Child Psychiatry Hum Dev (2006) 37:179–191

DOI 10.1007/s10578-006-0028-3

Sleep Disturbances and Correlates of Children

with Autism Spectrum Disorders

Xianchen Liu Æ Julie A. Hubbard Æ Richard A. Fabes Æ

James B. Adam

Published online: 26 September 2006

Ó Springer Science+Business Media, LLC 2006

Abstract This study examined sleep patterns, sleep problems, and their correlates
in children with autism spectrum disorders (ASD). Subjects consisted of 167 ASD
children, including 108 with autistic disorder, 27 with Asperger’s syndrome, and 32
with other diagnoses of ASD. Mean age was 8.8 years (SD = 4.2), 86% were boys.
Parents completed a self-administered child sleep questionnaire. Results showed
that average night sleep duration was 8.9 h (SD = 1.8), 16% of children shared a bed
with parent. About 86% of children had at least one sleep problem almost every day,
including 54% with bedtime resistance, 56% with insomnia, 53% with parasomnias,
25% with sleep disordered breathing, 45% with morning rise problems, and 31%
with daytime sleepiness. Multivariate logistic regression analyses indicated that
younger age, hypersensitivity, co-sleeping, epilepsy, attention-deficit/hyperactivity
disorder (ADHD), asthma, bedtime ritual, medication use, and family history of
sleep problems were related to sleep problems. Comorbid epilepsy, insomnia, and
parasomnias were associated with increased risk for daytime sleepiness. Results
suggest that both dyssomnias and parasomnias are very prevalent in children with
ASD. Although multiple child and family factors are associated with sleep problems,
other comorbid disorders of autism may play a major role.

Keywords Autistic spectrum disorder Æ Sleep patterns Æ Sleep problems Æ

Risk factors

X. Liu (&)
Department of Psychiatry, University of Pittsburgh School of Medicine, 134 Webster Hall,
3811 O’Hara Street, Pittsburgh, PA 15213, USA
e-mail: xcliu@pitt.edu

J. A. Hubbard Æ R. A. Fabes
Department of Family and Human Development, Arizona State University, Tempe,
AZ 85287-2502, USA

J. B. Adam
Department of Chemicals and Materials Engineering, Arizona State University, Tempe,
AZ 85257-6006, USA
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Introduction

Autism is a severe neurodevelopmental disorder characterized by impairment in

social interaction, communication deficits, and restricted, repetitive behaviors.
Children with autism may have a wide range of comorbid disorders [1]. One par-
ticular disorder that is often associated with autism is sleep problems [2–4]. The
severity of sleep problems in children with autism is of particular concern in light of
the increased burden and stress experienced in parenting a child with autism and the
potentially adverse effects of sleep problems and insufficient sleep on daytime
behavior and functioning [5–7].
There are reports that about two-thirds of children with autism exhibit sleep
problems [3], with prevalence rates ranging from 54 to 83% [5, 8]. Sleep disorders in
children are not a unitary clinical problem and are commonly classified into two
major categories: dyssomnias that include disorders of initiating or maintaining sleep
or of excessive sleepiness and parasomnias that are disorders that disrupt sleep after
it has been initiated [9]. All of the sleep problems may exacerbate difficulties with
behavior and emotion and therefore need to be addressed. However, most of the
sleep research in children with autism has focused on problems associated with
settling and insomnia. There is little data concerning parasomnias and sleep
breathing disorders [10].
In two sleep diary studies, frequency of sleepwalking, sleeptalking, and night-
mares did not differ between autistic and comparison children [6, 8]. Conversely,
Schreck and Mulick found that children with autism were more likely to exhibit
parasomnias, such as nightmares, sleepwalking, and bruxism [4]. A recent study of
eight children with autism reported all of the subjects had either historical or
polysomnographic (PSG) evidence of at least one parasomnia [11]. Another PSG
study of 11 children with autism reported that five children had rapid eye movement
sleep behavior disorder [12]. Growing literature has suggested that sleep apnea is
found more frequently in children with learning disabilities [13, 14]. However, it is
not clear if sleep-breathing problems are common in autism.
Multiple neurodevelopmental, medical, psychosocial, and environmental factors
may be associated with increased risk for sleep disorders in children with autism [3].
For example, children with autism may have a wide range of comorbid mental
disorders, including hyperactivity, impulsivity, aggressiveness, temper tantrums, self-
injurious and destructive behaviors, excessive fearfulness, anxiety or depression, or
mental retardation [1]. All of these symptoms and behaviors may contribute to sleep
disorders in autism [2, 3, 8, 10, 13, 14]. Research has shown that about 50% of
individuals with autism take medications including psychotropics, antiepileptics, and
others [15, 16]. There is evidence that children with autism are particularly sensitive
to being touched or to environmental stimuli, and they often react strongly to
seemingly benign environmental changes, such as light, color, sound, bed, or
movement of an object in the room, which may adversely affect their sleep [2]. Sleep
problems in children with autism may be the result of some medications and/or
hypersensitivity to environmental stimuli. In addition, a number of risk factors for
sleep problems in typically developing children may also contribute to increased risk
for sleep problems in children with autism. Research has demonstrated that poor
sleep practice and life styles are associated with child sleep disorders, such as
co-sleeping, noncompliance and oppositional behavior at bedtime, irregular bedtime

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and wakeup schedule, bedtime set too early, stimulating activities or caffeinated
beverages before bedtime, and lack of physical activity during the day [2, 17–19].
Furthermore, family and environmental factors may also be associated with sleep
disorders in children with autism, such as family history of sleep disorders, parenting
skills, family stress, crowded housing, light, noise and extreme temperature in the
room, and changes in sleep environment [13, 18–20]. However, little is known as to
what degree these factors contribute to sleep disorders in children with autism due to
the lack of empirical research.
The purpose of the current study was to describe sleep patterns, sleep prob-
lems, and their correlates in a community sample of 167 children with autism
spectrum disorders (ASD). Sleep problems were assessed by a structured ques-
tionnaire, consisting of dyssomnias and parasomnias. Variables of interest in this
study included a wide range of developmental, medical, family, and environ-
mental factors. To our knowledge, this is one of the first to investigate a wide
range of sleep problems and their correlates in a relatively large sample of
children with autism.

Methods

Subjects and procedure

Subjects were 167 children with ASD, recruited from parents who attended two
conferences of the Greater Phoenix Chapter of the Autism Society of America
(GPCASA) in Phoenix in January 2004 and in Tucson in July 2004. Of 167 children,
86% were boys, 77% were Caucasian, 7.9% were Hispanic, and mean age was
8.8 years (SD = 4.0, range = 2.4–18.2 years). Eighty percent of parents were mar-
ried, and 49% of mothers had college or graduate school education. Based on parent
report, 108 (65%) children were previously diagnosed with autistic disorder, 27
(16%) with Asperger’s syndrome, 13 (7.8%) with two diagnoses (7.8%), 13 (7.8%)
with a broad category of ASD, three with Pervasive Developmental Disorder ‘‘Not
Otherwise Specified’’, two with Pervasive Developmental Disorder, and one with
high-functioning autism. One hundred and twenty-one children (73%) were diag-
nosed by a developmental pediatrician, child psychiatrist, and/or neurologist, 18
children (11%) by a clinical psychologist, and 28 children (16%) by a doctor whose
specialization was unknown to the parent. Children’s disability was distributed as
mild (29%), moderate (55%), and severe (16%), based on a question for parent (In
your opinion, what is your child’s disability?). Comorbid disorders in this sample
were very prevalent, including attention-deficit/hyperactivity disorder (ADHD)
(31%), epilepsy (11%), asthma (17%), allergies (50%), and gastrointestinal symp-
toms (21% with vomiting, reflux, spit-ups, 17% with chronic diarrhea, 18% with
chronic constipation, 18% with abdominal pain, and 14% with intestinal bloating).
A total of 235 parents of children with ASD attended the GPCASA conferences
for 1 or 2 days. After a brief introduction of the purpose of the survey during the
conference, all parents who had a child with previously diagnosed ASD, aged 18 or
younger, were invited to participate in the study. Parents of 167 children (71%)
completed the questionnaires, with 158 questionnaires returned during the confer-
ence and nine returned within 2 weeks after the conference. The questionnaire was
mostly completed by mothers (84%), with some fathers (10%), and other caregivers
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(6%) participating. We offered a random drawing of respondents for a gift of $15,

with 10% of respondents obtaining the award.
If parents completed the questionnaire and their children were between 5 and
14 years, they were invited for a comprehensive study of sleep and adaptive behavior
in children with ASD. If they agreed to participate in further evaluation, they were
asked to contact us by phone, e-mail, or mail. Parents of 60 children were willing to
participate in further evaluation and the first 30 children on the waiting list were
administered the Autism Diagnostic Observation Schedule-Generic (ADOS-G). All
the 30 children met the diagnostic criteria of ADOS-G for autism and were in
agreement with parent reported diagnoses.
Parents gave consent to participate in the study, which was approved by the
Institutional Review Board of Arizona State University.

Measures

Sleep Problems and Sleep Patterns

A modified Child Sleep Habits Questionnaire (CSHQ) [21] was developed for this
study, based on previous studies of sleep in children with autism [2–4, 7, 10] and
other child sleep questionnaires, particularly the pediatric sleep questionnaire (PSQ)
[22]. The modified CSHQ consisted of five questions to assess children’s sleep pat-
terns on typical weekdays: bedtime, sleep onset time, morning wake time, night sleep
duration, and napping time, and a sleep problem scale including 34 individual items
related to sleep disturbances that potentially occurred at bedtime and morning rise
time, during sleep and daytime (see Table 2). Parents were asked to report their
child’s sleep behaviors during the past month. Sleep problems were rated on a
3-point scale: ‘‘usually’’ if the sleep behavior occurred 5–7 times per week
(score = 3); ‘‘sometimes’’ for 2–4 times per week (score = 2); and ‘‘rarely’’ for less
than one time per week (score = 1). The 34 sleep problem items were conceptually
grouped into seven subscales: bedtime resistance (five items), insomnia (five items),
parasomnias (seven items), sleep-disordered breathing (four items), morning rise
problems (six items), and daytime sleepiness (seven items). The sleep problem scale
had satisfactory reliability (as measured by Cronbach’s alpha: 0.87 for the total scale,
0.66 for bedtime resistance, 0.75 for insomnia, 0.65 for parasomnias, 0.67 for sleep-
disordered breathing, 0.79 for morning rise problems, and 0.61 for daytime sleepi-
ness). One–two weeks test–retest reliability was 0.69 for the total scale. A copy of
the sleep questionnaire can be obtained from the first author.

Sleep Practices and Child and Family Characteristics

A structured sleep and family demographic questionnaire was developed for the
parents to provide information about sleep practices (e.g., co-sleeping, bedtime ritual),
child characteristics, developmental and medical situation (e.g., age, gender, diagnosis,
severity of disability, commorbid physical and mental disorders, gastrointestinal
symptoms, hypersensitivity, use of medication, and alternative medications), and
family information (e.g., parental married status, number of children under 18 years in
the household, number of bedrooms in the household, parental married status,
maternal education level, family history of sleep, and mental health problems).
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Statistical Analysis

We performed analyses of covariance (ANCOVAs) with gender as a between-

subjects factor and age (in years) as a covariate to assess the effect of age and gender
on sleep patterns (bedtime and wakeup time), sleep latency, and sleep duration.
Type III sums of squares were used for main and interaction effects, whereby each
significant effect was tested after controlling for all other effects. We performed chi-
square tests to examine the effects of age (categorized as <6, 6–8, 9–12, and
>12 years) and gender on the frequency of napping, bedtime ritual, and co-sleeping.
Age and gender effects were examined because little is known about age and gender
differences in sleep patterns and problems in children with autism.
Multivariate logistic regression analyses were performed to examine significant
correlates of each domain of sleep problems (bedtime resistance, insomnia, para-
somnia, sleep disordered breathing, morning rise problems, and daytime sleepiness),
using a forward stepwise regression method. The subject was considered to have a
domain of clinically significant problems if he/she was rated as usually on one or
more problems in the subscale (see Table 2). For all logistic regressions, the
dependent variable was whether the subject had certain specific domain of clinically
significant sleep problems (yes = 1) or not (no = 0). Odds ratios (ORs) and 95%
confidence intervals (CI) were used to present associations of each form of suici-
dality with depressive symptoms and comorbid disorders.
All analyses were performed using the Statistical Program for Social Sciences
(SPSS), Version 13.0 for Windows. All statistical significance was set at P < 0.05.

Results

Sleep Practices and Sleep Patterns

As indicated in Table 1, 25.2% of children frequently napped, with an average

napping time of 75.7 min (SD = 37.6). Younger children were more likely to nap

Table 1 Sleep practices and sleep patterns among children with autism spectrum disorders

n %/M (SD) v2/ANCOVA

Gender Age

Napping (%) 159 25.2 NS 37.55***

Bedtime ritual (%) 167 67.7 NS NS
Cosleeping 167 NS 44.83***
Share a bed with parent (%) 27 16.2
Share a bed with sibling (%) 6 3.6
Sleep in own bed but share a room with parent (%) 7 4.2
Sleep in own bed but share a room with sibling (%) 26 15.6
Bedtime on weeknights (military time) 166 20:33 (2.73 h) NS NS
Sleep latency (minute) 158 32.51 (30.21) NS NS
Morning wake time on weekdays (military time) 164 06:41 (1.25 h) NS NS
Night sleep duration (hour) 157 8.91 (1.77) NS NS

NS not significant
* P < 0.05
** P < 0.01
*** p < 0.001
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Table 2 Frequency of sleep problems in children with autism spectrum disorders

Sleep problems during the past month Sometimes (%) Usually (%)

Bedtime resistance (a = 0.663) 53.9

Goes to bed at different time at night 25.1 11.4
Need parent in the room to fall asleep 17.4 23.4
Struggle at bedtime 29.3 20.4
Afraid of sleeping in the dark 12.6 25.1
Afraid of sleeping alone 16.8 15.6
Insomnia (a = 0.746) 56.3
Difficulty falling asleep in 20 min 32.3 28.1
Sleep too little each day 31.1 16.8
Easily wake up during the night 25.7 19.2
Need help to return to sleep after waking 25.7 21.0
Wake up too early in the morning 37.1 18.6
Parasomnias (a = 0.656) 53.3
Wet the bed at night 15.6 26.3
Talk during sleep 22.2 7.8
Restless and move a lot during sleep 36.5 28.7
Sleepwalk at night 9.6 3.6
Grind teeth during sleep 22.8 18.6
Awaken during the night screaming, sweating, inconsolable 15.0 5.4
Awaken alarmed by a frightening dream 17.4 4.2
Sleep disordered breathing (a = 0.670) 24.6
Snore loudly 22.8 7.2
Seem to stop breathing during sleep 10.2 1.8
Breathe through mouth during sleep 34.1 19.8
Snort and/or gasp during sleep 18.0 5.4
Morning rise problems (a = 0.794) 44.9
Awakened by others in the morning 27.5 26.9
Wake up in negative mood 37.7 15.0
Difficulty getting out of bed 32.3 19.2
Take a long time to become alert 31.7 18.0
Seem tired in the morning 36.5 21.6
Have a poor appetite in the morning 22.2 25.7
Daytime sleepiness (a = 0.811) 31.1
Appear sleepy during the day 36.5 15.0
Appear tired during the day 41.3 18.0
Sleepy while playing alone 24.6 6.6
Sleepy while watching TV 31.7 4.8
Sleepy while riding in the car 34.1 16.2
Sleepy when eating meals 18.6 3.0
Sleep too much 12.0 3.6
Overall 86.2

(v2 = 37.55, P < 0.001). Sixty-eight percent of children were reported to have a
bedtime ritual, with parent reading a story being one of the most common. Co-
sleeping was prevalent in this sample, including 16.2% sharing a bed with parents,
3.6% sharing a bed with a sibling, 4.2% sharing a room with parents, and 15.6%
sharing a room with siblings. The frequency of co-sleeping significantly declined with
age (v2 = 44.83, P < 0.001).
Table 1 also presents average bedtime, sleep onset latency, morning wake time,
and night sleep duration on weekdays. The average bedtime of this sample was
reported to be 20:33 (military time). Sleep onset latency varied greatly with a mean
of 33 min (SD = 30), ranging from less than 5–150 min. Mean morning wake time
was 06:41 (SD = 75 min), and mean night sleep duration was 8.9 h (SD = 1.8).
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All the sleep parameters did not significantly differ among children with autism,
Asperger’s syndrome, and other ASD as examined by chi-square tests for categorical
parameters and analysis of variance for continuous parameters (for all, P > 0.05).

Prevalence of Sleep Problems

Table 2 summarizes frequencies of each sleep problem that occurred sometimes and
usually during the past month. If a sleep problem occurred usually, this problem was
considered clinically significant. The overall prevalence of sleep problems was
86.2%, indicating that more than 86% of children with ASD had at least one sleep
problem that occurred almost every day during the past month. The prevalence rates
were 53.9% for bedtime resistance, 56.3% for insomnia, 53.3% for parasomnias,
24.6% for sleep disordered breathing, 44.9% for morning rise problems, and 31.1%
for daytime sleepiness. For individual sleep problems, restless during sleep (28.7%),
difficulty falling asleep (28.1%), awakened by others in the morning (26.9%), bed-
wetting (26.3%), and poor appetite in the morning (25.7%) were among the most
prevalent problems.

Associations Among Sleep Problems

Data concerning associations of specific pairs of sleep problems are presented in

Table 3. Results are shown in the forms of percentages and ORs.
As shown in Table 3, most ORs were greater than 2.0 and significant at P < 0.05,
ranging from 2.3 for morning rise problems to 4.3 for insomnia with bedtime resis-
tance as reference. In other words, children with bedtime resistance were two times
more likely to have morning rise problems and four times as likely to have insomnia
than children without bedtime resistance. Five ORs were less than 2.0 and not
significant. These results indicated that most sleep problems are highly comorbid
among children with ASD.

Factors Associated with Sleep Problems

Multiple stepwise logistic regression analyses were performed to examine significant

factors associated with each domain of sleep problems. Significant factors and the
magnitude of their associations with each sleep problem are summarized in Table 4.

Table 3 Comorbidity (%) and associations (OR, 95%CI) of sleep problems

1 2 3 4 5

Bedtime resistance (1)

Insomnia (2) 72.2
4.3(2.2–8.3)
Parasomnias (3) 66.7 63.8
3.3(1.7–6.3) 2.7(1.4–5.0)
Sleep disordered 23.3 34.0 34.8
breathing (4) 0.9(2.3–1.2) 3.7(1.6–8.3) 3.6(1.6–8.0)
Morning rise 54.4 51.1 49.4 56.1
problems (5) 2.3(1.2–4.4) 1.8(0.9–3.3) 1.5(0.8–2.7) 1.8(0.9–3.7)
Daytime 43.3 41.5 42.7 29.3 44.0
sleepiness (6) 3.8(1.8–7.8) 3.3(1.6–6.8) 3.4(1.7–7.0) 0.9(0.4–1.9) 3.0(1.5–6.0)

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Table 4 Correlates of sleep problems: multivariate logistic regression analysesa (OR, 95%CI)

Bedtime resistance Insomnia Parasomnias Daytime sleepiness

Age (year)
<6 2.9 (1.1–7.4)
6–8 2.7 (0.9–7.4)
9–12 1.1 (0.4–2.8)
>12 1.0
Epilepsy
No 1.0
Yes 10.7 (3.1–36.7)
Asthma
No
Yes 1.0
Allergy 3.1 (1.2–8.1)
No 1.0
Yes 3.9 (1.9–7.9)
Gastrointestinal symptoms
No 1.0 1.0
Yes 1.6 (1.0–2.4) 1.7 (1.1–2.8)
Hypersensitivity
No 1.0
Yes 1.4 (1.1–1.7)
Medication use
No 1.0
Yes 2.9 (1.4–5.8)
Bedtime ritual
No 1.0
Yes 2.4 (1.2–5.0)
Co-sleeping
Sleep alone 1.0
Share a bed 4.4 (1.6–11.9)
Share a room 1.3 (0.5–3.3)
Father sleep problems
No 1.0
Yes 3.3 (1.3–8.2)
Insomnia
No 1.0
Yes 3.1 (1.4–7.0)
Parasomnias
No 1.0
Yes 2.3 (1.1–5.1)
a
Other independent variables in the multivariate models included sex, severity of disability, diag-
nosis (autistic disorder, Asperger’s syndrome, and others), comorbid ADHD, parental married
status, maternal education, maternal sleep problems, number of children and number of bedrooms in
the household, bedtime and morning rise time, and all variables in this table. However, insomnia and
parasomnias were only used for daytime sleepiness

As indicated in Table 4, four factors were significantly associated with increased

risk for bedtime resistance: allergy (OR = 3.9), hypersentivity (OR = 1.4), bed-
sharing (OR = 4.4), and father sleep problems (OR = 3.3). For insomnia, significant
correlates were asthma (OR = 3.1) and gastrointestinal symptoms (OR = 1.6).
Younger age (OR = 2.9), gastrointestinal symptoms (OR = 1.8), use of medication
(OR = 2.9), and bedtime ritual (OR = 2.4) were related to parasomnias. Correlates
of daytime sleepiness that were significant in the multivariate model included
comorbid epilepsy (OR = 10.7), insomnia (OR = 3.1), and parasomnias (OR = 2.3).
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No significant correlates were detected for sleep disordered breathing and morning
rise problems. Furthermore, the type of ASD, severity of disability, child’s gender,
bedtime, morning rise time, and a number of family environmental factors, such as
number of children and number of bedrooms in the household, maternal married
status, and maternal education were not found to be significantly related to sleep
problems.

Discussion

This study was designed to investigate sleep problems and their correlates in a
relatively large sample of children with ASD (n = 167). Our main findings included
(1) 16% of children with ASD shared a bed with parent; (2) mean bedtime on
weeknights was 20:33, mean sleep onset time was 32 min, morning wake time was
06:41, and mean nocturnal sleep duration was 8.9 h; (3) 86% of children had at least
one sleep problem almost every day during the past month, about half of the chil-
dren had bedtime resistance, insomnia, parasomnias, and morning rise problems,
one-fourth and one-third of the children had sleep disordered breathing and daytime
sleepiness, respectively; (4) most sleep problems were coexisting; and (5) sleep
problems in children with ASD were related to multiple factors including younger
age, comorbid ADHD, asthma, epilepsy, allergy, gastrointestinal symptoms,
hypersensitivity to stimulus, co-sleeping, use of medication, and family history of
sleep problems.
Regular co-sleeping is not common among children in the US. According to the
2004 Sleep in America Poll [23], 78% of school-aged children slept in their own
room in their own bed alone, only 5% shared a bed with parents. In the current study
of 167 children with a mean age of 8.8 years, we found that regular co-sleeping in
children with ASD was relatively common, with 16% sharing a bed with parents.
Several factors may account for the high frequency of co-sleeping in children with
ASD. First, sleep problems are very prevalent in children with ASD. In our sample,
86% of children had at least one sleep problem almost every day. Sleep problems
may increase the likelihood of co-sleeping with parents. Second, because of the
child’s disability, parents may think that their child needs care during the night.
Third, children’s autistic behaviors may also contribute to the likelihood for
co-sleeping with parents. For example, children with ASD are characterized by
restricted and repetitive behaviors, which may make it difficult to separate the child
from the parent’s bed/room to a new sleep environment.
Estimates of sleep quantity (sleep length) in previous studies of children with
autism have not been consistent. For example, Schreck and Mulick did not find any
differences in sleep quantity parameters between autistic children and controls [4].
Richdale and Prior reported that night sleep duration was longer in low-functioning
autistic children than in typically developing children, but sleep duration was shorter
in high-functioning autistic children than controls of similar IQ [8]. In the only study
of autistic children (n = 8) using actigraphy, the authors did not find a significant
difference in sleep duration between autistic children and controls [24]. In our study,
mean night sleep duration was about 9.0 h and did not significantly differ among
children with autistic disorder, Asperger’s syndrome, and other ASD. Mean night
sleep duration in this sample of children with ASD is 1 h less than Owens et al.’s

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report of a community sample of children aged 4–10 years [21] and a half hour less
than the 2004 Sleep in America Poll’s report of preschool and school-aged children
[23], using a similar question to ask about child’s night sleep duration. Further
research needs to examine whether parents of children with ASD are more likely to
underestimate their child’s sleep duration.
Prevalence rates of sleep problems in prior studies vary from 54 to 83% [5, 8].
Greater variance in prevalence rates of sleep problems may be due to lack of con-
sistent definitions and criteria of sleep problems, small sample sizes, clinical/referral
samples, low-response rates, or reliance on parental report [3, 25]. In the current
study, we employed a structured questionnaire with satisfactory reliability to esti-
mate a wide range of sleep problems. Our results indicated that 86% of children with
ASD had at least one sleep problem that occurred almost every day, the rate being
higher than those in most previous studies [3]. The high rate in our study may be
attributed to the fact that we used individual items rather than a subscale as a basis
to estimate overall sleep problems and that we included a broader range of sleep
problems than in prior studies.
Several studies on parasomnias in autism have reported inconsistent results. Two
studies reported that the incidence of some parasomnias was low, and did not differ
from those of children in comparison groups [6, 8]. Conversely, three recent studies
have indicated that children with autism are more likely to exhibit parasomnias than
are other children [4, 11, 12]. In the current study, we found all sleep problems were
very prevalent in children with ASD compared to typically developing children in
prior studies. Our results indicated that about half of children had bedtime resis-
tance, insomnia, parasomnias, and morning rise problems and that one-fourth and
one-third of children had sleep disordered breathing and daytime sleepiness. Most
sleep problems were comorbid (see Table 3). Together with several recent studies [4,
11], our results suggest that sleep problems in children with ASD are not a unitary
clinical problem but that multiple sleep problems are coexisting and may have
effects on each other.
Research has demonstrated that multiple psychosocial, biological, and environ-
mental factors are associated with increased risk for child sleep problems, such as
psychiatric disorders and physical conditions (e.g., asthma, allergies, epilepsy),
medications (e.g., stimulatants, antipsychotics), lack of physical activities, excessive
watching of TV/video, life stress, bedtime and sleep practices, parental personality,
psychopathology (e.g., maternal depression), family history of sleep disorders, poor
parenting skills, family conflict, socioeconomic disadvantage, overcrowded housing
conditions, noise, light, and extreme temperature in the room [2, 14, 18–20].
Although there exists a number of clinical observations and descriptions of sleep
disorders in children with autism and speculations about the vulnerability, little
empirical or analytic epidemiological research has been conducted. In our study, we
found that sleep problems in children with ASD were associated with multiple
factors, including younger age, sleep arrangement (co-sleeping), medication use,
comorbid physical/mental disorders, and family history of sleep problems. These
results provide evidence that sleep problems in children with ASD may not be a
simple comorbid condition but may stem from the interaction of multiple neuro-
developmental, medical, genetic, psychosocial, and environmental factors [10, 13].
There are several limitations to the current study. First, we relied on parent report
as a sole source of information about child’s sleep and all child and family correlates
of interest. We could not exclude the possibility that parents underestimate or
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overestimate their child’s sleep problems. The association between various corre-
lates and sleep problems may be due to parent’s recall bias or shared variance.
Second, it should be noted that what we reported as prevalence rates are simply the
frequencies with which the parents answered the question positively, according to
their own definitions, rather than DSM-IV or the International Classification of
Sleep Disorders [9]. However, these limitations are common within the literature
[5, 6]. Third, this is a cross-sectional survey. We could not conclude causal rela-
tionships between most significant factors and sleep problems. The significant
association may be causal, bidirectional, or caused by a third factor, such as the
relationship between co-sleeping and insomnia. Fourth, this study did not include
comparison children, such as typically developing children and/or children with
other developmental disorders. We do not know whether these sleep problems
identified in this group of children are autism specific or are simply part of the
general disability associated with a developmental disorder. Fifth, subjects in this
study were recruited from parents who attended two conferences of a local chapter
of the Autism Society of America. They may represent a highly motivated and
interested group. Further investigation into whether our findings can generalize to
other children with ASD in the community is needed. Finally, children’s diagnoses of
ASD were based on parent reports. However, a subsample of 30 children were
administered ADOS-G and their diagnoses were consistent with parent reports. This
assures parent reported diagnoses. Agreement between parent report and ADOS-G
may reflect the fact that more than 80% of our children were diagnosed by a child
psychiatrist, neurologist, or a developmental pediatrician. Thus, there are reasons to
believe that parent reported diagnoses reflect diagnoses made by a clinical profes-
sional and are acceptable for a relatively large epidemiological survey of sleep
problems in children with ASD.

Summary

This study examined sleep problems and correlates in a relatively large sample of
children with ASD (n = 167). Our results indicate that sleep problems in children
with ASD are very prevalent (86%), much more than reported in most previous
studies. Sleep problems in children with ASD are not a unitary clinical problem but
multiple sleep problems coexist. Sleep problems in children with autism are not
caused by a single factor but by multiple biological, family, and environmental
factors. These findings have important implications for clinical practice. Given the
high frequency and adverse effects of sleep problems on child and family, clinical
professionals should pay close attention to sleep problems when assessing and
treating autistic behaviors or comorbid disorders. There is evidence that behavior
therapy is effective and well accepted by parents in the treatment of sleep problems
in children with autism [26–28]. Thus, parental sleep hygiene education and behavior
intervention of child’s sleep should be considered an important aspect for the
treatment of autism. Clinical intervention research is recommended for the devel-
opment and evaluation of pharmacological and behavioral treatment strategies of
sleep problems in children with autism.

Acknowledgments The authors would like to acknowledge the Greater Phoenix Chapter of the
Autism Society of America for assistance in data collection and thank all the parents who

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participated in this study. In addition, the authors thank Dr. Jaswinder Kaur Ghuman in the
Department of Psychiatry of University of Arizona, for her comments on an earlier draft of the
manuscript.This study was supported in part by the Internal Grants Program (RWR P002),
Arizona State University.

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