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Sleep issues occur at higher rates in children with neurodevelopmental disorders than in the typical population. Little is known about the impact of COVID-19 on sleep issues in this population
Method
This integrative review aimed to characterize studies during the COVID-19 pandemic (2020–2022) addressing the prevalence and management of sleep issues in children and youth with neurodevelopmental disorders.Comprehensive database searches were used to identify articles, and 31 studies were considered suitable for this review.
Results
Most studies reported worsening sleep disturbances during COVID-19 restrictions. All studies were conducted when clinics were closed; only two studies addressed treatment options such as music therapy and sleep hygiene education and found improvement in sleep issues.
Discussion
Future research needs to concentrate on developing interventions to assist families remotely and empower families with a toolkit of preparedness in times of crisis
A notable COVID-19 outbreak rapidly spread throughout many countries in December 2019; stay-at-home orders were issued to contain the virus in the ensuing months. These lockdown orders persisted for several weeks to months, causing a complete disruption of daily routines in the general population because of working from home, homeschooling, and reduced levels of physical activity and social gatherings (
). During the COVID-19 restrictions, only 4.8% of children and 0.6% of youth met recommended activity guidelines, whereas leisure screen time and social media use were reported as much higher than before the COVID-19 lockdowns (
Adverse Effects of the COVID-19 Pandemic on Movement and Play Behaviours of Children and Youth Living with Disabilities: Findings from the National Physical Activity Measurement (NPAM) Study.
International Journal of Environmental Research and Public Health.2021; 18: 12950
Children with neurodevelopmental disorders (NDD) such as autism spectrum disorder (ASD) commonly have difficulties in behavior, communication, and sensory integration (
Predicting impairment in major life activities and occupational functioning in hyperactive children as adults: Self-reported executive function (EF) deficits versus EF tests.
). In addition, 35% to 95% of children with NDD reported sleep-related symptoms such as restless sleep, waking very early, and being tired during the daytime, but only 15% of them reported complaints about sleep problems (
Thus, disruption to daily activities, educational routines, and scheduled therapies because of COVID-19 lockdowns may have been a source of stress leading to an exacerbation of sleep problems. Synthesizing information on the impact of COVID-19 restrictions on sleep is crucial to recovering from the pandemic and may also assist in preparing this vulnerable population for future public health stressors. In addition, this information is crucial to providers in addressing parental questions and concerns while providing therapeutic advice.
METHODS
The authors conducted an integrative review following the updated methodology described by
, comprising a five-step process: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation. The integrative review methodology allows researchers to summarize empirical studies with varied methodologies to better understand a health care phenomenon (
). Although the method explicitly allows for the inclusion of theoretical literature, the authors chose to restrict their analysis to empirical studies.
Problem Identification
Sleep issues occur at higher rates in children with NDD than in the typical population. Little is known about the impact of COVID-19 on sleep issues in this population. This integrative review aimed to characterize empirical studies focused on sleep behaviors in children and youth, aged from birth to 21 years, with NDD during the COVID-19 pandemic (2020–2022).
Literature Search
The authors created comprehensive searches in PubMed, CINAHL, Embase (Embase.com), American Psychological Association PsycINFO (EBSCOhost), and Scopus to identify articles that addressed sleep issues in children with NDD during the COVID-19 pandemic. The search strategy focused on four broad sets of terms, including (1) sleep and sleep disorders, (2) neurodevelopmental disorders, (3) children, and (4) COVID. The search included keywords, database-specific controlled vocabulary terms (e.g., MESH, Emtree, etc.), Boolean operators, and term truncation, as necessary, to maximize search results. When appropriate, controlled vocabulary terms were “exploded,” a search process that simultaneously searches for a broad concept such as sleep disorders while searching for a list of specific sleep disorders. To maximize retrieval related to the COVID-19 pandemic, the authors used the Canadian Agency for Drugs and Technologies in Health PubMed and Scopus search strings and adapted the Embase search string, which was written for Ovid. Because the search strings were not written for CINAHL and American Psychological Association PsycINFO, the authors used them as a starting point to develop the COVID searches, substituting appropriate controlled vocabulary from each database (
). The searches were finalized and conducted in each database on May 6, 2022, and were limited to English-language articles published in 2020–2022. Interested readers can view the full text of the searches at https://doi.org/10.6084/m9.figshare.20186600.
Inclusion criteria were empirical studies that addressed children with NDD and sleep issues that specifically addressed the COVID-19 pandemic. For this review, children were defined as aged from birth to 21 years because the U.S. Individuals with Disabilities Education Act provides services through 21 years of age (1990). Articles were excluded if they did not describe a study methodology, were not in English, not available in full text, or did not specifically address the impact of the COVID-19 pandemic on sleep in children with NDD.
The Figure shows the steps of the study selection process using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (
). The authors used Covidence systematic review management system (https://www.covidence.org/) to collaborate on the review process. Covidence removes duplicate references and enables team members to screen titles and abstracts independently for inclusion and full-text articles for exclusion. When team members’ decisions differed, they discussed the studies via live meetings and email to reach a consensus. After completing all these steps, the authors identified 61 studies for full-text review and selected 31 studies for data extraction.
FIGUREPreferred Reporting Items For Systematic Reviews and Meta-Analyses flow diagram.
). This system includes five levels, A through E, and is effective when quantitative and qualitative primary sources are included. Level A is the highest level of evidence and includes meta-analyses and meta-synthesis. Level E is the lowest level and includes case reports and expert opinions. All studies in this review met level C evidence, encompassing qualitative, descriptive, or correlational studies, integrative reviews, systematic reviews, or some randomized controlled trials that bear inconsistent results. Because relatively few empirical studies have been published that address the COVID-19 pandemic's impact on sleep in children with NDD, the authors chose the American Association of Critical Care Nurses hierarchy as the most appropriate method to evaluate the overall quality of studies. Evaluation methods also included ensuring that the studies fully addressed the research question and specific research method. The authors chose to eliminate case studies, which they concluded provided minimal evidence that could be used to address the research question.
Data Analysis and Presentation
The authors constructed a matrix table to capture study characteristics, including setting/country purpose, research design, period, sample size and characteristics, and measurements/instruments. After extracting the data from the matrix, the authors reviewed it for accuracy and completeness. The authors then thematically analyzed the results matrix to find their commonalities and differences.
RESULTS
Samples
All 31 studies focused on children and youth with NDD, grouped or separated into specific populations. Twelve studies (39%) focused solely on ASD, whereas six (19%) enrolled participants with ADHD only. One study compared these two sample populations. Nine studies (29%) enrolled participants with neurodevelopmental disorders, including ASD, ADHD, learning disabilities, cerebral palsy (CP), or other physical, sensory, neurological, or cognitive diagnoses. Three individual publications emerged for CP, epilepsy, and fragile X syndrome. See Table 1 for sample sizes.
To investigate the effects of the COVID-19 pandemic on body structures and functions, activity and participation levels, and environmental factors of children with CP
To investigate the feasibility and impact of a home-based music therapy program to sustain children with developmental disorders secondary to neurological diseases and their parents
Changes in sleep patterns and disorders in children and adolescents with attention deficit hyperactivity disorders and autism spectrum disorders during the COVID-19 lockdown.
To evaluate the impact of the lockdown on sleep patterns and sleep disturbances with respect to the preceding conditions in children and adolescents with ASD
Descriptive
May to June 2020
111 participants with ASD, aged 1–18 years
A modified version of the Sleep Disturbance Scale for Children (SDSC)
To investigate the relationship between chronotype preference/sleep problems and symptom severity of children with ADHD and to assess the chronotype preference/sleep problems that may playa mediating role in the relationship between the reactions to trauma and the severity of ADHD symptoms
To evaluate the effects of COVID-19 quarantine on sleep quality as an indicator of psychological well-being among children and adolescents
Cross-sectional
September–October 2020
6,210 children aged 0–18 years, including children affected with specific learning disabilities, ASD, other disabilities, chronic diseases, and multiple conditions
Those in the shadow of the pandemic: Impacts of the COVID-19 outbreak on the mental health of children with neurodevelopmental disorders and their parents.
To investigate the emotional and behavioral responses of children with neurodevelopmental disorders and their parents during the recent novel coronavirus disease (COVID-19) pandemic and the associated factors
Cross-sectional
April 2020
299 children and adolescents with neurodevelopmental disorders aged 2–18 years
Sociodemographic form and COVID-19 pandemic-related characteristics, HADS
COVID-19 pandemic effects in people with autism spectrum disorder and their caregivers: Evaluation of social distancing and lockdown impact on mental health and general status.
Research in Autism Spectrum Disorders.2021; 83101757
To examine the impact of the COVID-19 pandemic on child mental health and socioemotional and physical well-being (including sleep, diet, exercise, use of electronic media; caregiver perceptions of symptoms of child NDD and comorbidities), and caregiver mental health and well-being, social support and service use
Cross-sectional
May–June 2020
302 caregivers of children with neurodevelopmental disabilities aged 2–17 years
Child symptom severity and well-being, parent well-being, and service access and satisfaction questionnaire
To explore how the lives of children with special needs and their families were affected by the COVID-19 pandemic
Descriptive
Enrolled in April 2020 (approximately 6 weeks after the lockdown)
117 children with DD, ASD, hearing or language impairments, and receiving special education, aged 4–6 years
Five-part questionnaire focusing on the amount of change caused by the COVID-19 pandemic on feeding, toilet habits, daily routines, development, physical activities, daily activities, one-on-one time durations with parents, screen time, and whether and how much they performed and maintained their previous educator-provided special education at home were collected using
To define the frequency and types of sleep problems in a sample of children with DDs, determine the proportion of pediatricians who addressed such difficulties, assess the effects of SH, and describe the impact of the COVID-19 pandemic on sleep
Quasi-experimental
May 2020
161 children with DDs, ages 1–6 years, who attended clinic visits between July 2019 and March 2020 with follow-up before July 2020
Children's Sleep Habits Questionnaire, Spanish version (CSHQ-S), completed before and after interventions
Adverse Effects of the COVID-19 Pandemic on Movement and Play Behaviours of Children and Youth Living with Disabilities: Findings from the National Physical Activity Measurement (NPAM) Study.
International Journal of Environmental Research and Public Health.2021; 18: 12950
Behavioral implications of the Covid-19 process for autism spectrum disorder, and individuals’ comprehension of and reactions to the pandemic conditions.
To investigate how individuals with ASD responded to COVID-19 regarding their comprehension and adherence to implemented measures, changes in their behavioral problems, and how their caregivers’ anxiety levels relate to these behavioral changes
Not specified
During the last 1-month, COVID-19 measures were implemented
87 individuals with ASD, mean age 13.96 ± 6.1, and age range of 3–29 years
To evaluate the consequences of the lockdown in children and teenagers diagnosed with ADHD, sleep-related problems, and problems with executive functions
Associative-comparative and explanatory
April 2020
234 children divided into two groups, confined ADHD and confined non-ADHD, aged 6–18 years
STAIC self-assessment questionnaire, BEARS sleep-screening tool for sleep disorders in childhood, BDEFS- CA, short form
A study on impact of corona virus disease 2019 pandemic on activities of daily living, play, and sensory behaviors of children with autism spectrum disorder: A cross-sectional survey study.
Indian Journal of Occupational Therapy.2021; 53: 64-76
Comparing the impact of the first and second wave of COVID-19 lockdown on Slovak families with typically developing children and children with autism spectrum disorder.
To explore how the first and second waves of the COVID-19 outbreak affected the mental health of families in Slovakia, focusing on comparing families with autistic children to a general sample. Focused on the prevalence of depression, anxiety, and stress symptoms among the parents and maladaptive behavior or sleep disturbances of their children and their correlations
Not specified
First wave from June to July 2020, and second wave from November to December 2020
332 caregivers, 155 having children with ASD (179 surveyed during the first wave and 153 during the second wave)
To assess how the COVID-19 pandemic has affected children with epilepsy
Not specified
May 2020
3,321 responses to the survey (96.6% caregivers of patients aged 0 to > 18 years), 59.7% of patients had an intellectual disability, and 44.3% had behavioral disturbances
To investigate the relationship between chronotype preference/sleep problems and symptom severity of children with ASD during the confinement and social isolation of the COVID-19 outbreak
To evaluate how the QOL of children and their parents has been affected by changes in the sleep cycles of children with NDDs and stresses caused by mothers’ work patterns during the COVID-19 pandemic
Not specified
April–May 2020
136 school-age children with IDD, mean age 10.6 ± 2.6
CBCL, WISC-IV, WHO-QOL-BREF, CES-D, STAI, PSI
Note. ABC, aberrant behavior checklist; ABCD, Adolescent Brain Cognitive Development study; ADHD, attention deficit hyperactivity disorder; ADL, activities of daily living; ADOS-2, Autism Diagnostic Observation Schedule-2; ASD, autism spectrum disorder; AuBC, autism behavior checklist; BAI, Beck Anxiety Inventory; BDEFS-CA, Barkley Deficits in Executive Functioning Scale—Children and Adolescents; CAPES-DD, Child Adjustment and Parent Efficacy Scale-Developmental Disability; CBCL, Child Behavior Checklist; CCQ, Children's Chronotype Questionnaire; CES-D, Center for Epidemiologic Studies Depression scale; CP, cerebral palsy; CRIES-8, Children's Impact of Event Scale;
GAD-7, generalized anxiety disorder 7; GMFCS, Gross Motor Function Classification System; GMFCS-FR, Gross Motor Function Classification System Family Report; HADS, Hospital anxiety and depression scale; KSADS-5, kiddie schedule for affective disorders and schizophrenia for DSM-5; NDD, neurodevelopmental disorders; PHQ-9, Patient Health Questionnaire 9;
PMQ, parental monitoring survey; PSI, Parental Stress Index; QOL, quality of life; PMP, parent medications survey inventory modified from PhenX; PSI-SF, Parent Stress Index-short form
PSQI, Pittsburgh Sleep Quality Index; RRR, rapid response research survey; SAS, Self-Rating Anxiety Scale; SDSC, Sleep Disturbance Scale for Children; SH, sleep hygiene; SHQ, Sleep Health Questionnaire; SNAP-IV, Swanson, Nolan, and Pelham Teacher and Parent Rating Scale; SRPF, School Risk and Protective Factors Survey; STAI, State-Trait Anxiety Inventory; STAIC, State-Trait Anxiety Inventory for Children; T-DSM-IV-S, Turgay DSM-IV Disruptive Behavior Disorders Rating Scale; VABS-II, Vineland Adaptive Behavior Scales, second edition; WHO-QOL-BREF, World Health Organization quality of life; WISC-IV, Wechsler Intelligence Scale for Children (fourth edition).
Each of the 31 studies examined sleep in various ways. Six validated sleep instruments were employed in 11 quantitative studies. These tools included: the Sleep Habits Survey (
The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence.
Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
Journal of the American Medical Association.1999; 282: 1737-1744
). The remainder of the quantitative studies included ad hoc sleep questions in surveys or study-specific instruments (e.g., mCare tools). The one qualitative study employed a semistructured phone interview (
Changes in sleep patterns and disorders in children and adolescents with attention deficit hyperactivity disorders and autism spectrum disorders during the COVID-19 lockdown.
). Children with ADHD demonstrated later bedtime and rise time than those with ASD or controls. Both clinical groups significantly demonstrated a reduced sleep duration compared with controls. These two groups also had an increase in hypnic jerks, rhythmic movement disorders, night awakenings, restless sleep, sleepwalking, and daytime sleepiness over the control group. All groups had increased anxiety at bedtime, difficulties falling asleep, and daytime sleepiness.
ASD: Validated sleep tools
Using the SDSC, one study found a significant increase in sleep disturbances, difficulty falling asleep, anxiety at bedtime, sleep terrors, and daytime sleepiness (
). Parents reported the following factors impacting their child's sleep: lack of obliged rise time, lack of sports activities, increased screen time, more time spent with family, and changes in routine (
Behavioral implications of the Covid-19 process for autism spectrum disorder, and individuals’ comprehension of and reactions to the pandemic conditions.
). Parents who were asked to complete one copy of the CSHQ with reference to behaviors during the pandemic and one copy with reference to prepandemic behaviors reported that 89.3% of children had clinically significant sleep disturbances during the pandemic (
). Employing both the CSHQ and CCQ, researchers reported that children with ASD had significantly greater sleep problems and chronotype score (eveningness) during home confinement, and sleep problems mediated the relationship between chronotype score and severity of autism symptoms (
When parents were asked to rate changes in their child's sleep during the pandemic, most respondents reported no change in sleep (55.5%), but when a change was reported, it was perceived as worsening (
). These authors also performed a multivariate analysis that revealed that a higher Autism Diagnostic Observation Schedule-2 score was associated with a decreased probability of improvement in sleep, and belonging to a single-parent home was associated with worsening sleep (
). An observational study of nine adolescents with ASD found that while sleep and wake times may have shifted, there were no reported differences in sleep duration prepandemic or during the pandemic (
). A larger survey discovered that half the parents reported sleep problems in their children and reduced outdoor activity. These families also reported a lack of professional support during the pandemic (
COVID-19 pandemic effects in people with autism spectrum disorder and their caregivers: Evaluation of social distancing and lockdown impact on mental health and general status.
Research in Autism Spectrum Disorders.2021; 83101757
). A parent survey that focused on activities of daily living, play, and sensory behaviors identified 67% of the sample as having inconsistent sleep routines; the occupation of homemaker was 2.51 times more likely to report difficulty in managing their child's sleep schedule (
A study on impact of corona virus disease 2019 pandemic on activities of daily living, play, and sensory behaviors of children with autism spectrum disorder: A cross-sectional survey study.
Indian Journal of Occupational Therapy.2021; 53: 64-76
). When comparing children with ASD to a control group, children with ASD demonstrated a significantly later bedtime, but as the COVID-19 lockdown progressed, sleep routines partially returned to pre-COVID-19 condition (
Comparing the impact of the first and second wave of COVID-19 lockdown on Slovak families with typically developing children and children with autism spectrum disorder.
A longitudinal study that used two mCare tools to gather pre-lockdown, lockdown, and post-lockdown information on 30 behavioral parameters found four behaviors (i.e., aggression, lack of concentration, pain sensitivity, sleep problems) were negatively impacted during the lockdown (
Through a semistructured phone interview, researchers found sleep to be a common topic. Challenges were shared about children with ASD having difficulties falling asleep, frequent awakenings, or night terrors. The situation was compounded by closed outpatient clinics; some parents explored new ways to deal with their child's sleep issues (e.g., obtaining melatonin from another country;
In a prospective study, parents completed the Sleep Habits Survey and adolescents with ADHD completed the SDSC; findings indicated shifts in sleep/wake schedules and longer sleep duration with clinically elevated rates of difficulties initiating and maintaining sleep; more worried/afraid effect, and less time outdoors correlated with more delayed sleep/wake behaviors (
). In a large sample of children and adolescents with ADHD, a modified version of the SDSC showed that the imposed COVID-19 lockdown affected sleep-wake rhythm dramatically from previous bedtime behaviors. These changes were associated with increased screen time (
). One study that used both the CSHQ and CCQ along with the perception of trauma found eveningness chronotypes exhibited higher trauma symptoms and sleep problems, higher trauma scores were associated with higher chronotype scores, sleep problems, and oppositional defiant disorder symptoms, sleep levels mediated the relationship between trauma and oppositional defiant disorder symptoms, and sleep levels mediated the relationship between trauma and chronotype scores (
). When comparing children and adolescents with and without ADHD, those with ADHD were more negatively affected by the lockdown and had higher reported sleep problems, anxiety, and executive function issues (
The Adolescent Brain and Cognitive Development Study compared youth with ADHD and matched controls without ADHD and found 1 year into the pandemic that youth with ADHD exhibited greater sleep problems with medium effect sizes (d = −0.52); the combined main effects of ADHD medication, ADHD diagnostic status, and screen time were significant predictors of sleep problems (
). In a study investigating lifestyle behaviors in children with ADHD during the pandemic, these youth showed worsening changes in sleep, eating, screen time, and exercise with reported correlations to depression, anxiety, and ADHD symptoms (
A prospective noncontrolled pilot study using the SDSC investigated the impact of a home-based music therapy intervention and observed significant improvements in sleep quality and reduction of parental stress in a cohort of children with developmental delay (
). A quasi-experimental study using the CSHQ-S before and after pediatricians addressed sleep hygiene found half of the children with developmental delay had sleep problems that worsened during the pandemic, insomnia being most prevalent; pediatricians addressed sleep hygiene in only 45% of cases, but the intervention was found to be beneficial for most cases (
The Child Behavior Checklist subscale for sleep problems revealed a clinically worsening condition during the pandemic in younger children with neurological and/or psychiatric disorders (
). A large web-based survey examined sleep disorders in children aged < 18 years, including those with disabilities, ASD, chronic disorders, and specific learning disabilities; results indicated more difficulties falling asleep, staying asleep, and increased frequency of nightmares and/or sleep terrors with additional analyses identifying multiple risk factors (
). Delayed sleep phase and dyssomnia were the most frequently reported sleep problems in a survey investigating emotional and behavioral responses of children with neurodevelopmental disorders to the pandemic (
Those in the shadow of the pandemic: Impacts of the COVID-19 outbreak on the mental health of children with neurodevelopmental disorders and their parents.
). Two similarly designed studies reported reduced sleep quality and worsening sleep in children with neurodevelopmental disabilities and comorbidities (
). The National Physical Activity Measurement Study surveyed parents of children and youth with developmental, physical, and/or sensory type of disabilities and reported a slight increase in sleep quantity, and parent capacity and opportunity to support a child's sleep was associated with better sleep quality (
Adverse Effects of the COVID-19 Pandemic on Movement and Play Behaviours of Children and Youth Living with Disabilities: Findings from the National Physical Activity Measurement (NPAM) Study.
International Journal of Environmental Research and Public Health.2021; 18: 12950
). Worsening sleep patterns in children with neurodevelopmental disorders was one of several factors associated with low quality of life for both parents and children during COVID-19 (
A prospective investigation on the functional health status of children with CP reported that 17.5% experienced a decrease in sleep duration, whereas 25.2% experienced an increase in sleep duration (
). Children with fragile X syndrome demonstrated significant sleep changes during the lockdown, including difficulties falling asleep, longer falling asleep time, and frequency of night awakenings (
The impact of the COVID-19 pandemic and subsequent lockdowns was a universal phenomenon. The studies selected in this review represented various countries that experienced similar restrictions. Although studies varied in the number of participants, tools used to measure changes in sleep, and study design, all participant sampling focused on children with NDD. A common hypothesis among the studies was that children with NDD have higher rates of reported sleep problems at the most typical times.
All but two studies that enrolled ASD participants reported worsening sleep behaviors. A noted difference between the two studies was the sample size.
had 28 participants who had clinically significant sleep problems before the pandemic and reported that sleep problems either did not change or improved.
enrolled nine participants and reported no changes in sleep duration but only shifts in sleep times.
Several studies with ASD participants investigated correlations with sleep. Children with higher Autism Diagnostic Observation Schedule-2 scores, belonging to single-parent households, the occupation of homemakers, and less time outdoors was associated with worsened sleep (
A study on impact of corona virus disease 2019 pandemic on activities of daily living, play, and sensory behaviors of children with autism spectrum disorder: A cross-sectional survey study.
Indian Journal of Occupational Therapy.2021; 53: 64-76
All studies with ADHD participants reported consistent worsening sleep problems and other behavioral changes. Predictors of sleep quality in this population included ADHD medication, diagnostic status, and screen time (
). All studies included in this review were conducted when clinics were closed, and behavioral support and treatment options were minimally available. Without treatment options, the quality of life for families was challenged (
Overall, this integrative review uncovered a trend toward worsening sleep problems in a sample of international studies focusing on children with NDD. These studies underscored that sleep behaviors rarely occur in isolation but can predict, mediate, or be associated with other personal or environmental factors. All studies included in this review measured sleep using subjective instruments. Strong evidence supports the use of actigraphy to objectively monitor and track sleep in children with neurodevelopment disorders (
). The actigraph device measures sleep in-home setting and are considered an objective method for measuring sleep onset, sleep-wake patterns, and sleep duration. Future studies should consider this method to provide objective and detailed data to obtain valuable information about this population. Future research will also need to develop interventions that consider personal or environmental factors to assist families during periods of isolation and when clinical support are lacking. It would behoove clinicians to assimilate techniques that easily transfer to home-based interventions and that can empower families with a toolkit of preparedness in times of crises.
The authors would like to add one final note. Providing in-depth assessment and treatment options for sleep problems in children with NDD is beyond the scope of this integrative review. Comprehensive practice guidelines for treating insomnia and disrupted sleep in ASD have been developed by a subcommittee of the American Academy of Neurology (
Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.
). These guidelines provide evidenced-based recommendations for both nonpharmacologic and pharmacological treatment options. We encourage clinicians to refer to these guidelines and develop their sleep assessment and treatment toolkit on the basis of the unique needs of their practice population. Because the first crucial step to effectively addressing sleep problems is gaining a thorough understanding of the scope and characteristics of the chief concerns, we offer Table 2, which includes a summary of validated sleep assessment tools and additional resources for ease of reference.
TABLE 2Validated sleep assessment tools often used in children with NDD
Screening tool
Description
Reference
BEARS
BEARS is divided into 5 major sleep domains (B = Bedtime Issues, E = Excessive Daytime Sleepiness, A = Night Awakenings, R = Regularity and Duration of Sleep, S = Snoring). Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview
The 22-item scale gathers comprehensive sleep habits information about daytime habits, prebedtime habits, presence of a bedtime routine, sleep environment, and parental behaviors surrounding bedtime
Fifty-one items are structured in two parts: Part 1 targets sleep quantity and quality, and Part 2 targets specific sleep disorders. The 36 items scored on a Likert scale pertain to six common sleep problem categories: bedtime resistance/struggles, sleep onset delay, parasomnias, sleep-disordered breathing, sleep anxiety, and daytime sleepiness
Various diaries are available to record information on a nightly basis. Preferred measurement for more detailed assessment of sleep-wake rhythms. Highly correlated to actigraphy for monitoring sleep schedule
26 Likert-type items were divided into six categories items into six categories: disorders of initiating and maintaining sleep, sleep breathing disorders, disorders of arousal/nightmares, sleep-wake transition disorders, disorders of excessive somnolence, and sleep hyperhidrosis (nighttime sweating)
The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence.
Predicting impairment in major life activities and occupational functioning in hyperactive children as adults: Self-reported executive function (EF) deficits versus EF tests.
Changes in sleep patterns and disorders in children and adolescents with attention deficit hyperactivity disorders and autism spectrum disorders during the COVID-19 lockdown.
The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence.
Those in the shadow of the pandemic: Impacts of the COVID-19 outbreak on the mental health of children with neurodevelopmental disorders and their parents.
COVID-19 pandemic effects in people with autism spectrum disorder and their caregivers: Evaluation of social distancing and lockdown impact on mental health and general status.
Research in Autism Spectrum Disorders.2021; 83101757
Adverse Effects of the COVID-19 Pandemic on Movement and Play Behaviours of Children and Youth Living with Disabilities: Findings from the National Physical Activity Measurement (NPAM) Study.
International Journal of Environmental Research and Public Health.2021; 18: 12950
Behavioral implications of the Covid-19 process for autism spectrum disorder, and individuals’ comprehension of and reactions to the pandemic conditions.
A study on impact of corona virus disease 2019 pandemic on activities of daily living, play, and sensory behaviors of children with autism spectrum disorder: A cross-sectional survey study.
Indian Journal of Occupational Therapy.2021; 53: 64-76
Comparing the impact of the first and second wave of COVID-19 lockdown on Slovak families with typically developing children and children with autism spectrum disorder.
Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
Journal of the American Medical Association.1999; 282: 1737-1744
Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology.
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