Review ArticleSleep in children with autistic spectrum disorder
Introduction
Autism spectrum disorders (ASD) are life-long neurodevelopmental disorders that affect all areas of child development, characterized by markedly abnormal or impaired social interaction and communication, restricted interests, and stereotypical behaviors [1]. Numerous research studies indicate that children with ASD experience more sleep problems than the general population. The main objective of this review is to present research data on the sleep problems in children with ASD with emphasis on their prevalence, clinical characteristics, sleep architecture, potential etiology, influence on daytime behavior, assessment and treatment.
Section snippets
Prevalence of sleep problems in ASD
Sleep problems are highly prevalent in children with ASD ranging from 40% to 80% [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. A recent study showed that sleep problems rank as one of the most common concurrent clinical disorders among children with ASD [13]. Since the majority of research studies include children with ASD and intellectual deficits, the prevalence rates of sleep problems need to be evaluated in the context of comorbid intellectual disability. Some reports revealed
Clinical characteristics of sleep in children with ASD
Sleep onset and maintenance problems resulting in reduced sleep duration are the most common concerns expressed by the parents of children with ASD. Several studies have reported settling problems with some children with ASD taking more than an hour to fall asleep [10], [17], [26]. According to parental reports, night wakings also commonly occur in children with ASD. Periods of nocturnal awakening lasting for up to 2–3 h have been reported when the child may simply laugh, talk, scream, or get up
Sleep architecture in children with ASD
Several PSG studies have confirmed the presence of disrupted sleep architecture in children with ASD [14], [38], [39], [40], [41]. PSG abnormalities include increased REM density [39], reduction of REM sleep, and an increase of undifferentiated sleep with a clear abundance of spindle activity not only during stage 2 sleep but also during SWS and REM sleep [38]. Longer sleep latency, increased night wakings, lower sleep efficiency, increased stage 1 sleep and decreased SWS as well as decreased
Pathophysiological mechanisms of sleep disorders in ASD
Richdale and Schreck [20] proposed that sleep problems in ASD might occur as a result of complex interactions between biological, psychological, social/environmental and family factors, including child rearing practices that are not conducive to good sleep. Any one or combination of these factors might contribute to sleep problems in children with ASD.
Neurobiological abnormalities
Intrinsic biological or genetic abnormalities that alter neuronal pathways in the brain might contribute to sleep problems in ASD. Most autistic children exhibit abnormal EEG and sleep/wake patterns, suggesting that the balance of excitation–inhibition is disrupted. Proposed hypotheses of sleep dysregulation in autism include abnormalities in the hypothalamic–pituitary–adrenal axis regulating circadian rhythms and alteration in hormone/neurotransmitter (melatonin/serotonin) production [9].
Circadian abnormalities
Bourgeron [50] suggested that clock genes associated with low melatonin may be involved in abnormal circadian timing in autism. He hypothesized that circadian abnormalities in autism might be the result of genetic abnormalities related to melatonin synthesis and melatonin’s role in modulating synaptic transmission. An association between clock gene polymorphisms and autism has been reported [51]. These findings support the hypothesis of circadian abnormalities underlying sleep disturbances in
Psychological or behavioral factors
Children with ASD have a high rate of psychiatric comorbidities that may interfere with the regulation of sleep. Anxiety disorders, mood disorders, and attention-deficit/hyperactivity disorder frequently occur in patients with ASD [59], resulting in complicated presentations of sleep disturbances [8], [9], [37], [60].
Behavioral sleep disorders such as bedtime resistance, sleep-onset association and limit-setting types of behavioral insomnia are common among children with ASD and can be
Developmental regression and sleep problems
In a minority of patients, symptoms of autism become apparent after a period of normal or mildly delayed development followed by the loss of previously acquired skills [66], [67]. Autistic regression typically occurs between 1 and 3 years of age, with a peak at around 24 months. This regression occurs in about 15–40% of children with autism [66], [67], [68], [69], [70]. Even though the mechanisms underlying autistic regression are still unknown, it has been postulated that rapid synaptic growth
Impact of sleep problems on daytime behavior in children with ASD
An important reason, if not the most important, for intervening when children with ASD have sleep problems is to improve daytime functioning. Parents of poorly sleeping children with ASD routinely report worse daytime behavior following nights of fragmented or insufficient sleep. Although several studies have pointed out the negative effect of sleep disorders on daytime behavior in children with intellectual disabilities [22], [78], [79], [80], few studies have evaluated the effect of sleep
Non-pharmacological treatment
Sleep hygiene and behavioral therapy have been shown to be effective interventions for both typically developing children and for children with ASD. Several studies have demonstrated effectiveness of behavioral interventions for sleep onset and maintenance problems in children with ASD [61], [62]. Richdale and Wiggs [82] have written a comprehensive review of behavioral interventions in children with developmental disabilities and autism. Basic principles of sleep hygiene include the selection
Pharmacological treatment
When behavioral interventions are not effective or lead only to a partial response, pharmacological treatment options should be considered in as an adjuvant to ongoing behavioral therapy for sleep disorders. When considering pharmacological options, it is important to realize that there are no medications approved by the Food and Drug Administration (FDA) for the treatment of pediatric insomnia. Selection of a sleep-promoting agent should be based on the individual patient’s characteristics,
Conclusion
Children and adolescents with an ASD are at substantial risk for experiencing sleep problems, particularly insomnia. The clinician assessing a child with an ASD should screen carefully for sleep disorders and make referrals as indicated. Identifying and treating sleep disorders may result not only in improved sleep, but also impact favorably on daytime behavior and family functioning. Fortunately, there are a variety of treatments available, including behavioral interventions and
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