Sleep and Behavioral Disturbances in Children with Autism Spectrum Disorders: Evidence from India

Background: Sleep problems are considered a common clinical characteristic of children with autism spectrum disorders (ASDs). Little evidence is, however, available on sleep related difficulties in children with autism from developing countries leading to major gaps in the knowledge about children with autism from the majority world and the needs of these children.

Objectives:  To compare parent reported sleep problems of children with ASD and typically developing children and to study the association of sleep problems with daytime behavioral difficulties in children with ASD.

Methods:  Sixty children diagnosed with ASD (Mean age= 6.1 years, SD=2.4) were recruited from the Department of Pediatrics of a tertiary care teaching hospital in India. An age and socio-economic status matched group of typically developing children (N=60) were also recruited. The Children’s Sleep Habits Questionnaire (CSHQ) was used to measure sleep problems. The 33 items scale assesses resistance to bedtime, delay in onset of sleep, duration of sleep, parasomnias, sleep-disordered breathing, sleep anxiety, awakenings at night, and daytime sleepiness. The Childhood Psychopathology Measurement Schedule, the Indian adaptation of the Child Behavior Checklist, was used to measure day time behavioral difficulties. The study was approved by the ethics committee of the Institute and a written informed consent was taken from all the parents/caregivers.

Results: The prevalence of sleep problems in children with ASD was 88%, nearly twice as more as compared to controls (47%). The ASD group as compared to typically developing children had significantly higher total scores on the CSHQ (t= 5.3, P=.001) and more sleep related problems (t =3.6, P=.001). As compared to controls, significantly higher proportion of children with ASD reported bedtime struggles (25% vs. 7%, P=.001), problems in initiating sleep (28% vs. 0 %, P=.001), sleeping for inadequate duration (30% vs. 1%, P=.001), frequent sleep disruptions (28% vs. 13%, P=.006), not falling sleep in own bed (72% vs. 38%, P=.001), afraid of sleeping in the dark (32% vs. 13%, P=.002), and bed wetting (13% vs. 2%, P=.02). A significant correlation was found between sleep and daytime behavioral problems (r=0.53, P=.01). Sleep difficulties of the ASD children did not differ by socio-economic status, education of the mother, autism severity score as measured by the Childhood Autism Rating Scale (CARS) score.

Conclusions:  Children with ASD are at a high risk for sleep problems and this may be associated with daytime behavioral difficulties. Clinicians should routinely screen ASD children for sleep problems and initiate appropriate interventions.