| Background and ObjectiveAbout 50% to 80% of children with autism spectrum disorders(ASD)suffer from one or more sleep problems,which increase with age.Compared with the ASD children without sleep disorder,the children with sleep disorder often have more serious language disorder,social disorder,problem behavior and emotional problems,which seriously affects the rehabilitation effect of children with sleep disorders.Sleep assessment of children with ASD includes subjective assessment and objective assessment.Subjective assessments include the Children’s Sleep Habits Questionnaire,The Family Inventory of Sleep Habits,Achenbach Child Behavior Checklist,which can measure the time to fall asleep,sleep latency,sleep duration,night awakening,and Family sleep habits,daytime habits,daily behaviors,etc.each of the above scales has its own advantages and limitations,but no single scale can fully assess the sleep status of children with ASD.Objective assessment includes polysomnography,watch-type motion recorder,and video recorder,which can be used to measure sleep quality or sleep structure;Because of the high cost of objective evaluation and difficult and complicated operation,it is less used in clinical practice.Studies have shown that sleep behavior education and treatment are the most important treatment methods for sleep disorders in ASD.However,the exact cause of sleep disorders in children with ASD is not completely clear,so sleep behavior and treatment of many children with ASD sleep improvement is not obvious.There are no specific drugs or treatments for sleep disorders in children with ASD.Foreign literature reports that repetitive transcranial magnetic stimulation(r TMS)can improve sleep behavioral symptoms by inhibiting the dorsolateral prefrontal cortex and regulating the function of different cortical circuits in children with ASD.However,the sample size of this study is small and has not clarify the mechanism of action.Therefore,the purpose of this study is to: Observe the clinical efficacy of r TMS combined with sleep behavior education and treatment on sleep disorders in children with ASD compared with pure sleep behavior education and treatment.MethodsFrom Jan2019 to Dec2020 in the Child Psychology Department of Maternal and Child Health Hospital of Qingyuan City,381 children aged 2 to 6 years old ASD were selected as 234 children with sleep disorders.Then according to the guardian’s wishes(the researchers explained the harm of sleep disorder to children with ASD and the role of r TMS and sleep behavior education and treatment,the guardian freely chose the treatment plan after informed consent)234 children with ASD comorbid sleep disorder were divided into the control group and the study group;In the control group,sleep behavior education and treatment(including sleep behavior education for caregivers,sleep schedule,sleep routine,regular sleep time and behavior therapy)were used to treat children’s sleep problems for 4 weeks;the research group adopts r TMS combined with sleep behavior education and treatment,r TMS was performed by researchers at the hospital,The resting motor threshold should be measured during the first treatment,Stimulating the right thumb motor cortex(Cz)using monopulse mode 10 times,of which 5 times could induce the movement of the extensor pollicis muscle(the evoked potential of the extensor pollicis muscle is more than 50μV),then the stimulation intensity is the resting motor threshold.Because of the immature cerebral cortex and the language and social disorder of ASD children,its resting motion threshold is more likely to be undetectable.The stimulation site was left anterior frontal lobe dorsal lateral region,stimulus frequency: 1Hz,The stimulation intensity was 90% resting motor threshold threshold×2.88T(Using fixed stimulation intensity of 40%×90%×2.88 T for children who can not measure the threshold),1000pulses/s,stimulation10 s,stimulation10,interval 10 s,repeated 45 times,treatment time: 15min/time,5 times/week,continuous treatment for 4 weeks.After 4 weeks,the two groups continued to sleep behavior education and treatment at home for 12 weeks.The Childhood Autism Rating Scale(CARS)was used to assess the severity of the children’s core symptoms during the baseline period,and The children’s sleep habit questionnaire,The family inventory of sleep habits,and Achenbach child behavior checklist were used during the baseline period,4 weeks of treatment,and 16 weeks of treatment.The table above assesses children’s sleep behavior,sleep habits,and daily behaviors.All data were entered into Excel tables and a database was established;SPSS25.0 was used for statistical analysis,The sex ratio of the two groups was tested by chi-square test,measurement data were all represented by(X ±s),Independent sample t-test,repeated measurement variance analysis,covariance analysis and Spearman for statistical analysis;statistically significant(P<0.05).Results1.General information and baseline dataAfter 234 children entered the study program,35 children withdrew from the study halfway;101 children in the study group and 98 children in the control group completed the study.The sex ratio of the two groups was tested by Chi-square test and the difference was statistically significant(P>0.05);the age CARS score,CSHQ score,FISH score and CBCL score of the two groups of children were not statistically significant by independent sample t-test(P>0.05).2.Comparison of sleep factor scores in the Children’s Sleep Habits Questionnaire sleep between two groups of children before and after treatment(X±s).After 4 weeks of treatment,the scores of sleep factors in the control group were lower than those before treatment,and the total score of CSHQ,sleep conflict,delayed falling asleep,night awakening,parasomnia,and daytime sleep were significantly improved,and the difference was statistically significant(P<0.05);While there were improvements in sleep duration,sleep anxiety and sleep disordered breathing,the difference was not statistically significant(P>0.05).The sleep factors and total scores of the study group were also reduced compared to before treatment.The CSHQ total score,sleep resistance,delayed falling asleep,sleep anxiety,night awakening,parasomnia,sleep disordered breathing,and daytime sleep improved significantly,and the differences was significant(P<0.05);Although there was improvement in sleep duration,the difference was not statistically significant(P>0.05).After 16 weeks of treatment,the sleep factors and total scores of the control group and the study group were reduced compared with those before treatment,the quality of sleep was improved significantly,and the difference was statistically significant(P<0.05).The study group improved better than the control group in terms of CSHQ total score,sleep conflict,delayed falling asleep,sleep anxiety,night awakening,and parasomnia,and the difference was statistically significant(P<0.05);but there was no significant difference between those two groups in improving sleep duration,sleep disordered breathing,and daytime sleep(P>0.05).3.Comparison of changes in the scores of the sleep habit factors of the two groups of children before and after treatment(X±s)After 4 weeks of treatment,the total score of FISH,daytime habits,sleep environment,sleep routine,and parental behavior before bedtime in the control group were higher than that before treatment.The difference was statistically significant in improving parental behavior beforebedtime(P<0.05);Although therewere improvements in FISH total score,daytime habits,sleep environment,and sleep routines,the difference was not statistically significant(P>0.05);on the contrary,the pre-bedtime habit,the score decreased,the pre-bedtime habit became worse,the difference was statistically significant(P<0.05).The scores of each sleep habit factor in the study group were increased compared with thosebefore treatment.The total score of FISH,day habits,pre-bedtime habit,and sleep routine were improved significantly,and the difference was statistically significant(P<0.05);However,there was no significant difference in sleep environment and parent’s behavior before sleep(P>0.05).After 16 weeks of treatment,the sleep habit factors and total scores of the control group were increased compared with those before treatment,the sleep habit was significantly improved,and the difference was statistically significant(P<0.05).The total scores of FISH,daytime habits,the pre-bedtime habit,sleep routines,and parental behaviors before bedtime in the study group were also higher than before treatment.Sleeping habits improved significantly,and the difference was statistically significant(P<0.05);Although there was improvement in sleep environment,the difference was not significant(P>0.05).Compared with the control group,each sleep habit factor and FISH total score of study group were improved significantly than the control group(P<0.05).4.Comparison of changes in the scores of each behavior factor of the Achenbach Children’s Behavior Scale between the two groups before and after treatment(（？）±s)After 4 weeks of treatment,the behavioral factors and total scores of the control group were reduced significantly compared with those before treatment(P<0.05),;however,in terms of the total scores of CBCL,social withdrawal,depression,physical complaints,act of aggression,and sabotage behavior,the difference was not statistically significant(P>0.05).The behavioral factors and total scores of the study group were decreased compared with those before treatment,and the difference was statistically significant in improving behavioral symptoms and CBCL total scores(P<0.05).After 16 weeks of treatment,the total scores of behavior factors and CBCL in the control group were lower than those before treatment.There were significant differences in the improvement of CBCL scores,depression,sleep problems,somatic complaints,aggressive and destructive behaviors(P<0.05);While there was improvement in social withdrawal,the difference was not statistically significant(P>0.05).The behavioral factors and CBCL total score of the study group were significantly reduced compared with those before treatment,and daily behavior was significantly improved compared with before,the difference was statistically significant(P<0.05).Compared with the control group,depression,physical complaints,and aggressive behavior of the study group were improved remarkablyt The difference was statistically significant(P<0.05);However,there was no significant difference in the improvement of social withdrawal,sleep problems,disruptive behavior and CBCL scores between the two groups(P>0.05).5.Adverse eventsThere were no serious adverse events such as epileptic seizures,headache,dizziness,hearing and visual problems during r TMS treatment.9 cases of caregivers had symptoms of excitement and irritation during the first week of treatment.The researchers did not do special treatment,and the children had no discomfort during the second week of treatment until the completion of the study.ConclusionSleep behavior education and treatment can improve the sleep behavior and habit of preschool children with ASD.r TMS combined with sleep behavior education and treatment can better improve the sleep resistance,sleep delay,sleep anxiety,night wake,abnormal sleep,sleep habits and emotional behavior in children with ASD.The use of r TMS in preschool children with ASD is safe and tolerable without serious adverse events. |
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