Sleep patterns in children with and without autism spectrum disorders: developmental comparisons

Sex Differences in Sleep and Physical Activity Patterns in Autism Spectrum Disorder

Physical activity (PA) programs have been found to result in improved sleep in males with autism spectrum disorder (ASD), but little is known about the female characteristics. The aim of this work was to assess sex differences in sleep and PA indices using an accelerometer over 7 days and 7 nights. Sleep and PA variables were measured with questionnaires and with accelerometry in twenty-four children with ASD (16 boys, 10.3 ± 2.8; 8 girls, 11.1 ± 3.9). Some significant differences were reported between girls and boys. The total time in bed and wake time after sleep onset (WASO) were significantly higher in girls compared to boys (p < 0.01), whereas sleep efficiency was significantly lower in girls (p < 0.01). The results obtained from the sleep questionnaire (CSHQ) show averages above the threshold of 41 in both groups (the threshold indicates the presence of sleep disorders or low sleep quality). The number of daily steps was significantly lower in the girls' group (p < 0.01), and the PA volume for vigorous and strong vigorous intensities was significantly higher in the boys' group (p < 0.01 and p < 0.05, respectively). Our results show major alterations in girls, with a low level of PA and sleep alteration. PA is a relevant non-pharmacological approach to improve sleep quality and achieve sufficient sleep duration. However, particularly for girls with ASD, more personalized approaches to improve sleep may be needed to manage specific associated disorders.

Sex differences in sleep deficits in mice with an autism-linked Shank3 mutation

BACKGROUND

Insomnia is more prevalent in individuals with Autism Spectrum Disorder (ASD), can worsen core-symptoms and reduces quality of life of both individuals and caregivers. Although ASD is four times more prevalent in males than females, less is known about sex specific sleep differences in autistic individuals. Recent ASD studies suggest that sleep problems may be more severe in females, which aligns with the sex bias seen in insomnia for the general population. We have previously shown that male mice with a mutation in the high confidence ASD gene Shank3, Shank3∆C, recapitulate most aspects of the ASD insomnia phenotype. The objective of the present study was to leverage the Shank3∆C model to investigate sex-specific effects in sleep using polysomnography.

METHODS

Adult male and female Shank3∆C and wildtype (WT) littermates were first recorded for 24 h of baseline recordings. Subsequently, they were sleep deprived (SD) for five hours via gentle handling and allowed 19 h of recovery sleep to characterize the homeostatic response to SD. Vigilance states (rapid eye movement (REM) sleep, non-rapid eye movement (NREM) sleep and wake) were assigned by manual inspection using SleepSign. Data processing, statistical analysis and visualization were conducted using MATLAB.

RESULTS

Sex and genotype effects were found during baseline sleep and after SD. At baseline, male Shank3∆C mice sleep less during the dark period (active phase) while female Shank3∆C mice sleep less during the light period (rest phase) and sleep more during the dark period. Both male and female Shank3∆C mice show reduced spectral power in NREM sleep. We detect a significant effect of sex and genotype in sleep onset latency and homeostatic sleep pressure (sleepiness). In addition, while male Shank3∆C mice fail to increase sleep time following SD as seen in WT, female Shank3∆C mice decrease sleep time.

CONCLUSIONS

Overall, our study demonstrates sex differences in sleep architecture and homeostatic response to SD in adult Shank3∆C mice. Thus, our study demonstrates an interaction between sex and genotype in Shank3∆C mice and supports the use of the Shank3∆C model to better understand mechanisms contributing to the sex differences in insomnia in ASD in clinical populations.

Usability of an augmented reality bedtime routine application for autistic children

Sleep problems are highly prevalent in autism and negatively impact the physical and mental health of children and their caregivers. Sleep education programs are often recommended as a first line-treatment to help parents implement healthy sleeping habits and a bedtime routine at home; however, the accompanying paper-based toolkits used in the bedtime routines have limitations related to engagement and adherence. To address these gaps, we iteratively developed and tested the usability of an augmented reality (AR) bedtime routine application. Our single participant design study (n = 7 child/parent dyads) found 86% compliance with the program and suggested good-excellent usability of the app with a trend toward increased willingness and faster completion of children's bedtime routines. This work supports the feasibility of using technology-based tools in sleep education programs and informs future clinical studies examining the effectiveness of these approaches for mitigating sleep difficulties.

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.

Cortical parvalbumin neurons are responsible for homeostatic sleep rebound through CaMKII activation

The homeostatic regulation of sleep is characterized by rebound sleep after prolonged wakefulness, but the molecular and cellular mechanisms underlying this regulation are still unknown. In this study, we show that Ca2+/calmodulin-dependent protein kinase II (CaMKII)-dependent activity control of parvalbumin (PV)-expressing cortical neurons is involved in homeostatic regulation of sleep in male mice. Prolonged wakefulness enhances cortical PV-neuron activity. Chemogenetic suppression or activation of cortical PV neurons inhibits or induces rebound sleep, implying that rebound sleep is dependent on increased activity of cortical PV neurons. Furthermore, we discovered that CaMKII kinase activity boosts the activity of cortical PV neurons, and that kinase activity is important for homeostatic sleep rebound. Here, we propose that CaMKII-dependent PV-neuron activity represents negative feedback inhibition of cortical neural excitability, which serves as the distributive cortical circuits for sleep homeostatic regulation.

Sleeping Sound Autism Spectrum Disorder (ASD): Cost-Effectiveness of a Brief Behavioural Sleep Intervention in Primary School-Aged Autistic Children

Disordered sleep is common in autistic children. This study aimed to evaluate the cost-effectiveness of a brief behavioural sleep intervention, the 'Sleeping Sound intervention', in primary school-aged autistic children in Australia. A cost-effectiveness analysis was undertaken alongside a randomised controlled trial over a 6-month follow-up period from both a societal and healthcare sector perspective. Resources used by participants were collected from a resource-use questionnaire and administrative data; intervention costs were determined from study records. Mean costs and quality-adjusted life-years (QALYs) were compared between the intervention and treatment as usual (TAU) groups. Uncertainty analysis using bootstrapping and sensitivity analyses were conducted. The sample included 245 children, with 123 participants randomised to the intervention group and 122 to TAU. The mean total costs were higher for the Sleeping Sound intervention with a mean difference of A$745 (95% CI 248; 1242; p = 0.003) from a healthcare sector perspective and A$1310 (95% CI 584; 2035, p < 0.001) from a societal perspective. However, the intervention also resulted in greater QALYs compared with TAU, with a mean difference of 0.038 (95% CI 0.004; 0.072; p = 0.028). The incremental cost-effectiveness ratio was A$24,419/QALY (95% CI 23,135; 25,703) from a healthcare sector perspective and A$41,922/QALY (95% CI 39,915; 43,928) from a societal perspective; with a probability of being cost-effective of 93.8% and 74.7%, respectively. Findings remained robust in the sensitivity analyses. The Sleeping Sound intervention offers a cost-effective approach in improving sleep in primary school-aged autistic children.Trial registration The trial was registered with the International Trial Registry (ISRCTN14077107).

Correlations between sleep problems, core symptoms, and behavioral problems in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis

Children and adolescents with autism spectrum disorder (ASD) experience various sleep problems. Sleep problems co-occur in a bidirectional relationship with ASD core symptoms and behavioral problems. However, studies on how these three factors are intricately linked to each other are limited. This meta-analysis examined the differential relationship between specific sleep problems, core symptoms, and behavioral problems in this population. This study was registered in PROSPERO (CRD42022339695). We systematically searched the PubMed/MEDLINE, Web of Science, and Scopus databases from inception to April 27, 2022. Observational studies that reported correlations between measures of sleep problems, ASD core symptoms, or ASD behavioral problems were included, and participants aged 18 years or below were enrolled. The correlation coefficient (r) was assessed as the primary effect metric. Total 22 cross-sectional studies were included, which comprised 2655 participants (mean age = 6.60 years old; mean percentage of boys = 80.64%). We found correlations between total sleep problems and total core symptoms (r 0.293 [95% confidence interval - 0.095 to 0.604]), total sleep problems and total behavioral problems (r 0.429 [0.299-0.544]), and total core symptoms and total behavioral problems (r - 0.050 [- 0.177 to 0.079]) and identified statistically significant correlations between specific components of sleep problems, ASD core symptoms, and ASD behavioral problems. Each specific sleep problem showed a unique association with core symptoms and behavioral problems. Sleep problems in ASD should be explored in detail, and the closely linked core symptoms and behavioral problems should be common therapeutic targets.

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.

Randomised Controlled Trial of a Behavioural Sleep Intervention, 'Sleeping Sound', for Autistic Children: 12-Month Outcomes and Moderators of Treatment

This study examined the sustained and moderating effects of a behavioural sleep intervention for autistic children in a randomised controlled trial. Autistic children (5-13 years) with sleep problems were randomised to the Sleeping Sound intervention or Treatment as Usual (TAU). At 12-month follow-up (n = 150), caregivers of children in the Sleeping Sound group reported greater reduction in child sleep problems compared to TAU (p < .001, effect size: - 0.4). The long-term benefits of the intervention were greater for children taking sleep medication, children of parents who were not experiencing psychological distress, and children with greater autism severity. The Sleeping Sound intervention demonstrated sustained improvements in child sleep. Identified moderators may inform treatment by indicating which subgroups may benefit from further support.

Age-Related Differences in Accelerometer-Assessed Physical Activity and Sleep Parameters Among Children and Adolescents With and Without Autism Spectrum Disorder: A Meta-Analysis

Importance

Physical inactivity and sleep disorders are health-related concerns of youth with autism spectrum disorder (ASD) that can persist from childhood and exacerbate core symptoms. However, evidence on group differences in accelerometer-assessed physical activity and sleep parameters among youth with and without ASD is inconclusive and age-specific effects remain unclear.

Objective

To synthesize evidence on group differences in accelerometer-assessed physical activity and sleep parameters and examine the moderating effects of age between children and adolescents with and without ASD.

Data Sources

American Psychological Association PsychInfo, CINAHL Ultimate, ERIC, MEDLINE, SPORTDiscus with Full Text, and Web of Science from inception to February 2023.

Study Selection

Two independent reviewers screened articles for observational research comparing accelerometer-assessed physical activity levels and sleep parameters in children and adolescents with and without ASD.

Data Extraction and Synthesis

After developing a standardized form, relevant data were extracted. Quality was assessed using the McMaster Critical Review Form and rated based on sample, measurement, and analyses. The Preferring Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed.

Main Outcomes and Measures

The primary outcomes were actigraphy-measured MVPA, sleep latency, sleep efficiency, total sleep time, and wake after sleep onset. Data were pooled using a random-effects model. Hedges g was used to express the effect size index. Meta-regression on age was also performed to investigate the potential moderating effects.

Results

Collectively, 1757 studies were initially identified. Among 104 articles that were assessed, 28 were included, comprising moderate-to-vigorous physical activity (MVPA), 4 sleep parameters, and 73 independent effect sizes. A total of 28 studies were included in analysis, comprising 805 children and adolescents with ASD and 1573 without ASD (age range, 5.1-16.9 years). Compared with peers without ASD, children and adolescents with ASD had a small-to-moderate difference in MVPA (g = -0.450; 95% CI, -0.622 to -0.277), total sleep time (g = -0.332; 95% CI, -0.574 to -0.090), sleep efficiency (g = -0.424; 95% CI, -0.645 to -0.203), and a moderate difference in sleep latency (g = 0.514; 95% CI, 0.351 to 0.677) measured by actigraphy. Children and adolescents with ASD experienced an age-related decline in moderate-to-vigorous physical activity (β = -0.049 [95% CI, -0.097 to -0.001]; P = .045), indicating that younger children with ASD showed a smaller difference in MVPA compared with their peers without ASD. Moderating effects of age on sleep parameters were not significant.

Conclusions and Relevance

The findings of this meta-analysis suggested that children and adolescents with ASD had lower MVPA and worse sleep than peers without ASD, and the difference in MVPA varied with age. These findings reinforce the need for public health initiatives aimed at reducing these group disparities.

Updated consensus guidelines on the management of Phelan-McDermid syndrome

Phelan-McDermid syndrome (PMS) is a genetic condition caused by SHANK3 haploinsufficiency and characterized by a wide range of neurodevelopmental and systemic manifestations. The first practice parameters for assessment and monitoring in individuals with PMS were published in 2014; recently, knowledge about PMS has grown significantly based on data from longitudinal phenotyping studies and large-scale genotype-phenotype investigations. The objective of these updated clinical management guidelines was to: (1) reflect the latest in knowledge in PMS and (2) provide guidance for clinicians, researchers, and the general community. A taskforce was established with clinical experts in PMS and representatives from the parent community. Experts joined subgroups based on their areas of specialty, including genetics, neurology, neurodevelopment, gastroenterology, primary care, physiatry, nephrology, endocrinology, cardiology, gynecology, and dentistry. Taskforce members convened regularly between 2021 and 2022 and produced specialty-specific guidelines based on iterative feedback and discussion. Taskforce leaders then established consensus within their respective specialty group and harmonized the guidelines. The knowledge gained over the past decade allows for improved guidelines to assess and monitor individuals with PMS. Since there is limited evidence specific to PMS, intervention mostly follows general guidelines for treating individuals with developmental disorders. Significant evidence has been amassed to guide the management of comorbid neuropsychiatric conditions in PMS, albeit mainly from caregiver report and the experience of clinical experts. These updated consensus guidelines on the management of PMS represent an advance for the field and will improve care in the community. Several areas for future research are also highlighted and will contribute to subsequent updates with more refined and specific recommendations as new knowledge accumulates.

Critical periods and Autism Spectrum Disorders, a role for sleep

Brain development relies on both experience and genetically defined programs. Time windows where certain brain circuits are particularly receptive to external stimuli, resulting in heightened plasticity, are referred to as "critical periods". Sleep is thought to be essential for normal brain development. Importantly, studies have shown that sleep enhances critical period plasticity and promotes experience-dependent synaptic pruning in the developing mammalian brain. Therefore, normal plasticity during critical periods depends on sleep. Problems falling and staying asleep occur at a higher rate in Autism Spectrum Disorder (ASD) relative to typical development. In this review, we explore the potential link between sleep, critical period plasticity, and ASD. First, we review the importance of critical period plasticity in typical development and the role of sleep in this process. Next, we summarize the evidence linking ASD with deficits in synaptic plasticity in rodent models of high-confidence ASD gene candidates. We then show that the high-confidence rodent models of ASD that show sleep deficits also display plasticity deficits. Given how important sleep is for critical period plasticity, it is essential to understand the connections between synaptic plasticity, sleep, and brain development in ASD. However, studies investigating sleep or plasticity during critical periods in ASD mouse models are lacking. Therefore, we highlight an urgent need to consider developmental trajectory in studies of sleep and plasticity in neurodevelopmental disorders.

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.

Associations between autistic traits and early ear and upper respiratory signs: a prospective observational study of the Avon Longitudinal Study of Parents and Children (ALSPAC) geographically defined childhood population

OBJECTIVE

To determine whether early ear and upper respiratory signs are associated with the development of high levels of autistic traits or diagnosed autism.

DESIGN

Longitudinal birth cohort: Avon Longitudinal Study of Parents and Children (ALSPAC).

SETTING

Area centred on the city of Bristol in Southwest England. Eligible pregnant women resident in the area with expected date of delivery between April 1991 and December 1992 inclusive.

PARTICIPANTS

10 000+ young children followed throughout their first 4 years. Their mothers completed three questionnaires between 18-42 months recording the frequency of nine different signs and symptoms relating to the upper respiratory system, as well as ear and hearing problems.

OUTCOME MEASURES

Primary-high levels of autism traits (social communication, coherent speech, sociability, and repetitive behaviour); secondary-diagnosed autism.

RESULTS

Early evidence of mouth breathing, snoring, pulling/poking ears, ears going red, hearing worse during a cold, and rarely listening were associated with high scores on each autism trait and with a diagnosis of autism. There was also evidence of associations of pus or sticky mucus discharge from ears, especially with autism and with poor coherent speech. Adjustment for 10 environmental characteristics made little difference to the results, and substantially more adjusted associations were at p<0.001 than expected by chance (41 observed; 0.01 expected). For example, for discharge of pus or sticky mucus from ears the adjusted odds ratio (aOR) for autism at 30 months was 3.29 (95% CI 1.85 to 5.86, p<0.001), and for impaired hearing during a cold the aOR was 2.18 (95% CI 1.43 to 3.31, p<0.001).

CONCLUSIONS

Very young children exhibiting common ear and upper respiratory signs appear to have an increased risk of a subsequent diagnosis of autism or demonstrated high levels of autism traits. Results suggest the need for identification and management of ear, nose and throat conditions in autistic children and may provide possible indicators of causal mechanisms.

The impact of COVID-19 on sleep for autistic children: A systematic review

Background

Up to 80% of children with autism experience behavioural sleep problems, predominantly relating to bedtime resistance, sleep anxiety, sleep dysregulation, and shorter duration, which are associated with increased autistic symptom expression and emotional and behavioural difficulties. Researchers predicted the COVID-19 pandemic would worsen sleep and behavioural difficulties for autistic children, due to their need for routine and certainty. This systematic review is the first to focus on delineating the role of sleep disturbance in exacerbating autistic symptoms and internalising and externalising behaviours during the pandemic.

Method

In this PROSPERO registered systematic review, we aggregated and synthesised findings from empirical studies from 2020 onwards that included children with autism and examined sleep outcomes, using narrative and framework synthesis due to the variety of methods and designs employed. We identified additional relevant themes through inductive thematic analysis.

Results

Seventy-one studies met the search criteria, and we selected seventeen for review following screening and quality assessment. These studies reported mixed findings; with strongest support for worsening of sleep problems typically experienced by autistic children, including difficulties with sleep regulation and shorter sleep duration. Further, sleep problems were associated with increased expression of autistic characteristics.

Conclusions

Preliminary findings of worsening sleep and increased autistic characteristics for autistic children throughout the COVID-19 pandemic highlight the need for ongoing, accessible and flexible service provision during exposure to environmental stressors. We propose that behavioural sleep interventions are well suited to telehealth adaptation and play an important role in supporting families when in-person treatment for sleep problems is not possible.

Stronger Associations Between Sleep and Mental Health in Adults with Autism: A UK Biobank Study

This study examined sleep and its cognitive and affective correlates in adults with and without autism spectrum disorder (ASD), utilizing UK Biobank data. There were no group differences in subjective sleep duration [n = 220 ASD; n = 2200 general population (GP)]. Accelerometer measures of sleep duration or nighttime activity did not differ by group, but sleep efficiency was marginally lower in ASD (n = 83 ASD; n = 824 GP). Sleep efficiency was associated with wellbeing and mental health, and pathways between accelerometer sleep measures and wellbeing and mental health were significantly stronger for adults with ASD (who also reported substantially poorer wellbeing and > 5 × likelihood of experiencing mental distress). These findings highlight the need to monitor sleep to maintain good mental health in adult ASD.

Evaluation of the Relationship of Sleep Disturbances to Severity and Common Behaviors in Autism Spectrum Disorder

Background

Autism spectrum disorder (ASD) is one of the most puzzling disorders of childhood. Recent research of comorbidities that accompany ASD and are commonly attributed to the diagnosis, indicate that they may contribute to the severity of behavioral symptoms of the disorder.Disturbed sleep in all children can decrease cognition, decrease focus, increase performance problems, and alter mood and behavior. Children with ASD experience an increased sensitivity to disturbed sleep that may increase the severity of the disorder. Disturbed sleep patterns, such as increased sleep latency, nighttime waking and early arousal, have been identified in up to 80% of children with ASD. This study explored the relationship of disturbed sleep and the severity of the core ASD symptoms.

Methods

Actigraphy and an accompanying sleep diary captured disturbed sleep patterns in 24 children, ages 6-12, with ASD. Participants wore a GT3X actigraphy monitor for 7 nights to collect data on patterns of disturbed sleep. Parents completed a sleep diary and the Autism Spectrum Rating Scale (ASRS) questionnaire.A descriptive analysis was used to report the characteristics of nighttime sleep and sleep efficiency as well as sleep disturbances. Pearson's r determined the relationships between the number of sleep disturbances and the severity of ASD behavioral scores and diagnostic severity (determined by the ASRS).

Results

Of the 24 study participants, almost 92% had one or more sleep disturbances. A positive correlation was present between the number of sleep disturbances and the severity of delays in social and communication symptoms. A moderate effect size was found between the number of sleep disturbances and unusual behaviors in ASD suggests a possible, unanticipated, inverse relationship.

Conclusions

Exploring the relationship of disturbed sleep to behavior and symptom severity in children with ASD can provide an understanding of how poor sleep influences ASD symptoms. This study identified distinct differences in ASD symptom severity between and within individual participants and found unique, and unexpected, symptom patterns. This finding supports the need, in research and treatment, to identify comorbidities and symptoms that contribute to individual behavioral profiles and phenotypes of the disorder.

Reduced epilepsy development in synapsin 2 knockout mice with autistic behavior following early systemic treatment with interleukin-6 receptor antibody

BACKGROUND

Individuals with autism spectrum disorder (ASD) have an increased risk of developing epilepsy. Both ASD and epilepsy have been associated with increased levels of immune factors in the blood, including the proinflammatory cytokine interleukin 6 (IL-6). Mice lacking the synapsin 2 gene (Syn2 KO) exhibit ASD-like behavior and develop epileptic seizures. Their brains display neuroinflammatory changes including elevated IL-6 levels. We aimed to investigate the effect of systemic IL-6 receptor antibody (IL-6R ab) treatment on seizure development and frequency in Syn2 KO mice.

MATERIAL AND METHODS

Weekly systemic (i.p.) injections of IL-6R ab or saline were given to Syn2 KO mice starting either early in life at 1 month of age, before seizure debut or at 3 months of age, directly after seizure debut and continued for 4 or 2 months, respectively. Seizures were provoked by handling the mice three times per week. The neuroinflammatory response and synaptic protein levels in the brain were determined by ELISA, immunohistochemistry and western blots. In an additional group of Syn2 KO mice, with IL-6R ab treatment early in life, ASD-related behavioral tests including social interaction and repetitive self-grooming, as well as cognitive memory and depressive-/anxiety-like tests, and actigraphy measurements of circadian sleep-awake rhythm were analyzed.

RESULTS

The IL-6R ab treatment reduced seizure development and frequency in Syn2 KO mice when initiated before, but not after, seizure debut. However, early treatment did not reverse the neuroinflammatory response or the imbalance in synaptic protein levels in the brain previously reported in Syn2 KO mice. The treatment did not affect social interaction, performance in memory, depressive-/anxiety-like tests or the sleep-awake rhythm of Syn2 KO mice.

CONCLUSION

These findings suggest the involvement of IL-6 receptor signaling during epilepsy development in Syn2 KO mice, without significant alterations of the immune reaction in the brain, and independently of cognitive performance, mood and circadian sleep-awake rhythm.

Cross-country comparison of parental reports and objective measures of sleep patterns of typically developing children and autistic children between the UK and South Korea

Sleep duration and disturbances in typically developing (TD) children have been found to vary across countries. Given the impact of culture on sleep patterns in TD children, it is also necessary to examine the impact of culture on sleep patterns in children with atypical development. However, previous studies have often relied only on parent reports of children's sleep. Hence, the present study conducted a cross-cultural comparison of sleep duration and disturbances of school-aged TD children and autistic children in the UK and South Korea (hereafter Korea) using both subjective and objective sleep measurements. Cultural differences were observed in both actigraphy measures and parent reports of children's sleep duration and disturbances. Both TD children and autistic children in Korea had a later bedtime, later getting up time and shorter nocturnal sleep duration than their peers in the UK (p < .05). Furthermore, greater parent-reported sleep disturbances were reported in TD children in Korea compared to TD children in the UK and in autistic children in the UK compared to autistic children in Korea. Correlational analyses indicated that most parent-reported measures of children's sleep did not significantly correlate with objective measures and child reports, suggesting that studies on children's sleep can benefit by collecting data from multiple sources. Taken together, these findings suggest a cultural influence on sleep duration and disturbances of both TD children and autistic children. This study raises questions for further research to identify factors underlying cultural differences in children's sleep duration and disturbances.

Sleep problems in children with autism spectrum disorder in Hong Kong: a cross-sectional study

Background

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with a growing prevalence of sleep problems associated with significant behavioral problems and more severe autism clinical presentation. Little is known about the relationships between autism traits and sleep problems in Hong Kong. Therefore, this study aimed to examine whether children with autism have increased sleep problems than non-autistic children in Hong Kong. The secondary objective was to examine the factors associated with sleep problems in an autism clinical sample.

Methods

This cross-sectional study recruited 135 children with autism and 102 with the same age range of non-autistic children, aged between 6 and 12 years. Both groups were screened and compared on their sleep behaviors using the Children's Sleep Habits Questionnaire (CSHQ).

Results

Children with autism had significantly more sleep problems than non-autistic children [t _(226.73) = 6.20, p < 0.001]. Bed -sharing [beta = 0.25, t ₍₁₆₅₎ = 2.75, p = 0.07] and maternal age at birth [beta = 0.15, t ₍₁₆₅₎ = 2.05, p = 0.043] were significant factors associated with CSHQ score on the top of autism traits. Stepwise linear regression modeling identified that only separation anxiety disorder (beta = 4.83, t = 2.40, p = 0.019) best-predicted CSHQ.

Conclusion

In summary, autistic children suffered from significantly more sleep problems and co-occurring separation anxiety disorder brings greater sleep problems as compared to non-autistic children. Clinicians should be more aware of sleep problems to provide more effective treatments to children with autism.

Shank3 influences mammalian sleep development

Sleep problems are prevalent in autism spectrum disorder (ASD), can be observed before diagnosis, and are associated with increased restricted and repetitive behaviors. Therefore, sleep abnormalities may be a core feature of the disorder, but the developmental trajectory remains unknown. Animal models provide a unique opportunity to understand sleep ontogenesis in ASD. Previously we showed that adult mice with a truncation in the high-confidence ASD gene Shank3 (Shank3^∆C ) recapitulate the clinical sleep phenotype. In this study we used longitudinal electro-encephalographic (EEG) recordings to define, for the first time, changes in sleep from weaning to young adulthood in an ASD mouse model. We show that Shank3^∆C male mice sleep less overall throughout their lifespan, have increased rapid eye movement (REM) sleep early in life despite significantly reduced non-rapid eye movement (NREM) sleep, and have abnormal responses to increased sleep pressure that emerge during a specific developmental period. We demonstrate that the ability to fall asleep quickly in response to sleep loss develops normally between 24 and 30 days in mice. However, mutants are unable to reduce sleep latency after periods of prolonged waking and maintain the same response to sleep loss regardless of age. This phenomenon seems independent of homeostatic NREM sleep slow-wave dynamics. Overall, our study recapitulates both preclinical models and clinical studies showing that reduced sleep is consistently associated with ASD and suggests that problems falling asleep may reflect abnormal development of sleep and arousal mechanisms.

Acceptability of a behavioural sleep intervention for autistic children: A qualitative evaluation of Sleeping Sound

OBJECTIVE

The aim of the current study was to evaluate parental perceptions of the acceptability of a brief behavioural sleep intervention for autistic children (aged 5-13 years) using the Theoretical Framework of Acceptability (TFA).

METHODS

Qualitative data were collected during a large randomised controlled trial evaluating the efficacy of the Sleeping Sound intervention: 123 families were randomised to the intervention group, of which 115 (93%) completed at least one intervention session and 82 (67%) provided qualitative evaluation data in the 3-month follow-up survey. Consultation records from intervention sessions and parent surveys were qualitatively analysed post hoc using a hybrid approach to thematic analysis.

RESULTS

Findings were categorised under the seven themes of the TFA (affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, self-efficacy) in addition to three themes that were defined following inductive and deductive coding (barriers to implementation, facilitators to implementation, suggestions for improvement). Participants spoke positively about their experience participating in the intervention and perceived the intervention to be appropriate and effective. Most parents (95.5%) reported that they would recommend the Sleeping Sound intervention to other families of autistic children. Barriers to implementation included child and parent anxiety, child health problems, parental preferences, family circumstances, and other (e.g., school holidays). Facilitators to implementation included family support and consistency with strategies.

CONCLUSIONS

The Sleeping Sound intervention was considered acceptable to parents of autistic children as evidenced by largely positive feedback regarding their experience. The results highlighted areas for improvement which can be used to inform future iterations of the intervention.

Gastrointestinal symptoms have a minor impact on autism spectrum disorder and associations with gut microbiota and short-chain fatty acids

Children with autism spectrum disorder (ASD) experience gastrointestinal (GI) issues more frequently and severely than children who are typically developing (TD). The connections between gastrointestinal problems, microbiota, and short-chain fatty acids (SCFAs) in ASD are still being debated. We enrolled 90 children, 45 of whom were diagnosed with ASD, and examined the impact of GI disorders on ASD. The six-item GI Severity Index questionnaire was used to evaluate gastrointestinal symptoms, while the Social Responsiveness Scale was used to evaluate autism symptoms. Further, the Children’s Sleep Habits Questionnaire and the Children’s Eating Behavior Questionnaire are used to assess sleep and eating disorders in children. We assessed fecal microbiota by 16S rRNA gene sequencing, and SCFA concentrations by gas chromatography/mass spectrometry. The results revealed that children with ASD exhibited a high rate of gastrointestinal issues (78%), as well as higher rates of social impairment and poor sleeping habits, compared to TD children. However, GI disturbances have a minor impact on autism. In addition, the levels of propionic acid, butyric acid, and valeric acid were significantly higher in the ASD group. Besides, the ASD, TD, and GI subgroups possessed distinct microbiome profiles. These findings suggest that gastrointestinal disturbances have no discernible effect on the core symptoms of autism. Although autism may not cause an increase in GI symptoms directly, alterations in metabolites, such as SCFAs, may cause GI symptoms.

Investigating the contributions of circadian pathway and insomnia risk genes to autism and sleep disturbances

Sleep disturbance is prevalent in youth with Autism Spectrum Disorder (ASD). Researchers have posited that circadian dysfunction may contribute to sleep problems or exacerbate ASD symptomatology. However, there is limited genetic evidence of this. It is also unclear how insomnia risk genes identified through GWAS in general populations are related to ASD and common sleep problems like insomnia traits in ASD. We investigated the contribution of copy number variants (CNVs) encompassing circadian pathway genes and insomnia risk genes to ASD risk as well as sleep disturbances in children with ASD. We studied 5860 ASD probands and 2092 unaffected siblings from the Simons Simplex Collection (SSC) and MSSNG database, as well as 7509 individuals from two unselected populations (IMAGEN and Generation Scotland). Sleep duration and insomnia symptoms were parent reported for SSC probands. We identified 335 and 616 rare CNVs encompassing circadian and insomnia risk genes respectively. Deletions and duplications with circadian genes were overrepresented in ASD probands compared to siblings and unselected controls. For insomnia-risk genes, deletions (not duplications) were associated with ASD in both cohorts. Results remained significant after adjusting for cognitive ability. CNVs containing circadian pathway and insomnia risk genes showed a stronger association with ASD, compared to CNVs containing other genes. Circadian genes did not influence sleep duration or insomnia traits in ASD. Insomnia risk genes intolerant to haploinsufficiency increased risk for insomnia when duplicated. CNVs encompassing circadian and insomnia risk genes increase ASD liability with little to no observable impacts on sleep disturbances.

Efficacy of auricular plaster therapy for sleep disorders in preschool children with autism spectrum disorders: Study protocol for a randomized controlled trial

Background

Children with autism spectrum disorders (ASDs) suffer from sleep disorders to a considerable degree; however, there is no safe and effective treatment available in clinical practice. The objective of the trial is to assess the clinical effectiveness of auricular plaster therapy (APT) in treating sleep disorders in children with ASD.

Method

This is a single-center, patient-assessor blind, randomized controlled trial. A total of 44 preschool children with sleep disorders with ASD will be included in this study. Eligible participants will be randomly assigned to either the auricular plaster group or the sham auricular plaster group in a 1:1 ratio. Participants in the different groups will receive APT or sham APT, respectively, for a total of 30 sessions over 30 days. The primary outcome includes the Children's Sleep Habits Questionnaire (CSHQ), while secondary outcomes include the Autism Behavior Checklist (ABC) and polysomnography (PSG) for total sleep time, sleep latency, awakening duration, and sleep structures. The CSHQ and ABC will be assessed at baseline, 10, 20, 30, 60, 90, and 120 days after randomization, whereas PSG will be assessed at baseline and 30 days after randomization. The follow-up period will be scheduled to be 60, 90, and 120 days after randomization.

Discussion

The results of this study may provide evidence of the efficacy of APT, as well as offer new alternatives for the treatment of sleep disorders in children with ASD.

Trial registration

CHiCTR.org.cn (ChiCTR2100048257). Registered on July 5, 2021.

COVID-19 Pandemic and Autism Spectrum Disorder, Consequences to Children and Adolescents - a Systematic Review

In this systematic review, we aimed to identify the impact of the COVID-19 pandemic on children/adolescents with a diagnosis of autism spectrum disorder (ASD). The protocol was registered on PROSPERO CRD42021255848. Articles were selected from PubMed, Embase, and LILACS according to these characteristics: patients from zero to 18 years old, exposed to the COVID-19 pandemic, impact on social communication/interaction and restricted/repetitive behavior domains. The Newcastle-Ottawa Scale was used to assess methodological quality and the risk of bias. Of the 351 articles initially identified, 26 were finally included with information on 8,610 patients. Although the studies were heterogeneous, they indicated that the pandemic-related issues experienced by patients with ASD were mostly manifested in their behavior and sleep patterns.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40489-022-00344-4.

Habilitation of sleep problems among mothers and their children with autism spectrum disorder: Insights from multi-level exploratory dyadic analyses

Few habilitation strategies for children with autism spectrum disorder (ASD) consider their sleep-related problems. Together with the fact that caregivers of children with ASD also face issues with sleep, there may be yet-to-be uncovered relationships between caregiver-child sleep patterns and sleep quality, offering a key opportunity for clinicians to consider the needs of both child and caregiver in terms of sleep. 29 dyads of mothers and their children with ASD were recruited for this cohort study and both subjective (self-report questionnaires and sleep diaries) and objective (cortisol samples and actigraphy) measures of sleep were collected to investigate significant predictors of sleep quality. Comparative, correlational, and hierarchical analyses were conducted. Findings indicated that both mother and child experience sleep deprivation in terms of shorter sleep duration and poor sleep quality in terms of longer sleep onset latencies and a higher frequency of wake bouts. Exploratory hierarchical analyses also found that child-related sleep difficulties such as sleep disordered breathing and night waking significantly predict mothers' sleep quality, which may point to the bi-directional influence of mother-child sleep. Based on these findings, it is recommended that clinicians adopt a family systems perspective and consider the sleep environment of the household, particularly that of the caregiver and child, when designing interventions for sleep-related problems in ASD. Finally, there is a need for additional support to promote good quality sleep among caregivers of children with ASD to bolster out-of-clinic care.

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.

Analysis of sleep problem in children aged 1-3 years with autism spectrum disorder in Zhejiang province, China

Background

High prevalence of sleep problems have been founded in children with Autism Spectrum Disorder (ASD), with rates ranging from 50 to 80%. We aimed to study the sleep status and the occurrence of sleep problems in children with autism spectrum disorder (ASD) aged 1-3 years, and to provide reference for guiding early comprehensive intervention for ASD children from the perspective of sleep.

Methods

From January 1 to December 31, 2021, 74 ASD children who met the diagnostic criteria of "Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-V)" served as case group while 84 typically-developing children of the same sex and age served as control group. An original Children's Sleep Habit Questionnaire was adopted to compare the sleep status of children in the two groups and to conduct statistical analysis on related factors.

Results

The incidence of sleep problems in the case group (78.4%) was significantly higher than that in the control group (34.5%) (P < 0.001). Compared with the children in the control group, children in the case group had later bedtime (P < 0.05) and less sleep duration (P < 0.05), and required longer time to fall asleep (P < 0.001) The incidence of sleep problems in children who could fall asleep autonomously in the case group was significantly lower than that in children who needed parental help (P < 0.05). In the case group, the longer the screen exposure time, the higher the incidence of sleep problems (P < 0.05).

Conclusions

The incidence of sleep problems in ASD children aged 1-3 years is also high, mainly manifested in late bedtime, difficulty falling asleep, frequent night awakenings and less sleep duration. Both sleep patterns and screen exposure can impact their sleep. In the early comprehensive intervention of ASD children, it is necessary to pay full heed to their sleep status and take timely intervention measures in order to improve the quality of life for the ASD children and their families.

The Sensory Abnormality Mediated Partially the Efficacy of Repetitive Transcranial Magnetic Stimulation on Treating Comorbid Sleep Disorder in Autism Spectrum Disorder Children

Sleep disorder emerges as a common comorbidity in children with autism spectrum disorder (ASD), and the interaction between the core symptoms of ASD and its sleep disorder remains unclear. Repetitive transcranial magnetic stimulation (rTMS) was used on the bilateral dorsolateral prefrontal cortex (DLPFC) to investigate the efficacy of rTMS on the core symptoms of ASD and comorbid sleep problems as well as the mediation role of the ASD symptoms between rTMS intervention and sleep improvement. A total of 41 Chinese children with ASD and who met the criteria in the fifth edition of the American Diagnostic and Statistical Manual of Mental Disorders were recruited, and 39 of them (mean age: 9.0 ± 4.4 years old; the male-female ratio was 3.9: 1) completed the study with the stimulating protocol of high frequency on the left DLPFC and low frequency on the right DLPFC. They were all assessed three times (before, at 4 weeks after, and at 8 weeks after the stimulation) by the Children's Sleep Habits Questionnaire (CSHQ), Strengths and Difficulties Questionnaire (SDQ), Childhood Autism Rating Scale, Repetitive Behavior Questionnaire-2, and Short Sensory Profile (SSP). The repeated-measures ANOVA showed that the main effect of "intervention time" of CSHQ (F = 25.103, P < 0.001), SSP (F = 6.345, P = 0.003), and SDQ (F = 9.975, P < 0.001) was statistically significant. By Bayesian mediation analysis, we only found that the total score of SSP mediated the treating efficacy of rTMS on CSHQ (αβ = 5.11 ± 1.51, 95% CI: 2.50-8.41). The percentage of mediation effect in total effect was 37.94%. Our results indicated the treating efficacy of rTMS modulation on bilateral DLPFC for both autistic symptoms and sleep disturbances. The sensory abnormality of ASD mediated the improvement of rTMS on sleep problems of ASD.

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.

Transdermal Electrical Neuromodulation for Anxiety and Sleep Problems in High-Functioning Autism Spectrum Disorder: Feasibility and Preliminary Findings

BACKGROUND

Autism spectrum disorder (ASD) is associated with anxiety and sleep problems. We investigated transdermal electrical neuromodulation (TEN) of the cervical nerves in the neck as a safe, effective, comfortable and non-pharmacological therapy for decreasing anxiety and enhancing sleep quality in ASD.

METHODS

In this blinded, sham-controlled study, seven adolescents and young adults with high-functioning ASD underwent five consecutive treatment days, one day of the sham followed by four days of subthreshold TEN for 20 min. Anxiety-provoking cognitive tasks were performed after the sham/TEN. Measures of autonomic nervous system activity, including saliva α-amylase and cortisol, electrodermal activity, and heart rate variability, were collected from six participants.

RESULTS

Self-rated and caretaker-rated measures of anxiety were significantly improved with TEN treatment as compared to the sham, with effect sizes ranging from medium to large depending on the rating scale. Sleep scores from caretaker questionnaires also improved, but not significantly. Performance on two of the three anxiety-provoking cognitive tasks and heart rate variability significantly improved with TEN stimulation as compared to the sham. Four of the seven (57%) participants were responders, defined as a ≥ 30% improvement in self-reported anxiety. Salivary α-amylase decreased with more TEN sessions and decreased from the beginning to the end of the session on TEN days for responders. TEN was well-tolerated without significant adverse events.

CONCLUSIONS

This study provides preliminary evidence that TEN is well-tolerated in individuals with ASD and can improve anxiety.

An update on the cause and treatment of sleep disturbance in children and adolescents with autism spectrum disorder

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by abnormalities in social communication/interaction and restrictive, repetitive patterns of behavior. ASD is a relatively common psychiatric disorder, with a prevalence of approximately 1.7% in children. Although many children and adolescents with ASD visit the hospital for medical help for emotional and behavioral problems such as mood instability and self-harming behavior, there are also many visits for sleep disturbances such as insomnia and sleep resistance. Sleep disturbances are likely to increase fatigue and daytime sleepiness, impaired concentration, negatively impact on daytime functioning, and pose challenges in controlling anger and aggressive behavior. Sleep disturbance in children and adolescents with ASD negatively affects the quality of life, nothing to say the quality of life of their families and school members. In this review, sleep disturbances that are common in children and adolescents with ASD and adolescents are presented. The developmental and behavioral impacts of sleep disturbances in ASD were also considered. Finally, non-pharmacological and pharmacological treatments for sleep disturbances in children and adolescents with ASD and adolescents are reviewed.

Experience of Sleep for Families of Young Adults With Autism Spectrum Disorder

IMPORTANCE

Children with autism spectrum disorder (ASD) may experience sleep difficulties that worsen into adulthood and negatively influence both child and family, yet the experience is not well understood. Understanding the family's experience can inform occupational therapy providers, future research, and practice guidelines.

OBJECTIVE

To examine experiences surrounding sleep for families raising a young adult with ASD (YA-ASD).

DESIGN

Qualitative study in the phenomenological tradition of Moustakas (1994). Experienced researchers analyzed transcripts from in-depth, in-person interviews to triangulate data, distill themes, and construct the essence of family experience. Trustworthiness was established through member checking, audit trails, and epoché diaries that were maintained throughout data analyses.

SETTING

Community setting (large city in the northeastern United States).

PARTICIPANTS

People who self-identified as living in a family arrangement that included a YA-ASD age 15-21 yr, able to verbally participate in English. Families with children diagnosed with developmental disabilities other than ASD were excluded.

RESULTS

Six eligible families identified through volunteer sampling participated. The participants' sociodemographic diversity was limited across household income, education level, and ethnicity. All YA-ASD in this study were limited verbally and unable to contribute. Analyses of interview transcripts revealed five themes that form the essence of the families' experience surrounding sleep.

CONCLUSIONS AND RELEVANCE

Sleep issues for YA-ASD continue into adulthood and affect the entire family because of continuous co-occupation; occupational therapy support is therefore important for families of YA-ASD. The lack of effective evidence-based interventions supporting the YA-ASD population also reveals an area for growth. What This Article Adds: The results indicate the importance of addressing sleep for YA-ASD and their families in occupational therapy practice because of its considerable impact on family life.

Sleep quality, functional skills, and communication in preschool-aged children with autism spectrum disorder

AIM

This study aimed to correlate sleep quality, the performance of functional skills (mobility, self-care, and social function), communication, independence, and severity of ASD in children with ASD.

METHOD

58 children between 3 and 5 years and 11 months old were investigated. The Childhood Autism Rating Scale was applied to determine the severity of autism; the Sleep Disturbance Scale for Children was used to investigate sleep quality, and the Pediatric Evaluation of Disability Inventory to investigate functional abilities and independence of the children.

RESULTS

68.9 % of the children showed indicative of sleep disorders. There was no correlation between the different sleep disorders and communication. Sleep disorders showed a negative correlation with functional performance and a positive correlation with ASD severity.

INTERPRETATION

The current study offers an exploration between sleep and functional skills in children with ASD. These findings provide important clinical implications in the diagnosis and intervention process of children with ASD and also stimulate reflections on the importance in minimize the impact of sleep disorders and functional abilities on the quality of life of these individuals and their families.

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 ).

Cross-Sectional Age Analysis of Sleep Problems in 2 to 17 Year Olds with ADHD Combined, ADHD Inattentive, or Autism

Sleep problems are common in autism and ADHD. No study has compared sleep problems by age in 2 to 17 year olds with autism versus ADHD-Combined versus ADHD-Inattentive type. Mothers rated 1415 youth with autism and 1041 with ADHD on 10 Pediatric Behavior Scale sleep items. Nighttime sleep problems were most severe in autism, followed by ADHD-Combined, and then ADHD-Inattentive. Difficulty falling asleep, restless during sleep, and waking during the night were the most common problems. Adolescents slept more at night than other age groups, and youth who slept more at night were sleepier during the day. Sleep problems declined with age, but correlations were small. In adolescence, 63% with autism, 53% with ADHD-Combined, and 57% with ADHD-Inattentive had difficulty falling asleep. Given that the majority of children in all age groups had one or more sleep problem, developmentally appropriate interventions are needed to address sleep difficulties and limit their adverse effects.

Sleep problems in children with autism spectrum disorder and typical development

BACKGROUND

Although higher sleep problems have been mostly reported in children with autism spectrum disorder (ASD) compared with typically developing (TD) children, particularly in Western countries, such evidence is relatively scarce in developing countries. We therefore investigated sleep difficulties in Thai children aged 3-16 years with ASD compared with age- and gender-matched TD children by using the Children's Sleep Habits Questionnaire (CSHQ)-Thai version.

METHODS

Sixty-five children with ASD (mean age 97.7, SD 44.5 months; boys 70.8%) and 65 TD individuals (mean age 98.5, SD 43.5 months) were enrolled at a university-based hospital in Bangkok. Background characteristics, sleep duration variables, and the CSHQ were completed by the participants' parents. The CSHQ subscales and total score between children with ASD and TD controls were then compared.

RESULTS

Children with ASD were more likely to have longer sleep latency than TD individuals for both weekdays and the weekend. Those with ASD had higher CSHQ subscales including bedtime resistance, sleep onset delay, sleep anxiety, and night waking in addition to the CSHQ total scores than TD controls. In the ASD group, those who took psychostimulants for treatment of ADHD had lower scores on the sleep duration subscale compared with unmedicated individuals.

CONCLUSIONS

Sleep difficulties were more prevalent in children with ASD compared with TD individuals. Parents should be advised to be aware of sleep problems in individuals with ASD. As such, sleep disturbances will be identified early, resulting in appropriate management and improved quality of life, not only for those with ASD but also their families.

Complexity of Body Movements during Sleep in Children with Autism Spectrum Disorder

Recently, measuring the complexity of body movements during sleep has been proven as an objective biomarker of various psychiatric disorders. Although sleep problems are common in children with autism spectrum disorder (ASD) and might exacerbate ASD symptoms, their objectivity as a biomarker remains to be established. Therefore, details of body movement complexity during sleep as estimated by actigraphy were investigated in typically developing (TD) children and in children with ASD. Several complexity analyses were applied to raw and thresholded data of actigraphy from 17 TD children and 17 children with ASD. Determinism, irregularity and unpredictability, and long-range temporal correlation were examined respectively using the false nearest neighbor (FNN) algorithm, information-theoretic analyses, and detrended fluctuation analysis (DFA). Although the FNN algorithm did not reveal determinism in body movements, surrogate analyses identified the influence of nonlinear processes on the irregularity and long-range temporal correlation of body movements. Additionally, the irregularity and unpredictability of body movements measured by expanded sample entropy were significantly lower in ASD than in TD children up to two hours after sleep onset and at approximately six hours after sleep onset. This difference was found especially for the high-irregularity period. Through this study, we characterized details of the complexity of body movements during sleep and demonstrated the group difference of body movement complexity across TD children and children with ASD. Complexity analyses of body movements during sleep have provided valuable insights into sleep profiles. Body movement complexity might be useful as a biomarker for ASD.

Postural Control in Childhood: Investigating the Neurodevelopmental Gradient Hypothesis

Neurodevelopmental disorders (NDDs) have been suggested to lie on a gradient continuum, all resulting from common brain disturbances, but with different degrees of impairment severity. This case-control study aimed to assess postural stability against such hypothesis in 104 children/adolescents aged 5–17, of whom 81 had NDDs and 23 were healthy controls. Compared to healthy controls, Autism Spectrum Disorder (ASD) resulted in the most severely impaired neurodevelopmental condition, followed by Attention Deficit Hyperactive Disorder (ADHD) and Tourette Syndrome (TS). In particular, while ASD children/adolescents performed worse than healthy controls in a number of sensory conditions across all parameters, ADHD children/adolescents performed worse than healthy controls only in the sway area for the most complex sensory conditions, when their vision and somatosensory functions were both compromised, and performance in Tourette Syndrome (TS) was roughly indistinguishable from that of healthy controls. Finally, differences were also observed between clinical groups, with ASD children/adolescents, and to a much lesser extent ADHD children/adolescents, performing worse than TS children/adolescents, especially when sensory systems were not operationally accurate. Evidence from this study indicates that poor postural control may be a useful biomarker for risk assessment during neurodevelopment, in line with predictions from the gradient hypothesis.

Melatonin dispensing among New Zealand children aged 0-18 years with autism: a nationwide cross-sectional study

OBJECTIVE/BACKGROUND

Sleep problems in children on the autism spectrum are prevalent and persistent. Such problems are the result of a combination of biopsychosocial factors, including abnormal melatonin secretion. Exogenous melatonin is an empirically supported and popular treatment for sleep problems. However, we know little about rates of melatonin dispensing and associated variables. This study investigated rates of melatonin dispensing and the sociodemographic and child characteristics associated with its use in New Zealand.

METHODS

This nationwide cross-sectional study used linked administrative health data obtained via the Integrated Data Infrastructure (IDI). Data were obtained for 11,202, 0-18 year old children on the autism spectrum. Descriptive data, and adjusted and unadjusted risk ratios, were calculated for sociodemographic and child characteristics.

RESULTS

Melatonin is accessed by almost one quarter of children on the autism spectrum in New Zealand, with higher observed rates among females and those aged between 5 and 11 years, of European ethnicity, and presenting with co-occurring mental health conditions.

CONCLUSIONS

Findings are largely consistent with research investigating both sleep disturbances and psychotropic drug use among children on the autism spectrum. High rates of melatonin use, age- and sex-related differences in its use, and the complexity associated with the presence of co-occurring conditions necessitates development of practice guidelines for melatonin dispensing. Further investigation into the duration of melatonin use and the interaction between child characteristics, co-occurring conditions, sociodemographic variables and melatonin dispensing is warranted.

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.

Sleep Problems in Children with Autism Spectrum Disorder in Bangladesh: A Case-Control Study

BACKGROUND

Sleep problems in children with Autism Spectrum Disorder (ASD) are highly prevalent, but little information is available on this issue in low- to middle-income countries (LMIC) such as Bangladesh. Therefore, the present study investigated the prevalence and socio-demographic determinants of ASD sleep disturbances in a comparison with typically developing children (TDC).

METHODS

A cross-sectional interview study was carried out within a total of 446 Bangladeshi mothers, whose children's mean age was 8.1±2.9 years (151 ASD [8.5±2.7 years] and 295 TDC [7.9±2.9 years]); in addition to socio-demographics, the Child Sleep Habit Questionnaire (CSHQ) was used, and a cut-off score of 41 out of 93 points considered as reflecting sleep problems.

RESULTS

About 89.7% of the children reported having problems in sleep, with ASD reporting higher frequency vs TDC (94.00% vs 87.50%; χ²=4.678, p=0.031). The overall mean CSHQ score was 48.7±7.6 in total sample, whereas ASD children reported higher scores compared to TDCs (50.9±8.1 vs 47.5±7.0, p<0.001). Similarly, subscales of CSHQ such as sleep duration (4.23±1.56 vs 3.90±1.31, p=0.017), sleep anxiety (7.23±2.05 vs 6.45±1.92, p<0.001), night waking (3.82±1.07 vs 3.17±1.89, p<0.001), parasomnias (8.86±2.06 vs 7.85±2.27, p<0.001), and sleep disordered breathing (4.02±2.92 vs 3.43±2.07, p=0.014) were more problematic among ASD compared to TDC. Lastly, 28.5% of ASD reported taking sleep-related medications vs 0.3% for TDC (n=1).

CONCLUSION

Bangladeshi ASD children are highly likely to manifest sleep disturbances, which warrant urgent implementation of parental educational and support programs to mitigate the impact of sleep problems in ASD families.

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.

Associations Between Child Sleep Problem Severity and Maternal Well-Being in Children with Autism Spectrum Disorder

This study investigated whether sleep problem severity in children with autism spectrum disorder was associated with maternal well-being. Mothers of 234 children reported on their mental health (Kessler Psychological Distress Scale), parenting stress (Parenting Stress Index-4-SF), health-related quality of life (HRQoL; Assessment of Quality of Life-4D) and their child's sleep (Children's Sleep Habits Questionnaire-ASD). Analyses revealed sleep initiation and duration problem severity scores were associated with increased mental health difficulties. Specific child sleep problems were not associated with parenting stress or HRQoL. This study revealed the importance of considering sleep and the family system when assessing maternal well-being. Future research considering parent, child and family factors will be important to informing a family focused approach to mental health.