Sleep behaviors and sleep quality in children with autism spectrum disorders

Abstract

Study objectives: (1) Compare sleep behaviors of children with autism spectrum disorders (ASD) with sleep behaviors of typically developing (TD) children using the Children's Sleep Habits Questionnaire (CSHQ); (2) compare sleep quality--defined as mean activity, sleep latency, number of awakenings, sleep efficiency and total sleep time--of the cohort of children with ASD and TD, as measured by 10 nights of actigraphy; and (3) estimate the prevalence of sleep disturbances in the ASD and TD cohorts.

Design: Descriptive cross-sectional study.

Setting: The Children's Hospital of Philadelphia.

Participants: Randomly selected children from the Regional Autism Center. The ASD cohort of 59 children, aged 4 to 10 years, (26 with autism, 21 with pervasive developmental disorder-not otherwise specified [PDD-NOS], and 12 with Asperger disorder) were compared with 40 TD control subjects.

Measurements and results: The CSHQ, sleep diaries, and 10 nights of actigraphy using the Sadeh algorithm of children with ASD and TD control subjects were compared. CSHQ showed 66.1% of parents of children with ASD (62.5% autism, 76.2% PDD-NOS, 58.3% Asperger disorder) and 45% of parents of the control subjects reported that their children had sleep problems. Actigraphic data showed that 66.7% of children with ASD (75% autism, 52.4% PDD-NOS, 75% Asperger disorder) and 45.9% of the control subjects had disturbed sleep.

Conclusions: The prevalence estimate of 45% for mild sleep disturbances in the TD cohort highlights pediatric sleep debt as a public health problem of concern. The prevalence estimate of 66% for moderate sleep disturbances in the ASD cohort underscores the significant sleep problems that the families of these children face. The predominant sleep disorders in the ASD cohort were behavioral insomnia sleep-onset type and insomnia due to PDD.

Figure 1

The Children's Sleep Habits Questionnaire (CSHQ) cutoff subscale total score is 41, shown as a bold line. Forty-five percent of the typically developing (TD) control subjects scored greater than 41 (mean score 41.7, SD 4.56). Most children scored at or just above the cutoff, illustrating that most sleep difficulties in the TD cohort are mild.

Figure 2

The Children's Sleep Habits Questionnaire (CSHQ) cutoff subscale total score is 41, shown as a bold line. In contrast to the typically developing children (data shown in Figure 1), 66.1% of the cohort with an autism spectrum disorder (ASD) scored greater than the cutoff (mean score 47.39, SD of 8.21), representing more moderate to severe sleep problems.

Figure 3

The sleep latency for all three subgroups was statistically different from the TD cohort (see P values at top), showing that children across the autism spectrum had difficulties falling asleep. The Asperger Disorder subgroup had the longest sleep latency 38.5 minutes.

Figure 4

Data from 10 consecutive nights of actigraphy, obtained from an actigraph that was contained in a specially designed upper-sleeve pocket.

Figure 5

The x axis shows the time of day, 1900 to 0700. The y axis is the average activity count per hour of the typically developing (TD) and autism spectrum disorder (ASD) cohorts. On average, the TD and ASD cohorts went to bed wearing the actigraph at 2115 and woke at 0705, as reported by parents on the sleep diary.