Sleep problems in autism spectrum disorders: prevalence, nature, & possible biopsychosocial aetiologies

Usability of an augmented reality bedtime routine application for autistic children

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

Multi-site investigation of gut microbiota in CDKL5 deficiency disorder mouse models: Targeting dysbiosis to improve neurological outcomes

Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is a rare neurodevelopmental disorder often associated with gastrointestinal (GI) issues and subclinical immune dysregulation, suggesting a link to the gut microbiota. We analyze the fecal microbiota composition in two CDKL5 knockout (KO) mouse models at postnatal days (P) 25, 32 (youth), and 70 (adulthood), revealing significant microbial imbalances, particularly during juvenile stages. To investigate the role of the intestinal microbiota in CDD and assess causality, we administer antibiotics, which lead to improved visual cortical responses and reduce hyperactivity. Additionally, microglia morphology changes, indicative of altered surveillance and activation states, are reversed. Strikingly, fecal transplantation from CDKL5 KO to wild-type (WT) recipient mice successfully transfers both visual response deficits and hyperactive behavior. These findings show that gut microbiota alterations contribute to the severity of neurological symptoms in CDD, shedding light on the interplay between microbiota, microglia, and neurodevelopmental outcomes.

Autism Spectrum Disorder Phenotypes Based on Sleep Dimensions and Core Autism Symptoms

Previous studies have used cluster analysis to address the diagnostic heterogeneity of autism spectrum disorder, but have been limited by identifying subgroups solely on the basis of core autism symptoms. The present study aimed to identify sleep phenotypes and their clustering with core autism symptoms in youth diagnosed with autism. 1397 patients (1-17y, M = 6.1 ± 3.3y; M IQ = 88.5 ± 27.2; 81.2% male, 89.0% white) with autism. Principal component analysis (PCA) was performed on 10 sleep items from the Pediatric Behavior Scale. Latent class analyses (LCA) determined phenotypes characterized by core autism symptoms and sleep clusters, accounting for age, sex, Intelligence Quotient (IQ), and medication use.PCA identified three distinct sleep clusters (disturbed sleep, insufficient sleep and hypersomnolence) explaining 48.4% of the variance. LCA revealed four phenotypes based on core ASD symptoms and sleep clusters. Compared to Class 1 (54.8%) as the reference group, Class 2 (26.3%) had a similar degree of sleep problems, higher IQ and milder autism symptoms, less problems with selective attention/fearlessness; Class 3 (14.5%) was characterized by insufficient and disturbed sleep, perseveration and somatosensory disturbance, and higher medication use, while Class 4 (4.4%) was by hypersomnolence, problems with social interactions, and higher medication use.We found four distinct clustering of core autism symptoms and sleep problems differing in their sleep profiles as well as in relation to clinical characteristics, demographics, internalizing/externalizing symptoms, and functional outcomes. Our findings underscore the heterogeneity of autism based on sleep-wake problems, advocating for personalized therapeutic interventions targeting nighttime sleep and daytime alertness.

Cdkl5 Knockout Mice Recapitulate Sleep Phenotypes of CDKL5 Deficient Disorder

Cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder (CDD) is an X-linked rare neurodevelopmental disorder associated with severe sleep disturbances. However, little is known about the mechanisms underlying sleep disturbances in CDD patients. Here, we employed the electroencephalogram (EEG) recording to characterize sleep-wake behaviors and EEG activity in male CDKL5-deficient mice. We found that young adult and middle-aged Cdkl5 knockout (KO) mice recapitulated sleep phenotypes in patients with CDD, including difficulties in initiating and maintaining sleep, reduction in total sleep time, and frequent night awakenings. Cdkl5 KO mice exhibited pre-sleep arousal, but normal circadian rhythm and homeostatic sleep response. Conditional knockout (cKO) of Cdkl5 in glutamatergic neurons resulted in reduced sleep time and difficulty in sleep maintenance. Further, the rate of age-associated decline in sleep and EEG activity in Cdkl5 KO mice was comparable to that of wild-type littermates. Together, these results confirm a causative role for CDKL5 deficiency in sleep disturbances observed in CDD patients and establish an animal model for translational research of sleep treatment in CDD. Moreover, our results provide valuable information for developing therapeutic strategies and identifying sleep and EEG parameters as potential biomarkers for facilitating preclinical and clinical trials in CDD.

The perspectives of autistic adolescents and their parents on sleep strategies for insomnia

BACKGROUND

Autistic adolescents are vulnerable to sleep difficulties, with up to 80 % experiencing sleep problems, most commonly insomnia. Little is known about how autistic adolescents are involved in their own sleep treatment, and their depth of knowledge about their sleep difficulties. The aims of this study were to investigate autistic adolescent and parent perspectives of experiencing and managing insomnia, and what factors influence the development of these perspectives on insomnia and treatment.

METHOD

Semi-structured interviews were conducted with 11 autistic adolescents with insomnia (45 % female, mean age 11.6 years) and 16 parents of an autistic adolescent with insomnia (94 % female, mean age 45.1 years). A qualitative content analytic approach was used to identify categories in the data.

RESULTS

Adolescents often perceived themselves to sleep well, despite reporting symptoms and functional outcomes of insomnia. Insomnia was managed through a range of intentional routine activities involving sounds, stimulus reduction, and regular bedtimes. Parents generally sought their own information about sleep, while adolescents obtained most of their knowledge from their parents.

DISCUSSION

Findings from this study highlight a range of techniques that autistic adolescents and their parents use to address sleep difficulties. Findings suggest the need for increased professional awareness of sleep problems in autistic adolescents and further recommendations to parents for available sleep services.

Scoping Review of Socio-Ecological Factors Contributing to Sleep Health Disparities in Children with Autism Spectrum Disorder

Given the high prevalence of sleep problems in children with autism spectrum disorder (ASD), there is a critical need to examine how sleep problems may be exacerbated for children exposed to social and environmental adversity. Guided by the socio-ecological model, this review aimed to evaluate factors linked to sleep health disparities (SHDs) in children with ASD, determine possible gaps/limitations in existing literature, and identify possible solutions. A scoping review was selected to ascertain what is known about SHDs in ASD. Four databases identified articles from 2004 to 2023. Included articles were those conducted in children with ASD that focused on sleep and examined socio-ecological factors (i.e., individual, family, neighborhood and socio-cultural) possibly contributing to SHDs. 41 studies were extracted; 31 (75.6%) focused on individual factors, 27 (65.9%) focused on family factors, 11 (26.8%) focused on neighborhood and/or socio-cultural factors; 3 (7.3%) focused on factors across all three socio-ecological levels. Six studies included interventions that found improvements in child sleep, behavior, and quality of life. Representation of racial and ethnic minoritized groups was limited across studies. Most studies focused on individual child factors associated with sleep problems, with less research focused on family factors, and very few studies examining broader neighborhood and socio-cultural factors. Only about half of studies reported race and ethnicity data, with sparse representation of racial and ethnic minoritized children and families overall. These findings highlight the need for future research on modifiable socio-ecological factors to guide equitable sleep interventions for children with ASD.

Autism Spectrum Disorder and Epilepsy: Pathogenetic Mechanisms and Therapeutic Implications

The co-occurrence of autism spectrum disorder (ASD) and epilepsy is a complex neurological condition that presents significant challenges for both patients and clinicians. ASD is a group of complex developmental disorders characterized by the following: (1) Social communication difficulties: challenges in understanding and responding to social cues, initiating and maintaining conversations, and developing and maintaining relationships. (2) Repetitive behaviors: engaging in repetitive actions, such as hand-flapping, rocking, or lining up objects. (3) Restricted interests: focusing intensely on specific topics or activities, often to the exclusion of other interests. (4) Sensory sensitivities: over- or under-sensitivity to sensory input, such as sounds, touch, tastes, smells, or sights. These challenges can significantly impact individuals' daily lives and require specialized support and interventions. Early diagnosis and intervention can significantly improve the quality of life for individuals with ASD and their families. Epilepsy is a chronic brain disorder characterized by recurrent unprovoked (≥2) seizures that occur >24 h apart. Single seizures are not considered epileptic seizures. Epilepsy is often idiopathic, but various brain disorders, such as malformations, strokes, and tumors, can cause symptomatic epilepsy. While these two conditions were once considered distinct, growing evidence suggests a substantial overlap in their underlying neurobiology. The prevalence of epilepsy in individuals with ASD is significantly higher than in the general population. This review will explore the epidemiology of this comorbidity, delve into the potential mechanisms linking ASD and epilepsy, and discuss the implications for diagnosis, treatment, and management.

Internet-Delivered Parent-Child Interaction Therapy and Sleep Quality in Children With Developmental Delay: Examining the Mediating Role of Bedtime Resistance Behaviors

OBJECTIVE

Sleep problems are frequently reported and associated with externalizing behavior problems in young children, especially those with developmental delay (DD). Parent-child interaction therapy (PCIT) led to improved sleep in young children with DD, but research has not examined the effect of internet-delivered PCIT (iPCIT) on sleep quality or changes in bedtime resistance behaviors as a mediator. This study examined iPCIT's effect on sleep quality in young children with DD through its impact on bedtime resistance behaviors.

METHOD

Participants were from a previously completed randomized controlled trial and included 150 children with DD (M age = 36.2 months, SD = 1.0 months) and their caregivers who were randomized to iPCIT or referrals as usual (RAU). Path analyses examined links between treatment condition, post-treatment bedtime resistance, and sleep quality reported at 6-month follow-up.

RESULTS

Treatment condition significantly influenced bedtime resistance behaviors (β = 0.17, 90% CI, [0.04, 0.29], p = 0.01), and these changes, in turn, significantly affected sleep quality reported at 6-month follow-up (β = 0.18, 90% CI, [0.03, 0.33], p = 0.02). Caregivers receiving iPCIT reported fewer bedtime resistance behaviors after treatment and improved child sleep quality at 6-month follow-up than caregivers receiving RAU.

CONCLUSION

Although effects were smaller than in other studies examining PCIT's effect on sleep, these results highlight how iPCIT led to improved sleep quality in children with DD through changes in bedtime resistance. Further research is needed to explore differences in the effectiveness of in-person versus iPCIT, as well as other mechanisms (such as parenting behaviors) through which iPCIT affects child sleep quality.

Exploratory analyses of sleep intraindividual variability and fatigue in parents of children on the autism spectrum

Fatigue is associated with numerous harmful physical and mental health outcomes. Despite the established relationship between sleep and fatigue, research examining sleep variability within a person (i.e. intraindividual variability; IIV) and fatigue is limited. In addition, the associations between child and parent sleep regarding parent fatigue have not been explicitly explored, which could be relevant for parents of autistic children with increased sleep disturbance likelihood. The current study used two weeks of objective sleep (actigraphy) and subjective fatigue data from 81 parents and their children to explore associations among child sleep IIV, parent sleep IIV, and parent average daily fatigue, including evaluating evidence for mediation. Sleep IIV was estimated using a validated Bayesian model. Linear regression analyses indicated that greater parent total sleep time IIV predicted significantly higher fatigue levels. Child sleep IIV was unrelated to parent sleep IIV and fatigue, unsupportive of hypothesized mediation. Similarly, post hoc analyses examining child sleep averages, parent total sleep time IIV, and average parent fatigue were insignificant. Findings cautiously support the uniqueness of total sleep time IIV within parental sleep's relationship with fatigue, independent of child sleep. Objective sleep IIV should continue to be examined in addition to average levels.Lay abstractFatigue is associated with numerous harmful physical and mental health outcomes. Despite research indicating a relationship between fatigue and sleep, there has been a limited focus on how the variability of a person's sleep may be associated with fatigue. In addition, previous studies have not explicitly explored relationships among child sleep, parent sleep, and parent fatigue. Increasing knowledge about this area of research could be particularly relevant for families with autistic children with an increased likelihood of sleep disturbances. The current study used two weeks of objective sleep (actigraphy) data and subjective ratings of parent fatigue from 81 parents and their autistic children to examine associations among child and parent within-person sleep variability regarding average parent fatigue levels. Evidence was assessed for the role of parent sleep variability in hypothesized connections between child sleep variability and parent fatigue. We found that only greater variability in parents' total sleep time was associated with higher levels of parents' average daily fatigue rating over the two weeks. Child sleep variability was not significantly associated with parent sleep variability or average daily fatigue. In addition, average levels of child sleep were unrelated to parent total sleep time variability and fatigue. Although cautious interpretation is required, findings support the idea that variability in total sleep time may be a unique aspect of parental sleep's association with fatigue, independent of child sleep. In addition, sleep variability could be important to consider when examining sleep in addition to average levels of parameters like total sleep time.

Sleep disturbances in autistic youth with and without bipolar disorder: A matched case-control study

BACKGROUND

Sleep disturbances are common in individuals with autism spectrum disorder (ASD) or bipolar disorder (BD). However, to the best of our knowledge, there has been no study investigating prevalence and features of sleep disorders in youth with ASD with and without comorbid BD. The aim of this case-controlled study was to investigate sleep disturbances in autistic youth with and without comorbid BD.

METHODS

The study included 43 individuals with both ASD and BD as the case group, and 43 age and gender-matched participants with ASD but no mood disorders as the control group. Both groups were assessed using the Sleep Disturbance Scale for Children (SDSC), the Childhood Autism Rating Scale (CARS), and the Aberrant Behavior Checklist (ABC).

RESULTS

The case group exhibited significantly higher levels of sleep breathing disorders, disorders of arousal, disorders of excessive somnolence, and sleep hyperhidrosis on the SDSC compared to the control group (p < 0.05). Partial correlation analysis revealed a significant association between total SDSC scores and total ABC scores in the case and control groups (r = 0.424, p = 0.005; r = 0.629, p < 0.001, respectively) CONCLUSIONS: Sleep disturbances are common in youth with ASD with further increased rates in the presence of comorbid BD. Sleep disturbances are also associated with more behavioral problems among youth with ASD regardless of comorbid BD diagnosis. Clinicians working with youth with ASD should routinely assess sleep habits and related problems and should give particular attention in the presence of comorbid mood disorders. This study highlights the importance of recognizing and managing sleep disturbances in this unique population.

Sleep and circadian disturbances in children with neurodevelopmental disorders

Sleep is essential for brain development and overall health, particularly in children with neurodevelopmental disorders (NDDs). Sleep disruptions can considerably impact brain structure and function, leading to dysfunction of neurotransmitter systems, metabolism, hormonal balance and inflammatory processes, potentially contributing to the pathophysiology of NDDs. This Review examines the prevalence, types and mechanisms of sleep disturbances in children with NDDs, including autism spectrum disorder, attention-deficit hyperactivity disorder and various genetic syndromes. Common sleep disorders in these populations include insomnia, hypersomnia, circadian rhythm disorders, sleep-related breathing disorders and parasomnias, with underlying factors often involving genetic, neurobiological, environmental and neurophysiological influences. Sleep problems such as insomnia, night awakenings and sleep fragmentation are closely linked to both internalizing symptoms such as anxiety and depression, and externalizing behaviours such as hyperactivity and aggression. Assessment of sleep in children with NDDs presents unique challenges owing to communication difficulties, comorbid conditions and altered sensory processing. The Review underscores the importance of further research to unravel the complex interactions between sleep and neurodevelopment, advocating for longitudinal studies and the identification of predictive biomarkers. Understanding and addressing sleep disturbances in NDDs is crucial for improving developmental outcomes and the overall quality of life for affected individuals and their families.

Caregiver report of infant behavior associated with autism likelihood in first year of life

BACKGROUND

Identification of prodromal indicators of autism in infancy has the potential to identify behaviors relevant to early autism screening.

METHODS

We report on data from a prospective general population birth cohort with maternal reported measures at 9 and 12 months: the Survey of Well-Being of Young Children (SWYC; general developmental surveillance) and the First Year Inventory-Lite v3.1b (FYI-Lite; autism specific parent report research tool). Mothers completed the surveys and the Broad Autism Phenotype Questionnaire (BAPQ), a self-report measure of subclinical features of autism.

RESULTS

In this sample of 332 infants (168 males), maternal-reported infant developmental milestones and behavioral indicators of difficult temperament, poor adaptability, and sleep problems at 9 months (SWYC) and maternal self-reported subclinical autism characteristics (BAPQ) were correlated with maternal-reported autism-related behaviors on the FYI-Lite at 12 months. Regression models revealed significant unique associations between infant temperament, developmental milestones, and FYI-Lite scores while controlling for significant effects of maternal BAPQ scores and education.

CONCLUSIONS

Maternal report of infant temperament and developmental milestones at 9 months were associated with maternal-report early indicators of autism likelihood at 12 months in a general birth cohort. Follow up of this cohort is needed to determine associations with formal diagnostic outcomes.

IMPACT

Identifying scalable measures of infant behaviors in general and specific to autism may help identify targets of intervention for infants in the first year of life. This study aims to contribute to improved first-year surveillance by assessing potential early autism indicators in a prospective general birth cohort, whereas other observational studies utilize enriched risk cohorts (e.g., infant siblings of autistic children). Preliminary findings of this cohort revealed that a maternal report of 9-month temperament significantly predicted higher scores on a maternal report 12-month autism screener and indicated the importance of considering maternal self-reported subclinical autism characteristics when interpreting parent report screeners.

Pharmacological treatment in autism: a proposal for guidelines on common co-occurring psychiatric symptoms

BACKGROUND

The prevalence of autism spectrum disorder (ASD) has surged, with an estimated 1 in 36 eight-year-olds in the United States meeting criteria for ASD in 2020. Autistic individuals face elevated rates of co-occurring medical, psychiatric, and behavioral conditions compared to non-autistic individuals. The rising ASD-patient demand is increasingly outpacing the capacity of ASD-specialty clinics, resulting in urgent need for autism-competent providers in general practice settings. This work aims to empower healthcare providers, especially primary care providers (PCPs), with guidelines for the recognition and safe pharmacologic management of common co-occurring psychiatric and behavioral conditions in ASD.

METHODS

Lurie Center for Autism medical providers, who have extensive experience in ASD care, delineated approaches for recognition and pharmacological treatment of sleep disturbances, attention-deficit/hyperactivity disorder (ADHD), anxiety, depression, and irritability tailored to ASD patients. Pharmacological guidelines were iteratively refined until consensus was reached. Treatment differences relative to standard of care (SOC) of non-autistic individuals are noted. Key literature and clinical trial results were reviewed to supplement clinical experience.

RESULTS

The pharmacological treatment pathways reflect how appropriate medication options for ASD patients can depend on many factors unique to the patient and can differ from established non-autistic SOC. Key takeaways include: For sleep disturbances in ASD, initial strategies align with non-autistic SOC, emphasizing sleep hygiene and melatonin use. First-line recommendations for treating ADHD, anxiety, and depression in ASD differ from non-autistic SOC; α2-adrenergic agonists are more suitable than stimulants for some ASD-ADHD patients, buspirone and mirtazapine are preferred to selective serotonin reuptake inhibitors (SSRIs) for anxiety, and duloxetine, mirtazapine, bupropion, and vortioxetine are recommended ahead of SSRIs for depression. Addressing irritability in ASD requires interdisciplinary evaluation of contributing factors, and guanfacine, risperidone, or aripiprazole may be appropriate, depending on severity.

CONCLUSIONS

Recognition and treatment of co-occurring psychiatric and behavioral conditions in autistic patients must account for differences in clinical presentation and medication effectiveness and tolerability. Drawing on evidence-based clinical insights, these guidelines seek to support PCPs in making informed decisions when prescribing medications for ASD patients with co-occurring psychiatric and behavioral conditions, ultimately enhancing access to timely, comprehensive care for all individuals with ASD.

Elevated parkinsonism symptoms in autism during middle and older adulthood are linked with psychosocial, physical health, and mental health outcomes

Evidence is growing for a link between parkinsonism, or the motor symptoms associated with Parkinson's Disease and autism. However, research to date has yet to examine whether the presence of these motoric symptoms impacts critical adult outcomes in autism. Therefore, the current study utilized a screening measure to bifurcate a relatively large (n = 379) sample of middle and older age autistic adults (40-83 years) into parkinsonism screen positive (n = 119) versus parkinsonism screen negative (n = 260) groups in order to compare them on broad metrics of daily living skills and subjective quality of life as well as non-motoric features linked to parkinsonism, namely memory problems, sleep quality, and depression symptoms. Overall, co-occurring parkinsonism was linked with lower subjective quality of life, more memory problems, lower sleep quality, and greater depression symptoms in autistic adults. Taken together, these findings implicate an important co-occurring motoric phenotype in middle and older adulthood for autistic people that could have significant real-world impacts yet has been largely neglected in the extant literature to date.

Associations of maternal peripregnancy cannabis use with behavioral and developmental outcomes in children with and without symptoms of autism spectrum disorder: Study to Explore Early Development

Some studies report increased prevalence of autism spectrum disorder (ASD) and associated symptoms with prenatal cannabis exposure. We examined whether associations of maternal cannabis use from 3 months preconception through delivery ("peripregnancy") with behavior and development in the offspring varied with the presence of ASD symptoms. Children ages 30-68 months with ASD symptoms (i.e., met study criteria for ASD or had ASD symptoms on standardized assessments or community ASD diagnosis, N = 2734) and without ASD symptoms (other developmental delay/disorders or general population sample, N = 3454) were evaluated with the Child Behavior Checklist and Mullen Scales of Early Learning. We examined cannabis use during three time periods: peripregnancy, pregnancy, and only preconception. Peripregnancy cannabis exposure was reported for 6.0% of children with and 4.6% of children without ASD symptoms. Preconception-only cannabis use (versus no use) was associated with more aggressive behavior, emotional reactivity, and sleep problems in children with ASD symptoms, but not in children without ASD symptoms. Cannabis use during pregnancy was associated with increased attention and sleep problems in children with ASD symptoms; these associations did not differ significantly by ASD symptoms. Peripregnancy cannabis use was not associated with child developmental abilities regardless of ASD symptoms. In summary, associations of peripregnancy cannabis use with some behavioral outcomes differed in children with and without ASD symptoms. With rising cannabis use among pregnant women, future studies that examine a range of developmental risks associated with timing and patterns of cannabis use prior to conception as well as during pregnancy could inform clinical guidance.

Dimensional Validation of the Italian Revised Version of the Children's Sleep Habits Questionnaire (CSHQ-r) for Children and Adolescents with ASD

Sleep problems are common in children with autism spectrum disorder (ASD), with potential repercussions on neurobehavioral functioning exacerbating socio-communicative impairments and aggressive behaviors. Parent reports are the most used method to assess sleep in pediatric populations and a modified 23-item of Children's Sleep Habits Questionnaire (CSHQ) for ASD has been proposed in the United States. The generalizability of the CSHQ for ASD has yet to be validated across countries, including Italy. To extend the CSHQ applicability to Italian youth with ASD, we back-translated to Italian and revised the 23-item CSHQ, validating its dimensional structure in a sample of children and adolescents with ASD using Explorative Graph Analysis. In addition, we compared the revised scale scores of the ASD group with a typically developing (TD) group. The revised Italian version of the CSHQ (CSHQ-r) consisted of a 15-item tool with a four-dimension structure (Sleep initiation/duration, Sleep anxiety/Co-sleeping, Night awakenings/Parasomnias, and Daytime alertness) with good structural stability. Group comparison indicated significantly higher scores in the ASD group than the TD group, suggesting greater prevalence of sleep disturbances in ASD. The four-dimensional CSHQ-r may represent a useful screening tool to assess sleep disorders in Italian children and adolescents with ASD, with potential implications for clinical practice.

Effects of Extremely Low-Frequency Electromagnetic Field Treatment on ASD Symptoms in Children: A Pilot Study

BACKGROUND/OBJECTIVES

Autism Spectrum Disorder (ASD) are neurodevelopmental disorders marked by challenges in social interaction, communication, and repetitive behaviors. People with ASD may exhibit repetitive behaviors, unique ways of learning, and different ways of interacting with the world. The term "spectrum" reflects the wide variability in how ASD manifests in individuals, including differences in abilities, symptoms, and support needs, and conditions characterized by difficulties in social interactions, communication, restricted interests, and repetitive behaviors. Inflammation plays a crucial role in the pathophysiology, with increased pro-inflammatory cytokines in cerebrospinal fluid. Previous studies with transcranial magnetic stimulation have shown promising results, suggesting nervous system susceptibility to electromagnetic fields, with evidence indicating that extremely low-frequency electromagnetic field (ELF-EMF) treatment may modulate inflammatory responses through multiple pathways, including the reduction of pro-inflammatory cytokines like IL-6 and TNF-α, and the enhancement of anti-inflammatory mediators.

METHODS

This pilot study included 20 children (ages 2-13) with a confirmed diagnosis of ASD. A 15-week protocol involved ELF-EMF treatments using the SEQEX device, with specific day and night programs. Assessment was conducted through standardized pre- and post-treatment tests: Achenbach Child Behavior Checklist, Peabody Picture Vocabulary Test-4, Expressive One Word Picture Vocabulary Test-4, and Conner's 3GI.

RESULTS

Statistically significant improvements were observed in receptive language (PPVT-4: from 74.07 to 90.40, p = 0.002) and expressive language (EOWPVT-4: from 84.17 to 90.50, p = 0.041). Notable reductions, with statistical significance, were found in externalizing problems across both age groups (1.5-5 years: p = 0.028; 6-18 years: p = 0.027), with particular improvement in attention and behavioral problems. The results were observed over a short period of 15 weeks, therefore excluding the possibility of coincidental age-related gains, that would typically occur during a normal developmental timeframe. Parent evaluations showed significant reduction in ASD symptoms, particularly in the 1.5-5 years group (p = 0.046).

CONCLUSIONS

ELF-EMF treatment demonstrated a high safety profile and efficacy in mitigating ASD-related symptoms. The observed improvements suggest both direct effects on central and autonomic nervous systems and indirect effects through inflammatory response modulation. Further studies are needed to confirm these promising results through broader demographics and randomized control designs.

Circuit mechanism underlying fragmented sleep and memory deficits in 16p11.2 deletion mouse model of autism

Sleep disturbances are prevalent in children with autism spectrum disorder (ASD). Strikingly, sleep problems are positively correlated with the severity of ASD symptoms, such as memory impairment. However, the neural mechanisms underlying sleep disturbances and cognitive deficits in ASD are largely unexplored. Here, we show that non-rapid eye movement sleep (NREMs) is fragmented in the 16p11.2 deletion mouse model of ASD. The degree of sleep fragmentation is reflected in an increased number of calcium transients in the activity of locus coeruleus noradrenergic (LC-NE) neurons during NREMs. In contrast, optogenetic inhibition of LC-NE neurons and pharmacological blockade of noradrenergic transmission using clonidine consolidate sleep. Furthermore, inhibiting LC-NE neurons restores memory. Finally, rabies-mediated screening of presynaptic neurons reveals altered connectivity of LC-NE neurons with sleep- and memory-regulatory regions in 16p11.2 deletion mice. Our findings identify a crucial role of the LC-NE system in regulating sleep stability and memory in ASD.

A pilot randomised controlled trial of a telehealth-delivered brief 'Sleeping Sound Autism' intervention for autistic children

BACKGROUND

Access to behavioural sleep intervention is beneficial for autistic children, yet many families face barriers to access associated with location and time. Preliminary evidence supports telehealth-delivered sleep intervention. However, no studies have evaluated brief telehealth sleep intervention. To address this, we evaluated telehealth delivery of the brief behavioural Sleeping Sound Autism intervention, using a two-armed, parallel-group, non-blinded, pilot randomised controlled trial (RCT) design (trial registration: ANZCTR12620001276943).

METHOD

Sixty-one families of autistic children without intellectual disability (5-12 years, 46% female) with caregiver-reported moderate-severe behavioural sleep problems participated Australia-wide, randomised to an intervention (n = 30) or treatment as usual control group (n = 31). Intervention group participants were invited to attend two video-conference telehealth sessions and one follow-up phone call with a trained clinician. Survey data was collected from caregivers at baseline and three- and six-months post-randomisation, to evaluate feasibility, acceptability, and efficacy. Ten intervention group caregivers participated in end-of-study semi-structured interviews to explore their experiences.

RESULTS

Forty-nine caregivers completed surveys. At baseline, 87% felt positive and 84% felt confident about participating via telehealth, and 75% believed the program would improve child sleep. At three-months, intervention group caregivers (n = 24) reported the usefulness (100%) of and preference for (71%) telehealth, and 95.8% would recommend this sleep program to other families. A significant group by time difference was observed in child sleep (Children's Sleep Habits Questionnaire) with large effect sizes (d = 0.87-1.05), emotion and behaviour (Developmental Behavior Checklist 2) with moderate effect sizes (d = 0.40-0.57), and caregiver mental health (Kessler 10) with small to moderate effect sizes (d = 0.60-0.28), favouring the intervention group (n = 23). There were no significant group differences in child (Child Health Utility instrument) or caregiver (Assessment of Quality of Life) quality of life. However, there were individual differences in the clinical significance of improved child sleep. Qualitative data showed that whilst telehealth was convenient for caregivers, without attenuating the benefits of most key intervention features, not all children were able to engage effectively with the clinician via telehealth.

CONCLUSIONS

This first pilot RCT of a brief telehealth behavioural sleep intervention for primary-school-aged autistic children suggests that telehealth delivery is acceptable, feasible and likely efficacious in improving sleep in the short-term. Providing families with ongoing choice of mode of delivery (telehealth/in-person) and examining the person-environment fit of telehealth for autistic children is important.

Evaluating Sleep in Autism Using CSHQ and CSHQ-Autism - A Perspective Through the Cultural Lens

The Child Sleep Hygiene Questionnaire (CSHQ) and its adapted version for autistic children, known as CSHQ-Autism, have gained recognition as essential tools for studying pediatric sleep patterns. 67 autistic children were evaluated using these questionnaires. 52 children screened positive on the CSHQ while 18 were screened positive on the CSHQ-Autism. Notably, both tools showed elevated ratings in the domains of sleep anxiety and co-sleeping, which may hinder their ability to accurately distinguish sleep disturbances. However, the prevalence of sleep anxiety/co-sleeping in Indian culture was found to be linked to more severe sleep disorders, while also serving as a protective factor against separation anxiety and sudden infant death syndrome (SIDS). Therefore, while the CSHQ and CSHQ-Autism serve as valuable assessment tools, their scores may be inflated by ingrained cultural norms in the Indian context.

Diagnostic usefulness of 24-h polysomnography for idiopathic hypersomnia co-occurring with neurodevelopmental disorders: A case report

Background

Although central disorders of hypersomnolence (CDH) and attention-deficit/hyperactivity disorder (ADHD) are frequently comorbid, they often remain underdiagnosed, leading to insufficient treatment and sociopsychological outcomes.

Case Presentation

Here, we present a case of a male in his late 20s with ADHD and autism spectrum disorder who exhibited symptoms suggestive of idiopathic hypersomnia (IH), a subtype of CDH. The patient experienced difficulty waking up and dropped out of university. Additionally, although methylphenidate extended-release was prescribed, he often forgot to take his medication, resulting in difficulty waking up until late afternoon. No symptoms related to rapid eye movements sleep were observed. Considering the possibility of concurrent hypersomnia with neurodevelopmental disorders, we conducted 24-h polysomnography (PSG). The results demonstrated total sleep time of 774.5 min (≥660 min). Together with other criteria, we diagnosed him as having IH. Following discharge and discussion with the patient, we provided sleep hygiene education for him, and he resumed day care attendance to establish a social routine.

Conclusion

In cases where hypersomnia may co-occur with neurodevelopmental disorders, active utilization of 24-h PSG enables detailed evaluation of sleep-wake patterns and behaviors, facilitating effective guidance on sleep hygiene and promoting improvements in social rhythms and sociability.

Sleep problems and circadian rhythm functioning in autistic children, autism with co-occurring attention deficit hyperactivity disorder, and typically developing children: A comparative study

LAY ABSTRACT

Sleep problems are common in autism spectrum disorder (ASD) and different factors can contribute to its occurrence in this population. Misalignment of the biological clock (our circadian system) has been described as one possible explanation. While there is a body of research on sleep problems, relatively less is known about circadian functioning and the specific population of autistic children with co-occurring attention deficit hyperactivity disorder (ADHD). Using an ambulatory circadian monitoring (ACM) system, which resembles a common watch, we gathered sleep parameters and the different rhythms obtained from measuring motor activity, light exposure and distal temperature in 87 autistic children and adolescents, 27 of whom were diagnosed with co-occurring ADHD, and 30 neurotypical children and adolescents as a comparison group. Autistic children and, especially, those with co-occurring ADHD showed greater motor activity during sleep which would be worth studying in future projects which could better define this restless sleep. Of note, we observed an atypical pattern of wrist temperature, with higher values in neurotypical children, followed by autistic children and, ultimately, those with co-occurring ADHD. Temperature is one of the most valuable factors evaluated here as it is closely connected to sleep-wakefulness and the hormone melatonin. Its special pattern during day and nighttime would support the hypothesis of an atypical secretion of melatonin in autistic individuals which would also link with the higher presence of sleep problems in this neurodevelopmental condition.

Exploring sensory alterations and repetitive behaviors in children with autism spectrum disorder from the perspective of artificial neural networks

BACKGROUND

Restrictive repetitive behaviors (RRBs) and sensory processing disorders are core symptoms of autism spectrum disorder (ASD). Their relationship is reported, but existing data are conflicting as to whether they are related but distinct, or different aspects of the same phenomenon.

AIMS

This study investigates this relationship using artificial neural networks (ANN) analysis and an innovative data mining analysis known as Auto Contractive Map (Auto-CM), which allows to discover hidden trends and associations among complex networks of variables (e.g. biological systems).

METHODS AND PROCEDURES

The Short Sensory Profile and the Repetitive Behavior Scale-Revised were administered to 45 ASD children's caregivers (M 78 %; F 22 %; mean age 6 years). Questionnaires' scores, clinical and demographic data were collected and analyzed applying Auto-CM, and a connectivity map was drawn.

OUTCOMES AND RESULTS

The main associations shown by the resulting maps confirm the known relationship between RBBs and sensory abnormalities, and support the existence of sensory phenotypes, and important links between RRBs and sleep disturbance in ASD.

CONCLUSIONS AND IMPLICATIONS

Our study demonstrates the usefulness of ANNs application and its easy handling to research RBBs and sensory abnormalities in ASD, with the aim to achieve better individualized rehabilitation technique and improve early diagnosis.

PAPER'S CONTRIBUTION

Restricted, repetitive patterns of behaviors and interests and alteration of sensory elaboration are core symptoms of ASD; their impact on patients' quality of life is known. This study introduces two main novelties: 1) the simultaneous and comparative use of two parent questionnaires (SSP and RBS-R) utilized for RRBs and alteration of sensory profile; 2) the application of ANNs to this kind of research. ANNs are adaptive models particularly suited for solving non-linear problems. While they have been widely used in the medical field, they have not been applied yet to the analysis of RRBs and sensory abnormalities in general, much less in children with ASD. The application of Auto Contractive Map (Auto-CM), a fourth generation ANNs analysis, to a dataset previously explored using classical statistical models, confirmed and expanded the associations emerged between SSP and RBS-R subscales and demographic-clinical variables. In particular, the Low Energy subscale has proven to be the central hub of the system; interesting links have emerged between the subscale Self-Injurious Behaviors and the variable intellectual disability and between sleep disturbance and various RRBs. Expanding research in this area aims to guide and modulate an emerging targeted and personalized rehabilitation therapy.

From Alert Child to Sleepy Adolescent: Age Trends in Chronotype, Social Jetlag, and Sleep Problems in Youth with Autism

PURPOSE

Developmental changes in sleep in youth with autism spectrum disorder (ASD) are understudied. In non-ASD youth, adolescents exhibit a "night owl chronotype" (i.e., later sleep/wake timing) and social jetlag (i.e., shifts in sleep timing across school nights and weekends), with corresponding sleep problems. The purpose of this study is to evaluate age trends in chronotype, social jetlag, and sleep problems in high-risk youth with ASD.

METHODS

Youth with ASD (N = 171), ages 5-21 years old, were enrolled at the time of admission to specialized psychiatric units. Caregivers reported children's demographic information, habitual sleep timing, and sleep problems. Multivariate analyses evaluated the effect of age on chronotype, social jetlag, and sleep problems and the effects of chronotype and social jetlag on sleep problems. Covariates and moderators included sex, race, verbal ability, autism symptom severity, supplemental melatonin, and pubertal status.

RESULTS

Older age was associated with later chronotype, more social jetlag, fewer sleep anxiety/co-sleeping problems, fewer night waking and parasomnia problems, and more daytime alertness problems. The effect of age on chronotype was stronger for youth with greater social affective symptom severity. Mediation analyses showed that later chronotype statistically mediated the association between age and daytime alertness problems.

CONCLUSIONS

Youth with ASD may exhibit night owl chronotype behavior and social jetlag as they enter adolescence. Shifts toward a later chronotype may be exacerbated by autism severity and may contribute to alertness problems and sleepiness during the day. Chronotype is modifiable and may be leveraged to improve daytime functioning in youth with ASD.

Sleep in hospitalized children with cancer: relationship with psychiatric disorders and hospital conditions

BACKGROUND

Children with cancer often undergo prolonged and recurrent hospitalization, which leads to an increased incidence of sleep disruptions and psychiatric disorders. This study aimed to objectively quantify the prevalence of sleep disruptions in hospitalized pediatric oncology patients and to determine the effects of psychiatric disorders, treatment regimens, and hospital conditions on sleep patterns.

METHOD

This cross-sectional study included 39 children who were undergoing treatment and monitoring in the pediatric oncology inpatient service. Parents completed questionnaires providing information about their child's sleep patterns, quality of life, and hospital conditions. The children were monitored for five days using actigraphy to record sleep parameters. They were evaluated with a semi-structured interview form (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version-DSM 5-Turkish Adaptation) for psychiatric diagnoses.

RESULTS

Sleep disruptions were identified in 27 (69.2%) children with cancer. In addition to adjustment disorder and anxiety disorder psychiatric diagnoses, behavioral problems and emotional symptoms were more common in the group with sleep disruptions. Actigraphy measurements indicated that poor sleep was associated with younger age, recent cancer diagnosis, specific phobias, depression, daytime napping, and frequent vital sign assessments.

CONCLUSION

Sleep problems in hospitalized children with cancer are linked to psychiatric comorbidities, treatment routines, and hospital conditions. By recognizing psychiatric symptoms and optimizing hospital conditions that affect sleep, healthcare providers can enhance the quality of sleep for these children.

Indian Hedgehog (IHh) Protein and COX-2 as Biomarkers to Define the Mechanism of Epilepsy and Gastrointestinal Problems as Comorbid Medical Illnesses in Autism Spectrum Disorder: Combining ROC Curves to Improve Diagnostic Values

Background/Objectives: Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is increasing throughout the world. Nevertheless, no specific diagnostic or even risk assessment marker is available. Combining more than one marker can improve the diagnostic value of each marker alone and maximize the AUC for ROC curve. Hedgehog (Hh) signaling modulates both intestinal inflammation and immunity. Cyclooxygenase-2 (COX-2) is required for inflammation, and it has been related to epileptic seizures. COX-2 generates prostaglandins-EP2 (PGE2) in the brain, which plays a major role in neuropathology and epilepsy. This study aims to understand the pathophysiology of ASD by investigating the diagnostic value of COX-2 and IHh using independent and combined ROC curves. Methods: COX-2 and IHh were measured in 40 children with ASD and 41 age and sex-matched controls using ELISA. Statistical analyses were performed using ROC curves, odds ratios, and multiple logistic regression models. Results: Higher levels of COX-2 and IHh were observed in the plasma of patients with autism than in controls. The ROC curve of HIh and COX-2 independently showed poor and fair AUCs of 0.662 and 0.776, respectively, while the combined ROC for both variables in relation to the control group increased the AUC = 0.831 significantly (p < 0.001). Conclusions: Thus, combining these variables could be a useful diagnostic marker for ASD.

Sleep Problems and Autism Impairments in a Large Community Sample of Children and Adolescents

Sleep problems are common in individuals with autism spectrum disorder (ASD). How sleep problems reflect specific ASD phenotypes is unclear. We studied whether sleep problems indexed functional impairment in a heterogeneous community sample of individuals with ASD. We analyzed 977 probands (233 females; age = 11.27 ± 4.13 years) from the Rhode Island Consortium for Autism Research and Treatment dataset, a unique public-private-academic collaboration involving all major points of service for families in Rhode Island. We found that individuals with a confirmed diagnosis of ASD were more likely to have sleep problems. However, across the whole sample and above and beyond a formal diagnosis, sleep problems were dimensionally associated with worse social impairment and poorer adaptive functioning. By using a large dataset reflective of the diversity of presentations in the community, this study underscores the importance of considering sleep problems in clinical practice to improve adaptive functioning in individuals with ASD.

Impact of adverse childhood experiences and family resilience on sleep duration in autistic children

LAY ABSTRACT

Autistic children are more likely to have sleep difficulties and to experience adverse childhood experiences. Adverse childhood experiences can include parental divorce, bullying, or witnessing violence. We also know that children in families who are resilient (e.g. families who are connected, work together, and help each other) are less impacted by adverse childhood experiences. Our study examined whether there was a relationship between adverse childhood experiences and sleep duration in autistic children. We also wanted to find out whether family resilience protects from the negative impact of adverse childhood experiences on sleep duration. We used data from 3247 parent surveys about their children that we got from the National Survey of Children's Health. We found that children with adverse childhood experiences are more likely to get less sleep. We also found that children with resilient families were more likely to get more sleep. Our results show that family resilience helps weaken the relationship between adverse childhood experiences and sleep, so it is important to help families build resilience.

An evaluation of psychosocial sleep interventions for children with chronic health conditions: A systematic review

Chronic health conditions (CHC; e.g., cystic fibrosis, type 1 diabetes) in children are associated with disease-specific physical symptoms that contribute to a high prevalence of sleep problems. Sleep problems exacerbate other health-related sequelae and can impede therapeutic response to health treatments, increasing the overall complexity of symptom management. Psychosocial sleep interventions (PSI) improve sleep in children with typical development and neurodevelopmental conditions. Yet, the effectiveness of PSI for children with CHC has scarcely been investigated. This systematic review appraises the literature examining the effectiveness and acceptability of PSI for children with CHC. A search identified 20 studies that met inclusion criteria. Data related to participant characteristics, sleep targets, research design and methods, measures, sleep outcomes and collateral effects were extracted. Study rigor was then evaluated. Most studies evaluated youth-directed Cognitive Behavioral Therapy for Insomnia or parent-implemented behavioral sleep interventions. Twelve studies demonstrated positive sleep treatment effects and four demonstrated mixed effects. Collateral improvements were reported in child mental health and parental health and well-being, though physical health benefits for children were not consistently reported. One, five and 14 studies were rated as having strong, adequate, and weak methodological rigor respectively. Recommendations for clinical practice and future research are made.

The Moderating Effect of Sex on Autistic Trait Emotional Intelligence, Alexithymia, and Empathy

Autism spectrum disorder (ASD) is associated with differences in social communication, and these differences are related to trait emotional intelligence (TEI), alexithymia, and empathy. Autism is known to present differently in males and females, but research on sex differences in TEI, alexithymia, and empathy is largely relegated to non-autistic people. Therefore, the current research sought to explore individual relationships between autistic characteristics and TEI, alexithymia, and empathy, as well as the possible influence of sex in these relationships. In the current study, autistic and non-autistic adults reported on their autistic characteristics, TEI, alexithymia, and empathy. Based on previous research, it was hypothesized that more autistic characteristics would be associated with less TEI, more alexithymia, and less empathy, and that these relationships would be more prominent amongst males. More autistic characteristics were associated with greater challenges across the three areas of interest. However, only the relationship between TEI and autistic characteristics was moderated by sex, such that males demonstrated higher support needs related to TEI than females. Results from this analysis indicate that adults with more autistic characteristics, regardless of diagnostic status, demonstrate differences in TEI, alexithymia, and empathy. The current analysis may offer additional context to the evolving understanding of empathy and autism by suggesting that TEI and alexithymia could account for differences in empathy. Moreover, sex seems to play a role in the relationship between autistic characteristics and TEI such that differences are especially prominent for males.

Sensorimotor variability distinguishes early features of cognition in toddlers with autism

The potential role of early sensorimotor features to atypical human cognition in autistic children has received surprisingly little attention given that appropriate movements are a crucial element that connects us to other people. We examined quantitative and observation-based movements in over 1,000 toddlers diagnosed with autism spectrum disorder (ASD) with different levels of cognitive abilities (intelligence quotient, IQ). Relative to higher-IQ ASD toddlers, those with lower-IQ had significantly altered sensorimotor features. Remarkably, we found that higher IQ in autistic toddlers confers resilience to atypical movement, as sensorimotor features in higher-IQ ASD children were indistinguishable from those of typically developing healthy control toddlers. We suggest that the altered movement patterns may affect key autistic behaviors in those with lower intelligence by affecting sensorimotor learning mechanisms. Atypical sensorimotor functioning is a key feature in lower-IQ early childhood autism. These findings have implications for the development of individualized interventions for subtypes of autism.

Physiological and Family-Level Correlates of Autistic Adolescents' Sleep Quality

PURPOSE

Autistic adolescents commonly experience sleep-related difficulties and prior studies have sought to separately examine physiological and family-level predictors of their sleep quality. The current study aimed to conceptually replicate and extend to an adolescent sample a prior study that found respiratory sinus arrhythmia was associated with sleep quality in autistic children. In addition, the current study also examined whether the quality of the family environment was associated with sleep quality in autistic adolescents.

METHODS

The sample consisted of 107 autistic adolescents who completed a baseline measure of respiratory sinus arrhythmia and then watched a video of their parents engaged in a discussion about a topic of disagreement while their respiratory sinus arrhythmia reactivity was measured. Adolescents also completed questionnaires measuring their sleep quality and family environment.

RESULTS

In regression models, adolescents' physiological functioning was not a significant predictor of their sleep quality; however, adolescents living in poorer quality family environments reported worse sleep quality after controlling for their physiological functioning. The interaction between physiological functioning and the family environment predicting sleep quality was non-significant.

CONCLUSION

Although the current study did not conceptually replicate prior work, the findings highlight the importance of the family environment for adolescents' sleep. Implications and future directions are discussed.

The impact of the physical activity intervention on sleep in children and adolescents with neurodevelopmental disorders: a systematic review and meta-analysis

Objective

The purpose of this review was to synthesize the current literature on the relationship between sleep and physical activity in children and adolescents with neurodevelopmental disorders.

Methods

Articles were searched in PubMed, Web of Science, EBSCO, Cochrane, and Embase until April 2024. The meta-analysis was performed using Review Manager 5.3.

Results

Our results show that measuring sleep parameters by means of different measuring tools yields different results. Most studies have found no association between sleep and physical activity in children with neurodevelopmental disorders, especially when measured subjectively, such as parent reports and sleep logs. Physical activity interventions had a significant effect on sleep efficiency, wake after sleep onset, and sleep duration when measured objectively using instruments such as wrist actigraphy. Meta-analysis showed that children and adolescents with neurodevelopmental disorders who participated in mind-body activities (SMD = -3.01, 95%CI = -4.15~-1.87, p < 0.001, I2 = 99%) showed significant improvements in sleep, which were sessions lasting more than 12 weeks (SMD = -1.01, p < 0.01, I2 = 97%), performed at least 3 times per week (SMD = -0.81, 95%CI = -1.53~-0.10, p = 0.03, I2 = 95%), and lasted for more than 60 min per session (SMD = -1.55, 95%CI = -2.67~-0.43, p = 0.007, I2 = 97%). However, the results of these subgroup analyses must be interpreted with caution because of the small number of studies included.

Conclusion

Our results show that measuring sleep parameters by means of different measuring tools yields different results. There was difficulty in interpreting many of the studies included in this meta-analysis, in view of the non-standardization of protocol, especially the ability range of the cohort, duration of the study, recommended exercises, whether the caregivers or researchers supervised the exercise regime/activity, and the practicality of continuing the exercise long-term by caregivers.

Systematic review registration

Identifier, CRD42024541300.

Sleep Disturbances and Co-sleeping in Italian Children and Adolescents with Autism Spectrum Disorder

The current study aimed (1) to provide an analysis of the frequency and prevalence of sleep disturbances in a large Italian sample of children and adolescents with ASD, detecting specific predictors of the presence/absence of sleep disorders, (2) to examine the phenomenon of co-sleeping within a subgroup of participants with ASD. A total of 242 children and adolescents with ASD (194 males, mean age 5.03 ± 3.15 years) were included. After the diagnostic procedure, caregivers were requested to complete the Sleep Disturbance Scale for Children (SDSC) to assess sleep disorders among participants. The presence of co-sleeping was investigated in a subgroup of 146 children and adolescents with ASD. An elevated or clinically relevant global score for sleep disorders (≥ 60) was found in 33% of participants. The most prevalent sleep disorder in our group was related to difficulties with sleep onset and sleep maintenance (~ 41% of cases). Sleep disturbances were predicted by higher intelligence quotient (IQ)/developmental quotient (DQ), increased internalizing problems, and elevated parental stress. The subgroup of participants engaged in co-sleeping (N = 87) were younger and had lower IQ/DQ scores, reduced adaptive functioning, and diminished psychological wellbeing than the non-co-sleeping group. Our findings are consistent with the current literature highlighting that insomnia is the most widespread sleep problem associated with ASD. The relationship between IQ/DQ and sleep alterations is a crucial topic that deserves additional research. Future studies should assess sleep by objective measures such as EEG topography to better understand the mechanisms underlying sleep alterations in this neurodevelopmental disorder.

A Practice Pathway for the Treatment of Night Wakings in Children with Autism Spectrum Disorder

Children with autism spectrum disorder (ASD) report high rates of sleep problems. In 2012, the Autism Treatment Network/ Autism Intervention Research Network on Physical Health (ATN/AIR-P) Sleep Committee developed a pathway to address these concerns. Since its publication, ATN/AIR-P clinicians and parents have identified night wakings as a refractory problem unaddressed by the pathway. We reviewed the existing literature and identified 76 scholarly articles that provided data on night waking in children with ASD. Based on the available literature, we propose an updated practice pathway to identify and treat night wakings in children with ASD.

Pattern of sleep disorders among children with autism spectrum disorder

BACKGROUND

Sleep disorders (SDs) are among many co-morbid medical conditions that affect children with autism spectrum disorder (ASD). Raising awareness and improving the standard of care for children diagnosed with ASD may result from identifying SDs among them. This study aims to evaluate patterns of SDs among Sudanese children diagnosed with ASD.

METHOD

Using the Childhood Sleep Habit Questionnaire (CSHQ) to gather data on sleep disorders and SPSS version 26.0 for data analysis, a descriptive cross-sectional study was carried out in the five main autistic centres in Khartoum state covering all registered patients with ASD between April and June 2022. Ninety-two children diagnosed with ASD were enrolled in this study after the purpose of the research was explained and consent was obtained from their guardians. A p-value < 0.05 was considered to indicate statistical significance.

RESULTS

The mean age was 6.90 (± 2.6) years with a boys-to-girls ratio of 2.17:1. The prevalence of SDs (at least one sleep condition almost daily) was 95.65%. Sleep onset 71 (77.2%), limit setting 32 (32.6%), resistant onset to sleep 48 (52.2%), and combined 52 (56.5%) insomnia affected the majority of children. Additionally, there were significant associations between sex and Limit-setting insomnia, advanced sleep phase disorder, and narcolepsy type 2 (P values = 0.033, 0.009, and 0.037, respectively). Additionally, there was a significant association between age and sleep-related breathing disorders-snoring (p value = 0.031).

CONCLUSION

The frequency of SDs is significant among children diagnosed with ASD from Sudan, and certain SDs are associated with age and sex. Subsequent studies are required to develop national guidelines for the prevalence, presentation, screening, and treatment of SDs in children diagnosed with ASD.

Autism-associated neuroligin 3 deficiency in medial septum causes social deficits and sleep loss in mice

Patients with autism spectrum disorder (ASD) frequently experience sleep disturbance. Genetic mutations in the neuroligin 3 (NLG3) gene are highly correlative with ASD and sleep disturbance. However, the cellular and neural circuit bases of this correlation remain elusive. Here, we found that the conditional knockout of Nlg3 (Nlg3-CKO) in the medial septum (MS) impairs social memory and reduces sleep. Nlg3 CKO in the MS caused hyperactivity of MSGABA neurons during social avoidance and wakefulness. Activation of MSGABA neurons induced social memory deficits and sleep loss in C57BL/6J mice. In contrast, inactivation of these neurons ameliorated social memory deficits and sleep loss in Nlg3-CKO mice. Sleep deprivation led to social memory deficits, while social isolation caused sleep loss, both resulting in a reduction in NLG3 expression and an increase in activity of GABAergic neurons in the MS from C57BL/6J mice. Furthermore, MSGABA-innervated CA2 neurons specifically regulated social memory without impacting sleep, whereas MSGABA-innervating neurons in the preoptic area selectively controlled sleep without affecting social behavior. Together, these findings demonstrate that the hyperactive MSGABA neurons impair social memory and disrupt sleep resulting from Nlg3 CKO in the MS, and achieve the modality specificity through their divergent downstream targets.

A clinical-translational review of sleep problems in neurodevelopmental disabilities

Sleep disorders are very common across neurodevelopmental disorders and place a large burden on affected children, adolescents, and their families. Sleep disturbances seem to involve a complex interplay of genetic, neurobiological, and medical/environmental factors in neurodevelopmental disorders. In this review, we discuss animal models of sleep problems and characterize their presence in two single gene disorders, Rett Syndrome, and Angelman Syndrome and two more commonly occurring neurodevelopmental disorders, Down Syndrome, and autism spectrum disorders. We then discuss strategies for novel methods of assessment using wearable sensors more broadly for neurodevelopmental disorders in general, including the importance of analytical validation. An increased understanding of the mechanistic contributions and potential biomarkers of disordered sleep may offer quantifiable targets for interventions that improve overall quality of life for affected individuals and their families.

The Association Between Adverse Childhood Experiences and Sleep in Children with Autism Spectrum Disorder

Children with autism spectrum disorder are at higher risk for adverse childhood experiences (ACEs). They are also more vulnerable to sleep problems and are less likely to obtain the recommended number of hours of sleep than neurotypical children. In the general population, ACEs have been linked to future sleep difficulties. Despite increased vulnerabilities to both ACEs and sleep problems, no study has examined this association in ASD. Using the National Survey of Children's Health across four cohorts, we examined whether ACEs were a risk factor to obtaining the recommended number of hours of sleep, while accounting for demographic and health factors typically associated with sleep duration. Findings indicate that children with ASD with more ACEs were less likely to get the recommended number of hours of sleep than children with fewer ACEs. Other factors associated with sleep included race, anxiety, autism severity, and overall health. These findings indicate that sleep problems in children with ASD are complex and multifaceted. Among other considerations, it is important for clinicians to screen children with ASD for ACEs and consider the possible impact of ACEs on sleep.

Insomnia in children affected by autism spectrum disorder: The role of melatonin in treatment

The present article explores the connection between insomnia and Autism Spectrum Disorder (ASD), focusing on the efficacy and safety of melatonin treatments as supported by existing research and current guidelines. In this narrative review a group of Italian experts provide an analysis of the various aspects of managing insomnia in children with ASD, highlighting key points that could enhance the quality of life for both patients and their caregivers. This includes the significance of comprehensively understanding the root causes of a child's sleep difficulties for more effective, long-term management. Insomnia, a condition frequently documented in neurodevelopmental disorders such as ASD, greatly affects the lives of patients and caregivers. Recent data show that melatonin-based formulations are effective and safe for treating ASD-related insomnia both short and long term. In particular, prolonged-release melatonin is poised to be the optimal choice for this patient population. This formulation is approved for the treatment of insomnia in children and adolescents aged 2-18 years suffering from ASD and/or Smith-Magenis syndrome, where sleep hygiene measures and behavioral treatments have not been sufficient. In support, emerging research in pediatric settings indicates long-term efficacy and safety, although further research efforts are still needed. Current guidelines recommend managing insomnia and sleep disturbances in ASD using a combination of behavioral and pharmacological methods, primarily melatonin. Recent concerns about accidental melatonin ingestion highlight the need for high purity standards, such as pharmaceutical-grade prolonged-release formulations. The article also summarizes emerging molecular mechanisms from preclinical research, suggesting future therapeutic approaches.

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).

Impact of smart technology use on sleep quality in individuals with autism spectrum disorder: a mixed-methods investigation

Background

Sleep disturbances are common among individuals with autism spectrum disorder (ASD) and can have a negative impact on their daily functioning and core symptoms. As the use of smart technologies continues to rise, it is crucial to understand how these devices affect the sleep quality of individuals with ASD.

Aim

The objective of this study was to examine the relationship between the use of smart technology and sleep quality in individuals with ASD.

Methods

A mixed-methods approach was employed, combining both quantitative and qualitative data collection techniques. A sample of 83 individuals with ASD, aged between 8 and 25 years, assessed their sleep quality using the Pittsburgh Sleep Quality Index. Additionally, information regarding patterns of smart technology use and relevant covariates was collected. Correlation and regression analyses were conducted to analyze the data. Furthermore, semi-structured interviews were conducted with a subset of participants and their caregivers.

Results

Significant positive correlations were found between poorer sleep quality scores and total screen time (r = 0.42, p < 0.001), pre-bedtime technology use (r = 0.51, p < 0.001), gaming (r = 0.32, p = 0.003), and social media use (r = 0.29, p = 0.008). Pre-bedtime technology use was a significant predictor of poorer sleep quality (β = 0.32, p = 0.006), even after controlling for age, gender, and ASD severity.

Conclusion

The findings of this study emphasize the significant associations between the use of smart technology, particularly before bedtime, and poorer sleep quality in individuals with ASD. These results underscore the importance of developing evidence-based interventions and guidelines to promote healthy sleep habits and mitigate the negative effects of technology exposure in this population.

Circuit mechanism underlying fragmented sleep and memory deficits in 16p11.2 deletion mouse model of autism

Sleep disturbances are prevalent in children with autism spectrum disorder (ASD) and have a major impact on the quality of life. Strikingly, sleep problems are positively correlated with the severity of ASD symptoms, such as memory impairment. However, the neural mechanisms underlying sleep disturbances and cognitive deficits in ASD are largely unexplored. Here, we show that non-rapid eye movement sleep (NREMs) is highly fragmented in the 16p11.2 deletion mouse model of ASD. The degree of sleep fragmentation is reflected in an increased number of calcium transients in the activity of locus coeruleus noradrenergic (LC-NE) neurons during NREMs. Exposure to a novel environment further exacerbates sleep disturbances in 16p11.2 deletion mice by fragmenting NREMs and decreasing rapid eye movement sleep (REMs). In contrast, optogenetic inhibition of LC-NE neurons and pharmacological blockade of noradrenergic transmission using clonidine reverse sleep fragmentation. Furthermore, inhibiting LC-NE neurons restores memory. Rabies-mediated unbiased screening of presynaptic neurons reveals altered connectivity of LC-NE neurons with sleep- and memory regulatory brain regions in 16p11.2 deletion mice. Our findings demonstrate that heightened activity of LC-NE neurons and altered brain-wide connectivity underlies sleep fragmentation in 16p11.2 deletion mice and identify a crucial role of the LC-NE system in regulating sleep stability and memory in ASD.

Sleep and Activity Patterns in Autism Spectrum Disorder

Background

Autism spectrum disorder (ASD) is a highly heritable and heterogeneous neurodevelopmental disorder characterized by impaired social interactions, repetitive behaviors, and a wide range of comorbidities. Between 44-83% of autistic individuals report sleep disturbances, which may share an underlying neurodevelopmental basis with ASD.

Methods

We recruited 382 ASD individuals and 223 of their family members to obtain quantitative ASD-related traits and wearable device-based accelerometer data spanning three consecutive weeks. An unbiased approach identifying traits associated with ASD was achieved by applying the elastic net machine learning algorithm with five-fold cross-validation on 6,878 days of data. The relationship between sleep and physical activity traits was examined through linear mixed-effects regressions using each night of data.

Results

This analysis yielded 59 out of 242 actimetry measures associated with ASD status in the training set, which were validated in a test set (AUC: 0.777). For several of these traits (e.g. total light physical activity), the day-to-day variability, in addition to the mean, was associated with ASD. Individuals with ASD were found to have a stronger correlation between physical activity and sleep, where less physical activity decreased their sleep more significantly than that of their non-ASD relatives.

Conclusions

The average duration of sleep/physical activity and the variation in the average duration of sleep/physical activity strongly predict ASD status. Physical activity measures were correlated with sleep quality, traits, and regularity, with ASD individuals having stronger correlations. Interventional studies are warranted to investigate whether improvements in both sleep and increased physical activity may improve the core symptoms of ASD.

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

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

The Impact of Cognitive Behavioral Therapy on Sleep Problems in Autistic Children with Co-occurring Anxiety

PURPOSE

This study seeks to examine the relationship between anxiety-symptom severity and sleep behaviors in autistic children receiving cognitive behavioral therapy (CBT).

METHODS

We conducted a secondary-data analysis from a sample of 93 autistic youth, 4 to 14 years, participating in 24 weeks of CBT. Clinicians completed the Pediatric Anxiety Rating Scale (PARS) and parents completed the Children's Sleep Habits Questionnaire, Abbreviated/Short Form (CSHQ-SF) at baseline, mid-treatment, post-treatment and 3 months post-treatment. Mediation analysis evaluated the role of anxiety symptoms in mediating the effect of time in treatment on sleep.

RESULTS

There was a negative association between time in treatment and scores on the CSHQ-SF (b = - 3.23, SE = 0.493, t = - 6.553, p < 0.001). Increased time in treatment was associated with decreased anxiety (b = - 4.66, SE = 0.405, t = - 11.507, p < 0.001), and anxiety symptoms decreased with CSHQ-SF scores (b = 0.322, SE = 0.112, t = 2.869, p = 0.005). The indirect effect of time in treatment on CSHQ-SF scores through PARS reduction was negative, but not statistically significant.

CONCLUSION

Increased time in CBT was associated with decreased anxiety severity and improved sleep behaviors. Reductions in anxiety symptoms may mediate improvements in sleep problems, but larger sample sizes are necessary to explore this further.

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 impact of the physical activity intervention on sleep in children and adolescents with autism spectrum disorder: A systematic review and meta-analysis

Pharmacological treatments (i.e., melatonin) and non-pharmacological therapies (e.g., parent-based sleep education programs and behavioural interventions) have been found to result in improved sleep in children and adolescents with autism spectrum disorder (ASD). However, there are several limitations to these treatment approaches, including concerns about the possible side-effects and safety, high-cost and uncertainties of long-term effects. Physical activity (PA) intervention is a promising behavioural intervention that has received increasing attention. However, the effects of PA intervention on sleep are still unclear in this clinical group. This study aimed to synthesize available empirical studies concerning the effects of PA interventions on sleep in children and adolescents with ASD. Following PRISMA guidelines, seven electronic databases: APA PsychInfo, CINAHL Ultimate, ERIC, MEDLINE, PubMed, SPORTDiscus, and Web of Science, were searched from inception to March 2023. Randomized controlled trials/quasi-experimental designs with comparison groups were included. Initially, 444 articles were identified, 13 articles underwent systematic review, and 8 studies with control groups and sufficient statistical data were selected for meta-analysis. Compared to no-treatment control groups, PA interventions had a large positive effect on parent-reported general sleep problems, night awakenings, sleep resistance, sleep duration and actigraphy-assessed sleep efficiency in children and adolescents with ASD.

Disruption of Circadian Sleep/Wake Rhythms in Infants May Herald Future Development of Autism Spectrum Disorder

We investigated whether the abnormal rhythms in infants are related to the future development of autism spectrum disorder (ASD), using a questionnaire from September to October 2016. The parents of 160 children with ASD (male, n = 123; female, n = 37) were recruited from two hospitals in K and H cities, and as a control group, 145 children (male, n = 75; female, n = 70) were recruited from four nursery schools in T city. The associations between ASD and bedtime and waking time on weekdays and weekends in infancy (<1 years of age), at 1-3 years, and at 3-5 years of ages were studied using a multivariable logistic regression analysis. In particular, at <3 years of age, the following factors were associated with an increased prevalence of ASD in the future: (1) short sleep periods (<8 h); (2) taking a long time to fall asleep (>60 min); (3) sleep beginning after 22:00; (4) a wake-up time after 08:00; and (5) frequent (>3 times) and long-term awakening periods (>60 min). The misalignment and/or shift of the circadian rhythm in infants may be one of the precursors and/or risk factors for the future development of ASD.