Sleep Problems—Autism Toolkit

Sleep problems are prevalent in people with autism spectrum disorder (ASD). Several studies have shown an association between sleep problems and severity of ASD-related behaviors. Most of these studies have not addressed potential sex differences either in the prevalence of the sleep problems or in their association with the manifestation of other behavioral issues in ASD. Given the strong prevalence of ASD in males, we thought it important to address whether sex differences exist in this realm. We examined the association of sleep problems with the severity of ASD-behavioral measures in a large data set collected from an online phenotyping project: Simons Foundation Powering Autism Research for Knowledge. We confirmed a high prevalence of sleep problems in ASD and a strong association between sleep problems and severity of other ASD-related behaviors. Furthermore, we were able to detect sex differences in these associations. In children with ASD, there was a slightly stronger association between repetitive behaviors and diagnosed sleep problems in females compared to males. In children without diagnosed ASD (undiagnosed siblings), there was a stronger association between sleep problems and impairments in social communication in males compared to females. These data highlight potential sex differences in the association of sleep problems and behavioral problems in ASD. LAY SUMMARY: We tested for sex differences in the association between sleep deficiencies and behavior in autism spectrum disorder (ASD). In children with ASD, we found the association between sleep problems and repetitive behaviors was slightly stronger in females. In siblings without diagnosed ASD, the association between sleep problems and social communication scores was stronger in males. These data suggest that sex might play a role in an association between sleep deficiencies and behavioral impairments.

Sleep problems are highly prevalent in ADHD and autism spectrum disorder (ASD). Better insight in the etiology is of clinical importance since intervention and prevention strategies of sleep problems are directed at underlying mechanisms. We evaluated the association of sleep problems and sleep patterns with sleep hygiene (behavioral/environmental practices that influence sleep quality, e.g. caffeine use), access to electronic media, chronotype, and anxiety/depression in children aged 6–12 years with ADHD, ASD, or typical development (TD) using parental questionnaires. ANOVA and linear regression analyses were adjusted for age and sex. Children with ADHD and ASD showed more sleep problems (63.6 and 64.7%, vs 25.1% in TD) and shorter sleep duration than controls, while differences between ADHD and ASD were not significant. Sleep hygiene was worse in ADHD and ASD compared to TD, however, the association of worse sleep hygiene with more sleep problems was only significant in ASD and TD. There was a significant association of access to electronic media with sleep problems only in typically developing controls. Chronotype did not differ significantly between groups, but evening types were associated with sleep problems in ADHD and TD. Associations of greater anxiety/depression with more sleep problems were shown in ADHD and TD; however, anxiety/depression did not moderate the effects of chronotype and sleep hygiene. We conclude that sleep problems are highly prevalent in ADHD and ASD, but are differentially related to chronotype and sleep hygiene. In ASD, sleep problems are related to inadequate sleep hygiene and in ADHD to evening chronotype, while in TD both factors are important. Clinical implications are discussed.

BackgroundSleep 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).MethodsA 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.ResultsAbout 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).ConclusionBangladeshi 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.

Sleep in children with autistic spectrum disorder

Purpose of ReviewSleep problems are a common comorbidity for children with autism spectrum disorder (ASD), and research in this area has a relatively long history. Within this review, we first outline historic patterns in the field of sleep and ASD. Second, we conducted a systematic update and coded these studies based on their alignment with historic patterns. Research on ASD and sleep over the past two decades has primarily focused on four principal areas: (1) documenting the prevalence and types of sleep problems; (2) sleep problem treatment options and efficacy; (3) how sleep problems are associated with other behavioral, contextual, or biological elements; and (4) the impact of child sleep problems on families and care providers. The systematic update in this paper includes empirical studies published between 2018 and 2021 with terms for sleep and ASD within the title, keywords, or abstract.Recent FindingsIn sum, 60 studies fit the inclusion/exclusion criteria and most fit within the historic patterns noted above. Notable differences included more global representation in study samples, studies on the impacts of COVID-19, and a growing body of work on sleep problems as an early marker of ASD. The majority of studies focus on correlates of sleep problems noting less optimal behavioral, contextual, and biological elements are associated with sleep problems across development for children with ASD.SummaryRecommendations for future directions include continued expansion of global and age representation across samples, a shift toward more treatment and implementation science, and studies that inform our mechanistic understanding of how sleep and ASD are connected.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40675-022-00234-5.

McPheeters et al1 provided a systematic review of the evidence thatwas used by theUSPreventive Services Task Force (USPSTF) to make its recent recommendations on universal autism screening.2 The USPSTF concluded that there is currently insufficientevidenceto assess the benefits of universal screening for autismspectrumdisorder (ASD) inyoung children. Inparticular, theUSPSTFnoted that no studyhasdirectly compared the long-term outcomes of screened vs nonscreened children and, further, studies of the efficacy of early ASD treatment have not been based on samples identified through screening. Thus, theUSPSTFconcludes that the longterm benefits and harms of screening in the general population cannot yet be determined. The report was met with considerable controversy. The president of the American Academy of Pediatrics (AAP) promptly issued a statement noting that the USPSTF recommendations“runcounter toAAPguidelines”andthat the“AAP remains committed to its recommendation for the timely screeningand identificationof childrenwhobenefit fromearly intervention and treatment.”3 Autism advocacy organizations andUSRepsChris SmithandMikeDoyle, co-chairs of the Congressional Autism Caucus, urged the USPSTF to reconsider their recommendations on universal autism screening. What then is the basis of this controversy? The AAP and other professional and advocacy organizations that supportuniversal autismscreeninghavebased their currentpracticeguidelinesonseveral research findings,which are described in the reviewbyMcPheeters et al.1 First, autism is aprevalent condition, affecting 1 in68children in theUnited States, and associated with significant shortand long-term burdens.4 The lifetime cost of supporting an individual with ASD is estimated to be $1.4 million. That cost is $2.4 million for those who also have an intellectual disability.5 Second, current autism screening tools, while not perfect, adequately detect ASD in children between approximately 18 and 36months in age.6,7 Themost commonly used tool is aparentquestionnaire that requires little trainingby the health careprofessionals and takes less than5minutes to complete. If a child’s score falls in a questionable range, then an additional 5 to 10minutes of follow-up questions are needed. Large studies conducted in community primary care settings have found that, of those children who fail the screen, about 50%will bediagnosedwithASD, and98%will have anactionable developmental concern.6,7 Although the data on false negatives are scant, the available evidence suggests that the current screening tool does not miss a substantial number of children. All children who fail the screen can be referred for infant-toddler assessment and intervention services through Part C of the Individuals with Disabilities and Education Act, a programsupported by a federal grant established in 1986by Congress. Third, studies have shown that screening leads to earlier referral and diagnosis.8 Most children identified through screeninghavenotbeenpreviously identifiedbyeither thepediatrician or a parent. Childrenwho are screened, on average, arediagnosedearlier and thus receive servicesat anearlier age. This finding is especially significant forAfricanAmerican and Hispanic children, who tend to be diagnosed and access services at a later age than do white children.9 The majority of states have passed legislation that mandates insurance benefits for early intervention for children with diagnosed ASD. Finally, studies evaluating the efficacy of early intervention showsignificant improvements in cognitive and languageoutcomes, andayounger ageof enrollment in treatmenthasbeen shown to result in better outcomes.10,11 In short, researchhas shownthatuniversal screening leads to earlier diagnosis andearlier access to intervention and, further, that earlier intervention leads to better outcomes; however, no studyhas yet been conducted that examineswhether screening,per se, leads tobetteroutcomes. Suchastudywould require a large representative group of children from the general population to be randomly assigned to receive or not receive autism screening and then be followed up longitudinally to assess the impact of screening on the long-term outcomes of these children and their families, as well as the overall societal cost. Studies on the efficacy of early intervention insamplesofchildrenyounger than3yearswhowere identified through screening are also needed. Interventions appropriate for children with ASD younger than 3 years have been developed and evaluated. A systematic review of 24 studies related to intervention for children withASDyounger than3yearswas recentlypublished.12Compared with interventions for preschool-aged children, interventions for children younger than 3 years more often intensively involve parents and use naturalistic developmental behavioral approaches.13 Such interventions usually are delivered byparents in the context of everyday routines and the parents’ interactionswith their children, and all are designed topromote learning, engagement, andcommunicationand reduce behavioral challenges. The review identified 6 randomized clinical trials that assessed the efficacy of intervention in childrenwithASDyounger than3years,with treatments rangRelated article at jama.com Opinion

Introduction: Children with Autism Spectrum Disorder (ASD) suffer from insomnia at much higher rates than typically developing (TD) peers. Research indicates that sleep problems in ASD may be due to hypersensitivities to stimuli and melatonin deficiencies. Behavioral treatments for insomnia in ASD often include sleep hygiene recommendations to avoid physical activity and light intensity within two hours of bedtime. However, despite these recommendations, research examining the relationship between physical activity and light intensity close to bedtime and sleep outcomes in TD and ASD is sparse. The current study examines associations between pre-bedtime light intensity exposure, physical activity, and sleep in children with ASD and in TD children. Methods: Children with ASD (n=28, Mage=8.4, SD=1.7) and 27 TD children (n=27, Mage=8.9, SD=1.8) who met DSM-5 criteria for insomnia disorder completed 14 concurrent days of sleep diaries with parental assistance and 14 days of wrist worn actigraphy. Sleep diaries and actigraphy obtained estimates of sleep onset latency (SOL), wake time after sleep onset (WASO), and total sleep time (TST) for each night, and actigraphy also obtained light intensity exposure and average physical activity in five timeframes prior to bedtime (0-30 minutes, 0-60 minutes, 0-120 minutes, 120-240 minutes, and 240-360 minutes). Multi-level models examined intra-individual and inter-individual associations between pre-bedtime physical activity, light intensity, and subjective/actigraphic sleep outcomes, as well as whether these associations differed between children with ASD and TD. Results: Greater light intensity was associated with longer subjective SOL (B=0.18, p=0.04, 120-240 mins, inter-individual), longer subjective WASO (B=0.05, p&lt;0.001, 120-240 mins, intra-individual), and shorter subjective TST (B=-0.42, p=0.02, 120-240 mins, inter-individual) in TD but not ASD. Greater light intensity was associated with longer subjective SOL (B=0.08, p=0.05, 0-60 mins, intra-individual), and longer subjective TST (B=1.25, p=0.04, 0-120 mins, inter-individual) for ASD, but not TD. Greater light intensity was associated with longer actigraphic SOL (B=0.07, p=0.05, 0-60 mins, inter-individual) in ASD, but not TD, and longer actigraphic WASO (B=0.02, p&lt;0.01, 120-240 mins, intra-individual) in TD, but not ASD. Greater physical activity was associated with longer subjective TST (B=0.30, p=0.01, 0-30 mins, inter-individual; B=0.36, p&lt;0.01, 0-60 mins, inter-individual; B=0.26, p=0.02, 0-120 mins, inter-individual) and shorter actigraphic SOL (B=-0.05, p=0.01, 240-360 mins, intra-individual) in both ASD and TD. Conclusion: Results do not support sleep hygiene recommendations for avoidance of pre-bedtime physical activity, but they generally support avoidance of pre-bedtime light intensity. We speculate that pre-bedtime light intensity exposure may interfere with sleep outcomes through impeding melatonin secretion. Further, our results do not support the mechanism that hypersensitivities to light or physical activity are primarily responsible for insomnia in ASD relative to TD, since both ASD and TD showed similar associations between light, physical activity, and sleep outcomes (i.e., greater pre-bedtime light associated with worse sleep and greater pre-bedtime activity associated with better sleep). Future research should examine the relationship between pre-bedtime light exposure and melatonin production in ASD and explore whether sleep hygiene recommendations to avoid pre-bedtime physical activity are warranted in ASD and TD.

To compare parent reported sleep behaviors of children with Autism Spectrum Disorders (ASD) and normal healthy controls and to examine the association of sleep disturbances with daytime behavioral difficulties in children with ASD. Sixty ASD children (85% boys) (Mean age=6.1 y, SD=2.4) were recruited from the Psychology unit of the Department of Pediatrics of a tertiary care hospital. An age and socio-economic status matched group of typically developing (TD) children (N=60) were also recruited. The Children's Sleep Habits Questionnaire (CSHQ) was used to measure sleep problems. The Childhood Psychopathology Measurement Schedule was used to measure day time behavioral difficulties. Sleep problems were nearly two times more prevalent among children with ASD (88.3%) as compared to the TD group (46.7%) (χ2=23.74, P=0.0001). The total CSHQ and 6 out of the 8 subscales scores of the ASD group were also significantly higher than the TD group. Overall, children with ASD displayed significant more bedtime resistance than controls (t= 3.95, P=0.001). The sleep duration subscale showed that children with ASD, relative to the TD group, slept too little (χ2=23.08, P=0.0001), did not sleep the right amount of time (χ2= 11.86, P=0.003), and displayed significant variation in the duration of time slept (χ2=11.96, P=0.003). In addition, parent reported sleep dysfunction had a significant relationship with daytime reported behavior difficulties (r=0.53, P=0.01) in children with ASD. Stepwise multiple regression analysis revealed that 30% of the variance in number of daytime behavioral problems was explained by only two variables: total CSHQ scores and duration of night awake time (F=11.18, P=0.001). Children with ASD are at a high risk for sleep problems and this is associated with daytime behavior disturbances. Pediatricians should routinely screen ASD children for sleep problems and initiate timely and appropriate interventions.

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Prevalence of Sleep Abnormalities in Indian Children With Autism Spectrum Disorder: A Cross-Sectional Study

Behavioural sleep problems are common in children with autism spectrum disorder (ASD); however, evidence for the efficacy of behavioural sleep interventions is limited. This study examined the efficacy of a brief behavioural sleep intervention in autistic children. It was hypothesised that the intervention would reduce overall child sleep problems (primary outcome), in addition to improvements in children's social, emotional, cognitive, academic functioning, and quality of life, and parent/caregivers' stress, quality of life, and mental health (secondary outcomes). A randomised controlled trial was conducted with participants randomised via a computer-generated sequence to the sleeping sound intervention (n = 123) or treatment as usual (n = 122) group. Participants comprised 245 children with an ASD diagnosis. Inclusion criteria were as follows: confirmation of DSM IV or DSM-5 diagnosis of ASD, participants aged between 5 and 13 years and parent/caregiver report of moderate-severe sleep problems. Exclusion criteria were as follows: parent/caregiver intellectual disability or lacking sufficient English to complete questionnaires; and child participant with co-occurring medical conditions known to impact sleep. The intervention group received the sleeping sound intervention (2 × 50-min face-to-face sessions plus follow-up phone call) by a trained clinician. Change in children's sleep problems was measured by the Children's Sleep Habits Questionnaire (CSHQ) at 3 months post randomisation. Parents/caregivers of children in the intervention group reported a reduction in child sleep problems at 3 months post randomisation (effect size: E.S -0.7). There were also small effects in a number of child (internalising symptoms, emotional behavioural disturbance and quality of life) and parent/caregiver (mental health, parenting stress and quality of life) outcomes; however, these did not remain significant when controlling for multiple comparisons. The sleeping sound ASD intervention is an efficacious and practical way to reduce sleep problems for autistic children. This brief behavioural intervention has the potential to be embedded easily into the Australian healthcare system.

In children with autism spectrum disorder, there have been equivocal results regarding primary caregiver education level and its influence on sleep. Thus, we assessed if lower primary caregiver education level is associated with more sleep problems. We evaluated 4,636 children with autism spectrum disorder in the Autism Speaks Autism Treatment Network's United States and Canadian registry, whose caregivers completed the Children's Sleep Habits Questionnaire. Using regression analysis, there was an association between lower primary caregiver education level and more sleep problems. Secondary analyses demonstrated that younger age, Hispanic ethnicity, higher IQ, autism diagnosis and lower adaptive function were also associated with more sleep problems. The finding that lower primary caregiver education level was associated with increased sleep problems in a large sample of children with autism spectrum disorder highlights the importance of screening for risk factors affecting sleep to help moderate sleep problems.

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

This introductory chapter begins by explaining the increased risk for bedtime and sleep problems in young children with autism spectrum disorder (ASD). Commonly observed bedtime and sleep disturbances in autistic children include failure to effectively utilize bedtime and sleep hygiene practices, prolonged delays in sleep onset, sleep association problems, night wakings after sleep onset, and early morning wakings, collectively resulting in overall lower sleep quality and increased parental stress. The chapter then looks at behavioral interventions for sleep disturbances in children with ASD, particularly the Sleep Parent Training (SlePT) program. The SlePT program is intended for use with parents and other caregivers of young autistic children who are still very much involved in the evening routines and supervising their child’s sleep. The chapter considers the importance of measuring SlePT treatment fidelity, before outlining the SlePT sessions, the methods for assessing bedtime and sleep problems in young autistic children, and the Sleep Behavior Plan (SBP). It also examines the difference between clinic visits and telehealth delivery of SlePT.

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