Evaluating the effect of repetitive transcranial magnetic stimulation on sleep difficulties in children with autism spectrum disorder: a randomized controlled trial

Introduction There are no controlled studies examining the impact of repetitive transcranial magnetic stimulation (α-rTMS) on sleep difficulties in children with autism spectrum disorder (ASD). Method Twenty children (6-12yrs old; 16 males) with ASD (level 2) and sleep difficulties were recruited and randomised into α-rTMS and waitlist control groups (1:1). The treatment group received ten sessions of α-rTMS. Sleep outcomes were assessed at baseline and immediately post-α-rTMS on the Children Sleep Habit Questionnaire (CSHQ). Result The total CSHQ score was significantly improved in the treatment group as compared to the waitlist control group (-12.6; 95% CI –22.3, –2.3; p= 0.015; d= -1.25). Bedtime resistance (-0.61; 95% CI –1.04, –0.19; p= 0.008; d= -1.418), sleep onset delay (-1.0; 95% CI –1.7, -0.3; p= 0.006; d=-1.4), and sleep duration (-0.6; 95% CI –0.19 to –0.9, p= 0.007, d= -1.5), all improved. The treatment group reported no adverse events. Conclusion Preliminary evidence suggests that α-rTMS is well-tolerated and improves sleep difficulties in children with ASD.

Questionnaire Helps Identify Children's Sleep Disorders

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration. To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program. This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data. A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school. Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used. The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months. The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects. ClinicalTrials.gov Identifier: NCT03556462.

Sleep problems in children with fetal alcohol spectrum disorders (FASD) are reportedly common but not well characterized. Objectives were to: (1) assess sleep concerns in children with FASD using a caregiver-report survey, the Children's Sleep Habits Questionnaire (CSHQ); (2) compare CSHQ results with those of previously reported community sample; and (3) describe pilot polysomnography findings in children with FASD. Children with FASD were recruited from a behavioral intervention study, and participating caregivers completed the CSHQ. CSHQ results were compared with the original data from a previously published community sample of similar age. Participants with FASD and elevated CSHQ scores were offered overnight polysomnography. Thirty-three children with FASD (4.1-12.1 years) were enrolled; 85% of children with FASD scored above the clinical cutoff Total Score of 41, reflecting marked sleep disturbance. Elevated subdomain scores occurred primarily in areas concerning for pediatric insomnia. Those with comorbid ADHD had elevated CSHQ on additional subdomains with no difference in Total Scores. Compared with the community sample, children with FASD had higher Total Scores on the CSHQ (52 vs. 39, p < 0.001). Polysomnography, completed in 5 subjects, revealed mild sleep disordered breathing and fragmented sleep with elevated non-respiratory arousal indices. Clinically significant sleep problems are present in children with FASD on both subjective and objective measures. Further investigation is needed to better describe these sleep disturbances and their impact on overall health and daytime neurobehavioral problems in this clinical population.

Pain and sleep difficulties in young children with cerebral palsy does not vary by gross motor function, parent demographics, or parent expectations for rehabilitation therapy.

SummarySleep difficulties are presumably a transdiagnostic factor in the complex aetiology of psychiatric disorders in youth. This study assessed the prevalence of sleep difficulties in children and adolescents seeking specialized psychiatric care, examined the relationships of internalizing and externalizing problems, and considered the moderating role of sex and age on these relationships. Parent‐reported data on difficulties initiating sleep, difficulties maintaining sleep, early morning awakenings and daytime fatigue from a large sample of children and adolescents referred for specialized psychiatric care (n = 4638; < 18 years) were used to estimate prevalence rates. To examine associations between these sleep difficulties and internalizing/externalizing problems, multiple linear regression analyses were conducted on available data (n = 3768) stratified in three age groups (1.5–5 years; 6–11 years; 12–18 years). Overall prevalence, i.e. at least one sleep difficulty was reported to be often or always present, was 65%. Difficulties initiating sleep occurred the most, closely followed by daytime fatigue. In all age groups, sleep difficulties were positively related to internalizing and externalizing problems. In young children and school‐age children, age moderated the interaction between sleep difficulties and internalizing problems. To conclude, prevalence rates of sleep difficulties in children with mental illness appear higher than it has been reported in the general youth population, especially difficulties initiating sleep and daytime fatigue. We observed that the associations between internalizing problems and sleep difficulties in young children and school‐age children seemed to be amplified with age, suggesting a negative, bidirectional, spiral in development.

Sleep & attention profiles in children with Autism Spectrum Disorder

Association between sensory modulation and sleep difficulties in children with Attention Deficit Hyperactivity Disorder (ADHD)

Although higher sleep problems have been mostly reported in children with autism spectrum disorder (ASD) compared with typically developing (TD) children, particularly in Western countries, such evidence is relatively scarce in developing countries. We therefore investigated sleep difficulties in Thai children aged 3-16years with ASD compared with age- and gender-matched TD children by using the Children's Sleep Habits Questionnaire (CSHQ)-Thai version. Sixty-five children with ASD (mean age 97.7, SD 44.5months; boys 70.8%) and 65 TD individuals (mean age 98.5, SD 43.5months) were enrolled at a university-based hospital in Bangkok. Background characteristics, sleep duration variables, and the CSHQ were completed by the participants' parents. The CSHQ subscales and total score between children with ASD and TD controls were then compared. Children with ASD were more likely to have longer sleep latency than TD individuals for both weekdays and the weekend. Those with ASD had higher CSHQ subscales including bedtime resistance, sleep onset delay, sleep anxiety, and night waking in addition to the CSHQ total scores than TD controls. In the ASD group, those who took psychostimulants for treatment of ADHD had lower scores on the sleep duration subscale compared with unmedicated individuals. Sleep difficulties were more prevalent in children with ASD compared with TD individuals. Parents should be advised to be aware of sleep problems in individuals with ASD. As such, sleep disturbances will be identified early, resulting in appropriate management and improved quality of life, not only for those with ASD but also their families.

Sleep difficulties can co-occur with autistic traits and have been frequently reported in children diagnosed with autism. Thus, sleep difficulties may impact neural development, cognition, and behavioural functioning in children with autism. Interventions, such as repetitive transcranial magnetic stimulation (rTMS), that target aberrant neural structures underpinning autistic traits and sleep difficulties in children could have beneficial effects. The rTMS effects on the pathophysiological pathways hypothesised to underpin autism and sleep difficulties are well-established in the literature; however, clinical evidence of its potential to improve sleep difficulties in children with autism is limited. While the preliminary data is promising, further robust rTMS studies are warranted to encourage its use in clinical practices.

An exploratory study of sleep quality and quantity in children with causal variants in SYNGAP1, an autism risk gene

Correspondence of maternal and paternal perception of school-aged children's sleep with in-home sleep-electroencephalography and diary-reports of children's sleep

Sleep problems in children with autism spectrum disorder: examining the contributions of sensory over-responsivity and anxiety

Abstract: Introduction: Sleep difficulties are some of the marked challenges faced by young people with autism, their families, and caregivers. Aim: The present study investigated the buffering effects of parental sleep knowledge and social support in the relationship between sleep difficulties in children with autism and poor family functioning. Methods: A convenience sample of 200 participants was recruited. Questionnaires were used to collect data. Results: Parental sleep knowledge moderates the relationship between sleep difficulties in children with autism and poor family functioning (Hypothesis 1 and Model 1), social support moderates the relationship between sleep difficulties in children with autism and poor family functioning (Hypothesis 2 and Model 2), and parental sleep knowledge and social support together buffer the relationship between sleep difficulties in children with autism and poor family functioning (Hypothesis 3 and Model 3). There is a positive relationship between a child’s sleep problems and their parents’ family functioning. Discussion/Conclusion: It is reasonable to expect that if the child is not sleeping or is not sleeping well, the parent and family are also likely to experience sleep problems in some way. Moreover, sleep problems in children can significantly and profoundly impact not only the developmental trajectory of the child but also negatively impact the family and heighten stress.

To pilot a clinician-based outcome measure that provides complementary information to objective measures and parent-based questionnaires for insomnia in children with autism spectrum disorders (ASD). The authors developed a Pediatric Sleep Clinical Global Impressions Scale (CGI). Questions included (1) the child's ability to fall asleep and remain sleeping independently (i.e., apart from parents); (2) bedtime resistance; (3) sleep onset delay; (4) night awakening; (5) parental satisfaction with their child's current sleep patterns; (6) family functioning as affected by their child's current sleep patterns; and (7) clinician's overall concern with the child's sleep. After refining the instrument through the evaluation of vignettes by ASD and sleep experts, the authors piloted the Pediatric Sleep CGI in a 12-week randomized trial of iron supplementation in children with ASD. Clinicians completed Pediatric Sleep CGIs and structured sleep histories, parents completed the Children's Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches. In repeated measures models, the Pediatric Sleep CGI and CSHQ were correlated for sleep onset delay (r = .66, p < .001), night wakings (r = .40, p < .001), and total score (r = .29, p < .001). The CGI-S sleep onset delay and actigraphy sleep onset delay scores (r = .75, p = .0095) were also correlated. The overall CGI-S showed improvement with therapy (p = .047). The Pediatric Sleep CGI shows promise in measuring clinician-rated outcomes in pediatric insomnia in children with ASD. Larger samples will be necessary to examine reliability, validity, and measure to change, as well as applicability to other populations with pediatric insomnia.