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Keywords:

  • Autism spectrum disorders;
  • Crying;
  • Feeding;
  • Regulatory problems;
  • Sleeping

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Aim

To chart early registered regulatory problems (RP) in a representative group of young children with and without autism spectrum disorder (ASD).

Methods

The target group comprised 208 preschool children with ASD, whose records from the Child Health Centres (CHC) were reviewed regarding numbers of consultations for excessive crying, feeding and sleeping problems. The records from an age- and gender-matched comparison group were obtained from the same CHCs as those of the index children

Results

Significant differences between the ASD and comparison groups were found for each domain studied and when domains were collapsed. Two or more consultations had occurred in 44% of the children in the ASD group and in 16% of the comparison group (p < 0.001). No correlations were found with regard to gender, later severity of autism, cognitive level or degree of hyperactivity.

Conclusion

Regulatory problems (RP) were much more common in children who later received a diagnosis of ASD. Children with many RP in infancy require attention from CHC and paediatric services and need to be followed with regard to development and family support.

Key notes
  • Regulatory problems (RP) were much more common in children who later received an autism spectrum diagnosis.
  • No correlations were found with regard to gender, later severity of autism, cognitive level or degree of hyperactivity.
  • Children with many RP in infancy need to be followed with regard to development and family support.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The reported prevalence rates of regulatory problems (RP) in infants and young children, mostly expressed as excessive crying, feeding and sleeping problems, vary widely [1, 2]. Reasons for discrepant findings could be attributed to lack of standardized definitions, type of populations under study, and different methods used to measure and document the problems.

In the large ‘Copenhagen Child Cohort’ study of one- and half-year-old children, the prevalence of mental health problems was studied in the general child population – prospectively from birth. The authors found that the most common infant mental health problem was ‘regulatory disorder’, present in 7.1% of the general population [3].

Regulatory problems (RP)/regulatory disorders may be associated with adverse behavioural outcomes [2] – particularly externalizing and ADHD-problems. Persistent RP in general and infancy feeding problems in particular have been found to predict deficits in social skills and in adaptive behaviour in preschool age [1]. Moreover, infant RP is associated with high infant and parental burden and is a common reason for seeking help from health services [4].

Excessive crying during the first months in life has not generally been found to be associated with any long-term behavioural consequences. However, in a substantial proportion of children with persistent crying, this may be associated with multiple RP [5]. Persistent excessive crying after three months of age has been reported to be predictive of hyperactivity, discipline and cognitive problems [6, 7].

Typical feeding problems comprise for instance long mealtimes, short intervals between meals, excessive vomiting, food refusal or failure to thrive (FTT). Feeding problems are common in childhood and occur in as many as 25–35% of normally developing children and in up to 80% of those with developmental delay [8]. Feeding problems in children with autism spectrum disorder (ASD) are complex with biological vulnerability interacting with attachment and behavioural problems [6, 7]. The presence of severe or atypical feeding problems and FTT in infancy should alert professionals to a possible underlying autism spectrum disorder [9, 10].

Sleeping problems in infants and young children are prevalent, varying between 15 and 35% in children aged between 6 months and 5 year [11] and include difficulty falling asleep without parental help and/or frequent awakenings [1]. Severe sleep problems in infancy have been associated with subsequent development of ADHD [12]. In another study, family adversity was reported [13] instead of RP, as predictor for later hyperkinetic symptoms. Different types of sleep problems are reported in children with autism, sleep onset insomnia, sleep maintenance insomnia and irregularities of the sleep–wake cycle [14]. It has been reported that most cry–fuss and sleep problems in the first 2 years of life are transient. Persistent problems were found to contribute to maternal depression, parenting stress and subsequent child behaviour problems [15].

There are relatively few studies that specifically focus on the link between RP in infancy and later autism or ASD. The aim of this study was therefore to analyse different domains of early RP in a representative group of young children with ASD and to contrast these early regulatory problem signs with an age- and sex-matched comparison group.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Subjects (ASD group)

The target group comprised 208 preschool children with autism spectrum disorder, referred to a specialized habilitation centre for intervention. (habilitation is a term used in Sweden for habilitation/rehabilitation of children 0–17 years with different kinds of disabilities).

The children with ASD had all been referred from units specialized in neuropsychiatric assessments. At the first assessment, the children were between 20 months and 4, 5 years old and were seen by a neuro paediatrician or child psychiatrist, both at start and after the two-year follow-up. This group has been previously reported with regard to developmental profiles at referral, at a two-year follow-up and with regard to associated medical disorders [16-18]. Among the 208 children, 198 participated in the clinical follow-up study. Of these, 82% had autism/atypical autism, 7 % had Asperger syndrome and 11 % did not definitely meet full criteria for ASD but had additional developmental disorders. About 50% had intellectual disability, about 25 % had borderline intellectual functioning, and about 25% had average IQ. The group was considered population based and representative for preschool children with ASD in Stockholm County.

Measures

Records from Child Health Centres – ASD group

Of the 198 children with ASD, 190 children (161 boys, 29 girls) had complete Child Health Centres (CHC) records available and could be included in the study. The records were complete in the sense that the children had spent the majority of their first two years in Sweden, hence were not adopted or had lived abroad for any considerable period of time. These records were sent for with parents′ consent and reviewed with regard to data that had been documented at all regular check-ups at the CHCs (about every other month in the first year and at 18 months in the second year) and at all extra visits or telephone contacts that the parents had initiated with the CHC. Specifically, three symptom domains were studied, excessive crying, feeding and sleeping problems, based on the parents′ worries and their accompanying consultations at the CHC during the child′s first two years.

Records from Child Health Centres – Comparison groups

Child Health Centres (CHC) records from the comparison group were obtained from the same CHCs as the index children and from the same school healthcare unit areas as the index children, for those who had started school. Approximately one-third of the CHC records for the index children were still at CHCs, and two-thirds had been moved to school healthcare units. In order to include a sufficient number of children, the aim was to identify two comparison children, with the same sex and birth year to each index case.

Nurses at CHC were contacted and asked to pick out the child of the same sex immediately before and after the index child in their local archives. The archives were organized according to birth order. In this way, the comparison children were as close in age as possible to the index children. About 80% of the requested records were sent in. The child was excluded when CHC data were incomplete for the period studied and also when there were indications of a definite developmental disorder.

Obtaining comparison records from the school healthcare units was more difficult and resulted in only about 30% out of the expected. This hereby resulted in a smaller comparison group than intended.

The comparison group consisted initially of 185 children, and after correction for gender (by randomly excluding 24 girls), 161 children remained. The rate of boys was 84.7% in the ASD group and 84.5% in the comparison group.

All records were scrutinized by two of the authors together (MBO and LHC). The RP noted in the records were counted and registered from the second month of life and onwards, until two years of age.

Data from a parental interview of children with ASD

Information from a DISCO interview (Diagnostic Interview for Social and Communication Disorders) [19] that had been performed at the two-year follow-up was available for 105 of the children with ASD. This interview was only performed with the children with ASD, as it was part of the former study, and not used in the comparison group. DISCO is a standardized, semi-structured and investigator-based schedule for diagnosis of autism spectrum disorders (ASD). The objective of including the DISCO interview in the study was to see any possible correlation between the health records and the parental interview.

The same areas, excessive crying, feeding and sleeping problems, were rated. In each domain, there were two questions pertaining to the specific problem. Thus, a sum 0–2 was obtained in each domain. The questions were, regarding crying, 1/ Was A a good baby or did he/she cry a lot? 2/ When A cried was it easy to know why? Regarding feeding; 1/ Did A feed well as a baby? 2/ Did A need any treatment for excessive vomiting? Regarding sleeping; 1/ Did A tend to wake up screaming from sleep? 2/ Did A sleep well, after the first few weeks?

Ethics

The study was approved by the regional ethics committee in Stockholm.

Statistical analyses

Due to highly skewed distribution of the numbers of consultations for all three studied domains, the nonparametric Mann–Whitney test, Pearson's chi-square and odds ratio (OR) with 95% confidence interval (CI) were used to compare the two groups. An alpha level of 0.05 was used for all statistical tests.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Domains

Analyses were initially performed separately for each regulatory domain, using the Mann–Whitney test. The number of consultations was significantly higher in the ASD group, in each of the three studied domains, compared to the comparison group: crying U = 12031 (z = −4, 68, p < 0.001), feeding, U = 12745 (z = −3, 38, p = 0.001) and sleeping U = 13294 (z = −2, 78, p = 0.005).

As all three domains correlated positively and significantly with each other (Spearman's rho between crying and sleeping, rs = 0.35, p < 0.001, between crying and feeding, rs = 0.19, p < 0.001 and between sleeping and feeding, rs = 0.20, p < 0.001), they were merged into a total number of consultations when a regulatory problem had been reported. This total number was also significantly higher in the ASD group as compared to the comparison group (U = 10746.5, z = −5, 13, p < 0.001), see Figure 1.

image

Figure 1. Number of consultations for regulatory problems (RP) in children with autism spectrum disorder (ASD) and in the comparison group.

Download figure to PowerPoint

None or only one consultation for a reported regulatory problem had occurred in 106 of the 190 children (56%) in the ASD group and in 135 of the 161 children (84%) in the comparison group. On the other hand, at least two consultations had occurred in 84 of the 190 children (44%) in the ASD group and in 26 of the 161 children (16%) in the comparison group (inline image = 31.9, p < 0.001, OR = 4.11, 95% CI = 2.48–6.84).

It was found that of the 15 children, constituting the 5% with the highest number of consultations (n > 8), 14 came from the ASD group and one from the comparison group.

No correlations with regard to age at referral to the habilitation centre, gender, later severity of autism, cognitive level or degree of hyperactivity were found between total numbers of consultations, problems in any single domain or problems in several domains.

Of the 190 children with ASD, a DISCO interview had been performed with the parents of 105 children. There was a significant correlation between sleeping problems (rs = 0.37, p < 0.001) and feeding problems (rs = 0.21, p = 0.033) reported at CHC and at the current DISCO interview. However, the correlation between excessive crying in the two sources of information was not significant (rs = 0.12, p = 0.221. (DISCO and CHC data). Finally, the correlation between the total number of RP reported at the CHC and at the current DISCO interview was significant (rs = 0.26, p = 0.009).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

This study focused on three domains of early RP: excessive crying, eating/feeding and sleeping problems in a representative group of children with ASD and in a comparison group. The measure used to assess these problems was the number of registered consultations at the CHC concerning these domains during the child's first two years. No analyses other than regarding RP have been performed.

Children with ASD had had significantly more consultations for crying, feeding or sleeping problems at the CHC than the children in the comparison group. This applied both when individual domains were compared and when the domains were collapsed.

An important finding was that the odds for an ASD child to have many (2 or more) consultations related to a regulatory problem were about four times as high as for a child in the comparison group (OR = 4.11). Few (0–1) consultations had occurred significantly more often in the comparison group.

We could not demonstrate any correlation between number of consultations and age for referral to the habilitation centre, gender, type of ASD, intellectual level or reported hyperactivity in the total group of ASD or in the group with the highest number of consultations.

Data from CHC records and from the DISCO interview, performed with parents of children with ASD at the two-year follow-up, revealed a significant correlation for feeding and sleeping problems. A significant correlation between the two measures (CHC records and DISCO interview) was also found when the three domains were merged into one. Thus, parental information given later during the child's preschool age was consistent with early reports in the CHC record.

As children at this early age have not yet developed a spoken language, crying is usually the way in which they express fatigue, hunger, anxiety or any other means of discomfort. Possibly many children with developmental abnormalities are, already at an early stage, extra sensitive regarding their perceptual and sensory functioning [20].

This could in turn augment reactions in terms of more frequent or severe RP. In older children with ASD, it is well known that many have difficulties with eating (regulation of food amount, insistance of sameness etc.), demonstrate different kinds of sleep problems as well as disruptive behaviour (e.g. in transitions).

The study has certain limitations mainly related to that only one source for data collection was used (CHC records) and that data were not assessed with parental diaries. Besides this, we lack information on psychosocial risk factors. There might also be a general tendency of underrating problems in the children's records, to avoid pointing out deviances. However, if any of this is the case, the same policy should have been undertaken in the two groups. Overrating because of a known diagnosis is not probable because the children had not yet been assessed with regard to ASD at this early age, and there were no such indications in the records.

However, the sample is relatively large and representative, and, instead of parental diaries, documentation had been made in a consistent way by the child's nurse at every visit.

In conclusion, we found that the children who later had received a diagnosis of ASD had had more consultations at the CHC than children without ASD.

It is of great importance to all parents of infant children to have a good relation to the CHC and confidence in that their worries are taken seriously and handled with care. Even though these early findings cannot be seen as precursors of autism spectrum disorders or any other specific neurodevelopmental disorder, results from this study suggest that children with a great deal of RP in infancy, and many consultations at the CHC, should be closely followed, both with regard to the child's development in general but also to help with early interventions for the well-being of the whole family.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors are indebted to all nurses at the CHCs and at school health units for their collaboration in the study. Financial support was given through a grant support from Prima Child and Adult Psychiatry (MBO) and from The Gillberg Neuropsychiatry Centre in Gothenburg (to MBO and LHC).

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  • 1
    Schmid G, Schreier A, Meyer R, Wolke D. A prospective study on the persistence of infant crying, sleeping and feeding problems and preschool behaviour. Acta Paediatr 2010; 99: 28690.
  • 2
    Hemmi MH, Wolke D, Schneider S. Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis. Arch Dis Child 2011; 96: 6229. Review.
  • 3
    Skovgaard AM, Houmann T, Christiansen E, Landorph S, Jørgensen T; CCC 2000 Study Team, Olsen EM, Heering K, Kaas-Nielsen S, Samberg V, Lichtenberg A. The prevalence of mental health problems in children 1(1/2) years of age - the Copenhagen Child Cohort 2000. J Child Psychol Psychiatry 2007; 48: 6270.
  • 4
    St James-Roberts I. Infant crying and sleeping: helping parents to prevent and manage problems. Prim Care 2008; 35: 54767. Review.
  • 5
    von Kries R, Kalies H, Papousek M. Excessive crying beyond 3 months may herald other features of multiple regulatory problems. Arch Pediatr Adolesc Med 2006; 160:50811.
  • 6
    Wolke D, Rizzo P, Woods S. Persistent infant crying and hyperactivity problems in middle childhood. Pediatrics 2002; 109:105460.
  • 7
    Rao MR, Brenner RA, Schisterman EF, Vik T, Mills JL. Long term cognitive development in children with prolonged crying. Arch Dis Child 2004; 89: 98992.
  • 8
    Burklow KA, Phelps AN, Schultz JR, McConnell K, Rudolph C. Classifying complex pediatric feeding disorders. J Pediatr Gastroenterol Nutr 1998; 27: 1437.
  • 9
    Howlin P, Asgharian A. The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families. Dev Med Child Neurol 1999; 41: 8349.
  • 10
    Keen DV. Childhood autism, feeding problems and failure to thrive in early infancy. Seven case studies. Eur Child Adolesc Psychiatry 2008; 17: 20916.
  • 11
    Thunström M. Severe sleep problems among infants in a normal population in Sweden: prevalence, severity and correlates. Acta Paediatr 1999; 88: 135663.
  • 12
    Thunström M. Severe sleep problems in infancy associated with subsequent development of attention-deficit/hyperactivity disorder at 5.5 years of age. Acta Paediatr 2002; 91: 58492.
  • 13
    Becker K, Holtmann M, Laucht M, Schmidt MH. Are regulatory problems in infancy precursors of later hyperkinetic symptoms? Acta Paediatr 2004; 93: 14639.
  • 14
    Andersen IM, Kaczmarska J, McGrew SG, Malow BA. Melatonin for insomnia in children with autism spectrum disorders. J Child Neurol 2008; 23: 4825.
  • 15
    Wake M, Morton-Allen E, Poulakis Z, Hiscock H, Gallagher S, Oberklaid F. Prevalence, stability and outcomes of cry-fuss and sleep problems in the first 2 years of life: prospective community-based study. Pediatrics 2006; 117: 83642.
  • 16
    Fernell E, Hedvall A, Norrelgen F, Eriksson M, Höglund-Carlsson L, Barnevik-Olsson M, et al. Developmental profiles in preschool children with autism spectrum disorders referred for intervention. Res Dev Disabil 2010; 31: 7909.
  • 17
    Fernell E, Hedvall A, Westerlund J, Höglund Carlsson L, Eriksson M, Barnevik Olsson M, et al. Early intervention in 208 Swedish preschoolers with autism spectrum disorder. A prospective naturalistic study. Res Dev Disabil 2011; 32: 2092101.
  • 18
    Eriksson MA, Westerlund J, Hedvall A, Amark P, Gillberg C, Fernell E. Medical conditions affect the outcome of early intervention in preschool children with autism spectrum disorders. Eur Child Adolesc Psychiatry 2013; 22: 2333.
  • 19
    Wing L, Leekam SR, Libby SJ, Gould J, Larcombe M. The Diagnostic Interview for Social and Communication Disorders: background, inter-rater reliability and clinical use. J Child Psychol Psychiatry 2002; 43: 30725.
  • 20
    Wiggins LD, Robins DL, Bakeman R, Adamson LB. Brief report: sensory abnormalities as distinguishing symptoms of autism spectrum disorders in young children. J Autism Dev Disord 2009; 39: 108791.