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: [email protected]
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
- 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.
- 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.
- 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.
- 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.
- 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
- 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).
- 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).
- 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).
- 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).
- 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).
- 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).
- 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).
- 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).
- 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).
- 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 characteristics | Group:1 ASD group | Group:2 Control group |
| 1. | Number of participants | 22 | 23 |
| 2. | Age range | 6-18 | 6-18 |
| 3. | Mean age | 8.23 | 10.45 |
| 4. | Objective of the study: Correlation between sleeping pattern and behaviour |
| Paired Samples Statistics | |||||
| Mean | N | Std. Deviation | Std. Error Mean | ||
| Pair 1 | DIMS | 11.39 | 23 | 4.850 | 1.011 |
| DIMS | 11.22 | 23 | 3.554 | .741 | |
| Pair 2 | SBD | 5.78 | 23 | 1.445 | .301 |
| SBD | 5.00 | 23 | 1.348 | .281 | |
| Pair 3 | DA | 5.74 | 23 | 1.514 | .316 |
| DA | 4.65 | 23 | 1.369 | .285 | |
| Pair 4 | SWTD | 9.91 | 23 | 2.295 | .478 |
| SWTD | 7.87 | 23 | 2.418 | .504 | |
| Pair 5 | DEP | 9.48 | 23 | 2.556 | .533 |
| DES | 7.96 | 23 | 2.458 | .513 | |
| Pair 6 | SHY | 3.39 | 23 | 1.076 | .224 |
| SHY | 3.22 | 23 | .998 | .208 | |
| Pair 7 | TS | 43.35 | 23 | 8.381 | 1.748 |
| TS | 38.83 | 23 | 9.277 | 1.934 | |
| Pair 8 | CBCL | 66.04 | 23 | 7.848 | 1.636 |
| CBCL | 39.09 | 23 | 15.571 | 3.247 | |
| Paired Samples Correlations | ||||
| Pair | N | Correlation | Sig. | |
| 1 | DIMS and DIMS | 23 | -.145 | .509 |
| 2 | SBD and SBD | 23 | -.490 | .018 |
| 3 | DA and DA | 23 | -.199 | .362 |
| 4 | SWTD and SWTD | 23 | .162 | .461 |
| 5 | DEP and DES | 23 | .293 | .175 |
| 6 | SHY and SHY | 23 | .129 | .558 |
| 7 | TS and TS | 23 | .125 | .569 |
| 8 | CBCL and CBCL | 23 | -.008 | .972 |
| Paired Samples Test | ||||||
| Pair | Paired Differences | |||||
| Mean | Std. Deviation | Std. Error Mean | 95% Confidence Interval of the Difference | |||
| Lower | Upper | |||||
| 1 | DIMS - DIMS | .174 | 6.415 | 1.338 | -2.600 | 2.948 |
| 2 | SBD - SBD | .783 | 2.411 | .503 | -.260 | 1.825 |
| 3 | DA - DA | 1.087 | 2.234 | .466 | .121 | 2.053 |
| 4 | SWTD - SWTD | 2.043 | 3.052 | .636 | .724 | 3.363 |
| 5 | DEP - DES | 1.522 | 2.983 | .622 | .232 | 2.812 |
| 6 | SHY - SHY | .174 | 1.370 | .286 | -.419 | .766 |
| 7 | TS - TS | 4.522 | 11.696 | 2.439 | -.536 | 9.580 |
| 8 | CBCL - CBCL | 26.957 | 17.491 | 3.647 | 19.393 | 34.520 |
| Paired Samples Test | ||||
| Pair | t | df | Sig. (2-tailed) | |
| 1 | DIMS - DIMS | .130 | 22 | .898 |
| 2 | SBD - SBD | 1.557 | 22 | .134 |
| 3 | DA - DA | 2.333 | 22 | .029 |
| 4 | SWTD - SWTD | 3.211 | 22 | .004 |
| 5 | DEP - DES | 2.447 | 22 | .023 |
| 6 | SHY - SHY | .609 | 22 | .549 |
| 7 | TS - TS | 1.854 | 22 | .077 |
| 8 | CBCL - CBCL | 7.391 | 22 | .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
| DMS | Disorder of initiating and maintaining sleep |
| SBD | Sleep breathing disorders |
| DA | Disorder of arousal |
| SWTD | Sleep-wake transition disorder |
| DES | Disorder of excessive somnolence |
| SHY | Sleep hyperhydrosis |
| TS | Total score |
| CBCL | Child behaviour checklist |
| ASD | Autism spectrum disorder |
| SDSC | Sleep Disturbance Scale for Children |
| CBCL | Child Behaviour Checklist |
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Dr. Mahendran M
Paediatric Occupational Therapist
