Practice Tools for Screening and Monitoring Insomnia in Children and Adolescents with Autism Spectrum Disorder

Novel Insights into Somatic Comorbidities in Children and Adolescents Across Psychiatric Diagnoses: An Explorative Study

Many children with psychiatric disorders display somatic symptoms, although these are frequently overlooked. As somatic morbidity early in life negatively influences long-term outcomes, it is relevant to assess comorbidity. However, studies of simultaneous psychiatric and somatic assessment in children are lacking. The aim of this study was to assess the prevalence of somatic comorbidities in a clinical sample of children and adolescents with psychiatric disorders in a naturalistic design. Data were assessed from 276 children with various psychiatric disorders (neurodevelopmental disorders, affective disorders, eating disorders and psychosis) aged 6-18 years. These data were collected as part of routine clinical assessment, including physical examination and retrospectively analyzed. For a subsample (n = 97), blood testing on vitamin D3, lipid spectrum, glucose and prolactin was available. Results of this cross-sectional study revealed that food intake problems (43%) and insomnia (66%) were common. On physical examination, 20% of the children were overweight, 12% displayed obesity and 38% had minor physical anomalies. Blood testing (n = 97) highlighted vitamin D3 deficiency (< 50 nmol/L) in 73% of the children. None of the predefined variables (gender, age, medication and socioeconomic factors) contributed significantly to the prevalence of somatic comorbidities. The main somatic comorbidities in this broad child- and adolescent psychiatric population consisted of (1) problems associated with food intake, including obesity and vitamin D3 deficiency and (2) sleeping problems, mainly insomnia. Child and adolescent psychiatrists need to be aware of potential somatic comorbidities and may promote a healthy lifestyle.

Sleep Problems in Autism Spectrum Disorder

Sleep problems are common in children with autism spectrum disorder (ASD), with 40% to 80% prevalence. Common disorders include insomnia, parasomnias, and circadian rhythm sleep-wake disorders. These problems have a multifactorial etiology and can both exacerbate and be exacerbated by core ASD symptoms. Sleep problems also impact the health and quality of life of both patients and their caregivers. All children with autism should be regularly screened for sleep problems and evaluated for co-occurring medical contributors. Behavioral interventions with caregiver training remain first-line treatment for sleep disorders in both neurotypical and neurodiverse youth.

Adherence to treatment and parents' perspective about effectiveness of melatonin in children with autism spectrum disorder and sleep disturbances

OBJECTIVE

Melatonin is considered an effective pharmacological treatment for the sleep disturbances that are reported in > 50% of children with autism spectrum disorder (ASD). However, real-life data about the long-term course and effectiveness of melatonin treatment in children with ASD is lacking.

METHODS

In this retrospective cohort study, we assessed the adherence to melatonin treatment and parents' perspective of its effect on sleep quality and daytime behavior in children with ASD via a parental phone survey of children in the Azrieli National Center for Autism and Neurodevelopment Research (ANCAN) database. Cox regression analysis was used to assess the effect of key demographic and clinical characteristics on treatment adherence.

RESULTS

Melatonin was recommended for ~ 8% of children in the ANCAN database. These children were characterized by more severe symptoms of autism. The median adherence time for melatonin treatment exceeded 88 months, with the most common reason for discontinuation being a lack of effectiveness (14%). Mild side-effects were reported in 14% of children, and 86%, 54%, and 45% experienced improvements in sleep onset, sleep duration and night awakenings, respectively. Notably, melatonin also improved the daytime behaviors of > 28% of the children. Adherence to treatment was independently associated with improvements in night awakenings and educational functioning (aHR = 0.142, 95%CI = 0.036-0.565; and aHR = 0.195, 95%CI = 0.047-0.806, respectively).

CONCLUSIONS

Based on parents' report, melatonin is a safe and effective treatment that improves both sleep difficulties and daily behavior of children with ASD.

Impact of sleep disorders on behavioral issues in preschoolers with autism spectrum disorder

Background

Sleep disorders are one of the most common problems in children with Autism Spectrum Disorder (ASD). However, they often tend to be underdiagnosed and incorrectly treated in clinical practice. This study aims to identify sleep disorders in preschool children with ASD and to explore their relationship with the core symptoms of autism, the child's developmental and cognitive level as well as the psychiatric comorbidities.

Methods

We recruited 163 preschool children with a diagnosis of ASD. The Children's Sleep Habits Questionnaire (CSHQ) assessed sleep conditions. Multiple standardized tests were used to evaluate intellectual abilities, the presence of repetitive behaviors (through the Repetitive Behavior Scale-Revised), as well as the emotional-behavioral problems and the psychiatric comorbidities (through the Child Behavior Checklist -CBCL 11/2-5).

Results

The results showed that poor disorders had consistently higher scores in all areas assessed by the CSHQ and on the CBCL across all domains. The correlational analysis showed that severe sleep disorders were associated with higher scores in internalizing, externalizing, and total problems at the CBCL syndromic scales, and in all DSM-oriented CBCL subscales. Moreover, we found that the association between sleep disorders and restricted and repetitive behaviors (RRBs) is explained by the anxiety-related symptoms.

Conclusion

Based on these findings, the study recommends that screening for sleep problems followed by early intervention should constitute a routine part of clinical practice for children with ASD.

Sleep Disturbances in Children and Adolescents with Autism Spectrum Disorder: An Overview for Clinicians

Background:

Sleep disorders in autism spectrum disorders (ASD/SD) are distinct, broad, and highly variable clinical entities that ubiquitously affect core symptomatology, development of comorbid disorders, and overall quality of life for affected children and families. High genetic predisposition and the presence of co-occurring disorders present significant challenges in assessment and appropriate interventions.

Objective:

The study aimed to review the best available evidence and address the clinical gaps in the knowledge about sleep disorders in children and adolescents with autism spectrum disorders.

Methods:

The review provides a comprehensive literature search of 1622 articles and summarizes 110 selected for empirical evidence to methodically consider critical aspects of sleep disorders in ASD for informing clinicians of useful information.

Results:

Clinicians have insufficient guidance and support to effectively manage sleep disruptions in ASD youth in practice. Prevalence of sleep disruption in ASD, close to 80%, is characterized by unique subtypes, including but not limited to obstructive sleep apnea, circadian rhythm disorders, and sleep-related movement disorders. Greater awareness of sleep disruption, its neurodevelopmental basis, scope, and impact allows for improved treatment and prevention efforts of these conditions, and is critical for clinical practice and future research. The bidirectional nature of disruptive sleep and ASD is considered a major area requiring further clarification.

Conclusion:

Clinician-friendly screening tools are needed for everyday office practice to identify ASD/SD conditions and interventions, and mitigate harmful effects. Psychoeducational and cognitive-behavioral approaches for improving and supporting healthy sleep hygiene, considered the first line of treatment, are detailed. The weak database for the use of psychopharmacologic agents is summarized, and the strength of prescribing prolonged-release melatonin for optimal results is described. The promise of other medications is discussed.

Characterizing sleep disorders in an autism-specific collection of electronic health records

OBJECTIVE/BACKGROUND

Sleep problems are common in people on the autism spectrum. This study reviews one detailed approach to querying the electronic health record (EHR) in a large tertiary care center.

PATIENTS/METHODS

We developed methods for identifying people on the autism spectrum and defined their sleep problems using the key words, "sleep" or "melatonin", or International Classification of Diseases (ICD) codes. We examined treatment responses of these individuals to melatonin supplementation.

RESULTS

Sleep problems were documented in 86% of patients with ages ranging from 6 to 30 years old. Our specific keyword search yielded more patients with sleep diagnoses than ICD codes alone. About two-thirds of patients who received melatonin supplementation reported benefit from its use.

CONCLUSIONS

Our study provides a framework for using deidentified medical records to characterize sleep, a common co-occurring condition, in people on the autism spectrum. Using specific keywords could be helpful in future work that queries the EHR.

Sleep in Children with Autism Spectrum Disorder: A Narrative Review and Systematic Update

Purpose of Review

Sleep problems are a common comorbidity for children with autism spectrum disorder (ASD), and research in this area has a relatively long history. Within this review, we first outline historic patterns in the field of sleep and ASD. Second, we conducted a systematic update and coded these studies based on their alignment with historic patterns. Research on ASD and sleep over the past two decades has primarily focused on four principal areas: (1) documenting the prevalence and types of sleep problems; (2) sleep problem treatment options and efficacy; (3) how sleep problems are associated with other behavioral, contextual, or biological elements; and (4) the impact of child sleep problems on families and care providers. The systematic update in this paper includes empirical studies published between 2018 and 2021 with terms for sleep and ASD within the title, keywords, or abstract.

Recent Findings

In sum, 60 studies fit the inclusion/exclusion criteria and most fit within the historic patterns noted above. Notable differences included more global representation in study samples, studies on the impacts of COVID-19, and a growing body of work on sleep problems as an early marker of ASD. The majority of studies focus on correlates of sleep problems noting less optimal behavioral, contextual, and biological elements are associated with sleep problems across development for children with ASD.

Summary

Recommendations for future directions include continued expansion of global and age representation across samples, a shift toward more treatment and implementation science, and studies that inform our mechanistic understanding of how sleep and ASD are connected.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40675-022-00234-5.