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Sleep Characteristics in Children and Adolescents With Autism Spectrum Disorder

Article information

J Sleep Med. 2025;22(2):49-62
Publication date (electronic) : 2025 August 27
doi : https://doi.org/10.13078/jsm.250018
Lucía Monfort Belenguer,1orcid_icon, Teresa de la Calle Cabrera2orcid_icon, Gonzalo Pin Arboledas3orcid_icon
1Clinic Hospital of Valencia, Valencia, Spain
2University Hospital of Salamanca, Salamanca, Spain
3Clineva Clinc, Valencia, Spain
Address for correspondence Lucía Monfort Belenguer, MD Hospital Clinico Universitario de Valencia, Hospital Quiron Valencia, Cátedra de Sueño Universidad Europea-Exeltis, Blasco Ibañez, 17, Valencia 46010, Spain Tel: +34-961973500 E-mail: lumonbe@gmail.com
Received 2025 June 8; Revised 2025 July 5; Accepted 2025 August 1.

Abstract

This systematic review presents the known sleep characteristics of patients with autism spectrum disorder (ASD). Together with ASD, different diagnoses and comorbidities hinder the proper management of these patients. One of the most prevalent pathologies in patients with ASD is sleep disorder, with 50%–80% of children with ASD having insomnia. The literature describes that patients with ASD who have sleep problems will present an increase in their “core” symptoms: earlier development of attention deficit and hyperactivity disorder, irritability, aggressiveness, stereotypies, anxiety, and greater delay in language acquisition. Therefore, we consider it important to begin with a description of the sleep characteristics of patients with ASD, as this can serve as a foundation for establishing guidelines that support accurate identification and diagnosis, which is an important first step toward implemented targeted treatment both in terms of therapies and pharmacological management.

Keywords: Autism spectrum disorder; Sleep; Insomnia; Wakefulness; WASO

INTRODUCTION

Definitions

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in communication and social interaction, as well as restricted interests along with repetitive behaviors. These features are not best explained by intellectual disability or global developmental delay and are present from the earliest stages of development [1,2]. The point at which this functional impairment becomes evident varies according to the characteristics of the individual, their environment, the severity of the condition, the level of development, and chronological age; thus, the term “spectrum” is used. This definition by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is intended to be more precise and achieve earlier diagnosis in patients with ASD [3].

ASD is a neurobiological disorder influenced by both environmental and genetic factors that affect brain development. Investigations into the potential etiological mechanisms are currently ongoing, but no single cause of ASD has been identified to date [4].

There are many comorbidities described in patients diagnosed with ASD, including: 1) presence of other psychiatric diagnoses (anxiety, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder) [5] ; 2) digestive system involvement (constipation, diarrhea, irritable bowel syndrome, etc.) [5,6] ; 3) neurological disorders, the most frequent being epilepsy, with an increased risk in people with ASD, along with intellectual disability, female sex, age, and underlying genetic conditions [7,8] ; and 4) sleep disorders (insomnia, circadian rhythm disorders, etc.), the identification and management of which can improve epilepsy and behavioral problems [8,9].

Sleep is a complex neurophysiological process that varies throughout life, especially during the first 5 years [10,11]. Its macrostructure is divided into two phases: non-rapid eye movement sleep (NREM) and REM sleep. NREM is divided into three stages: light sleep (stage N1), transitional sleep (stage N2; K-complexes and sleep spindles), and deep sleep (stage N3). REM and NREM sleep progress cyclically, with each cycle lasting 50 minutes during infancy (0–1 years) and 90–110 minutes later [11-13]. Sleep affects physical wellbeing, attention, cognitive performance, mood, language, memory, and learning. Evidence suggests that sleep is involved in brain maturation and memory [12].

Prevalence and consequences

The American Academy of Pediatrics estimates that 25%–50% of children experience sleep difficulties [14]. This is significantly higher in patients diagnosed with ASD, reaching up to 50%–80% for sleep disturbances [15]. Other studies indicate that 44%–83% [16] of children with ASD have sleep problems. This high frequency of sleep disorders makes them one of the most common and clinically relevant comorbidities in the context of ASD.

Sleep disturbances in this population consistently include increased sleep onset latency, decreased sleep efficiency, reduced total sleep time (TST), elevated number of nocturnal awakenings (wakefulness after sleep onset [WASO]), and increased irregularity in circadian rhythms. In many studies, these characteristics have been associated with an increase in the severity of ASD symptoms such as stereotypies, behavioral problems, irritability and adaptive dysfunction. Likewise, a negative impact on cognitive development, attention, memory, and learning has been demonstrated, in addition to generating an increase in stress in the family nucleus.

Despite the growing volume of publications on sleep disorders and ASD, a significant portion of the literature has focused mainly on therapeutic interventions, validation of assessment scales, and heterogeneous populations with mixed neuropsychiatric diagnoses. Consequently, there is a clear need to systematically review scientific evidence that specifically describes the clinical and pathophysiological characteristics of sleep in children and adolescents with ASD and compare them with those of the neurotypical population. This approach would improve our knowledge of the mechanisms involved and facilitate the development of more effective diagnostic and therapeutic strategies.

Sleep problems in children with ASD are associated with reduced development of adaptive skills and increased internalizing and externalizing behaviors [17,18], including hyperactivity, sensory problems, anxiety, self-injury, tantrums, challenging behaviors, and reduced social skills.

Externalizing behaviors are directed toward the environment, specifically the external environment, and include hyperactivity-impulsivity or aggressiveness. Different articles have described that shorter sleep duration in early childhood is associated with an increase in externalizing behaviors, as well as with lower cognitive performance in neurodevelopmental tests [19,20]. A greater number of irritability problems, self-injurious behaviors, and social performance problems have also been demonstrated when comparing children with ASD who sleep adequately with those with ASD and insufficient sleep [21,22].

Therefore, this review is warranted due to the high prevalence of sleep disorders in ASD, their functional, cognitive, and emotional consequences, as well as the lack of studies that comprehensively and comparatively address sleep characteristics in this population.

A deeper understanding of these disturbances could contribute markedly to earlier detection, enable more appropriate interventions, and ultimately improve the quality of life of patients and their families.

METHODS

A systematic review of scientific literature was conducted following the criteria established in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to ensure a transparent and reproducible systematic review [23].

Research question in PICO format

To design the literature search strategy, a structured question was formed and divided into components using the patient, intervention, comparison, outcome (PICO) methodology. This subdivision was subsequently used to select and combine the appropriate terms or descriptors to search for answers in the databases.

The research question was: What are the characteristics of sleep in patients with ASD to improve diagnosis and treatment approaches? (Table 1). In addition to the survey content, other questions addressed sleep characteristics, comorbid sleep disorders, etiological hypotheses, and the impact of sleep disorders on ASD symptoms.

Components of the research question in PICO-D format

Search strategy

Inclusion and exclusion criteria

Publications that met all of the following criteria were included in the literature review:

• Published articles on specific sleep features in children diagnosed with ASD.

• Original review studies, systematic reviews, meta-analyses, case-control studies, and narrative reviews.

• Studies published in English or Spanish.

Exclusion criteria

• Items that include persons with ASD over 18 years of age.

• Articles that mainly discuss treatment.

• Articles in which the following were counted for a single patient.

• Comments or opinion articles.

• Articles with no full text available.

Search algorithm

Electronic databases specializing in the health sciences, PubMed, Web of Science, and Scopus, were consulted. The keywords used in the search were “Sleep disorders: (Sleep Wake Disorders) and (Sleep Disorders, Intrinsic)” as well as “Autism: (Autism Spectrum disorder) or (autistic disorder),” activating the search term “Medical Subject Headings (MeSH)” in the words that could create confusion in the search engine. The filter used was “Child: birth-18 years” and articles written in English or Spanish. The Boolean operators used were: “AND,” “OR.” The “OR” connector was used to join words or a set of words with similar meaning. The keywords were combined with connectors to identify valid articles for the objective of this work.

The Scopus database does not have its own thesaurus; therefore, the search was performed only for free-language terms. The MeSH terms of the PubMed database were used as a reference because Scopus contains the Medline thesaurus to match the search terms. Scopus allows a term to be defined as a key in parentheses as a keyword in the search, and was set as key word: sleep and autism. The study period was limited to the 10 year period from 2013 to 2024.

Selection of studies

For the selection of the studies to be included in this review, we first discarded duplicate articles and then read the titles and complete abstracts of the articles resulting from the definitive search. Articles that met the inclusion criteria were selected and those that met at least one of the exclusion criteria were discarded. The full texts of the remaining articles were retrieved through links found in the databases and libraries. Subsequently, the full texts of the articles were read, and those that did not meet the inclusion criteria were excluded.

In the search conducted in March 2024, 1,005 articles were identified. Of these, 955 were selected after eliminating duplicates and excluding articles by title. Of these, 69 met the inclusion criteria after reading the abstract. After reading the full texts, 30 articles were selected. These 30 studies met the established inclusion criteria and focused exclusively on the description of sleep characteristics in children under 18 years of age with a confirmed diagnosis of ASD. The flowchart for item search and selection is shown in Fig. 1.

Fig. 1.

Flowchart of search and selection of articles.

A total of 39 articles were excluded because they did not meet the inclusion criteria. Moreover, some of the excluded articles focused on other genetic syndromes and not exclusively on ASD, and several others focused more on therapeutic interventions than on the description of characteristics. In particular, in one excluded study had the aim of validating a sleep scale in this population and did not focus on the description of sleep disorders.

Extraction of data from publications

Data were extracted from the publications included in this systematic review following the criteria of the Strengthening of Observational Studies in Epidemiology (STROBE) statement [24].

The following data were identified for each item: 1) title, author/s, year of publication and journal of publication; 2) study design; 3) location; 4) time period; 5) study population; 6) objective; and 7) main results and their interpretation.

RESULTS

Descriptive analysis of the studies

After reading the full text, 30 articles were selected for the systematic review. Participants’ main descriptive characteristics are presented in Table 2.

Description of selected articles

Main results

The results were separated into three points, highlighting the importance of each section.

Sleep characteristics and comorbid sleep disorders

Patients with ASD have higher sleep latency, lower sleep efficiency, lower TST, and higher amount of WASO [25-31]. Sleep architecture was abnormal in children with ASD, characterized by increased spontaneous awakenings, prolonged REM latency, and reduced REM percentages, all of which are related to a significantly higher number of non-REM parasomnias in children with ASD [32], with night terrors and bruxism being the most commonly described. In addition, some studies have shown that having more parasomnia is associated with an increased risk of excessive daytime sleepiness [33].

Another sleep feature in children with ASD highlighted in some case-control studies is the greater prevalence of insomnia and sleep-disordered breathing compared to neurotypical children [34,35]. One narrative review mentioned the presence of earlier awakenings in patients with ASD [16]. Two other narrative reviews reported a higher prevalence of sleep problems in the ASD population than in patients with other neurodevelopmental disorders [31,16], with a prevalence between 60% and 86%. Both reviews refer to polysomnography findings with less REM sleep, which has an important influence on neuronal maturation.

Other studies refer to the presence of sleep-related respiratory disorders (SRD) in patients with ASD, where the authors described a higher prevalence of obstructive sleep apnea in this population. Given this higher prevalence and the influence of these respiratory disorders on autistic symptomatology, a more expansive search for these diagnoses is recommended since their treatment can produce neurocognitive and behavioral improvements in children with ASD (Table 3) [31,34,36,37].

Summary of sleep characteristics in patients with ASD

Etiological hypothesis

Some articles discuss a more irregular sleep-wake rhythm in patients with AS than in neurotypical patients [16,34,35]. This is also reflected in another review, which describes the presence of an alteration in the sleep/wake rhythm, together with an alteration of the cerebral areas of sleep and of the neurotransmitters that control sleep: gamma-aminobutyric acid (GABA) and melatonin are more predominantly related to its induction, and serotonin, acetylcholine, and glutamate more related to awakening [38]. This is also referred to in another article that mentions an alteration in the production and regulation of serotonin together with a disruption in circadian rhythm, leading to alterations in sleep patterns [39]. Delving into WASOs, one article refers to arousal dysregulation; more specifically, there is an alteration of the autonomic nervous system due to hyperarousal [16].

In the search, a reference was made to the multifactorial causes of sleep problems in patients with ASD. In one narrative review, a number of causes are described [31]. These include genetic alterations (related to acetylserotonin-O-methyltransferase [ASMT] regulatory genes, melatonin receptor 1A and melatonin receptor 1B [MT 1A and 1B], and mutations in the 15q region containing GABA genes), alterations in neurotransmitters (both by reduced levels of melatonin production, serotonin, and GABA, among others), the intrinsic characteristics of autism (such as hypersensitivity and behavioral alterations), the presence of other medical and psychiatric comorbidities and their pharmacological treatments, as well as nutritional alterations (restricted diets and food phobias) that can produce, for example, restless legs syndrome due to iron deficiency.

Impact of sleep disturbance on ASD symptoms

One systematic review insisted on the important relationship between sleep disorders and attentional problems, which did not seem to negatively influence executive functions or processing speed in such a significant way. In the article, the authors also refer to the need for early diagnosis of sleep problems for better adjustment of the cognitive functions of children with ASD [40].

Regarding autism symptoms, one article discusses that the intensity of sleep problems is related to increased symptomatology in patients with ASD [41,42]. Other studies have reported a significant relationship between insomnia and behavioral problems [34,35,43]. This is also described in another narrative review, which discusses that in children with ASD and frequent sleep problems, there is a worsening of core symptoms such as stereotypies and behavioral disturbances, and sleep disturbances are independently related to increased family stress [31,44,45].

The main characteristics of sleep symptoms in patients with ASD are summarized in Table 3, and the relationship between these sleep problems and the core symptoms of ASD is shown in Fig. 2.

Fig. 2.

Relationship of sleep with ASD symptomatology. ASD, autism spectrum disorder; SRD, sleep-related respiratory disorders.

DISCUSSION

Pediatric patients with ASD are vulnerable to sleep problems. After searching the literature, we identified several studies that discussed sleep characteristics in patients diagnosed with ASD. The most prevalent sleep disorder in this population is insomnia. Sleep in these children is characterized by lower efficiency, more nightly awakenings and early morning awakenings, together with lower TST, than in neurotypical individuals. All these sleep disturbances in children with ASD give rise to the main sleep disorders described in this population, such as insomnia, SRD, and parasomnia. The intensity of sleep disorders is related to greater attention problems during the day, as well as an increase in daytime symptoms (irritability, aggressiveness, stereotypies, etc.).

The finding of a high rate of parasomnias in PSG, together with abnormal frequencies of muscle twitching and increased activity during REM sleep, indicates a dysfunction in the monoaminergic excitatory pathways and other essential neurotransmitters involved in synaptic homeostasis related to the control of the sleep-wake cycle. This may imply different developmental and brain maturation pathways, providing an additional point of study to understand the etiology of ASD. For these reasons, we emphasize the importance of adequately detecting sleep problems in pediatric patients with ASD to enable early diagnosis and treatment, thereby promoting better outcomes in terms of language, learning, and behavior.

Among the most commonly used methods to detect sleep problems are subjective methods, such as the Children’s Sleep Habits Questionnaire (CSHQ) and the Sleep Disturbance Scale for Children (SDSC), which have been validated and are widely used in research to assess sleep patterns and problems in the pediatric population, as well as sleep diaries, where caregivers systematically record bedtimes, awakenings, nighttime awakenings, and related behaviors. Objective methods, such as actigraphy or ambulatory circadian monitoring, allow the detection of disturbances such as insomnia, frequent awakenings, and changes in sleep-wake cycles. Polysomnography, another objective method, is the gold standard for assessing sleep disorders. These methods, especially when combined, provide a solid evidence-based foundation for detecting and understanding sleep disturbance in patients with ASD, thereby facilitating more accurate and effective interventions.

Obtaining good rest is not only an advantage for these children but also for their families, which could translate into a double improvement in their assistance and education. In the future, more studies are necessary to gain an in-depth understanding of sleep problems in patients with ASD for enabling intervention in the most targeted manner, both in terms of sleep hygiene and pharmacological treatments.

Notes

The authors have no potential conflicts of interest to disclose.

Author Contributions

Conceptualization: Gonzalo Pin Arboledas. Investigation: all authors. Methodology: Lucía Monfort Belenguer. Writing—original draft: Lucía Monfort Belenguer. Writing—review & editing: all authors. Approval of final manuscript: all authors.

Funding Statement

None

Acknowledgments

We thank the Chair of Sleep at Sleep and Chronobiology Group of the Spanish Paediatrics Association (AEP) for encouraging and helping promote knowledge of sleep disorders in the pediatric population.

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Copyright © 2025 Korean Sleep Research Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Fig. 1.

Fig. 1.

Flowchart of search and selection of articles.

Fig. 2.

Fig. 2.

Relationship of sleep with ASD symptomatology. ASD, autism spectrum disorder; SRD, sleep-related respiratory disorders.

Table 1.

Components of the research question in PICO-D format

Description Aspects of interest
“P” Problem of interest Individuals under 18 years of age diagnosed with ASD
“I” Interest Clinical and pathophysiological sleep characteristics
“C” Comparison Neurotypical children
“O” Outcomes - Objectives: total sleep time, sleep latency, awakenings, sleep efficiency
- Subjective: % of children with onset or maintenance insomnia, parasomnias, SRD, circadian rhythm disturbance
Study design Systematic reviews
Meta-analysis
Clinical studies
Narrative reviews
Clinical practice guidelines

Sleep characteristics in children and adolescents with ASD. ASD, autism spectrum disorder; SRD, sleep-related respiratory disorders.

Table 2.

Description of selected articles

No Title Authors Magazine Year Country Design Subjects (n) Target Results Objective/subjective methods
1 Relationship of serum ferritin levels to sleep fragmentation and periodic limb movements of sleep on polysomnography in autism spectrum disorders Youssef J, Singh K, Huntington N, et al. Pediatric Neurology 2013 Boston, USA Retrospective review 53 Describe the relationship of ferritin levels with sleep fragmentation and periodic limb movements 47% sleep fragmentation in ASD with lower ferritin levels 8% neurotypicals 37% of OSA Objective methods: PSG and ferritin
2 Sleep problems are more frequent and associated with problematic behaviors in preschoolers with autism spectrum disorder Hirata I, Mohri I, Nishimura K, et al. Research in Developmental Disabilities 2016 Japan Cases and controls 965 preschoolers without ASD Comparing sleep problems between preschoolers with and without ASD and their relationship to behavioral problems OSA more frequent in ASD. Sleep problems (++ insomnia) are related to behavioral problems in ASD. Subjective methods: sleep questionnaires
193 with ASD
3 Prevalence of diagnosed sleep disorders and related diagnostic and surgical procedures in children with autism spectrum disorders Elrod MG, Nylund CM, Susi AL, et al. Journal of Developmental & Behavioral Pediatrics 2016 Bethesda, Maryland, USA Cases and controls 48762 Risk of sleep disturbance and diagnosis in children with ASD vs. control group Higher prevalence of sleep disorders in patients with ASD. More PSG with fewer surgeries. More complex diagnosis of OSA PSG (objective method)
1.Tr unspecified sleep
Insomnia
Respiratory tract
Parasomias
Periodic Movs
6.Tr. rhythm
Narcolepsy
4 Effectiveness of sleep-based interventions for children with autism spectrum disorder: a meta-synthesis Cuomo BM, Vaz S, Lim Lee A, et al. Pharmaco Therapy 2017 Australia and Sweden Systematic review 8 items To see the efficacy of different sleep interventions in patients with ASD Sleep problems they describe: increased latency, shorter sleep duration, sleep efficiency, bedtime resistance, co-sleeping, parasomnias, restless sleep, periodic leg movement, sleep-related respiratory disorders, sleep anxiety As it is a systematic review, there are articles with more objective measurements (actigraphy), but many of them are based on questionnaires.
5 Characterizing sleep in adolescents and adults with autism spectrum disorders Goldman SE, Alder ML, Burges HJ Journal of Autism Development Disorders 2017 Denver, USA Prospective observational study 28 To describe sleep characteristics in adolescents/young adults with ASD vs. non-ASD Adolescents with ASD have longer sleep latencies and more difficulty falling asleep, as well as more insomnia to fall asleep. No differences in cortisol values between ASD and non-ASD Objective methods: actigraphy and measurement of cortisol and melatonin.
Also with questionnaires
6 Sleep in children with autism spectrum disorder Souders MC, Zavodny S, Eriksen W, et al. Current Psychiatry Reports 2017 Philadelphia, USA Review of published literature - To provide an overview of sleep in children with ASD, hypothesized prevalence of insomnia. Practical guidance to promote optimal sleep Describes increased sleep latency, decreased sleep efficiency, decreased total sleep time, lower % of slow wave sleep and less REM sleep Objective methods:
PSG/actigraphy
Also with questionnaires
7 Prevalence of sleep abnormalities in indian children with autism spectrum disorder: a cross-sectional study Aathira R, Gulati S, Tripathi M, et al. Pediatric Neurology 2017 New Delhi, India Case-control study 71 with ASD Description of sleep disorders and prevalence of sleep disorders in patients with ASD Sleep problems more prevalent in ASD than in non-ASD. Poorer sleepers have more behavioral problems. PSG
65 without ASD Decreased sleep efficiency, decreased REMs, decreased slow wave sleep duration and desaturation index >1 Sleep questionnaires
8 Sleep, chronotype, and sleep hygiene in children with attention-deficit/hyperactivity disorder, autism spectrum disorder, and controls Van der Heijden KB, Stoffelsen RJ, Popma A, Swaab H European Child & Adolescent Psychiatry 2018 Leiden, The Netherlands Case-control study 115 cases (ASD and ADHD) Compare sleep problems and sleep patterns of children with ADHD, ASD and typically developing controls. Association of sleep problems with sleep hygiene and chronotype Longer sleep latency in ASD and ADHD. ASD and ADHD total sleep time shorter than control group. Evening chronotype: predictive value for sleep problems more in the ADHD group than in the control group Sleep and chronotype questionnaires
243 controls Sleep problems more prevalent in ASD and ADHD
9 Sleep in youth with autism spectrum disorders: systematic review and meta-analysis of subjective and objective studies Díaz-Román A, Zhang J, Delorme R, et al. Evidence Based Mental Health 2018 Southampton and Nottingham UK; Paris, France and New York, USA Systematic review 37 studies with objective and subjective methods Systematic review and meta-analysis of sleep studies using subjective and objective methods in patients with ASD Subjective: in ASD: more reluctance to go to sleep, increased sleep latency, sleep anxiety, nighttime awakenings, parasomnia, sleeprelated respiratory disorders and daytime sleepiness Subjective: questionnaires and objective: PSG and actigraphy
Objectives: with PSG: less total sleep time, more sleep latency, more time in phase 1 sleep, less REM sleep time, less sleep efficiency and more awakenings. With actigraphy: more sleep latency
10 Reduced sleep pressure in young children with autism Arazi A, Meiri G, Danan D, et al. Sleep Research Society 2020 Negev, Beer-Sheva, Israel Case-control study 29 with ASD Contribution of sleep homeostasis in sleep disorders through slow wave activity (sleep pressure measurement) In ASD: less time in bed, less total sleep time, higher % of N2 sleep, less REM sleep than controls Objective methods: PSG
23 without ASD
11 Autism spectrum disorder and sleep Johnson KP, Zarrinnegar P Child and Adolescent Psychiatric Clinics of North America 2020 Portland, USA Observational study - Description of sleep problems in patients with ASD Patients with ASD have more insomnia. Related to sleep disorders GABA, serotonin and melatonin Subjective measures
12 Sleep disorders in autism spectrum disorder preschool children: an evaluation using the sleep disturbance scale for children Romeo DM, Brogna C, Belli A, et al. Medicine 2021 Rome, Italy Case-control study 84 ASD To describe the incidence and characteristics of sleep disorders in preschoolers with ASD A high % of people witn ASD obtained altered results of the sleep questionnaire: in 3-year-old children with ASD+prevalence of parasomnia, sleep onset and maintenance insomnia and, excessive somnolence. In children aged 4-5 years, more sleep onset and maintenance insomnia, as well as hyper hidrosis. No correlation between AD OS-2 score and sleep questionnaire score Subjective: sleep questionnaires
84 non-ASD
13 Sleep problems in children with autism spectrum disorder and typical development Inthikoot N, Chonchaiya W Pediatrics International 2021 Bangkok, Thailand Case-control study 65 ASD Describing sleep problems in children with ASD in developing countries In children with ASD: increased sleep latency, reluctance to go to sleep, nocturnal awakenings, shorter sleep time Sleep questionnaires (subjective method)
65 non-ASD ASD with intellectual disability have more prolonged sleep latency, longer WASOs than high functioning ASDs
14 Sleep problems in children with autism spectrum disorder: a multicenter survey Chen H, Yang T, Chen J, Chen L, et al. BMC Psychiatry 2021 Chongqing, China Case-control study 1310 ASD To investigate sleep disturbances in patients with ASD in China Children with ASD: reluctance to go to sleep〉sleep anxiety; delayed sleep onset, daytime sleepiness Subjective methods: sleep questionnaires
1158 non -ASD These disturbances are related to the core symptoms of ASD} but not to the degree of disability.
15 Sleep architecture is associated with core symptom severity in autism spectrum disorder Kawai M, Buck C, Christina F, et al Sleep 2023 Stanford and Palo Alto, USA Case-control study 53 ASD Describe the differences in sleep architecture (in dow sleep waves and REM sleep) between persons with and without ASD. Possible relationship of these differences to core ASD symptoms People with ASD: higher ratio of slow wave sleep and less REM sleep than those without ASD. In the ASD group, the greater the amount of slow wave sleep, the greater the presence of inflexibility and stereotypies. More dow wave sleep reflects more brain immaturity. Objective methods with PSG and ADI-R and sleep and behavioral questionnaires
66 non-ASD
16 Relationship between sleep and measures of attention, executive functions, and processing speed in children with autism spectrum disorder: a systematic review Karavasilis G, Statiri A Psychiatriki 2023 Greece Systematic review 22 items To examine the correlation between sleep and measures of attention, executive functions and processing speed in children with ASD Strong correlation between sleep and attention, not so evident relationship between sleep and executive functions and processing speed Objective methods: actigraphy and subjective methods: with questionnaires for sleep and attention (and the rest of the learning measures)
17 Correlations between sleep problems, core symptoms, and behavioral problems in children and adolescents with autism spectrum disorder: a systematic review and meta-analysis Kim H, Kim JH, Yi JH European Child & Adolescent Psychiatry 2024 Meta-analysis 22 items To examine the relationship between sleep problems and core symptoms and behavioral problems in the ASD population Sleep anxiety and increased sleep latency are related to restrictive and repetitive behaviors. Parasomnias are clearly related to attention problems in patients with ASD. Subjective and objective methods (PSG and actigraphy and sleep and executive function questionnaires)
They have identified correlations between sleep problems, core ASD symptoms and behavioral problems.
18 Pattern of sleep disorders among children with autism spectrum disorder Mohammed MA, Abdalkhalig EM, Ali IA, et al. BMC Psychiatry 2024 Khartoum, Sudan Prospective observational study 92 people with ASD Assessing sleep disorders among Sudanese children with a diagnosis of ASD High frequency of sleep disorders. The most frequent disorder is insomnia and the least frequent is bruxism. Sleep phase delay and narcolepsy type 2 are more prevalent in boys than in girls. Subjectiv methods: questionnaires
19 Characteristics of sleep architecture in autism spectrum disorders: a meta-analysis based on polysomnographic research Chen X, Liu H, Wu Y, et al. Psychiatry Research 2021 Anhui, China Meta-analysis 11 items Description of sleep disorders based on articles that have used objective methods (PSG) People with ASD have less total sleep time and less sleep efficiency, as well as an increased SI phase, which has not been previously described. Objective methods: PSG
20 Sleep in children with autism spectrum disorder: a narrative review and systematic update Schwichtenberg AJ, Janis A, Lindsay A, et al. Current Sleep Medicine Reports 2022 West Lafayette, IN, USA Narrative review and meta-analysis 60 items Describe sleep in patients with ASD and see what is described in the literature Insomnia is the most common sleep disorder in ASD. Individuals with ASD with more inter-and externalizing symptomatology are more susceptible to sleep problems. Data obtained:
Subjective: sleep diary (13%) and questionnaires (91%). Mostly using: Childrens Sleep Habits Questionnaire
Targets: PSG (15%X actigraphy (18%)
21 Sleep in autism: a biomolecular approach to aetiology and treatment. Ballester P, Richdale AL, E.K. Baker EK, et al. Sleep Medicine Reviews 2020 Alicante (Spain) Theoretical review - To examine how altered sleep structure may be related to neurobiological alterations or mutations and the implications this may have for the choice of individualized treatments for children with ASD. In ASD: PSG: reduced REM, NREM2 and slow wave sleep; increased NREM1. It also describes longer sleep latency, longer WASO} less total sleep time and decreased sleep efficiency. Objective methods: PSG
Melbourne (Australia)
It also describes a reduction of GABA-A receptors in cortical frontal areas, with a reduced GABAergic inhibition. GABA may also influence by decreasing the secretion of melatonin and increasing the secretion of serotonin and its metabolites.
22 The relationship between sleep and behavior in autism spectrum disorder (ASD): a review Cohen S, Conduit R, Lockley SW, Rajaratnam SMW, Cornish KM Journal of Neurodevelopmental Disorders 2014 Melbourne, Australia Review - To describe the characteristics of sleep difficulties in persons with ASD and to highlight the complexity of sleep fragmentation in patients with severe ASD. Most prevalent sleep disorders in people with ASD: insomnia, parasomnias, and circadian rhythm disorders. There is insufficient scientific evidence to establish the relationship between sleep and the behaviors described in people with severe ASD. Objective (PSG) and subjective methods
23 Sleep in autism spectrum disorders Veatch OJ, Maxwell-Horn AC, Malow BA, et al. Current Sleep Medicine Reports 2015 Nashville, TN, USA Review Describe sleep problems within the ASD population and the need for knowledge for better treatment Predominance of insomnia with mention of movement disorders in relation to sleep (periodic movements and restless legs syndrome) Objective methods PSG and actigraphy
24 Systematic review of sleep disturbances and circadian sleep desynchronization in autism spectrum disorder: toward an integrative model of a self-reinforcing loop Carmassic C, Palagini L, Caruso D, et al. Frontiers in Psychiatry 2019 Brescia and Pisa, Italy Systematic review 15 articles on rhythm disturbances; 74 on movement disorders; 17 on disturbances of melatonin secretion in persons with ASD Compile what has been described in the literature on sleep and circadian rhythm disorders related to ASD at different ages Sleep characteristics: short total sleep time, low sleep efficiency; desynchronization of circadian rhythms Subjective and objective methods
Circadian rhythm disturbances have been related to the severity of ASD symptomatology.
25 Sleep in autism spectrum disorder and attention deficit hyperactivity disorder Singh K, Zimmerman AW Seminars in Pediatric Neurology 2023 Tucson, Worcester Review Articles published prior to 2015 on ASD and sleep Detailed literature review on the finding and prevalence of different sleep disorders in ASD and ADHD Presence in ASD patients: OSA on PSG (58%), restless legs syndrome (39%). More severe symptoms of ASD are related to increased slow wave sleep and more REM sleep. Objective and subjective methods (with questionnaires and PSG)
26 Efficacy of parent training incorporated in behavioral sleep interventions for children with autism spectrum disorder and/or intellectual disabilities: a systematic review Kirkpatrick B, Julia S, Louw JS Sleep Medicine 2019 Galway, Ireland Review 11 studies (416 children) To describe the evidence for the effectiveness of parent training in the sleep care of their children with ASD and/or intellectual disabilities Correlation between sleep problems and increased aggressiveness, increased social deficits and decreased social skills Subjective methods: questionnaires and objective methods: actigraphy
27 Age-related differences in accelerometer-assessed physical activity and sleep parameters among children and adolescents with and without autism spectrum disorder Liang X, Haegele JA, Healy S JAMA Network 2023 Hong Kong, Norfolk (Virginia), Limerick (Ireland), Guangzou (China) Meta-analysis 28 studies, 805 participants To synthesize the differences obtained by actigraphy in physical activity ana sleep and the moderating effects between children and adolescents with and without ASD Children and adolescents with ASD had less moderate to vigorous physical activity and worse sleep tnan their peers without ASD. Objective methods: actigraphy
28 Sleep disorders in children and adolescents with autism spectrum disorder: diagnosis, epidemiology; and management Cortese S, Wang F, Angriman M CNS Drugs 2020 UK Narrative review - Epidemiology overview diagnosis and treatment of sleep problems/disorders in children and adolescents with ASD Children and adolescents with ASD: more reluctance to go to sleep, delayed sleep onset, sleep anxiety, nighttime awakenings, parasomnias, sleep-related respiratory disorders and daytime sleepiness. In PSG and actigraphy: less total sleep time, higher sleep latency; less REM sleep, more time in sleep phase 1 Subjective and objective methods: PSG and actigraphy
29 Understanding the role of sleep and its disturbances in autism spectrum disorder Karthikeyan R, Cardinali DP, Shakunthala V, et al. International Journal of Neuroscience 2020 Tamil Nadu, India Narrative review - Describe and discus sleep difficulties, which are one of the most significant complications associated with ASD Sleep has an influence on brain development in children. Increased sleep problems are related to increased ASD symptomatology.
Toronto, Canada
30 Assessment of sleep problems and related risk factors observed in turkish children with autism spectrum disorders Mutluer T, Demirkaya SK, Abali O Autism Research 2016 Istanbul Case-control study 117,64 cases and 53 controls People with ASD have a higher frequency of sleep problems, snoring, sleep-related respiratory disorders, increased sleep latency and more behavioral

ASD, autism spectrum disorder; PSG, polysomnography; OSA, obstructive sleep apnea; ADHD, attention-deficit/hyperactivity disorder; REM, rapid eye movement; GABA, gamma-aminobutyric acid; WASO, wakefulness after sleep onset; ADOS-2, Autism Diagnostic Observation Schedule, Second Edition; ADI-R, Autism Diagnostic Interview-Revised; -, not available.

Table 3.

Summary of sleep characteristics in patients with ASD

Sleep characteristics in patients with ASD
- Increased sleep latency [25-27,30]
- Lower sleep efficiency [25-27,30]
- Decreased total sleep time, [25-27,30] irregular sleep-wake rhythm [38,39]
- Increased WASO [25-27,30]
- Less REM sleep [27,31,34]
- Predominance of earlier awakenings, [29] hyperarousal [16]
Etiological hypotheses of sleep characteristics and sleep disorders in people with ASD
- Higher prevalence of evening chronotype which is associated with more sleep disturbances [29]
- The fact that children with ASD have a higher percentage of slow sleep involves brain immaturity [31]
- Parasomnias NREM, night terrors and REM like nightmares, more intense or frequent in children with ASD due to: high anxiety, sensory hypersensitivity, and emotional processing difficulties [43]
- The desynchronisation of circadian rhythms [41]
- As well as altered melatonin secretion along with reduced melatonin levels [16,31]
Sleep disorders in patients with ASD
- The most prevalent sleep disorder in children with ASD is insomnia [31,38]
- Parasomnias NREM and REM
- Sleep-related respiratory disorders

ASD, autism spectrum disorder; WASO, wakefulness after sleep onset; REM, rapid eye movement.