روش هایی برای ارزیابی خواب در کودکان مبتلا به اختلالات طیف اوتیسم: بررسی

A literature review completed by Bauer and Blunden (2008) determined that compared to objective measures, subjective assessments of sleep for typically developing children (e.g., parental reports) were of limited utility. No comparable literature review has been undertaken to determine whether subjective measures are appropriate for assessing sleep in children with autism spectrum disorders (ASD). Such a review is necessary as children with ASD have more sleep problems than typically developing children and children's sleep difficulties can negatively affect the child and other family members. It is, therefore, important to have measures of sleep for children with ASD that can reliably detect sleep problems and track improvements in sleep. This literature review described frequently used measures of children's sleep and evaluated their utility for assessing sleep in children with ASD. It was determined that, with the exception of sleep latency, parents’ reports of children's sleep are not consistently associated with objective measures of children's sleep. This was true for single-item parent-reports and for a widely used multi-item parent-report measure of children's sleep. Limitations of objective sleep measures (e.g., polysomnography, actigraphy), including the inability of children with ASD to tolerate such methods, are described.

There is consensus that the majority of children with autism spectrum disorders (ASD) also have sleep difficulties (Arbelle and Ben-Zion, 2001, Johnson, 1996, Richdale and Schreck, 2009, Richdale, 1999, Richdale, 2001 and Stores and Wiggs, 1998). Although not part of the diagnostic criteria for ASD, the co-occurrence of ASD and sleep problems is sufficiently common to suggest that sleep difficulties may be a characteristic of the ASD phenotype (Limoges et al., 2005 and Richdale and Prior, 1995). Further, research reports significant correlations between the sleep problems of children with autism and the severity of autistic symptomology (Hoffman et al., 2005 and Schreck et al., 2004). Significant consequences have been associated with sleep difficulties. For instance, it has been demonstrated that children's sleep problems affect working memory (Steenari, Vuontela, & Paavonen, 2003), increase the risk for physical injury (Owens, Fernando, & Mc Guinn, 2005), and can lower school achievement and motivation (Blunden et al., 2001, Gozal, 1998 and Meijer and van den Wittenboer, 2004). The impacts of children's sleep problems are not limited to the child. The sleep problems of children with ASD have been associated with impaired parental sleep (Lopez-Wagner, Hoffman, Sweeney, Hodge, & Gilliam, 2008), minor parental psychopathology (Shang, Gau, & Soong, 2006) and parental stress (Becker et al., 1991, Doo and Wing, 2006, Hoffman et al., 2008, Kataria et al., 1987, Norton and Drew, 1994, Patzold et al., 1998 and Scott and Richards, 1990). Likewise, improvements in children's sleep are associated with improvements in parents’ sleep (Robinson and Richdale, 2004 and Wiggs and Stores, 2001), psychological well-being (Adams and Rickert, 1989 and Durand and Mindell, 1990) and stress (Wiggs & Stores, 2001). Given that children with ASD struggle with sleep difficulties that can affect the child and other family members, it is important to have valid means for assessing sleep in these children. Further, to understand the nature of children's sleep and plan effective interventions for sleep difficulties, it is important to have measures of sleep that can reliably detect sleep problems and track improvements in sleep. However, assessing the sleep of children with ASD presents unique methodological challenges that have not been fully addressed by researchers. The goal of this literature review was, therefore, to describe frequently used measures of children's sleep and to evaluate their utility for assessing sleep in children with ASD. Bauer and Blunden (2008) reviewed research published after 1992 and assessed the validity of subjective reports of sleep for typically developing children. The authors concluded that subjective methods are valid for screening, but are not reliable indicators of the time taken to fall asleep (i.e., sleep latency), the frequency or duration of waking after sleep onset (WASO), or actual duration of sleep. Because the sleep of children with ASD differs from that of typically developing children, it is not clear whether the conclusions of the Bauer and Blunden review will hold for children with ASD. Despite the fact that a number of researchers have questioned the ability of sleep measures to assess children with ASD (e.g., Goodlin-Jones et al., 2008b, Goodlin-Jones et al., 2009, Hering et al., 1999, Meltzer, 2011, Oyane and Bjorvatn, 2005, Sitnick et al., 2008, Wiggs et al., 2005 and Wiggs and Stores, 2004), no one has systematically addressed the issue. In undertaking this project, we utilized a two-stage review process. In the first stage, a literature search for scholarly (peer reviewed) journals was conducted via EBSCOhost utilizing the search terms of children, sleep, autism spectrum disorder. This process yielded 176 articles. In the second-stage, a graduate research assistant reviewed each article to determine whether it provided information on the rates or types of sleep problems experienced by children with ASD. Fifty-two articles met these criteria. Of these 52 articles, 11 presented information that allowed for a comparison across two or more methods of assessing sleep.

An earlier review concluded that parental reports of sleep in typically developing children were appropriate for screening, but were not valid indicators of sleep latency, WASO, or sleep duration (Bauer & Blunden, 2008). This appears to be the case for children with ASD, with the notable exception that parents of these children are accurate reporters of sleep latency. Parents of children with ASD may, in fact, be focused on latency to the extent that it overshadows other relevant aspects of sleep. This potentially leads to over identification of sleep problems in children with ASD who have difficulty falling asleep (i.e., long sleep latencies), but who sleep well once asleep. Conversely, children with ASD who fall asleep quickly, but who have difficulties remaining asleep, may be erroneously identified by their parents as good sleepers. On the whole, limitations relating to the use of objective measures of sleep (e.g., expense, standardized procedures) are the same for populations of children with and without ASD. For children with ASD special attention is warranted as tolerating actigraphy or PSG may be particularly difficult. The night-to-night variability evidenced in some research on children with ASD (e.g., Malow et al., 2006) may suggest that even for children with ASD who can tolerate PSG, the conditions under which PSG is conducted (e.g., in the lab with sensors attached) lead to atypical sleep; thereby undermining the utility of the approach in this population. The procedure adopted by Souders et al. (2009) in which an actigraph was placed in a pajama sleeve shows promise for increasing the numbers of children with ASD who can be assessed via actigraphy. Nonetheless, researchers need to be mindful that there may be a greater tendency for contented sleeplessness in children with ASD, which actigraphy can erroneously record as sleep. Therefore, when WASO is relevant, researchers need to consider using videosomnography as an alternative or adjunct to actigraphy. To the greatest extent possible, researchers interested in studying sleep in children with ASD are encouraged to use multiple and objective measures of children's sleep. Researchers who opt, out of necessity or practicality, for parental-reports, should appreciate that parents of children with ASD may over-rely on sleep latency as an indicator of overall sleep problems. This is premised on the consistent associations between objectively assessed sleep latency and both parent responses to single items and standardized measures (i.e., the CSHQ) and, additionally, by a lack of consistent associations between other aspects of sleep recorded via objective and subjective means. There is modest evidence to suggest that a holistic parent-report measure, such as the CSHQ, can be superior to single-item responses for gauging the overall quality of children's sleep. Clearly more research is needed. Until additional insight is gained, the greatest utility of parent-report measures is for gathering parental perceptions of children's sleep. The problems with objective approaches for assessing children's sleep notwithstanding, with the exception of sleep latency, there is scant evidence to support that subjective measures are valid indicators of any specific aspect of the sleep of children with ASD or of their overall sleep quality.