Top

Published in:

Open Access 01-12-2021 | Autism Spectrum Disorder | Research

Sleep problems in children with autism spectrum disorder: a multicenter survey

Published in: BMC Psychiatry | Issue 1/2021

Abstract

Background

High prevalence of sleep problems have been reported in children with Autism Spectrum Disorder (ASD). This study aims to investigate the sleep conditions of ASD children in China, and explore the relationship between the common sleep problems and core symptoms and developmental levels.

Methods

Using a cross-sectional design, we included 2 to 7-year-old children from 13 cities in China: 1310 with ASD and 1158 with typically-developing (TD) children. The neurodevelopmental level was evaluated with the revised Children Neuropsychological and Behavior Scale (CNBS-R2016). ASD were diagnosed with DSM-5 and Child Autism Rating Scale (CARS). the Social Responsiveness Scale (SRS), the Autism Behavior Checklist (ABC) and the communication warning behavior sub-scale in CNBS-R2016 valued autism behaviors. The children’ s sleep habits questionnaire (CSHQ) assessed sleep conditions.

Results

The prevalence of sleep disorders in ASD children was significantly higher than that in TD (67.4% vs. 51%, p < 0.01), and among them the four dimensions with the highest prevalence of sleep problems were bedtime resistance (25.6%), sleep anxiety (22.7%), sleep onset delay (17.9%) and daytime sleepiness (14.7%). ASD children with sleep onset delay or sleep anxiety had higher ABC, SRS scores and higher scores on communication warning behavior with sleep anxiety, with daytime sleepiness had higher ABC, SRS and CARS scores, and with bedtime resistance had higher SRS total scores. Differences in the neurodevelopmental level were not significant.

Conclusion

Children with ASD have a higher prevalence of sleep problems. Bedtime resistance, anxiety, sleep onset delay and daytime sleepiness may be related to the core symptoms, but not be related to the developmental level in ASD children. In the clinic, sleep assessment should be included in the routine of ASD visits, and during the intervention, sleep hygiene education is as important as the treatment of biological factors.

Trial registration

The study was approved by the ethics committee of the Children’s Hospital of Chongqing Medical University, Approval Number: (2018) IRB (STUDY) NO. 121, and registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR2000031194).

Available only for authorised users

Posar A, Resca F, Visconti P. Autism according to diagnostic and statistical manual of mental disorders 5(th) edition: the need for further improvements. J Pediatr Neurosci. 2015;10(2):146–8. https://doi.org/10.4103/1817-1745.159195.CrossRefPubMedPubMedCentral

Maenner MJ, Shaw KA, Baio J, et al. Prevalence of autism Spectrum disorder among children aged 8 years - autism and developmental disabilities monitoring network, 11 sites, United States, 2016. MMWR Surveill Summ. 2020;69(4):1–12. https://doi.org/10.15585/mmwr.ss6904a1 EdS, Washington A, Patrick M.CrossRefPubMedPubMedCentral

Zhu ZW, Jin Y, Wu LL, Liu XL. Current status and challenge in clinical work of autism spectrum disorders in China. World J Pediatr. 2018;14(3):209–11. https://doi.org/10.1007/s12519-018-0166-2.CrossRefPubMed

Zhou H, Xu X, Yan W, Zou X, Wu L, Luo X, et al. Prevalence of autism Spectrum disorder in China: a Nationwide multi-center population-based study among children aged 6 to 12 years. Neurosci Bull. 2020;36(9):961–71. https://doi.org/10.1007/s12264-020-00530-6.CrossRefPubMed

Cortesi F, Giannotti F, Ivanenko A, Johnson K. Sleep in children with autistic spectrum disorder. Sleep Med. 2010;11(7):659–64. https://doi.org/10.1016/j.sleep.2010.01.010.CrossRefPubMed

Petit D, Touchette E, Tremblay RE, Boivin M, Montplaisir J. Dyssomnias and parasomnias in early childhood. Pediatrics. 2007;119(5):e1016–25. https://doi.org/10.1542/peds.2006-2132.CrossRefPubMed

Allik H, Larsson JO, Smedje H. Insomnia in school-age children with Asperger syndrome or high-functioning autism. BMC Psychiatry. 2006;6(1):18. https://doi.org/10.1186/1471-244X-6-18.CrossRefPubMedPubMedCentral

Blunden S, Fatima Y, Yiallourou S. Sleep health in indigenous Australian children: a systematic review. Sleep Med. 2021;80:305–14. https://doi.org/10.1016/j.sleep.2021.01.065.CrossRefPubMed

Baker E, Richdale A, Short M, Gradisar M. An investigation of sleep patterns in adolescents with high-functioning autism spectrum disorder compared with typically developing adolescents. Dev Neurorehabil. 2013;16(3):155–65. https://doi.org/10.3109/17518423.2013.765518.CrossRefPubMed

10.

Richdale AL, Schreck KA. Sleep problems in autism spectrum disorders: prevalence, nature, & possible biopsychosocial aetiologies. Sleep Med Rev. 2009;13(6):403–11. https://doi.org/10.1016/j.smrv.2009.02.003.CrossRefPubMed

11.

Wang G, Liu Z, Xu G, Jiang F, Lu N, Baylor A, et al. Sleep disturbances and associated factors in Chinese children with autism Spectrum disorder: a retrospective and cross-sectional study. Child Psychiatry Hum Dev. 2016;47(2):248–58. https://doi.org/10.1007/s10578-015-0561-z.CrossRefPubMed

12.

Malow BA, Katz T, Reynolds AM, Shui A, Carno M, Connolly HV, et al. Sleep difficulties and medications in children with autism Spectrum disorders: a registry study. Pediatrics. 2016;137(Suppl 2):S98–S104. https://doi.org/10.1542/peds.2015-2851H.CrossRefPubMed

13.

Malow BA, Marzec ML, McGrew SG, Wang L, Henderson LM, Stone WL. Characterizing sleep in children with autism spectrum disorders: a multidimensional approach. Sleep. 2006;29(12):1563–71. https://doi.org/10.1093/sleep/29.12.1563.CrossRefPubMed

14.

Humphreys JS, Gringras P, Blair PS, Scott N, Henderson J, Fleming PJ, et al. Sleep patterns in children with autistic spectrum disorders: a prospective cohort study. Arch Dis Child. 2014;99(2):114–8. https://doi.org/10.1136/archdischild-2013-304083.CrossRefPubMed

15.

Krakowiak P, Goodlin-Jones B, Hertz-Picciotto I, Croen LA, Hansen RL. Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: a population-based study. J Sleep Res. 2008;17(2):197–206. https://doi.org/10.1111/j.1365-2869.2008.00650.x.CrossRefPubMedPubMedCentral

16.

Liu X, Hubbard JA, Fabes RA, Adam JB. Sleep disturbances and correlates of children with autism spectrum disorders. Child Psychiatry Hum Dev. 2006;37(2):179–91. https://doi.org/10.1007/s10578-006-0028-3.CrossRefPubMed

17.

Maquet P. The role of sleep in learning and memory. Science. 2001;294(5544):1048–52. https://doi.org/10.1126/science.1062856.CrossRefPubMed

18.

Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3 Pt 1):616–20. https://doi.org/10.1542/peds.102.3.616.CrossRefPubMed

19.

Mazurek MO, Petroski GF. Sleep problems in children with autism spectrum disorder: examining the contributions of sensory over-responsivity and anxiety. Sleep Med. 2015;16(2):270–9. https://doi.org/10.1016/j.sleep.2014.11.006.CrossRefPubMed

20.

Mannion A, Leader G. Sleep problems in autism Spectrum disorder: a literature review. Rev J Autism Devel Disord. 2013;1(2):101–9.CrossRef

21.

Goldman SE, McGrew S, Johnson KP, Richdale AL, Clemons T, Malow BA. Sleep is associated with problem behaviors in children and adolescents with autism Spectrum disorders. Res Autism Spectr Disord. 2011;5(3):1223–9. https://doi.org/10.1016/j.rasd.2011.01.010.CrossRef

22.

Henderson JA, Barry TD, Bader SH, Jordan SS. The relation among sleep, routines, and externalizing behavior in children with an autism spectrum disorder. Res Autism Spectr Disord. 2011;5(2):758–67. https://doi.org/10.1016/j.rasd.2010.09.003.CrossRef

23.

Kuhn DE, Matson JL. Assessment of feeding and mealtime behavior problems in persons with mental retardation. Behav Modif. 2004;28(5):638–48. https://doi.org/10.1177/0145445503259833.CrossRefPubMed

24.

Schreck KA, Mulick JA, Smith AF. Sleep problems as possible predictors of intensified symptoms of autism. Res Dev Disabil. 2004;25(1):57–66. https://doi.org/10.1016/j.ridd.2003.04.007.CrossRefPubMed

25.

Couturier JL, Speechley KN, Steele M, Norman R, Stringer B, Nicolson R. Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: prevalence, severity, and pattern. J Am Acad Child Adolesc Psychiatry. 2005;44(8):815–22. https://doi.org/10.1097/01.chi.0000166377.22651.87.CrossRefPubMed

26.

Giannotti F, Cortesi F, Cerquiglini A, Miraglia D, Vagnoni C, Sebastiani T, et al. An investigation of sleep characteristics, EEG abnormalities and epilepsy in developmentally regressed and non-regressed children with autism. J Autism Dev Disord. 2008;38(10):1888–97. https://doi.org/10.1007/s10803-008-0584-4.CrossRefPubMed

27.

Mannion A, Leader G, Healy O. An investigation of comorbid psychological disorders, sleep problems, gastrointestinal symptoms and epilepsy in children and adolescents with autism Spectrum disorder. Res Autism Spectr Disord. 2013;7(1):35–42. https://doi.org/10.1016/j.rasd.2012.05.002.CrossRef

28.

Gunes S, Ekinci O, Feyzioglu A, Ekinci N, Kalinli M. Sleep problems in children with autism spectrum disorder: clinical correlates and the impact of attention deficit hyperactivity disorder. Neuropsychiatr Dis Treat. 2019;15:763–71. https://doi.org/10.2147/NDT.S195738.CrossRefPubMedPubMedCentral

29.

Taylor MA, Schreck KA, Mulick JA. Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders. Res Dev Disabil. 2012;33(5):1408–17. https://doi.org/10.1016/j.ridd.2012.03.013.CrossRefPubMed

30.

Souders MC, Zavodny S, Eriksen W, Sinko R, Connell J, Kerns C, et al. Sleep in children with autism Spectrum disorder. Curr Psychiatry Rep. 2017;19(6):34. https://doi.org/10.1007/s11920-017-0782-x.CrossRefPubMedPubMedCentral

31.

Malow BA, Byars K, Johnson K, Weiss S, Bernal P, Goldman SE, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130(Suppl 2):S106–24. https://doi.org/10.1542/peds.2012-0900I.CrossRefPubMed

32.

Yang T, Zhu J, Li Q, Chen L, Wu LJ, Jia FY, et al. China multi-center preschool autism project (CMPAP): design and methodologies to identify clinical symptom features and biomarkers of autism Spectrum disorders. Front Psychiatry. 2020;11:613519.CrossRef

33.

Owens JA, Spirito A, McGuinn M. The Children's sleep habits questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep. 2000;23(8):1043–51.CrossRef

34.

Byars KC, Yeomans-Maldonado G, Noll JG. Parental functioning and pediatric sleep disturbance: an examination of factors associated with parenting stress in children clinically referred for evaluation of insomnia. Sleep Med. 2011;12(9):898–905. https://doi.org/10.1016/j.sleep.2011.05.002.CrossRefPubMed

35.

Li SH, Jin XM, Shen XM, Wu SH, Jiang F, Yan CH, et al. Development and psychometric properties of the Chinese version of Children's sleep habits questionnaire. Zhonghua Er Ke Za Zhi. 2007;45(3):176–80.PubMed

36.

First MB. Diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. J Nerv Ment Dis. 2013;201(9):727–9. https://doi.org/10.1097/NMD.0b013e3182a2168a.CrossRefPubMed

37.

Schopler E, Reichler RJ, DeVellis RF, Daly K. Toward objective classification of childhood autism: childhood autism rating scale (CARS). J Autism Dev Disord. 1980;10(1):91–103. https://doi.org/10.1007/BF02408436.CrossRefPubMed

38.

Lu JP, Yang ZW, Shu MY, Su LY. Reliability, validity analysis of the childhood autism rating scale. China J Modern Med. 2004;14(13):119–21.

39.

Cen CQ, Liang YY, Chen QR, Chen KY, Deng HZ, Chen BY, et al. Investigating the validation of the Chinese mandarin version of the social responsiveness scale in a mainland China child population. BMC Psychiatry. 2017;17(1):51. https://doi.org/10.1186/s12888-016-1185-y.CrossRefPubMedPubMedCentral

40.

Rellini E, Tortolani D, Trillo S, Carbone S, Montecchi F. Childhood autism rating scale (CARS) and autism behavior checklist (ABC) correspondence and conflicts with DSM-IV criteria in diagnosis of autism. J Autism Dev Disord. 2004;34(6):703–8. https://doi.org/10.1007/s10803-004-5290-2.CrossRefPubMed

41.

Li HH, Feng JY, Wang B, Zhang Y, Wang CX, Jia FY. Comparison of the children neuropsychological and behavior scale and the Griffiths mental development scales when assessing the development of children with autism. Psychol Res Behav Manag. 2019;12:973–81. https://doi.org/10.2147/PRBM.S225904.CrossRefPubMedPubMedCentral

42.

Kang YQ, Song XR, Wang GF, Su YY, Zhang X. Sleep problems influence emotional/behavioral symptoms and repetitive behavior in preschool-aged children with autism Spectrum disorder in the unique social context of China. Frontiers Psychiatry. 2020;11. https://doi.org/10.3389/fpsyt.2020.00273.

43.

Samanta P, Mishra DP, Panigrahi A, Mishra J, Senapati LK, Ravan JR. Sleep disturbances and associated factors among 2-6-year-old male children with autism in Bhubaneswar, India. Sleep Med. 2020;67:77–82. https://doi.org/10.1016/j.sleep.2019.11.1244.CrossRefPubMed

44.

Adams HL, Matson JL, Cervantes PE, Goldin RL. The relationship between autism symptom severity and sleep problems: should bidirectionality be considered? Res Autism Spectr Disord. 2014;8(3):193–9. https://doi.org/10.1016/j.rasd.2013.11.008.CrossRef

45.

Sikora DM, Johnson K, Clemons T, Katz T. The relationship between sleep problems and daytime behavior in children of different ages with autism Spectrum disorders. Pediatrics. 2012;130(Supplement):S83–90.CrossRef

46.

Hua X, Zhu J, Yang T, Guo M, Li Q, Chen J, et al. The gut microbiota and associated metabolites are altered in sleep disorder of children with autism Spectrum disorders. Front Psychiatry. 2020;11:855. https://doi.org/10.3389/fpsyt.2020.00855.CrossRefPubMedPubMedCentral

47.

Hollway JA, Aman MG, Butter E. Correlates and risk markers for sleep disturbance in participants of the autism treatment network. J Autism Dev Disord. 2013;43(12):2830–43. https://doi.org/10.1007/s10803-013-1830-y.CrossRefPubMed

48.

Kataria S, Swanson MS, Trevathan GE. Persistence of sleep disturbances in preschool children. J Pediatr. 1987;110(4):642–6. https://doi.org/10.1016/S0022-3476(87)80571-1.CrossRefPubMed

49.

Blader JC, Koplewicz HS, Abikoff H, Foley C. Sleep problems of elementary school children. A community survey. Arch Pediatr Adolesc Med. 1997;151(5):473–80. https://doi.org/10.1001/archpedi.1997.02170420043007.CrossRefPubMed

50.

Owens JA, Spirito A, McGuinn M, Nobile C. Sleep habits and sleep disturbance in elementary school-aged children. J Dev Behav Pediatr. 2000;21(1):27–36. https://doi.org/10.1097/00004703-200002000-00005.CrossRefPubMed

51.

Beltramini AU, Hertzig ME. Sleep and bedtime behavior in preschool-aged children. Pediatrics. 1983;71(2):153–8.PubMed

52.

Wilson KE, Lumeng JC, Kaciroti N, Chen SY, LeBourgeois MK, Chervin RD, et al. Sleep hygiene practices and bedtime resistance in low-income preschoolers: does temperament matter? Behav Sleep Med. 2015;13(5):412–23. https://doi.org/10.1080/15402002.2014.940104.CrossRefPubMed

53.

Wang G, Xu G, Liu Z, Lu N, Ma R, Zhang E. Sleep patterns and sleep disturbances among Chinese school-aged children: prevalence and associated factors. Sleep Med. 2013;14(1):45–52. https://doi.org/10.1016/j.sleep.2012.09.022.CrossRefPubMed

54.

Takahashi M, Wang G, Adachi M, Jiang F, Jiang Y, Saito M, et al. Differences in sleep problems between Japanese and Chinese preschoolers: a cross-cultural comparison within the Asian region. Sleep Med. 2018;48:42–8. https://doi.org/10.1016/j.sleep.2017.11.1145.CrossRefPubMed

55.

Tudor ME, Hoffman CD, Sweeney DP. Children with autism: sleep problems and symptom severity. Focus Autism Other Dev Disab. 2012;27(4):254–62. https://doi.org/10.1177/1088357612457989.CrossRef

56.

Goldman SE, Richdale AL, Clemons T, Malow BA. Parental sleep concerns in autism spectrum disorders: variations from childhood to adolescence. J Autism Dev Disord. 2012;42(4):531–8. https://doi.org/10.1007/s10803-011-1270-5.CrossRefPubMed

57.

Horiuchi F, Kawabe K, Oka Y, Nakachi K, Hosokawa R, Ueno SI. The association between autistic traits and sleep habits/problems in toddlers. Dev Neuropsychol. 2020. https://doi.org/10.1080/87565641.2020.1865357:1-11.

58.

Hodge D, Carollo TM, Lewin M, Hoffman CD, Sweeney DP. Sleep patterns in children with and without autism spectrum disorders: developmental comparisons. Res Dev Disabil. 2014;35(7):1631–8. https://doi.org/10.1016/j.ridd.2014.03.037.CrossRefPubMed

59.

Bourgeron T. The possible interplay of synaptic and clock genes in autism spectrum disorders. Cold Spring Harb Symp Quant Biol. 2007;72(1):645–54. https://doi.org/10.1101/sqb.2007.72.020.CrossRefPubMed

60.

Tordjman S, Anderson GM, Pichard N, Charbuy H, Touitou Y. Nocturnal excretion of 6-sulphatoxymelatonin in children and adolescents with autistic disorder. Biol Psychiatry. 2005;57(2):134–8. https://doi.org/10.1016/j.biopsych.2004.11.003.CrossRefPubMed

61.

Ritvo ER, Ritvo R, Yuwiler A, Brothers A, Freeman BJ, Plotkin S. Elevated daytime melatonin concentrations in autism: a pilot study. Eur Child Adolesc Psychiatry. 1993;2(2):75–8. https://doi.org/10.1007/BF02098862.CrossRefPubMed

62.

Nir I, Meir D, Zilber N, Knobler H, Hadjez J, Lerner Y. Brief report: circadian melatonin, thyroid-stimulating hormone, prolactin, and cortisol levels in serum of young adults with autism. J Autism Dev Disord. 1995;25(6):641–54. https://doi.org/10.1007/BF02178193.CrossRefPubMed

63.

Kulman G, Lissoni P, Rovelli F, Roselli MG, Brivio F, Sequeri P. Evidence of pineal endocrine hypofunction in autistic children. Neuro Endocrinol Lett. 2000;21(1):31–4.PubMed

64.

Braam W, Ehrhart F, Maas A, Smits MG, Curfs L. Low maternal melatonin level increases autism spectrum disorder risk in children. Res Dev Disabil. 2018;82:79–89. https://doi.org/10.1016/j.ridd.2018.02.017.CrossRefPubMed

65.

Pagan C, Delorme R, Callebert J, Goubran-Botros H, Amsellem F, Drouot X, et al. The serotonin-N-acetylserotonin-melatonin pathway as a biomarker for autism spectrum disorders. Transl Psychiatry. 2014;4(11):e479. https://doi.org/10.1038/tp.2014.120.CrossRefPubMedPubMedCentral

66.

Gail Williams P, Sears LL, Allard A. Sleep problems in children with autism. J Sleep Res. 2004;13(3):265–8. https://doi.org/10.1111/j.1365-2869.2004.00405.x.CrossRefPubMed

Title: Sleep problems in children with autism spectrum disorder: a multicenter survey
Publication date: 01-12-2021
Keywords: Autism Spectrum Disorder
Anxiety
Published in: BMC Psychiatry / Issue 1/2021
Electronic ISSN: 1471-244X
DOI: https://doi.org/10.1186/s12888-021-03405-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Sleep problems in children with autism spectrum disorder: a multicenter survey

Abstract

Background

Methods

Results

Conclusion

Trial registration

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2021

Discrepancy between experience and importance of recovery components in the symptomatic and recovery perceptions of people with severe mental disorders

Self-reported burden of caregiver of adults with depression: a cross-sectional study in five Western European countries

“Sex isn’t everything”: views of people with experience of psychosis on intimate relationships and implications for mental health services

Health anxiety and related factors among pregnant women during the COVID-19 pandemic: a cross-sectional study from Iran

Goal management training for adults with ADHD – clients’ experiences with a group-based intervention

The mediating roles of coping styles and resilience in the relationship between perceived social support and posttraumatic growth among primary caregivers of schizophrenic patients: a cross-sectional study