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The relationship between sleep and behavior in autism spectrum disorder (ASD): a review Simonne Cohen,corresponding author Russell Conduit, Steven W Lockley, Shantha MW Rajaratnam, and Kim M Cornishcorresponding author Author information Article notes Copyright and License information Disclaimer This article has been cited by other articles in PMC. Go to: Abstract Although there is evidence that significant sleep problems are common in children with autism spectrum disorder (ASD) and that poor sleep exacerbates problematic daytime behavior, such relationships have received very little attention in both research and clinical practice. Treatment guidelines to help manage challenging behaviors in ASD fail to mention sleep at all, or they present a very limited account. Moreover, limited attention is given to children with low-functioning autism, those individuals who often experience the most severe sleep disruption and behavioral problems. This paper describes the nature of sleep difficulties in ASD and highlights the complexities of sleep disruption in individuals with low-functioning autism. It is proposed that profiling ASD children based on the nature of their sleep disruption might help to understand symptom and behavioral profiles (or vice versa) and therefore lead to better-targeted interventions. This paper concludes with a discussion of the limitations of current knowledge and proposes areas that are important for future research. Treating disordered sleep in ASD has great potential to improve daytime behavior and family functioning in this vulnerable population.
Keywords: Autism spectrum disorder, Low-functioning autism, Sleep difficulties in ASD, Treating sleep in ASD Go to: Review Autism spectrum disorder (ASD) is a developmental disorder characterized by deficits in social communication and repetitive and stereotyped interests and behaviors [1]. Autism is among the most enigmatic disorders of child development, with a dramatic increase in prevalence from 1 in 88 children in 2008 to 1 in 68 children in 2010 [2]. While the global burden of ASD is currently unknown, in the United States, the annual societal cost of the condition was recently predicted to be $126 billion and $34 billion in the UK [3]. This escalation and economic burden identify individuals with ASD as one of the highest priority populations for clinical research and treatment development.
Currently, one of the most burdensome complaints among parents of children with autism is disrupted sleep, with more than 40–80% of children experiencing sleep problems, compared with 25–40% in typically developing children (TYP) [4, 5]. In a developing child, sleep serves multiple functions, including energy conservation, brain growth, memory consolidation, and cognition [6]. Given the importance of sleep in daily functioning, the consequence of disrupted sleep in individuals with ASD is potentially serious. Recent research has shown that insufficient sleep exacerbates the severity of core ASD symptoms (e.g., repetitive behaviors, social and communication difficulties) [7, 8], as well as other maladaptive behaviors (e.g., self–injury, tantrums, and aggression) [9, 10]. To date, however, the relationship between sleep profiles and behavioral problems in individuals with ASD is limited. Current sleep treatments fail to target the specific nature of deficits in individuals with low-functioning autism. In this paper, we emphasize that the identification sleep profiles in children with low-functioning autism are necessary to identify targeted interventions, particularly for challenging behaviors in this disorder. This review concludes with methodological considerations and offers suggestions for future research designed to more clearly understand disrupted sleep so as to provide targeted treatments in this population.
Low-functioning autism ASD is characterized by notable phenotypic heterogeneity, which is often viewed as an obstacle to the study of etiology, diagnosis, treatment, and prognosis [11]. The degree of impairment among individuals with ASD is variable, thereby requiring the distinction between individuals with low-functioning autism and high-functioning autism, defined as those which have an intellectual quotient that is below average (<70) and above average (=70), respectively [1]. What the current DSM-V fails to capture is that individuals with low-functioning autism experience significantly graver impairments than those experienced by their higher functioning counterparts [12]. In addition to displaying core symptoms of ASD, many children with low-functioning autism may exhibit serious behavioral disturbances such as tantrums, aggression, environmental destruction, socially inappropriate behavior, and self-injurious behavior [13]. Therefore, a child with low-functioning autism is likely to have a much more complex diagnostic picture, including a greater severity of ASD symptoms and associated co-morbidities and often require life-long extensive support. To date, these groups of individuals have not received comparable attention compared to individuals with high-functioning autism. This paper argues that these groups of individuals should be the focus of future research as they are most in need of treatment.
Sleep difficulties in autism spectrum disorder ASD is frequently accompanied by co-morbid disorders and associated problems, one of which is sleep disruption [14, 15]. One of the most burdensome and profound complaints among parents and caregivers of children with ASD is poor sleep. Research suggests that about 40–80% of individuals with an ASD experience a sleep problem, and the risk appears to be unrelated to the severity of cognitive impairment [16]. Other researchers have shown that individuals with low-functioning autism have a higher predisposition to chronic sleep-wake cycle disturbances when compared to higher-functioning individuals, given the degree and severity of their cognitive impairment [17]. This paper argues that understanding, identifying, and treating sleep disorders in low-functioning autism may impact favorably on associated conditions and daytime behavior and therefore improve the quality of life in this population.
Heterogeneity of sleep difficulties in ASD Since ASD is considered to be a multifaceted disorder reflected in different symptom profiles across individuals, it is not surprising that a multitude of sleep problems are prevalent in this population. Moreover, the variability of sleep profiles in ASD is suggestive of the mixed phenotypic profiles of ASD samples. Among children with ASD, the most common sleep issues are prolonged sleep latency, decreased sleep efficiency, reduced total sleep time, increased waking after sleep-onset, bedtime resistance, and daytime sleepiness; see [18] for a review. Accordingly, there does not appear to be one particular sleep problem that characterizes children with ASD, but many. These sleep difficulties appear to persist throughout the lifespan [19] and individuals with ASD who experience one sleep problem will often experience co-existing sleep problems [20]. Several of these sleep difficulties can be classified according to the International Classification of Sleep Disorders (ICSD-3) as primary sleep disorders (e.g., insomnia, parasomnia, and circadian rhythm sleep-wake disorders) [21]. In Table 1, the most common sleep problems in ASD have been reported against the ICSD-3 broad criteria for classifying sleep disorders in order to give a sense of the range and scope of sleep difficulties that are present in ASD. To date, most of the studies exploring sleep in ASD have focused on individuals with high-functioning autism, those individuals who have an ability to communicate and cooperate during actigraphy and polysomnography sleep studies [22]. Currently, there is an inconsistent understanding of the nature and prevalence of sleep difficulties in low-functioning autism. One study has suggested that the severity of sleep problems (such as sleep-onset delay and sleep duration) increases with the severity of autism symptoms (such as communication deficits) [8]. Another study has suggested that increased autism severity predicts an increased likelihood of sleep problems [23]; however, these links are still speculative, and sleep profiles in low-functioning autism are yet to be elucidated. To date, it is still unclear what specific sleep problems and symptom relationships are unique to individuals with low-functioning autism.
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