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Autism before diagnosis: crying, feeding and sleeping problems in the first two years of life

Children who are diagnosed with autism spectrum disorder (ASD), often in their first two years of life have problems with sleeping and feeding and excessive crying. Martina Barnevik Olsson – a child psychiatrist and PhD student at the Gillberg Neuropsychiatry Centre, has studied these regulatory problems as part of her dissertation project. The Researcher’s Corner met up with her to learn more about the study.

Could you tell us something about the purpose of the study and how the study came about?

- A previous intervention study that I took part in and which was led by Professor Elisabeth Fernell constituted the foundation for our study. It comprised 208 preschool children registered at the “Autism Centre for Young Children”, which is a part of the child habilitation services in Stockholm. For that study we had obtained the children’s CHC (Child Health Centres) records, containing a range of information pertaining to the time before the children had received their diagnosis of ASD. We grew interested in whether something could be derived from the CHC records of the children’s first two years, which could indicate a later ASD diagnosis, and we chose to focus on regulatory problems regarding feeding, sleeping and crying.

How was the study designed in terms of data collection, sample and control group?

- Regarding the sample we used the project group that I mentioned, where 190 of the 208 children had complete CHC records from the age of 0-2 years. The records of an age- and gender-matched comparison group were obtained from the same CHCs as those of the index children. The CHC nurses were asked to pick out the child of the same sex immediately before and after the index child in their local archives. All records were scrutinised by me and paediatrician Lotta Höglund Carlsson, and all notes regarding sleeping and feeding problems and excessive crying in the first two years of life were registered. Outcome thus consisted of the number of notes found in the records regarding these problems.

How are regulatory problems in children defined, and what is the link between regulatory problems and neuropsychiatric difficulties/disorders?

- Regulatory problems in small children are often manifested in self-regulation problems including eating and sleeping problems or excessive crying, but can also refer to behavioural regulation problems, for example activity level, mood or emotions. There doesn’t seem to be consensus regarding the links between early regulatory problems and later neuropsychiatric disorders. In some studies severe sleeping problems in infancy have been associated with subsequent development of ADHD and acting-out behaviour. Another study has shown persistent regulatory problems, and particularly regarding feeding, to be predictive of deficits in social skills and adaptive functioning in preschool age. Persistent excessive crying after three months of age has in one study been found to be predictive of hyperactivity, behavioural problems and cognitive deficits in preschool age. Regarding early regulatory problems and later ASD I don’t know of any other studies.

Can sleeping problems also manifest themselves in other ways than difficulties falling asleep and/or sleeping? If so, should this be reflected when asking parents about any sleep related problems in their children (i.e. should questions focus on deviating sleeping patterns/behaviour)?

- Sleeping problems can also imply excessive sleep although it is not as common for parents to seek consultation for that compared with problems falling asleep. I would recommend asking parents - both at CHC-visits and when children are referred for neuropsychiatric assessment - about any difficulties settling down and falling asleep, as well as about whether the child wakes up in the middle of the night, has disturbed sleep with, for example, nightmares and night terrors, and also about approximate number of sleeping hours. There should also be awareness that some forms of epilepsy can occur at night.

How is the awareness among clinicians and researchers regarding the link between regulatory problems and ASD?

- Both clinicians and researchers I think are very aware that regulatory problems are common in children with ASD throughout the childhood (and this is also true for other neuropsychiatric conditions), for example having difficulties related to sleep or selective eating. However, I wouldn’t say that regulatory problems alone would lead professionals to consider ASD – and that certainly doesn’t have to be the case. Regulatory problems are very common in children in the general population, particularly in the first years of life. According to studies in this field the prevalence is between 7% and 17 %, which is also in line with what we found in our comparison group.

Regarding your findings, what would you say were the most important results of the study?

- An important finding was that, in spite of regulatory problems being common in small children in the general public, there was a significant difference between the project group (who later received an ASD diagnosis) and the comparison group. Almost half of the children (44%) in the ASD group had had two consultations or more regarding the regulatory problems involved while this was the case in only 16% of the children in the comparison group. No particular area stood out but the results were valid for each domain studied as well as when domains were collapsed. It was interesting that no correlations were found with regard to later severity of autism, cognitive level, or degree of hyperactivity.

What would you say are the most important implications of your results from an assessment perspective? Implications of other practical relevance?

- The most important implications of this study I think pertain to reception and treatment at the CHCs. Even though these findings cannot be seen as precursors of ASD, a clear pattern emerged where the children who later received a diagnosis of ASD had had more consultations at the CHC regarding feeding, sleeping and excessive crying than children without ASD. Of the 15 children with the highest number of consultations at the CHC, 14 were from the project group. Possibly these children, already at an early stage, were extra sensitive regarding their perceptual and sensory functioning and this sensitivity manifested itself in these ways. It is therefore important that children with considerable and/or persistent regulatory problems are closely followed; both regarding these problems and with regard to their general development!


Barnevik Olsson, M., Carlsson, L.H., Westerlund, J., Gillberg, C., & Fernell, E. (2013). Autism before diagnosis: crying, feeding and sleeping problems in the first two years of life. Acta Paediatrica, 102, 635-639.

Av Nanna Gillberg


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