Monday, January 7, 2019

Sleep Problems in Children on the Autism Spectrum

Sleep Problems in Children on the Autism Spectrum

It is well documented that in addition to the core symptoms of social/communication deficits and restricted repertoire of behaviors, children with autism spectrum disorders (ASD) often experience other comorbid (co-occurring) conditions. In fact, studies estimate that approximately 70 to 84 percent of children with ASD might meet the criteria for a comorbid disorder or condition. Co-occurring conditions include mental health (ADHD, anxiety, depression), neurological (seizure disorder), physical (cerebral palsy, atypical gait), and medical (allergies, asthma, gastrointestinal) conditions. In addition, unusual responses to sensory stimuli, chronic sleep problems, and low muscle tone can occur in individuals with ASD.
Most parents have had some experience with a child who has difficulty falling asleep; wakes up frequently during the night, and/or only sleeps a few hours each night. Although temporary sleep difficulties are an expected phase of child development, ongoing and persistent sleep disturbances can have an adverse effect on the child, parents and other family members. Indeed, a child’s sleeping problems can quickly become a daily parenting challenge. Consequently, we should also expect that sleep problems in children and adolescents with ASD will represent an additional burden on their families, as they attempt to deal with the challenges associated with the symptoms of ASD.  Moreover, there is evidence to suggest that insomnia in itself can aggravate autistic symptoms and further impair adaptability.
Children with ASD appear to experience sleep disturbances more frequently and intensely than typically developing children. Previous population-based and retrospective clinical studies have found a high rate of sleep onset problems in young children with ASD compared to typically developing children. Between 44 and 86 percent of children with autism have a serious problem with sleep. By comparison, between 10 and 16 percent of children in the general population have difficulty sleeping. Research reports the following instances of sleep issues in children with autism:

  • 54% displayed resistance to bedtime
  • 56% experienced insomnia
  • 53% suffered from parasomnias, such as sleepwalking or night terrors
  • 25% experienced sleep-disordered breathing, including sleep apnea
  • 45% had difficulty waking up in the morning
  • 31% experienced daytime sleepiness

Emotional and behavioral problems are related to sleep problems in the general child population, and have also been associated with sleep problems in children with ASD. For example, a previous study of children with Asperger syndrome or high-functioning autism found that those with chronic insomnia were characterized by more emotional and behavioral symptoms than their peers. Co-occurring conditions, such as gastrointestinal (GI) problems, sensory sensitivities, attention deficit hyperactivity disorder (ADHD) and anxiety are also known to disrupt sleep. Although research suggests that children with ASD have a high rate of sleep problems, even when adjusted for other mental health problems, the lack of longitudinal data and population based studies has limited our ability to understand the complex relationship between co-occurring emotional and behavioral problems and sleep difficulties in this group of children. In order to examine the need for increased sleep health care in children with ASD, sleep problems should be longitudinally studied in a total population setting. This approach allows researchers to examine potential risk factors and assess the development of sleep problems over time, as well as plan for early prevention and identification.
A longitudinally-based study published in the journal Autism examined the prevalence and chronicity of sleep problems in children with problems believed to be typical of ASD. The children were assessed for autistic symptoms, sleep problems, and emotional and behavioral problems. Overall, the frequency of chronic insomnia was more than ten times higher in autistic children compared to non-autistic children (39.3% v 3.6%). These children also developed more sleep problems over time, with an incidence rate at of 37.5% compared to 8.6% in the controls at age 11-13 years. Likewise, sleep problems were more persistent over time in children with autistic symptomatology, with a remission rate of only 8.3% compared to 52.4% in the control group. Despite few girls being represented in the study, sleep problems were significantly less prevalent in girls than boys, and that their sleep problems were also more transient. The presence of comorbid attention-deficit/hyperactivity disorder (ADHD) was a strong and independent risk factor for sleep problems in the ASD group. While emotional and behavioral problems explained a large proportion of the association between sleep problems and autism, children with autistic symptoms had a three-fold increased risk of sleep problems.


Previous research and results of this longitudinal population-based study show a clear association between autism symptoms and sleep problems and support the generally high prevalence rates of sleep problems reported in children with autism. 
Research also suggests that sleep disturbances may represent early warning signs of autism, exacerbate autism symptoms severity, significantly decrease the health-related quality of life of individuals with ASD, and affect the mental health of family members. Problematically, sleep problems tend to exacerbate other issues characteristic of the ASD. For example, daytime sleepiness from lack of sleep often results in more severe repetitive behavior, hyperactivity, inattentiveness, and aggression during the day as well as deficits in higher-order and complex cognitive functions. This argues for the assessment and treatment of sleeping problems as a standard and integrated part of the symptom management of ASD. Diagnosing and treating sleeping problems in autistic children is important both to relieve symptom severity and improve quality of life for children and their families.
Key References and Further Reading

Adams, H. L., Matson, J. L., Cervantes, P. E., & Goldin, R. L. (2014). The relationship between autism symptom severity and sleep problems: should bidirectionality be considered? Research in Autism Spectrum Disorders, 8(3), 193–199. doi: 10.1016/j.rasd.2013.11.008.
Astill, R. G., Van der Heijden, K. B., Van Ijzendoorn, M. H., & Van Someren, E. J. (2012). Sleep, cognition, and behavioral problems in school-age children: a century of research meta-analyzed. Psychological Bulletin, 138(6), 1109–1138. doi: 10.1037/a0028204.

Devnani, P. A., & Hegde, A. U. (2015). Autism and sleep disorders. Journal of pediatric neurosciences10(4), 304–307. doi:10.4103/1817-1745.174438

Hodge, D., Carollo, T. M., Lewin, M., Hoffman, C. D., & Sweeney, D. P. (2014). Sleep patterns in children with and without autism spectrum disorders: developmental comparisons. Research in Developmental Disabilities, 35(7), 1631–1638. doi: 10.1016/j.ridd.2014.03.03

Mannion, A., Leader, G., & Healy, O. (2013). An investigation of comorbid psychological disorders, sleep problems, gastrointestinal symptoms and epilepsy in children and adolescents with autism spectrum disorder. Research in Autism Spectrum Disorders, 7(1), 35–42. doi: 10.1016/j.rasd.2012.05.002.

Mayes, S. D., & Calhoun, S. L. (2009). Variables related to sleep problems in children with autism. Research in Autism Spectrum Disorders, 3(4), 931–941. 

Mazurek, M. O., & Petroski, G. F. (2014). Sleep problems in children with autism spectrum disorder: examining the contributions of sensory over-responsivity and anxiety. Sleep Medicine. doi: 10.1016/j.sleep.2014.11.006.

Nadeau, J. M., Arnold, E. B., Keene, A. C., Collier, A. B., Lewin, A. B., Murphy, T. K., et al. (2014). Frequency and clinical correlates of sleep-related problems among anxious youth with autism spectrum disorders. Child Psychiatry & Human Development

Reynolds, AM, Soke, GN, Sabourin, KR, et al. (2019). Sleep problems in 2- to 5-year-olds with autism spectrum disorder and other developmental delays. Pediatrics. 143 (3):e20180492

Richdale, A. L., & Baglin, C. L. (2015). Self-report and caregiver-report of sleep and psychopathology in children with high-functioning autism spectrum disorder: a pilot study. Developmental Neurorehabilitation, 18(4), 272–279.

Sikora, D. M., Johnson, K., Clemons, T., & Katz, T. (2012). The relationship between sleep problems and daytime behavior in children of different ages with autism spectrum disorders. Pediatrics, 130(Supplement), S83–S90. doi: 10.1542/peds.2012-0900F.

Sivertsen, B., Posserud, M., Gillberg, C., Lundervold, A. J., & Hysing, M. (2012). Sleep problems in children with autism spectrum problems: A longitudinal population-based study. Autism, 16, 139-150. DOI: 10.1177/1362361311404255

Schreck, K. A., Mulick, J. A., & Smith, A. F. (2004). Sleep problems as possible predictors of intensified symptoms of autism. Research in Developmental Disabilities, 25(1), 57–66.

Taylor, M. A., Schreck, K. A., & Mulick, J. A. (2012). Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders. Research in Developmental Disabilities, 33(5), 1408–1417. doi: 10.1016/j.ridd.2012.03.013.

Lee A. Wilkinson, PhD, is a licensed and nationally certified school psychologist, and certified cognitive-behavioral therapist. He is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© Lee A. Wilkinson, PhD

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