC scores. Conclusions: Pre-school children with ASD showed a high incidence of sleep disorders with different distributions of specific sleep factors according to their age. We suggest a screening assessment of sleep disorders using the SDSC in these children with a more in-depth evaluation for those reporting pathological scores on the questionnaire.

Behavioral assessment and faded bedtime intervention for delayed sleep-onset in an adult with autism spectrum disorder

Faded bedtime has been evaluated as a behavioral intervention for delayed sleep-onset principally with children and youth who have intellectual and developmental disabilities in hospital and home settings. The present case report describes behavioral assessment and faded bedtime intervention in a 21-year old adult man with autism spectrum disorder at a community-based group home. The study also documented the effects of family home visits on the man's sleep when he returned to the group home. Compared to a pre-intervention (baseline) phase, faded bedtime was associated with increased intervals of recorded sleep and a decrease in sleep-onset latency over several months of implementation. We discuss clinical implications of the case and generality of findings across populations and settings.

Evidence Base Update on Assessing Sleep in Youth

BACKGROUND

Sleep is vital to youth well-being and when it becomes disturbed - whether due to environmental or individual factors - mental and physical health suffer. Sleep problems can also be a symptom of underlying mental health disorders. Assessing different components of sleep, including quality and hygiene, can be useful both for identifying mental health problems and for measuring changes in well-being over time. However, there are dozens of sleep-related measures for youth and it can be difficult to determine which to select for a specific research or clinical purpose. The goal of this review was to identify sleep-related measures for clinical and/or research use in youth mental health settings, and to update the evidence base on this topic.

METHOD

We generated a list of candidate measures based on other reviews and searched in PubMed and PsycINFO using the terms "sleep" AND (measure OR assessment OR questionnaire) AND (psychometric OR reliability OR validity). Search results were limited to studies about children and adolescents (aged 2-17) published in English. Additional criteria for inclusion were that there had to be at least three publications reporting on the measure psychometrics in community or mental health populations. Sleep measures meeting these criteria were evaluated using the criteria set by De Los Reyes and Langer (2018).

RESULTS

Twenty-six measures, across four domains of sleep - insomnia, sleep hygiene, sleepiness, sleep quality - met inclusion criteria. Each measure had at least adequate clinical utility. No measure(s) emerged as superior across psychometric domains.

CONCLUSION

Clinicians and researchers must evaluate sleep measures for each use case, as the intended purpose will dictate which measure is best. Future research is necessary to evaluate measure performance in transdiagnostic mental health populations, including youth with serious mental illness.

Factor analysis of the children's sleep habits questionnaire among preschool children with autism spectrum disorder

BACKGROUND

Sleep problems are prevalent among young children with autism spectrum disorders (ASD). The Children's Sleep Habits Questionnaire (CSHQ) is commonly used for assessment, but there are outstanding questions regarding its optimal measurement model.

AIMS

To examine the factor structure of the CSHQ in preschool children with ASD, and relationships between CSHQ factors and children's emotional, cognitive, and behavioral dysregulation.

METHODS AND PROCEDURES

Participants included 4- to 5-year-olds with ASD (n = 281). Confirmatory factor analysis was used to examine whether two previously reported CSHQ factor structures provided adequate fit to the sample data. Exploratory Factor Analysis (EFA) was used examine alternative models. Regression analyses were used to examine how CSHQ factor scores explained variance in dysregulation symptoms, measured by the Child Behavior Checklist.

RESULTS

Previously reported factor models in children with ASD were not confirmed, but a novel five-factor model identified using EFA provided excellent fit to the sample data. Sleep factors were generally not correlated with autism symptoms but were associated with aggression, anxiety/depression and attention problems, with evidence of specificity in these relationships.

CONCLUSIONS

The proposed CSHQ five-factor model may be useful in future studies of sleep problems in young children with ASD.

Sleep Problems Influence Emotional/Behavioral Symptoms and Repetitive Behavior in Preschool-Aged Children With Autism Spectrum Disorder in the Unique Social Context of China

Sleep disturbances are common in people with autism spectrum disorder (ASD), but research on this topic is still limited in China. In the current study, we evaluated the prevalence of sleep problems in preschool-aged children with ASD and to examine the correlations between sleep disturbances and emotional/behavioral symptoms and repetitive behavior in the unique social context of China. This study recruited 475 preschool-aged children aged 3-6 years old, including 252 children with ASD (mean age 5.13 ± 1.15, 80.6% male) and 223 age-matched typically developing (TD) children (mean age 5.12 ± 0.97, 74.9% male). The parents of all children completed a sociodemographic questionnaire and the Childhood Sleep Habits Questionnaire. The parents of 114 ASD children completed the Strengths and Difficulties Questionnaire (SDQ) and the Repetitive Behavioral Questionnaire-2 (RBQ-2). The prevalence of sleep problems in preschool-aged children with ASD in this study was 81.7%, which was higher than that in TD children (61.0%). The scores for bedtime resistance, sleep anxiety, sleep duration, parasomnias, and sleep onset delay in the ASD group were significantly higher than those in the TD group (t=-7.664, P=0.000; t=-10.477, P=0.000; t=-4.133, P=0.000; Z=-3.916, P=0.000; Z=-7.093, P=0.000; respectively). Sleep onset delay explained 17.3% of the variance (adjusted R² = 0.173) in the total SDQ score of children with ASD, and bedtime resistance explained a large proportion of total RBQ-2 score variance (adjusted R² = 0.206). The high rate of sleep disturbances in preschool-aged children with ASD emphasizes the importance of screening for sleep problems in this population. Attention should also be directed toward formulating good sleep hygiene practices for preschool-aged children in the particular social context and cultural setting of China.

Sleep disturbances and associated factors among 2-6-year-old male children with autism in Bhubaneswar, India

BACKGROUND

Sleep disturbances are considered one of the significant comorbidities of autism; they negatively impact the quality of life of children with autism as well as their parents or caregivers. This study aimed to determine the prevalence of sleep disturbances in Indian male children diagnosed with autism and examine the association of lifestyle behaviors and socio-demographic characteristics with sleep problems.

METHODS

The present cross-sectional study was conducted in Bhubaneswar city in the year 2018, involving mothers of 100 male children with autism aged 2-6 years. We used a children's sleep habits questionnaire (CSHQ) to evaluate the sleep problems in children with autism and a semi-structured schedule for gathering information regarding lifestyle behaviors and socio-demographic characteristics.

RESULTS

The overall prevalence of parent-reported sleep problems was 93%; the most prevalent CSHQ subscales were: bedtime resistance (95%), sleep anxiety (85%), and sleep duration (81%). The mean ISAA score of the study sample was 133.89 ± 19.59, where 12%, 71%, and 17% of the children had mild, moderate, and severe autism, respectively. Multiple linear regression analysis revealed that variables such as autism severity, screen time, caffeine intake, physical activity, maternal age, child's age, and birth weight were significantly associated with the CSHQ subscales.

CONCLUSION

The prevalence of parent-reported sleep problems is very high among the male children with autism in Bhubaneswar, India, and there is an urgent need for interventional measures for appropriate management of this problem among these children.