Parent-Based Sleep Education for Children with Autism—Role of Socioeconomic Status

Background: Training parents to improve sleep habits in their children with autism spectrum disorders (ASD) has shown promise on sleep and child/family functioning, although factors associated with efficacy have not been well characterized.  

Objectives: To examine biological and familial factors associated with efficacy in a parent-based sleep education for children with ASD.

Methods:  We carried out a multisite protocol at three sites within our Autism Treatment Network. Children ranged in age from 2-10 years, with their clinical diagnosis of ASD (by DSM-IV criteria) confirmed by the Autism Diagnostic Observation Schedule. All had sleep onset delay, defined by a sleep latency of 30 minutes or greater. Children were evaluated for medical co-occurring conditions that affect sleep, and children with these conditions were either excluded or treated prior to enrollment in the protocol. Parents were randomized to individualized (1 one-hour session with 2 follow-up calls) or group (2 two-hour sessions with 2 follow-up calls) to: (1) Learn techniques related to appropriate timing of sleep and sleep hygiene (e.g., daytime habits, evening habits, sleep environment); (2) Develop and implement an individualized bedtime routine; and (3) Discuss strategies to interact with their child to minimize bedtime resistance and night wakings. Two weeks of actigraphy were completed before and one-month after parent education. Bivariate and multivariate models were reviewed to determine the predictors of improvement in sleep latency, our primary outcome variable. Socioeconomic status (SES) was measured by the Hollinghead Four Factor Index, which incorporates parental education and occupational status.

Results: Data from 80 children [64 boys, 16 girls; ages 5.7 ± 2.6 years (mean ± standard deviation)] were analyzed. As format of education (group vs. individual) did not influence outcomes, results were analyzed for the entire dataset. Actigraphy showed an overall improvement in sleep latency from 58.2 ± 29.1 minutes to 39.6 ± 21.4 minutes (change in sleep latency of 18.6 ± 26.9 minutes; p < 0.0001).  Child age, gender, IQ, and medications did not affect sleep latency. Sleep latency was associated with SES, with a lower SES associated with a larger reduction in sleep latency (p = 0.03). The mean SES in our sample was 44.4 ± 12.3.

Conclusions: Lower SES was associated with a greater improvement in sleep latency in our parent-based sleep education program. The reasons for our findings warrant further study. One explanation for our findings is that families of higher SES may have previously received effective sleep training through educational materials and formal therapies and have had less to gain than those of lower SES. Further study of the role of SES in parent education programs for children with ASD appears warranted.

Acknowledgement: This research was conducted as part of the Autism Speaks Autism Treatment Network. Further support came from a cooperative agreement (UA3 MC 11054) from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program, to the Massachusetts General Hospital. The views expressed in this publication do not necessarily reflect the views of Autism Speaks, Inc.