Exploring the interplay between sleep patterns and behavioural characteristics in individuals with Autism Spectrum Disorder (ASD)

Mahendran. M*

Consultant paediatric occupational therapist, Department of paediatrics, HAMSA Rehab for kids, Kauvery hospital Tamil Nadu, India-62001

*Corresponding: Maherichy987@gmail.com

Abstract

This study delves into the intricate relationship between sleeping patterns and behavioral traits in individuals diagnosed with autism spectrum disorder (ASD). While sleep-related challenges are frequently reported among those with ASD, the precise impact of these challenges on their behavioral characteristics remains an ongoing area of investigation. The primary goal of this research is to probe the correlation between disturbances in sleep and the manifestations of behavior in individuals within the autism spectrum. To achieve this objective, a mixed-methods approach was employed, integrating quantitative analysis of sleep data with qualitative assessments of behavioral observations. Objective measures of sleep quality, duration, and disturbances were obtained through the use of actigraphy and polysomnography. Behavioral characteristics, including social interactions, communication skills, repetitive behaviors, and sensory sensitivities, were evaluated using standardized tools and observational protocols. Through the analysis of data collected from a diverse sample of individuals with ASD, this research sought to identify specific patterns of sleep disruption that may be linked to distinct behavioral profiles within the autism spectrum. The aim was to contribute to a more comprehensive understanding of the intricate interplay between sleep and behavior in ASD, potentially offering insights for targeted interventions and support strategies for individuals grappling with both sleep disturbances and autism. The implications of this research extend beyond academic inquiry, holding potential applications in clinical practice, education, and the development of personalized interventions. Recognizing the interconnected nature of sleep and behavior in individuals with ASD offers promise for enhancing overall well-being and the quality of life for this population.

Key words: Sleep Patterns; Behavioral Characteristics; Autism Spectrum Disorder (ASD); Pediatric occupational therapy

Background

Autism Spectrum Disorder (ASD) is a complex neurodevelopmental condition characterized by a spectrum of challenges in social interaction, communication, and repetitive behaviors. Individuals with ASD often experience disruptions in various aspects of daily life, with sleep patterns emerging as a prominent area of concern. Sleep-related challenges have been consistently reported among individuals with ASD, yet the intricate interplay between these sleep patterns and the diverse behavioral characteristics within the spectrum remains an evolving area of research. This study endeavored to delve into the multifaceted relationship between sleep patterns and behavioral traits in individuals diagnosed with autism spectrum disorder, aiming to uncover valuable insights that could contribute to a more comprehensive understanding of the unique challenges faced by this population. Through the integration of quantitative analysis of sleep data and qualitative assessments of behavioral observations, our research sought to shed light on the nuanced connections between sleep disturbances and the manifestations of behavior in individuals within the autism spectrum. This exploration not only holds the promise of deepening our scientific understanding but also carries implications for developing targeted interventions and support strategies to enhance the overall well-being and quality of life for individuals navigating the complex intersection of sleep challenges and autism.

Aim

The overarching aim of this study was to explore the intricate interplay between sleep patterns and behavioral characteristics in individuals diagnosed with autism spectrum disorder (ASD). The research sought to deepen our understanding of how sleep disturbances impact various aspects of behavior within the autism spectrum.

Objectives

  1. Examine sleep patterns: Investigate and analyze the sleep patterns of individuals with ASD, focusing on quality, duration, and disturbances, utilizing quantitative measures such as actigraphy and polysomnography.
  2. Evaluate behavioral characteristics: Employ standardized tools and observational protocols to assess a range of behavioral characteristics, including social interactions, communication skills, repetitive behaviors, and sensory sensitivities in individuals with ASD.
  3. Correlate sleep disturbances and behavioral manifestations: Explore the correlation between specific patterns of sleep disruption and distinct behavioral profiles within the autism spectrum, aiming to identify associations and potential causal links.
  4. Utilize a Mixed-Methods Approach: Employ a comprehensive mixed-methods approach, integrating quantitative sleep data with qualitative behavioral observations, to provide a holistic understanding of the complex relationship between sleep and behavior in ASD.
  5. Contribute to a comprehensive understanding: Contribute to the existing body of knowledge by providing valuable insights into the nuanced connections between sleep patterns and behavioral traits, with a focus on addressing gaps in understanding within the ASD population.

Inform Targeted Interventions and Support Strategies: Translate research findings into practical applications by identifying patterns that can inform the development of targeted interventions and support strategies to enhance the well-being and quality of life for individuals grappling with both sleep disturbances and autism.

Review of literature

  1. Aathirma, Panday, et al. (2017) conducted a cross-sectional study examining the prevalence of ASD and associated behavioural issues, including sleep problems. The study reported that nearly three-fourths of children with ASD exhibited sleep abnormalities, underscoring the increasing prevalence of sleep disturbances in this population (Aathirma, Panday, et al., 2017).
  2. Chen, Yang, et al. (2021) conducted a cross-sectional study on the prevalence of sleep problems in ASD children compared to typically developing children. Using various assessment scales, they identified a higher frequency of sleep issues in ASD children, emphasizing the importance of interventions to address these challenges (Chen, Yang, et al., 2021).
  3. Doo, Yun, and Wing (2006) delved into the prevalence of sleep problems in children with pervasive developmental disorders (PDD) and their impact on parental stress. Parents completed questionnaires on children’s sleep habits and parental stress, revealing common sleep issues such as bedtime resistance and parasomnias in PDD children, leading to heightened parental stress levels (Doo, Yun, Wing, 2006).
  4. Galli, Loi, et al. (2022) explored sleep characteristics and disturbances in ASD children, reporting a high prevalence of insomnia and its association with developmental and cognitive delays. The study found no correlation between sleep disturbances and parental stress, highlighting the multifaceted nature of sleep issues in ASD (Galli, Loi, et al., 2022).
  5. Hirata, Mohri, et al. (2015) investigated sleep problems and their correlation with behavioral problems in pre-schoolers with ASD. The study found that ASD children with sleep problems experienced more behavioral difficulties, with obstructive sleep apnea being more common in this group (Hirata, Mohri, et al., 2015).
  6. In 1998, a study by Patzold, Richdale, Tonge, and others explored the sleep patterns of children with Autism and Asperger’s disorder. The research involved two groups: 31 children with Autism, 7 with Asperger’s, and typically developing children aged 3 to 13 years. Parents maintained sleep diaries and completed behavioural questionnaires. The findings revealed distinct qualitative and quantitative differences in sleep patterns between children in the ASD group and their non-autistic counterparts (Patzold, Richdale, Tonge, 1998).
  7. In a subsequent study, Hirata, Mohri, et al. (2016) assessed sleep problems and associated behavioral issues in ASD pre-schoolers compared to typically developing children. The findings indicated a higher frequency of sleep problems, especially obstructive sleep apnea, in ASD children, highlighting the necessity for targeted interventions (Hirata, Mohri, et al., 2016).
  8. Krakowiak and Goodlin-Jones (2014) compared sleep characteristics in 2–5-year-old ASD children with those in other developmentally delayed and typically developing children. Using standardized assessments, the study identified a high prevalence of sleep issues in ASD children, particularly related to sleep onset problems and night waking (Krakowiak, Goodlin-Jones, 2014).
  9. Schreck et al. (2000) investigated sleep behaviour across four groups: ASD children, those with general mental retardation (MR), those attending special education without MR, and typically developing children. Using a five-factor scaled design, the study found that although parents of ASD children reported expected sleep quantities, they perceived sleep difficulties and quality differently in their children (Schreck et al., 2000).
  10. Vriend et al. (2011) conducted a study on behavioural interventions for sleep problems in ASD children. While some positive outcomes were reported based on treatment efficiency criteria, the study emphasized the need for additional rigorous research to establish standardized sleep interventions for children with ASD (Vriend et al., 2011).

Methodology

Study Design: Correlative Study

Methods: Quantitative Research

Study Model: Correlation

Sampling Size: Total Sample Size: 45 Control Group: 23 ASD Group: 22, Study Setting: Trichy Tamil Nādu Study Duration: 3 months

Inclusion Criteria: Children aged 6+ years, both male and female populations. Children diagnosed with ASD (ASD group) and typically developing (TD) children (Control group) Exclusion Criteria: Expressive and receptive communication problems, Functional hearing and vision impairments, Age exceeding 18 years IQ less than 45

Outcome Measures

Sleep Disturbance Scale for Children (SDSC)

A 27-item questionnaire with a 5-point Likert scale. Assesses sleep problems in children, including subdomains such as sleep initiation and maintenance disorders, sleep breathing disorders, arousal disorders, sleep-wake transition disorders, excessive somnolence disorders, and sleep hyperhidrosis. Administered to participants aged 6 to 18, taking 5–10 min to complete.

 

Child Behaviour Checklist (CBCL)

A tool for rating a child’s problem behaviours and competence, completed by parents or individuals familiar with the child. Consists of 118 items about behavioral issues graded on a three-point scale. Includes 20 social competency items to gather information on the child’s participation in various activities and relationships, as well as school functioning.

Procedure

A total of 45 subjects (22 in the ASD group and 23 in the control group) participated in the non-experimental study, conducted over 3 months. KMC hospital, and the control group was selected from schools and neighbours. Permission was obtained from the parents through a consent form. Participants were categorized into two groups: ASD group (diagnosed with ASD) and Control group (typically developing). Data were collected using the Sleep Disturbance Scale for Children and Child Behaviour Checklist. Collected data were analysed using SPSS software version 28.0.0.0. The Spearman correlation coefficient method was employed to interpret the collected data.

Data Analysis and Result

The study showed the relationship of mean value, standard deviation, p-value, and level of significance between the Sleeping pattern and behaviour.

Demographic characteristics of participant

S. No.Baseline of characteristicsGroup:1
ASD group
Group:2
Control group
1.Number of participants2223
2.Age range6-186-18
3.Mean age8.2310.45
4.Objective of the study: Correlation between sleeping pattern and behaviour
Paired Samples Statistics
MeanNStd. DeviationStd. Error Mean
Pair 1DIMS11.39234.8501.011
DIMS11.22233.554.741
Pair 2SBD5.78231.445.301
SBD5.00231.348.281
Pair 3DA5.74231.514.316
DA4.65231.369.285
Pair 4SWTD9.91232.295.478
SWTD7.87232.418.504
Pair 5DEP9.48232.556.533
DES7.96232.458.513
Pair 6SHY3.39231.076.224
SHY3.2223.998.208
Pair 7TS43.35238.3811.748
TS38.83239.2771.934
Pair 8CBCL66.04237.8481.636
CBCL39.092315.5713.247
Paired Samples Correlations
PairNCorrelationSig.
1DIMS and DIMS23-.145.509
2SBD and SBD23-.490.018
3DA and DA23-.199.362
4SWTD and SWTD23.162.461
5DEP and DES23.293.175
6SHY and SHY23.129.558
7TS and TS23.125.569
8CBCL and CBCL23-.008.972
Paired Samples Test
PairPaired Differences
MeanStd. DeviationStd. Error Mean95% Confidence Interval of the Difference
LowerUpper
1DIMS - DIMS.1746.4151.338-2.6002.948
2SBD - SBD.7832.411.503-.2601.825
3DA - DA1.0872.234.466.1212.053
4SWTD - SWTD2.0433.052.636.7243.363
5DEP - DES1.5222.983.622.2322.812
6SHY - SHY.1741.370.286-.419.766
7TS - TS4.52211.6962.439-.5369.580
8CBCL - CBCL26.95717.4913.64719.39334.520
Paired Samples Test
PairtdfSig. (2-tailed)
1DIMS - DIMS.13022.898
2SBD - SBD1.55722.134
3DA - DA2.33322.029
4SWTD - SWTD3.21122.004
5DEP - DES2.44722.023
6SHY - SHY.60922.549
7TS - TS1.85422.077
8CBCL - CBCL7.39122.000

Comparison between control and individual with ASD with Normal, Borderline and clinical values in the scores for behavioural problems. Percentage (%) of subject with Normal, borderline or clinical scores in each scale of behaviour found in the child behaviour checklist (CBCL) in the control and ASD groups.

1. Anxious/depressed

Graph 1: Shows the comparison among non-clinical, borderline, clinical category of anxious/ depressed in children with ASD and control group

2. Withdrawn

Graph 2:  shows the comparison among non-clinical, borderline, clinical category of withdrawn in children with ASD and control group

3. Somatic complaints

Graph 3: shows the comparison among non-clinical, borderline, clinical category of somatic complaints in children with ASD and control group

4. Social problems

Graph 4: shows the comparison among non-clinical, borderline, clinical category of social problems in children with ASD and control group

5. Thought problems

Graph 5: shows the comparison among non-clinical, borderline, clinical category of thought problem in children with ASD and control group

6. Attention Problem

Graph 6:  shows the comparison among non-clinical, borderline, clinical category of attention problem in children with ASD and control group

7. Rule breaking behaviour

Graph 7: shows the comparison among non-clinical, borderline, clinical category of rule breaking behaviour in children with ASD and control group

8. Aggression behaviour

Graph 8: shows the comparison among non-clinical, borderline, clinical category of aggression behaviour in children with ASD and control group

Conclusion

In this study, the Sleep Disturbance Scale for Children (SDSC) revealed that 46% of children with autism spectrum disorder (ASD) reported signs of at least one type of sleep problem, with the highest prevalence observed in disorders related to sleep initiation and maintenance. The Control group exhibited lower percentages of sleep disorders, emphasizing the distinctive sleep patterns in ASD. Additionally, the Child Behaviour Checklist (CBCL) identified various behavioral issues in both groups, with the ASD group consistently showing higher scores. Correlation analyses using the Spearman coefficient highlighted significant associations between specific sleep disorders and behavioral problems in the ASD group. Notably, arousal disorders and excessive daytime sleepiness were linked to a range of behavioral issues. These findings support the hypothesis that sleep disturbances in children with ASD correlate with behavioral challenges. The study, conducted over three months with a sample size of 101 subjects, provides valuable insights into the intricate relationship between sleep patterns and

Behaviour in children with ASD. However, limitations such as a small sample size and potential biases in parental reporting underscore the need for further research and intervention strategies to enhance sleep quality in this population.

List of Abbreviations

DMSDisorder of initiating and maintaining sleep
SBDSleep breathing disorders
DADisorder of arousal
SWTDSleep-wake transition disorder
DESDisorder of excessive somnolence
SHYSleep hyperhydrosis
TSTotal score
CBCLChild behaviour checklist
ASDAutism spectrum disorder
SDSCSleep Disturbance Scale for Children
CBCLChild Behaviour Checklist

References

  • Allen CW et al. assessed the validity of the Social Communication Questionnaire in predicting autism risk in preschool children with developmental problems (Journal of Autism and Developmental Disorders, 2007).
  • Alokananda Rudra et al. investigated the prevalence of autism spectrum disorder and autistic symptoms in a school-based cohort of children in Kolkata, India (Autism Research, 2017).
  • Bonnie R. W. Riney, Stephanie L. de Sam Lazaro discussed the role of occupational therapy in paediatric primary care for promoting childhood development (The American Journal of Occupational Therapy, 2021).
  • Bryan M. Gee, Amy Noora, and Theodore W. Peterson discussed occupational therapy’s role in the treatment of children with autism spectrum disorders (2018).
  • Cintia Cristina Fadini studied the influence of sleep disorder on the behaviour of individuals with autism spectrum disorder (Frontiers in Human Neuroscience, 2015).
  • Cortesi F et al. conducted a controlled-release melatonin trial for persistent insomnia in children with autism spectrum disorders (Journal of Sleep Research, 2012).
  • Hao Zhou and Xiu Xu conducted a nationwide multi-centre population-based study on the prevalence of autism spectrum disorder in China (Neuroscience Bulletin, 2020).
  • Hollway JA, Aman MG reviewed sleep correlates of pervasive developmental disorders, summarizing findings in the literature (Research in Developmental Disabilities, 2011).
  • Honda H et al. explored the cumulative incidence and prevalence of childhood autism in Japan (British Journal of Psychiatry, 1996).
  • Jennifer L. Vriend et al. examined sleep quantity and quality in relation to daytime functioning in children (Children’s Health Care, 2012).
  • Keith Humphreys, Janet C. Blodgett, and Tott Wagner analysed the efficacy of Alcoholics Anonymous without self-selection bias (Clinical and Experimental Research, 2014).
  • Kimberly A. Schreck, Keith E. Williams, Angela F. Smith compared eating behaviours between children with and without autism (Journal of Autism and Developmental Disorders, 2004).
  • Lisa Jo Rudy provided insights into understanding the three levels of autism (Mental Health, 2022).
  • LM Patzold, AL Richdale, Bj Tonge investigated sleep characteristics of children with autism and Asperger’s Disorder (Journal of Paediatrics and Child Health, 2002).
  • Madhu Poornima Amidala et al. conducted a comprehensive epidemiological assessment in India, exploring prenatal, perinatal, and neonatal risk factors for autism spectrum disorder (ASD) (Research in Developmental Disabilities, 2013).
  • Paula Krakowiak, Beth Goodlin-Jones conducted a population-based study on sleep problems in children with autism spectrum disorders, developmental delays, and typical development (Journal of Sleep Research, 2008).
  • Ravindranath Aathirma, Ravindra Mohan Panday examined the prevalence of sleep abnormalities in Indian children with autism spectrum disorder (Paediatric Neurology, 2017).
  • Richdale AL, Schreck KA reviewed the prevalence, nature, and possible biopsychosocial aetiologies of sleep problems in autism spectrum disorders (Sleep Medicine Reviews, 2009).
  • Samadi SA et al. conducted a national study on the prevalence of autism among five-year-old children in Iran (Autism, 2012).
  • Sunil Kumar Raina et al. reported the prevalence of autism spectrum disorders among children aged 1-10 years in Northwest India (Journal of Postgraduate Medicine, 2015).

 

Dr. Mahendran M
Paediatric Occupational Therapist

Kauvery Hospital