Sleep Is Associated with Problem Behaviors in Children with Autism Spectrum Disorder

Background: Sleep problems are common in children with Autism Spectrum Disorder (ASD) with rates estimated to range from 44 – 83%. Previous research has suggested that sleep problems are associated with challenging behaviors in children with ASD. However, these samples were small and did not use standardized definitions of ASD. Substantiation of these findings within a large cohort of individuals would support the development of treatments targeted at improving sleep disturbances as an avenue to improve behavior.

Objectives: The goal of this analysis was to identify the sleep factors associated with problematic daytime behavior.

Methods: The study population was 1056 children, ages 3 – 18, participating in the Autism Treatment Network (ATN). The ATN is a registry collecting data on children with ASD across 14 sites in the United States and Canada. All children have a clinical diagnosis of ASD confirmed by the Autism Diagnostic Observation Schedule (ADOS). Sleep behaviors were derived from the Children’s Sleep Habits Questionnaire (CSHQ), a validated, parental questionnaire describing sleep behaviors in children, including overall sleep problems, sleep anxiety, sleep duration, and parasomnias.  Daytime behaviors were obtained from the Child Behavior Checklist (CBCL), a validated, parentally completed questionnaire used to examine behaviors in children.  Two separate forms spanning the age ranges 1½–5 years and 6–18 years are available. We analyzed T-scores from scales common to both age groups, as well as analyzing each age group individually.
Descriptive statistics were calculated for all major variables. Pearson product-moment correlation coefficients were calculated to identify associations between sleep and behavior. We chose a correlation coefficient value of ≥0.30 and p-value <0.05 to represent significance.

Results:

CSHQ surveys were completed by 1056 parents (564 ages 2-5 and 492 ages 6-18). Across all ages, the CSHQ total score was associated with the total CBCL score (r =0.47) and CBCL affective problems subscale (r = 0.55). The CSHQ total score and sleep anxiety domains were both associated with the CBCL anxiety subscale (r = 0.34 for both). The CSHQ sleep duration domain was associated with the CBCL affective problems scale (r = 0.46), and the parasomnia domain was associated with the total problem scale (r = 0.36). In the older children the CSHQ sleep total domain was associated with the CBCL total problem scale (r = 0.43) and the CBCL affective problems scale (r = 0.50).

Conclusions:

Our findings support the hypothesis that sleep factors are associated with problematic daytime behaviors in a large cohort of children with well-defined ASD. We showed that the behavioral domains of affective disorders and anxiety are associated with problematic sleep. The high rates of association call for longitudinal studies to demonstrate cause and effect as well as pharmacological and behavioral trials to define the effects of improving sleep on daytime behaviors.

SUPPORT: Grant support received from the Autism Treatment Network, Health Resources and Services Administration (UA3 MC11054).