ArticlePDF AvailableLiterature Review

Autism and sleep disorders

Authors:
Article

Autism and sleep disorders

Abstract

'Autism Spectrum Disorders' (ASDs) are neurodevelopment disorders and are characterized by persistent impairments in reciprocal social interaction and communication. Sleep problems in ASD, are a prominent feature that have an impact on social interaction, day to day life, academic achievement, and have been correlated with increased maternal stress and parental sleep disruption. Polysomnography studies of ASD children showed most of their abnormalities related to rapid eye movement (REM) sleep which included decreased quantity, increased undifferentiated sleep, immature organization of eye movements into discrete bursts, decreased time in bed, total sleep time, REM sleep latency, and increased proportion of stage 1 sleep. Implementation of nonpharmacotherapeutic measures such as bedtime routines and sleep-wise approach is the mainstay of behavioral management. Treatment strategies along with limited regulated pharmacotherapy can help improve the quality of life in ASD children and have a beneficial impact on the family. PubMed search was performed for English language articles from January 1995 to January 2015. Following key words: Autism spectrum disorder, sleep disorders and autism, REM sleep and autism, cognitive behavioral therapy, sleep-wise approach, melatonin and ASD were used. Only articles reporting primary data relevant to the above questions were included. © 2015 Journal of Pediatric Neurosciences | Published by Wolters Kluwer - Medknow.
304 / © 2015 Journal of Pediatric Neurosciences | Published by Wolters Kluwer - Medknow
Review Article
Autism and sleep disorders
Preeti A. Devnani1,2, Anaita U. Hegde3
1Sleep Disorders Clinic, 2Department of Neurology and Clinical Neurophysiology, Jaslok Hospital, 3Jaslok Hospital and Research
Centre, Breach Candy Hospital Trust, Wadia Children’s Hospital, Mumbai, Maharashtra, India
Address for correspondence: Dr. Preeti A. Devnani, Sleep Disorders Clinic, 1st Floor, Agnelo House, 156, S. V. Road, Khar (West),
Mumbai ‑ 400 052, Maharashtra, India. E‑mail: drdevnani@gmail.com
ABSTRACT
Autism Spectrum Disorders” (ASDs) are neurodevelopment disorders and are characterized by persistent
impairments in reciprocal social interaction and communication. Sleep problems in ASD, are a prominent
feature that have an impact on social interaction, day to day life, academic achievement, and have been
correlated with increased maternal stress and parental sleep disruption. Polysomnography studies of ASD
children showed most of their abnormalities related to rapid eye movement (REM) sleep which included
decreased quantity, increased undifferentiated sleep, immature organization of eye movements into discrete
bursts, decreased time in bed, total sleep time, REM sleep latency, and increased proportion of stage 1 sleep.
Implementation of nonpharmacotherapeutic measures such as bedtime routines and sleep‑wise approach is
the mainstay of behavioral management. Treatment strategies along with limited regulated pharmacotherapy
can help improve the quality of life in ASD children and have a beneficial impact on the family. PubMed search
was performed for English language articles from January 1995 to January 2015. Following key words: Autism
spectrum disorder, sleep disorders and autism, REM sleep and autism, cognitive behavioral therapy, sleep‑wise
approach, melatonin and ASD were used. Only articles reporting primary data relevant to the above questions
were included.
Key words: Autism, autism spectrum disorder children, melatonin and autism, rapid eye movement sleep and
autism, sleep disorders and autism, sleep disorders in autism, sleep in autistic kids
Introduction
Autism Spectrum Disorders” (ASDs) are neurodevelopment
disorders with a heterogeneous spectrum of clinical
symptomatology related to social interaction and
communication. ASD is characterized by persistent
impairments in reciprocal social interaction and
communication across multiple contexts, along with the
presence of restricted, repetitive, and stereotyped behaviors
and interests. Children with ASD often exhibit high levels
of co-occurring behavioral issues.[1] Sleep problems in
ASD, are a prominent feature and occurs secondary to
complex interactions among biological, psychological, social/
environmental and family factors, and child rearing practices
that may not be conducive to good sleep.
Methodology
PubMed search was performed for English language articles
from January 1995 to January 2015.
Following key words: Autism spectrum disorder, sleep
disorders and autism, rapid eye movement (REM) sleep and
autism, cognitive behavioral therapy, sleep-wise approach,
melatonin and ASD were used.
Cite this article as: Devnani PA, Hegde AU. Autism and sleep disorders.
J Pediatr Neurosci 2015;10:304-7.
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com
Access this article online
Quick Response Code:
Website:
www.pediatricneurosciences.com
DOI:
10.4103/1817-1745.174438
[Downloaded free from http://www.pediatricneurosciences.com on Wednesday, September 28, 2016, IP: 91.248.105.162]
Devnani and Hegde: Autism and sleep disorders
2015 / Oct-Dec / Volume 10 / Journal of Pediatric Neurosciences / 305
Only articles reporting primary data relevant to the above
questions were included.
Pevalence sleep disorders in autism spectrum disorder
ASD is a neurodevelopmental disorder and can present
with varying severity. The Center for Disease Control and
Prevention report (2008) indicates that the prevalence of
ASD is one in 88 children with a 4.6:1 male to female ratio.
According to the Autism and Developmental Disabilities
Monitoring Network, in 2000, the prevalence of ASD
children was found to be 1 in 150 children, in 2008 it was
found to be 1 in 88 children, and in 2010 the prevalence was
1 in 68 children.[2]
Children and adolescents with ASD suffer from sleep
problems, particularly insomnia, at a higher rate than typically
developing (TD) children, ranging from 40% to 80%.[3]
A study based on parental reports showed that 53% of children
(2–5 years of age) with ASD suffered from a sleep problem.[4]
56/89 children with ASD (n = 89) had sleep disorders (difficulty
falling asleep = 23, frequent awakening = 19, and early
morning awakening = 11) with varying presentations of
insomnia.[5] 86% of children (n = 167), suffered from sleep
problems daily. The spectrum of sleep disturbances included
54% bedtime resistance problems, 56% insomnia, 53%
parasomnias, 25% sleep disordered breathing, 45% morning
arising problems, and 31% daytime sleepiness. Hence, there
is a lot of evidence to show that sleep disturbance is very
common in ASD children.[6]
Etiology of sleep problems in autism
The etiologies of sleep disorders in ASD children is
multifactorial, with genetic, environmental, immunological,
and neurological factors thought to play a role in the
development of ASD. There is evidence that there is an
association between the sleep and melatonin rhythms with
alterations in this synchronization of the melatonin rhythm
causing sleep problems. Neurotransmitters such as serotonin,
GABA, and melatonin are required for establishing a regular
sleep wake cycle. Any impairment in the production of
these neurotransmitters may disrupt sleep.[7] Melatonin
is a hormone that helps in maintaining and synchronizing
the circadian rhythm. Melatonin regulation may be
abnormal in autism. Clock genes may be involved in the
modulation of melatonin and also in the integrity of synaptic
transmissions in ASD.[8] Exogenous therapy of melatonin
has shown to improve the sleep patterns in ASD children.[9]
In melatonin synthesis, the final enzyme encoded by the
N-acetylserotonin O-methyltransferase gene demonstrated
less activity in ASD children; therefore, implying lower
levels of melatonin.[10] The major sleep promoting area,
that is, the preoptic area in the hypothalamus uses GABA
as a neurotransmitter. In autism, GABAergic interneurons
migration and maturation may be affected. A region of
genetic susceptibility has been identified on chromosome
15q that contains GABA-related genes.[25] Vitamin D is
required for embryogenesis, neural development, and also
for activating certain genes, deficiency in this vitamin
during pregnancy could be an environmental risk factor
for the development of ASD.[11]
Sleep architecture and its clinical relevance
Polysomnography (PSG) studies of ASD children showed
most of their abnormalities related to REM sleep which
included decreased quantity, increased undifferentiated
sleep, immature organization of eye movements into discrete
bursts, decreased time in bed, total sleep time (TST),
REM sleep latency, and increased proportion of stage 1
sleep. Greater number of muscle twitches compared with
healthy controls are reported.[12,13] 5 of 11 children with
ASD with disrupted sleep had nocturnal awakenings,
REM sleep behavior disorder, with lack of muscle atonia
during REM sleep.[14] A study between the children with
ASD in comparison to TD showed that ASD children
had longer sleep onset latency (SOL), reduced sleep
efficiency, and increased wake after sleep onset compared
to controls, no significant differences in the sleep stage
percentages between the two groups was seen. Neither
group demonstrated correlations between sleep stage
percentages and cognitive test scores. Children with ASDs
have more disturbed sleep and affective problems than TD
children.[15]
Affective problems improve with increased sleep, particularly
REM and slow wave sleep, in TD children, but not in
children with ASDs. Reduced TST has been shown to
correlate with Childhood Autism Rating Scale (CARS)
severity and inversely related to social quotient in a pilot
study. SOL and REM latency were higher in children with
moderate to severe attention deficit hyperactivity disorder.
A trend was observed in the correlation of higher CARS
being related to lower REM percentage and reduced TST
to higher REM latency.
Impact of sleep disturbances in children with autism
spectrum disorders on care‑givers
Sleep problems in ASD have also been correlated with
increased maternal stress and parental sleep disruption.
Children with ASD have common sleep disturbances that
could negatively impact not only the quality of life and
the daytime functioning of the child, but also the family,
increasing the stress level. This has also shown to have
an association with more challenging behaviors of ASD
children during the day and have an impact on the ability
to regulate emotion.[16] Common medical issues such as
upper respiratory problems and vision problems have shown
an association with sleep quality. Increased night time
awakening and decreased willingness to fall asleep were
shown to be associated with poor appetite and growth.[17]
Increased aggression, hyperactivity, and social difficulties
could be indicators for poor mental health outcomes that
were observed due to sleep disturbance in children with
ASD.
[Downloaded free from http://www.pediatricneurosciences.com on Wednesday, September 28, 2016, IP: 91.248.105.162]
Devnani and Hegde: Autism and sleep disorders
306 / Journal of Pediatric Neurosciences / Volume 10 / Oct-Dec / 2015
Assessment of sleep problems in autism spectrum
disorders
An early and routine assessment of sleep in children with
ASD could help children as well as their parents. Sleep may
be assessed utilizing subjective and/or objective measures.[18]
Subjective measures would include parental questionnaires
and sleep diaries whereas objective measures would include
actigraphy and PSG for assessing the sleep disorders.[19]
Actigraphy is a study in which an actigraph device is worn on
the wrist to record movements that can be used to estimate
sleep parameters with specialized algorithms in computer
software programs. PSG is continuous monitoring of multiple
neurophysiological and cardiorespiratory variables, usually
over the course of a night, to study different aspects of sleep.
Psychological assessments, detailed history from parents,
teachers, and care-givers that describes the child’s current
sleep problem is obtained.
The sleep history should include:
• Predisposingfactors(e.g.,developmentalvulnerabilities)
• Precipitatingfactors(e.g.,onsetofmedicalconditionsor
medications; poor sleep hygiene)
• Perpetuatingfactors(e.g.,nappingduringtheday,
co-sleeping, and parenting behaviors). Maintaining a
sleep log or a sleep dairy could help determine factors
that might be resulting in poor sleep.
Establishing positive sleep patterns for young children
with autism spectrum disorder
Children with ASD may experience various sleep complaints
such as difficulty falling asleep, analysis of frequent awakening
during the night, and/or reduced TST. Ongoing and persistent
sleep disturbances can have an adverse effect on the child,
parents, and other household members.
Reinforcing a positive sleep pattern is of paramount
importance.
Following are helpful strategies:
• Assessmentofanyunderlyingmedicalproblemssuchas
tonsillitis, adenoids, gastrointestinal disturbances, and
seizures that may affect sleep
• Evaluationofbedtimeroutines
• Screeningforintrinsicsleepdisorderssuchassleep
apnea, restless legs syndrome, or periodic limb movement
disorder
• Assessmentforfoodand/orenvironmentalallergiesthat
are commonly observed in ASD.
Environmental variables
Assess the environmental variables that could affect the
child’s sleep such as temperature of the room, bedding, and
sleep clothes. Certain textures can relax or arouse your child
that could be disturbing the child’s sleep. Consider noises
levels, visual stimuli in the room, and how they affect the
child.
Bedtime routines
Bedtime rituals are very important for most children, they
help in establishing positive sleep patterns. Make a visual
bedtime schedule and pick a specific time for bed that is
reasonable, provide reminders and consistency for the whole
family. A good bedtime routine will help teach a child to calm
down, relax, and get ready to sleep.
Sleep training
After the bedtime routine is done and the child is in his bed
or crib- but is upset and obviously not sleeping, wait a few
minutes and then go back into the child’s room to check on
him/her. Checks involve going back into the child’s room and
briefly (not more than a minute, preferably less) touching,
rubbing, or maybe giving a “high five,” “thumbs up,” or hug
for an older child who better responds to these gestures.
Gently but firmly say, “it’s okay, it’s bedtime, you are okay” or
a similar phrase and then leave the room until it is time for
the next check or until the child falls asleep. It is important
to know that it is very likely that the child’s behavior will get
worse for a few days or more before it improves.
Sleep-wise approach
Establish a routine
Sensory cues/needs
Music
Aromatherapy
Eye pillow
Massage
Weighted quilts and pillows
Communication cues/level
Sleep stories
Visual prompts
Visual sequence
Reward charts
Visual cue cards
Behavioral
Timetabling of sleep
Change the bedtime
Change bedtime when not asleep
Restrict sleep
Gradual distancing of parents
Ignoring
Standard
Gradual
With parents present
Schedule awakening
Role of pharmacotherapy
If the child does not respond to behavioral changes
advised, then medications may be considered. Medications
such as benzodiazepines and diphenhydramine given as
over-the-counter drugs were shown to have paradoxical and
excitatory responses that have been reported.[20]
The alpha-2 adrenergic agonist, clonidine reduced the time
to sleep and also nighttime awakenings, this was observed in
a small open label trial.[21]
[Downloaded free from http://www.pediatricneurosciences.com on Wednesday, September 28, 2016, IP: 91.248.105.162]
Devnani and Hegde: Autism and sleep disorders
2015 / Oct-Dec / Volume 10 / Journal of Pediatric Neurosciences / 307
Role of melatonin
Melatonin is a pineal hormone that regulates the circadian
rhythm. Melatonin appears to be effective in reducing time
to sleep, but its efficacy in reducing nighttime awakenings
and other aspects of sleep disturbances is variable.[22] In a
study, n = 24, 1–3 years ASD children, when treated with
1 mg or 3 mg showed improvement in sleep latency that was
measured by actigraphy. This treatment not only showed
an improvement in the sleep pattern of the children, but
also the behavior and parental stress.[23] In another study,
n = 107, ASD children (2–18 years), after receiving
melatonin 0.75–6 mg, 25% of the parents had no more sleep
concerns, 60% reported improved sleep, 13% continued
to have sleep as a major problem, 1% had worsened sleep
after initiating melatonin, and 1% could not determine the
response.[24]
Children with autism and neurological impairments present
special challenges for drug administration. They may present
with unusual feeding difficulties and restrictive diets. Parents
often have to be extremely creative in disguising or mixing
medication with the right type of liquid or food. Melatonin
can also be administered in toothpaste form.
Conclusion
There is a high prevalence of sleep disturbances among
children with ASD, many of which are unrecognized. Sleep
disturbances have an adverse effect on their social interaction,
academic achievement, and well-being of the care-givers.
Implementation of nonpharmacotherapeutic measures such
as bedtime routines and sleep-wise approach are the mainstay
of management.
These treatment strategies along with limited regulated
pharmacotherapy can help improve the quality of life in ASD
children and also decrease the family and parental distress.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Boonen H, Maljaars J, Lambrechts G, ZInk I, Van Leeuwen K, Noens I.
Behavior problems among school-aged children with autism spectrum
disorder: Associations with children’s communication difficulties and
parenting behaviors. Res Autism Spectr Disord 2014;8:716-25..
2. Baio J. Prevalence of autism spectrum disorder among children aged
8 years – Autism and developmental disabilities monitoring network,
11 sites, United States, 2010. MMWR Morb Mortal Wkly Rep
2014;63;2:1-21. Available from: http://www.cdc.gov/library/sciclips/
issues/v6issue16.html.
3. Cortesi F, Giannotti F, Ivanenko A, Johnson K. Sleep in children with
autistic spectrum disorder. Sleep Med 2010;11:659-64.
4. Krakowiak P, Goodlin- Jones B, Hertz-Picciotto I, Croen LA,
Hansen RL. Sleep problems in children with autism spectrum disorders,
developmental delays, and typical development: A population-based
study. J Sleep Res 2008;17:197-206.
5. Taira M, Takase M, Sasaki H. Sleep disorder in children with autism.
Psychiatry Clin Neurosci 1998;52:182-3.
6. Liu X, Hubbard JA, Fabes RA, Adam JB. Sleep disturbances and
correlates of children with autism spectrum disorders. Child Psychiatry
Hum Dev 2006;37:179-91.
7. Cortesi F, Giannotti F, Ivanenko A, Johnson K. Sleep in children with
autistic spectrum disorder. Sleep Med 2010;11:659-64.
8. Bourgeron T. The possible interplay of synaptic and clock genes
in autism spectrum disorders. Cold Spring Harb Symp Quant Biol
2007;72:645-54.
9. Leu RM, Beyderman L, Botzolakis EJ, Surdyka K, Wang L, Malow BA.
Relation of melatonin to sleep architecture in children with autism.
J Autism Dev Disord 2011;41:427-33.
10. Melke J, Goubran Botros H, Chaste P, Betancur C, Nygren G,
Anckarsäter H, et al. Abnormal melatonin synthesis in autism spectrum
disorders. Mol Psychiatry 2008;13:90-8.
11. Duan XY, Jia FY, Jiang HY. Relationship between Vitamin D
and autism spectrum disorder. Zhongguo Dang Dai Er Ke Za Zhi
2013;15:698-702.
12. Elia M, Ferri R, Musumeci SA, Del Gracco S, Bottitta M, Scuderi C,
et al. Sleep in subjects with autistic disorder: A neurophysiological and
psychological study. Brain Dev 2000;22:88-92.
13. Malow BA, Marzec ML, McGrew SG, Wang L, Henderson LM,
Stone WL. Characterizing sleep in children with autism spectrum
disorders: A multidimensional approach. Sleep 2006;29:1563-71.
14. Thirumalai SS, Shubin RA, Robinson R. Rapid eye movement
sleep behavior disorder in children with autism. J Child Neurol
2002;17:173-8.
15. Maski K, Holbrook H, Manoach D, Hanson E, Stickgold R. Sleep
architecture and neurobehavioral and cognitive functioning in children
with autistic spectrum disorders. Neurology 2013;80.
16. Gail Williams P, Sears LL, Allard A. Sleep problems in children with
autism. J Sleep Res 2004;13:265-8.
17. May T, Cornish K, Conduit R, Rajaratnam SM, Rinehart NJ. Sleep in
high-functioning children with Autism: Longitudinal developmental
change and associations with behaviour problems. Behav Sleep Med
2015;13:2-18.
18. Jeste SS. The neurology of autism spectrum disorders. Curr Opin Neurol
2011;24:132-9.
19. Tsai L. Children with autism spectrum disorder: Medicine today and in
the new millennium. Focus Autism Other Dev Disabl 2000;15:138-45.
20. Ming X, Gordon E, Kang N, Wagner GC. Use of clonidine in children
with autism spectrum disorders. Brain Dev 2008;30:454-60.
21. Myers SM, Johnson CP; American Academy of Pediatrics Council
on Children With Disabilities. Management of children with autism
spectrum disorders. Pediatrics 2007;120:1162-82.
22. Malow B, Adkins KW, McGrew SG, Wang L, Goldman SE, Fawkes D,
et al. Melatonin for sleep in children with autism: A controlled trial
examining dose, tolerability, and outcomes. J Autism Dev Disord
2012;42:1729-37.
23. Andersen IM, Kaczmarska J, McGrew SG, Malow BA. Melatonin for
insomnia in children with autism spectrum disorders. J Child Neurol
2008;23:482-5.
24. McCauley JL, Olson LM, Delahanty R, Amin T, Nurmi EL, Organ EL,
et al. A linkage disequilibrium map of the 1-Mb 15q12 GABA (A)
receptor subunit cluster and association to autism. Am J Med Genet
B Neuropsychiatr Genet 2004;131B: 51-9.
[Downloaded free from http://www.pediatricneurosciences.com on Wednesday, September 28, 2016, IP: 91.248.105.162]
... Sleep problems in children with ASD include: bedtime resistance, trouble falling asleep, maintaining sleep, parasomnias (e.g., bruxism, night terrors), early morning awakening Katz et al., 2018). Parents may also report resulting daytime sleepiness (Devnani & Hegde, 2015). Sleep disturbances in children with ASD are multifactorial and may persist into adulthood (Goldman et al., 2017). ...
... Sleep disturbances in children with ASD are multifactorial and may persist into adulthood (Goldman et al., 2017). Factors that may contribute to sleep disturbance in children with ASD include: heightened arousal, anxiety, adverse effects of medication, genetic (i.e., altered sleep-wake rhythms; Charrier et al., 2017), environmental (i.e., light exposure), physical inactivity, iron deficiency, and poor sleep hygiene (i.e., lack of an established bedtime routine; Devnani & Hegde, 2015;Dosman et al., 2007;Esteves et al., 2021;Johnson et al., 2018;Malow & McGrew, 2008;Mazzone et al., 2018;Souders et al., 2017). Insufficient sleep in children with ASD is associated with increased irritability, stereotypic behavior, and decreased participation in learning opportunities (Cohen et al., 2018;Mazurek & Sohl, 2016;Schreck et al., 2004). ...
Article
Full-text available
This research evaluated the feasibility of actigraphy to measure sleep and physical activity in children (ages 2-8 years) with autism spectrum disorder (ASD). We also explored associations between sleep and physical activity. Validated screening measures established eligibility. Questionnaires, diaries, and 5 days and 5 nights of actigraphy monitoring were used to collect data. Of the 32 children enrolled, 27 (84.4%) completed actigraphy monitoring. Based on the median steps per day, children with high physical activity had lower total sleep time and more disruptive behaviors than children with low physical activity. Findings support the feasibility of using actigraphy to measure sleep and physical activity in children with ASD. Larger studies are needed to evaluate interactions of physical activity on sleep in this population.
... As expected, parents of children with ASD reported expending significantly more effort than parents of neurotypical children and ASD symptom severity was positively associated with effort levels. For children with ASD, language delays (24), sensory sensitivities (25), sleep differences (26), and behavioral rigidity and maladaptive behaviors (27) may increase parent effort demands. When parents of children with ASD perceive that they are unable to manage these challenging behaviors, they may experience internalized stigma and further restrict their child's participation opportunities for fear of others' judgement (28). ...
Article
Full-text available
Objective: The Parent Effort Scale (PES) is a parent report questionnaire designed to quantify the level of effort required of caregivers to assist their children in developmentally appropriate home- and community-based activities. This manuscript describes the psychometric evaluation of the PES. Method: Data collected from 304 parents of children ages 2-7 years (167 parents of a children with autism spectrum disorder and 137 parents of neurotypical children) were factor analyzed, calibrated using item response theory, and evaluated for construct validity. Results: The final PES scales are reliable and valid measures of the level of parental effort required to assist children in dressing, personal hygiene, sleep, socialization at home, participation in community events, and access to healthcare. A total score reflects overall parental effort. Conclusion: The PES can be used to plan and evaluate the effectiveness of interventions that aim to help parents enhance children's participation opportunities and thus, support their cognitive and social development.
... [5] Melatonin has demonstrated a decent impact in treating resting disarranges in neurodevelopment challenges kids. [6] Patients with circadian mood rest issue can be utilized oral melatonin to help entrain (naturally synchronize in the right stage) to the ecological light-dim cycle. Melatonin diminishes rest beginning idleness to subjects with postponed rest stage issue than in subjects sleep deprivation. ...
... However, there is no single medicine that the Food and Drug Administration has licensed for use in patients with ASD. [32,34,35] There is a need for high-level studies in many areas and perspectives on this subject in the literature, as can be seen in the study published in 2020 by Cortese et al. [36] However, knowing that sleep issues and their influence can be controlled in people with ASD will improve patients' quality of life. ...
Article
Full-text available
Sleep is one of the essential requirements for maintaining human mental and cognitive function. It is not merely a condition of rest, as was previously believed. Instead, it is composed of several stages and active processes. As new sleep processes are discovered, these factors have increased concern regarding the connection between sleep and diseases. As a consequence of the research concluded, it has become known that sleep, as it comprises standard processes, has a significant role in internal and psychological disorders. It has been demonstrated to be a prognostic, diagnostic, or predictive factor in Alzheimer's disease (AD), significant depression, and anxiety disorders. Major depression also displayed a higher level of specificity than other psychiatric disorders. It has been demonstrated to play a role in other mental conditions such as schizophrenia, attention deficit hyperactivity disorder (ADHD), and autism spectrum disorder (ASD). However, research is still ongoing to elucidate its precise role in these conditions. In this review, relationship between sleep disturbance and schizophrenia, ADHD, AD, ASD, anxiety, and major depressive disorder were discussed.
... Autism spectrum disorder (ASD) is a condition characterized by abnormalities in behavior, deficits in communication, language, and social interactions; restricted and repetitive interests are also reported [7]. Sleep disorders in ASDs are noted [12,13], and different studies continue to find parent-reported sleep problem rates ranging from around 50% to 80% for children with an ASD, compared with 9% to 50% for comparison groups [14,15]. The sleep disorders most frequently observed in these children [16] include delay in sleep onset, frequent nocturnal awakenings, and reduced sleep duration. ...
Article
Full-text available
Sleep disorders in children with autism spectrum disorders (ASDs) are well-described. However, there is a lack of specific assessment tools to investigate sleep disturbance in this target population. The present investigation reports the Italian validation of the Sleep Disturbance Scale for Children (SDSC) in the ASD population, also investigating the correlation between sleep disorders In both children and parents. Internal consistency and test–retest reliability were investigated using Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Concurrent validity was analyzed by comparing the score of the SDSC with the Pittsburgh Sleep Quality Index (PSQI), while the correlation between the SDCS score and the General Sleep Disturbance Scale (GSDS) was used to analyze the correlation between sleep disorders in children and sleep disorders in their parents. In total, 99 children with a diagnosis of ASD participated in the study. Cronbach’s alpha revealed satisfactory value (0.853), as well as reliability (ICC 0.972) and concurrent validity (0.745). Our results also revealed a significant linear correlation between children’s and parents’ sleep disorders (p < 0.05). In conclusion, we found the SDSC to be a useful tool for measuring sleep disorders in ASD children. Our findings offer concrete inputs to achieve adequate pathways for taking care of children with ASDs and their parents.
Article
We asked mothers of children with intellectual disability about the factors that affected their and their children's sleep quality. We found that factors in the body, mind and environment all affect sleep quality. We suggest that parents would benefit from education and counselling to help establish good bedtime routines and manage stress. We asked mothers of children with intellectual disability about the factors that affected their and their children's sleep quality. We found that factors in the body, mind and environment all affect sleep quality. We suggest that parents would benefit from education and counselling to help establish good bedtime routines and manage stress. Sleep is an important physiological need for children with intellectual disabilities and their mothers. The present study aims to obtain detailed information on the factors that are hindering and facilitating the sleep quality of children with intellectual disabilities and their mothers. Twenty‐one mothers of children with intellectual disabilities aged 2–18 years were interviewed to identify their perceptions of the factors that hindered or facilitated the quality of their sleep and that of their children. The interviews were transcribed, coded and analysed thematically using the MAXQDA qualitative data analysis program. The interview data generated three main themes relating to factors that are hindering and facilitating sleep quality in children with intellectual disabilities and their mothers: physiological, psychological and environmental factors. Mothers reported that sleep problems negatively affect themselves and their children with intellectual disabilities. Parent education and counselling on topics of environmental regulation, methods of coping with stress and establishing and maintaining routines are recommended to enhance sleep quality.
Article
Full-text available
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.
Article
Autism is a neurodevelopmental condition that is highly heterogeneous in its clinical presentation. In addition to differences in social interaction and communication, and the presence of restrictive, repetitive behaviors, metabolic dysfunction is becoming more widely known and studied as a co-occurring condition seen in autistic individuals. However, the etiology of these metabolic alterations in autism remains unclear. Here, we utilized a combination of metabolomic, physiological, and behavioral assays to investigate how disruption of the autism-risk gene, neurexin-1, influences energy metabolism and associated behaviors in Drosophila melanogaster. These analyses revealed that Drosophila lacking neurexin-1 expression exhibit decreased resistance to environmental stressors, specifically starvation stress and heat stress. These findings lead us to consider whether the neurexin-1 mutant flies have an altered metabolic status, thus we performed metabolomics and complementary colorimetric assays and found that these flies have a distinct metabolic profile, with decreased lipid and carbohydrate stores. Moreover, neurexin-1-null Drosophila exhibit decreased levels of NAD+, an important cofactor in many energy production pathways. Interestingly, loss of neurexin-1 also results in disruptions in mitochondrial morphology in Drosophila flight muscle, in addition to decreased flight ability. Finally, we observed mechanically-induced seizure-like activity in the neurexin-1 mutant flies, which closely mimics clinical data wherein patients with deletions in Neurexin-1 experience seizures. Together, these findings point to a novel role for neurexin-1 in the regulation of energy metabolism and autism-related behavioral phenotypes in Drosophila, in addition to providing a foundation for further investigation into the etiology of metabolic dysfunction and seizures in autism.
Article
Full-text available
Autism spectrum disorders (ASDs) represent a diagnostic challenge with a still partially uncertain etiology, in which genetic and environmental factors have now been assessed. Among the hypotheses underlying the involvement of biological and environmental factors, the gut–brain axis is of particular interest in autism spectrum disorders. Several studies have highlighted the related incidence of particular gastrointestinal symptoms (GISs) in children suffering from ASDs. Probiotics have shown success in treating several gastrointestinal dysbiotic disorders; therefore, it is plausible to investigate whether they can alleviate behavioral symptoms as well. On these bases, a randomized double-blind crossover study with a placebo was conducted, evaluating the effects of a mixture of probiotics in a group of 61 subjects aged between 24 months and 16 years old with a diagnosis of ASD. Behavioral evaluation was performed through the administration of a questionnaire including a Parenting Stress Index (PSI) test and the Vineland Adaptive Behavior Scale (VABS). The Psycho-Educational Profile and the Autism Spectrum Rating Scale (ASRS) were also evaluated. Microbial composition analyses of fecal samples of the two groups was also performed. The study showed significant improvements in GISs, communication skills, maladaptive behaviors, and perceived parental stress level after the administration of probiotics. Microbiome alpha diversity was comparable between treatment arms and no significant differences were found, although beta diversity results were significantly different in the treatment group between T0 and T1 time points. Streptococcus thermophilus, Bifidobacterium longum, Limosilactobacillus fermentum, and Ligilactobacillus salivarius species were identified as some of the most discriminant taxa positively associated with T1 samples. This preliminary study corroborates the relationship between intestinal microbiota and ASD recently described in the literature.
Article
Full-text available
Pediatricians have an important role not only in early recognition and evaluation of autism spectrum disorders but also in chronic management of these disorders. The primary goals of treatment are to maximize the child's ultimate functional independence and quality of life by minimizing the core autism spectrum disorder features, facilitating development and learning, promoting socialization, reducing maladaptive behaviors, and educating and supporting families. To assist pediatricians in educating families and guiding them toward empirically supported interventions for their children, this report reviews the educational strategies and associated therapies that are the primary treatments for children with autism spectrum disorders. Optimization of health care is likely to have a positive effect on habilitative progress, functional outcome, and quality of life; therefore, important issues, such as management of associated medical problems, pharmacologic and nonpharmacologic intervention for challenging behaviors or coexisting mental health conditions, and use of complementary and alternative medical treatments, are also addressed.
Article
Full-text available
Sleep disturbance is common in autism spectrum disorder (ASD), but longitudinal trajectories are poorly defined. This study measured sleep disturbance at baseline and 1 year later examining change over time and associated problem behaviors. Participants were 84 gender-matched children, aged between 7 and 12 years at baseline; 46 children were diagnosed with ASD, and 38 were typically developing (TYP) children. Parent reports on a range of scales were collected. The ASD group had more sleep disturbance than the TYP group. Sleep disturbance decreased over the year in children with ASD, but not in TYP children. Reduced sleep disturbance was associated with improved social ability. Sleep disturbance at baseline predicted later anxiety. Findings indicated different trajectories of sleep disturbance in ASD, and the implications are discussed.
Article
Full-text available
Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder, with multiple genetic and environmental risk factors. The interplay between genetic and environmental factors has become the subject of intensified research in the last several years. Vitamin D deficiency has recently been proposed as a possible environmental risk factor for ASD. Vitamin D has a unique role in brain homeostasis, embryogenesis and neurodevelopment, immunological modulation (including the brain's immune system), antioxidation, antiapoptosis, neural differentiation and gene regulation. Children with ASD had significantly lower serum levels of 25-hydroxy vitamin D than healthy children.Therefore vitamin D deficiency during pregnancy and early childhood may be an environmental trigger for ASD.
Article
Full-text available
Supplemental melatonin has shown promise in treating sleep onset insomnia in children with autism spectrum disorders (ASD). Twenty-four children, free of psychotropic medications, completed an open-label dose-escalation study to assess dose-response, tolerability, safety, feasibility of collecting actigraphy data, and ability of outcome measures to detect change during a 14-week intervention. Supplemental melatonin improved sleep latency, as measured by actigraphy, in most children at 1 or 3 mg dosages. It was effective in week 1 of treatment, maintained effects over several months, was well tolerated and safe, and showed improvement in sleep, behavior, and parenting stress. Our findings contribute to the growing literature on supplemental melatonin for insomnia in ASD and inform planning for a large randomized trial in this population.
Article
Description of System: The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance system in the United States that provides estimates of the prevalence of ASD and other characteristics among children aged 8 years whose parents or guardians live in 11 ADDM sites in the United States. ADDM surveillance is conducted in two phases. The first phase consists of screening and abstracting comprehensive evaluations performed by professional providers in the community. Multiple data sources for these evaluations include general pediatric health clinics and specialized programs for children with developmental disabilities. In addition, most ADDM Network sites also review and abstract records of children receiving specialeducation services in public schools. The second phase involves review of all abstracted evaluations by trained clinicians to determine ASD surveillance case status. A child meets the surveillance case definition for ASD if a comprehensive evaluation of that child completed by a qualified professional describes behaviors consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for any of the following conditions: autistic disorder, pervasive developmental disorder-not otherwise specified (including atypical autism), or Asperger disorder. This report provides updated prevalence estimates for ASD from the 2010 surveillance year. In addition to prevalence estimates, characteristics of the population of children with ASD are described. Results: For 2010, the overall prevalence of ASD among the ADDM sites was 14.7 per 1,000 (one in 68) children aged 8 years. Overall ASD prevalence estimates varied among sites from 5.7 to 21.9 per 1,000 children aged 8 years. ASD prevalence estimates also varied by sex and racial/ethnic group. Approximately one in 42 boys and one in 189 girls living in the ADDM Network communities were identified as having ASD. Non-Hispanic white children were approximately 30% more likely to be identified with ASD than non-Hispanic black children and were almost 50% more likely to be identified with ASD than Hispanic children. Among the seven sites with sufficient data on intellectual ability, 31% of children with ASD were classified as having IQ scores in the range of intellectual disability (IQ ≤70), 23% in the borderline range (IQ = 71-85), and 46% in the average or above average range of intellectual ability (IQ > 85). The proportion of children classified in the range of intellectual disability differed by race/ethnicity. Approximately 48% of non-Hispanic black children with ASD were classified in the range of intellectual disability compared with 38% of Hispanic children and 25% of non-Hispanic white children. The median age of earliest known ASD diagnosis was 53 months and did not differ significantly by sex or race/ethnicity. Interpretation: These findings from CDC's ADDM Network, which are based on 2010 data reported from 11 sites, provide updated population-based estimates of the prevalence of ASD in multiple communities in the United States. Because the ADDM Network sites do not provide a representative sample of the entire United States, the combined prevalence estimates presented in this report cannot be generalized to all children aged 8 years in the United States population. Consistent with previous reports from the ADDM Network, findings from the 2010 surveillance year were marked by significant variations in ASD prevalence by geographic area, sex, race/ethnicity, and level of intellectual ability. The extent to which this variation might be attributable to diagnostic practices, underrecognition of ASD symptoms in some racial/ethnic groups, socioeconomic disparities in access to services, and regional differences in clinical or school-based practices that might influence the findings in this report is unclear. Public Health Action: ADDM Network investigators will continue to monitor the prevalence of ASD in select communities, with a focus on exploring changes within these communities that might affect both the observed prevalence of ASD and population-based characteristics of children identified with ASD. Although ASD is sometimes diagnosed by 2 years of age, the median age of the first ASD diagnosis remains older than age 4 years in the ADDM Network communities. Recommendations from the ADDM Network include enhancing strategies to address the need for 1) standardized, widely adopted measures to document ASD severity and functional limitations associated with ASD diagnosis; 2) improved recognition and documentation of symptoms of ASD, particularly among both boys and girls, children without intellectual disability, and children in all racial/ethnic groups; and 3) decreasing the age when children receive their first evaluation for and a diagnosis of ASD and are enrolled in community-based support systems.
Article
Research has clearly demonstrated that behavior problems are common among children with ASD. These co-occurring behavior problems place children with ASD and their families at risk for a range of negative outcomes. This questionnaire study aimed to investigate whether and how age, gender, and communication difficulties at the child level and parenting behaviors at the family level are associated with externalizing and internalizing problems among children with ASD (n = 206) and without ASD (n = 187) aged 6–12 years. Results indicated that pragmatic language difficulties of the child and negative controlling parenting behaviors both made a significant and unique contribution to externalizing behavior problems for the ASD group. In the control group, chronological age and pragmatic language difficulties were the most robust concurrent predictors of externalizing problems. With regard to internalizing problems, pragmatic language difficulties and ASD adapted parenting behaviors were significant predictors for both the ASD and control group.
Article
This article examines the role and future of medicine and medically oriented interventions for children and youth with autism spectrum disorder. Included in the discussion are the diagnostic issues and medication treatments available currently and those that will become available in the new millennium.
Article
Autism is a complex genetic neuropsychiatric condition characterized by deficits in social interaction and language and patterns of repetitive or stereotyped behaviors and restricted interests. Chromosome 15q11.2-q13 is a candidate region for autism susceptibility based on observations of chromosomal duplications in a small percentage of affected individuals and findings of linkage and association. We performed linkage disequilibrium (LD) mapping across a 1-Mb interval containing a cluster of GABAA receptor subunit genes (GABRB3, GABRA5, and GABRG3) which are good positional and functional candidates. Intermarker LD was measured for 59 single nucleotide polymorphism (SNP) markers spanning this region, corresponding to an average marker spacing of 17.7 kb−1. We identified haplotype blocks, and characterized these blocks for common (>5%) haplotypes present in the study population. At this marker resolution, haplotype blocks comprise <50% of the DNA in this region, consistent with a high local recombination rate. Identification of haplotype tag SNPs reduces the overall number of markers necessary to detect all common alleles by only 12%. Individual SNPs and multi-SNP haplotypes were examined for evidence of allelic association to autism, using a dataset of 123 multiplex autism families. Six markers individually, across GABRB3 and GABRA5, and several haplotypes inclusive of those markers, demonstrated nominally significant association. These results are positively correlated with the position of observed linkage. These studies support the existence of one or more autism risk alleles in the GABAA receptor subunit cluster on 15q12 and have implications for analysis of LD and association in regions with high local recombination. This article contains supplementary material, which may be viewed at the American Journal of Medical Genetics website athttp://www.interscience.wiley.com/jpages/0148-7299:1/suppmat/index.html. © 2004 Wiley-Liss, Inc.
Article
Neurological comorbidities in autism spectrum disorders (ASDs) are not only common, but they are also associated with more clinical severity. This review highlights the most recent literature on three of autism's most prevalent neurological comorbidities: motor impairment, sleep disorders and epilepsy. Motor impairment in ASDs manifests as both delays and deficits, with delays found in gross and fine motor domains and deficits found in praxis, coordination and gait, all of which affect other cognitive and behavioral domains. Sleep disorders, especially insomnia, occur in up to 83% of children with ASDs and recent studies have begun to explore the underlying biochemical and behavioral basis of the impairment, which has bolstered treatment studies. Epilepsy is reported in up to one third of children with ASDs, and new studies have focused on identifying the genetic causes of this association. Better characterization of the phenotype, developmental trajectory and underlying pathophysiology of these neurological comorbidities will enable us to define neurological endophenotypes within the autism spectrum. Future studies must investigate the emergence of these comorbidities prospectively in order to determine whether they lie on the causal pathway to ASDs or whether they reflect epiphenomena of the disorder. As epilepsy and sleep disorders can be treated and may contribute significantly to behavioral and cognitive abnormalities in ASDs, their identification is of high clinical relevance.
Article
Children with autism often suffer from sleep disturbances, and compared to age-matched controls, have decreased melatonin levels, as indicated by urine levels of the primary melatonin metabolite, 6-sulfatoxymelatonin (6-SM). We therefore investigated the relationship between 6-SM levels and sleep architecture in children with autism spectrum disorders (ASD). Twenty-three children, aged 4-10 years, completed two nights of polysomnography and one overnight urine collection for measurement of urinary 6-SM excretion rate. Parents completed the Children's Sleep Habits Questionnaire. We found that higher urinary 6-SM excretion rates were associated with increased N3 sleep, decreased N2 sleep, and decreased daytime sleepiness. The results warrant further examination to examine the effects of supplemental melatonin on sleep architecture and daytime sleepiness.