Sleeping sound with autism spectrum disorder (ASD): study protocol for an efficacy randomised controlled trial of a tailored brief behavioural sleep intervention for ASD

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).

Sleep and Autism: Current Research, Clinical Assessment, and Treatment Strategies

Autism spectrum disorder is associated with a high rate of sleep problems, affecting over 80% of autistic individuals. Sleep problems have pervasive negative effects on health, behavior, mood, and cognition but are underrecognized in autistic children. Problems initiating and maintaining sleep-hallmarks of insomnia-are common. Sleep-disordered breathing and restless legs syndrome have also been described in autism at a higher prevalence than in community populations. The authors describe current research on sleep in autistic children and potential pathophysiologic mechanisms. They describe practical approaches to sleep assessment and synthesize approaches to addressing sleep problems in autistic children.

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.

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.

Telehealth parent training for sleep disturbances in young children with autism spectrum disorder: A randomized controlled trial

BACKGROUND AND PURPOSE

Young children with autism spectrum disorder (autism) have bedtime and sleep disturbances at much higher frequency and persistency than their neurotypical counterparts. Hence, access to early, effective treatment is critical in view of the importance of sleep in early childhood. Telehealth delivery could be a means to expand access to such early treatment if efficacious. The aim of this randomized control trial (RCT) was to compare a manualized, telehealth delivered, behaviorally based sleep parent training (SPT) intervention for parents of young children with autism and sleep disturbances to a control condition, a telehealth delivered parent education program with one sleep focused session (SPE). We hypothesized that the SPT group would show more improvements on child measures of sleep outcome measures, and daytime behaviors and parent measures of stress and sense of competence. We further aimed to explore the overall feasibility of telehealth delivery of SPT and SPE.

PARTICIPANTS AND METHODS

Parents of 77 young children, ages 2-7 years, with autism and co-occurring sleep disturbances were enrolled in this study. Participants were randomized to either SPT or a comparison arm that included non-sleep related parent education except for one session. Each participant was individually administered a 5 session program delivered over 10 weeks. Outcome measures, including child sleep measures, child daytime behavior and parent stress and sense of competency were collected at weeks 5 and 10 after the baseline time point. Feasibility indicators (treatment fidelity, parent adherence, and parent attendance), and safety measures were also collected.

RESULTS

Of 77 randomized participants, data were available for 36 participants randomized to SPT and 38 participants randomized to SPE. The mean age was 3 years, 8 months. Results support the efficacy of this manualized SPT intervention for bedtime and sleep disturbances. Sleep outcome measures were significantly improved in the SPT group compared to SPE on the Modified Simonds & Parraga Sleep Questionnaire-Composite Sleep Index (MSPSQ - CSI) (p < 0.001) with a large effect size of 0.83 at week 10. Positive response to treatment, as determined from the Clinical Global Impression-Improvement scale (CGI-I) at week 10 was observed in 56% of SPT participants compared to 32% in SPE (p = 0.037). There were no significant group differences in either the ABC-I as measure of daytime behaviors or in parental stress. There were group differences in favor of SPT over SPE on the PSOC, a measure of parent sense of competency. Feasibility and safety were further demonstrated with telehealth delivery.

CONCLUSIONS

This RCT demonstrated the efficacy of a telehealth delivered parent training intervention for bedtime and sleep disturbances in young autistic children compared to an active control condition. Further, parents in SPT reported more confidence in their parenting role than those in the SPE group, but SPT did not result in overall decreases in parental stress. Telehealth delivery allowed for a much broader reach with enrolled participants from 24 states. This study supports a telehealth approach to a manualized behavioral parent mediated intervention for sleep disturbance in young autistic children and offers an alternative to in-person delivered approaches. This telehealth delivery has the potential to improve access for families who have a young autistic child with sleep disturbances. Given the small sample size, determining predictors and moderators of treatment response was not possible and should be examined in a larger trial.

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.

Outcomes from Individual Alpha Frequency Guided Repetitive Transcranial Magnetic Stimulation in Children with Autism Spectrum Disorder - A Retrospective Chart Review

AIMS AND OBJECTIVES

Individual alpha frequency (IAF) is a biomarker of neurophysiological functioning. The IAF-guided repetitive transcranial magnetic stimulation (α-rTMS) is increasingly explored in diverse neurological conditions. However, there is limited data on the efficacy and safety of α-rTMS in children with autism spectrum disorder (ASD).

MATERIALS AND METHODS

The IAF, childhood autism rating scale (CARS), Pediatric Quality of Life Inventory 4.0 (PedsQLTM 4.0), and semi-structured interview data of patients that received 19 α-rTMS sessions (4 weeks) were aggregated and analysed using paired student t-test and descriptive method.

RESULTS

Data were retrieved from 28 patients (26 males, aged 3-9years (mean ± SD age: 6.1 ± 1.8years)). The post-α-rTMS data shows a significant improvement in IAF (9.4 Hz; p ≤ 0.025) towards 10 Hz. The CARS and PedsQLTM 4.0 surveys indicate that patients' ASD symptoms and quality of life improved significantly. Specifically, reports from semi-structured interviews suggest improved sleep trouble - the most significant comorbidity. The experiences of minor side effects such as hyperactivity resolved within two hours following α-rTMS sessions.

CONCLUSION

This study presents evidence on the efficacy and safety of α-rTMS in improving ASD symptoms, quality of life and comorbid sleep troubles in children. However, these findings should be interpreted as preliminary pending the presentation of double-blind, randomised clinical trials.

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.

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.

Behavioural Treatments for Sleep Problems in Children with Autism Spectrum Disorder: a Review of the Recent Literature

PURPOSE OF REVIEW

Behavioural sleep problems in children with autism spectrum disorder (ASD) are common and burdensome for both the child and their family. We provide an up-to-date review on behavioural sleep interventions and their core features and conclude with expert recommendations regarding the modification of interventions for children with ASD.

RECENT FINDINGS

In the past 3 years, four original research studies (n ≥ 10) have evaluated behavioural sleep interventions for children with ASD (one RCT, three pre-post studies). All four studies reported significant improvements across various sleep outcomes and daytime behaviours. The interventions varied, however, in assessment comprehensiveness, nature of implementation support, length and delivery of intervention, outcome measurements, and follow-up periods. Clinically, behavioural sleep interventions are regarded as the first-line of treatment for sleep problems experienced by children with ASD. However, there is still much to be learnt regarding their clinical effectiveness.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.