Autism has been researched for more than 60 years, but until recently little focus has been placed upon the sleep problems often associated with it. Even within the sleep community, few have studied the relationship of sleep and autism. Much greater attention in our field has to be focused on autism because of the impact of sleep problems on the individual and others who typically have reported the most significant impacts, such as caregivers and the household.1 With a greater focus on autism and the sleep problems associated with the disorder, sleep medicine professionals can more confidently and appropriately address the sleep-related issues linked to the population with autism.
CLINICAL DEFINITION OF AUTISM
In 1943, Leo Kanner, MD,2 first used the term “autism” to describe a complex set of characteristics he noticed in 11 male children—impaired communication and social interaction, as well as stereotypical behavior. While Kanner and Asperger3 independently provided the original clinical background accounts of autism and what has become known as Asperger syndrome (AS), prior to these dates those with autism were likely labeled as “wild” or “feral.”4 Recorded contemporary history of autism began at least in the mid-18th century with one of the earliest putative cases of autism: Hugh Blair of Borgue.5,6
The characteristic triad of impairments identified in early clinical research on autism has essentially endured over time.7 The essential features of autism described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) still encompass Kanner’s three characteristics, with an early childhood onset.8 However, diagnosticians have now recognized that a wide spectrum of phenotypes exist, which has given rise to the term autism spectrum disorders (ASDs), which includes autistic disorder, AS (or Asperger’s disorder), and pervasive developmental disorder not otherwise specified (PDDNOS). A condensed representation of the DSM-IV-TR diagnostic criteria for autistic disorder is provided in Table 1. With the growing awareness, diagnosis of ASDs, prevalence (0.6% prevalence rate9), and the number of children with ASDs and sleep problems, knowledge of ASDs and sleep has become a significant issue that sleep centers will have to continue to address.
SLEEP PROBLEMS ASSOCIATED WITH AUTISM
Reports of high rates of sleep problems in young children with autism have a long history.10,11 Sleep difficulties have appeared to be more common in younger children, but can be persistent through childhood and adolescence for many children. Children with autism have difficulty settling with long sleep latency, wake for long periods, and have shortened night’s sleep and early morning waking.12,13 Compared with typically developing children and children with other developmental disorders, children with autism have been distinguished by a higher rate of settling difficulties and co-sleeping.14 Research has continued to confirm the high rate of sleep problems in autism as well as AS and PDDNOS,15-21 with additional problems reported including enuresis, parasomnias, high variability or delay in sleep onset and wake times, and daytime sleepiness.
Summarized Diagnostic Criteria for Autistic Disorder
Qualitative impairment in social interaction
- Impairment in multiple nonverbal behaviors
- Failure to develop peer relationships
- Lack of spontaneously seeking to share enjoyment
- Lack of social/emotional reciprocity
Qualitative impairment in communication
- Delay/lack of spoken language
- Impaired ability to initiate/sustain conversations
- Stereotypical/repetitive/idiosyncratic language
- Lack of imaginative play
Restricted, repetitive, and stereotyped behavior
- Stereotyped/restricted interests abnormal inintensity/focus
- Inflexible routines/rituals
- Stereotyped/restricted motor mannerisms
- Preoccupation with parts of objects8
Studies using actigraphy have also supported the presence of sleep problems in both autism and ASD.15,22-24 The study by Wiggs and Stores probably has been the most comprehensive.24 In this study, the sleep patterns of children with an ASD appeared compromised regardless of whether they had a parent-reported sleep problem. Long sleep latencies, delayed or advanced sleep onset and waking, night waking, low sleep efficiency, and abnormal activity pattern during the night were reported, thus generally confirming diary and questionnaire reports.
Sleep abnormalities have also been confirmed in a number of recent polysomnography studies.25-30 Longer sleep latency and frequent night waking, lower sleep efficiency, alterations to non-REM sleep stages, lower sleep spindle density, a variety of REM sleep abnormalities, REM sleep behavior disorder, periodic limb movements in sleep, obstructive sleep apnea, and reduced sleep in the first two thirds of the night have been reported. However, these studies have had low participant numbers (<20), variously have included adults and children, and have covered a wide range of intellectual functioning.
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Thus, actigraphy and polysomnography studies have indicated that a range of sleep difficulties have been commonly reported in children with ASDs that likely have had some biological foundation. Additionally, medical conditions, medication,18 and anxiety12,16,24 have been associated with sleep difficulties. This initial connection to anxiety and additional evidence of a behavioral component and amenability of sleep problems such as settling and night waking to behavioral interventions have led researchers to explore the daytime correlates with sleep problems in this population.
IMPACT OF SLEEP PROBLEMS IN AUTISM
Within other populations, the sleep problems reported above have been suggested to cause daytime problems, such as decreased learning rates and decreased cognitive and creative performance31-34; altered emotional states32,34,35; impaired flexibility to change31,33; increased general behavior problems34,36; noncompliance37; inattention to task34; irritability35; depression35; hyperactivity36; aggression36; and self-injurious behavior.38 No research has indicated that in the population of people with an ASD, sleep problems and disorders have caused problems with daytime behavior. However, evidence has suggested a relationship.
Initial research has designated a variety of daytime behaviors related to sleep problems for people with an ASD. Some researchers have suggested that the intensity of developmental disturbances39 and general autism symptoms40 is increased in relation to sleeping problems. Further research delineating the relationships among some of the key diagnostic factors in ASDs (eg, communication difficulties, stereotypic behavior, difficulties breaking routines, and social problems) has indicated that intensified symptoms in these areas are related to disturbed sleep.18,39-41 Other more general daytime behavior problems have been reported as related to sleep problems for people with an ASD, such as overactivity,13 psychopathology,12 and disruptive behavior.12
Autism and sleep disorder research are relatively new areas of investigation. While the relationships between autism and sleep problems have not been thoroughly explored, associations have been identified. These foundational research findings can be advantageous in improving quality of life in these patients with autism.
Recommended Additional Reading
Readings Concerning Autism Diagnostics
- Hollander E, Anagnostou E, eds. Clinical Manual for the Treatment of Autism. Arlington, Va: American Psychiatric Publishing Inc; 2007.
- Volkmar FR, Paul R, Klin A, Cohen D, eds. Handbook of Autism and Pervasive Developmental Disorders. 4th ed. Vol 1& 2. Hoboken, NJ: John Wiley & Sons Inc; 2005.
Readings on Sleep and Autism
- Arebell S, Ben-Zion I. Sleep problems in autism. In: Schopler E, Yirmiya N, Schulman C, Marcus LM, eds. The Research Basis for Autism Intervention. New York: Kluwer Academic/Plenum Publishers; 2001:219-227.
- Richdale A. Sleep in children with autism and Asperger syndrome. In: Stores G, Wiggs L, eds. Sleep Disturbance in Children and Adolescents with Disorders of Development: Its Significance and Management. London: Mac Keith Press; 2001:181-191.
Pediatric Sleep Problems
- Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Philadelphia: Lippincott Williams & Wilkins; 2003.
David B. Harrell, PhD, FRIPH, entered molecular biology more than 15 years ago and began focusing upon sleep in 2001. One of his research focuses since then has been sleep in children with and without autism spectrum disorders. He is innovation research director at Pro-Tech in Mukilteo, Wash. Kimberly A. Schreck, PhD, BCBA, is an associate professor in psychology and coordinator of the Applied Behavior Analysis Masters Program at Penn State University—Harrisburg. She has been researching and treating sleep problems for young children with and without autism spectrum disorders for approximately 12 years. Amanda Richdale, PhD, MAPS, is a psychologist and university lecturer who has worked in the field of autism for 20 years. One of her research focuses has been sleep problems in autism and in other developmental disabilities. She is associate professor of developmental psychology at the School of Health Sciences, RMIT University, Melbourne, Australia.
- Kryger MH. Differential diagnosis of pediatric sleep disorders. In: Sheldon SH, Ferber R, Kryger MH, eds. Principles and Practice of Pediatric Sleep Medicine. Philadelphia: Elsevier Inc; 2005:17-25.
- Kanner L. Autistic disturbances of affective contact. Nerv Child. 1943;2:217-250.
- Asperger H. Die autistichen Psychopathin im Kindersalter. Arch Psychiatry Nervenkrank. 1944;117:76-136.
- Wing L. The history of ideas on autism. Autism. 1997;1:13-23.
- Houston R, Frith U. Autism in History: The Case of Hugh Blair of Borgue. Malden, Mass: Blackwell Publishers Inc; 2000.
- Frith U. Autism: Explaining the Enigma. 2nd ed. Malden, Mass: Blackwell Publishing; 2003.
- Volkmar FR, Woodbury-Smith M. Clinical diagnosis of autism. In: Hollander A, Anagnostou E, eds. Clinical Manual for the Treatment of Autism. Arlington, Va: American Psychiatric Publishing Inc; 2007:1-26.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
- Fombonne E. The changing epidemiology of autism. Journal of Applied Research in Intellectual Disabilities. 2005;18:281-294.
- DeMeyer MK. Sleeping problems. Parents and Children in Autism. New York: John Wiley; 1979:89-100.
- Hoshino Y, Watanabe H, Yashima Y, Kaneko M, Kumashiro H. An investigation on sleep disturbance of autistic children. Folia Psychiatrica et Neurologica Japonica. 1984;38:45-51.
- Patzold LM, Richdale AL, Tonge BJ. An investigation into sleep characteristics of children with autism and Asperger’s Disorder. J Paediatr Child Health. 1998;34:528-533.
- Richdale AL, Prior MR. The sleep/wake rhythm in children with autism. Eur Child Adolesc Psychiatry. 1995;4:175-186.
- Cotton S, Richdale A. Brief report: parental descriptions of sleep problems in children with autism, Down syndrome, and Prader-Will syndrome. Res Dev Disabil. 2006;27:151-161.
- Allik H, Larsson JO, Smedje H. Sleep patterns of school-age children with Asperger syndrome or high-functioning autism. J Autism Dev Disord. 2006;36:585-595.
- Couturier JL, Speechley KN, Steele M, Norman R, Stringer B, Nicolson R. Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: prevalence, severity and pattern. J Am Acad Child Adolesc Psychiatry. 2005;44:815-822.
- Doo S, Wing YK. Sleep problems of children with pervasive developmental disorders: correlation with parental stress. Dev Med Child Neurol. 2006;48:650-655.
- Liu X, Hubbard JA, Fabes RA, Adam JB. Sleep disturbances and correlates of children with autism spectrum disorders. Child Psychiatry Hum Dev. 2006;37:179-191.
- Polimeni MA, Richdale AL, Francis AJP. A survey of sleep problems in autism, Asperger’s disorder and typically developing children. J Intellect Disabil Res. 2005;49:260-268.
- Schreck KA, Mulick JA. Parental report of sleep problems in children with autism. J Autism Dev Disord. 2000;30:127-135.
- Williams PG, Sears LL, Allard A. Sleep problems in children with autism. J Sleep Res. 2004;13:265-268.
- Hering E, Epstein R, Elroy S, Iancu DR, Zelnik N. Sleep patterns in autistic children. J Autism Dev Disord. 1999;29:143-147.
- Øyane NMF, Bjorvatn B. Sleep disturbances in adolescents and young adults with autism and Asperger syndrome. Autism. 2005;9:83-94.
- Wiggs L, Stores G. Sleep patterns and sleep disorders in children with autistic spectrum disorders: insights using parent report and actigraphy. Dev Med Child Neurol. 2004;46:372-380.
- Daoust A-M, Limoges É, Bolduc C, Mottron L, Godbout R. EEG spectral analysis of wakefulness and REM sleep in high functioning autism spectrum disorders. Clin Neurophysiol. 2004;115:1368-1373.
- Diomedi M, Curatolo P, Scalise A, Placidi F, Caretto F, Gigli GL. Sleep abnormalities in mentally retarded autistic subjects: Down’s syndrome with mental retardation and normal subjects. Brain Dev. 1999;21:548-553.
- Elia M, Ferri R, Musumeci SA, et al. Sleep in subjects with autistic disorder: a neurophysiological study. Brain Dev. 2000;22:88-92.
- Godbout R, Bergeron C, Limoges É, Stip E, Mottron L. A laboratory study of sleep in Asperger’s syndrome. Neuroreport. 2000;11:127-130.
- Limoges É, Mottron L, Bolduc C, Berthiaume C, Godbout R. Atypical sleep architecture and the autism phenotype. Brain. 2005;128:1049-1061.
- Thirumalai SS, Shubin RA, Robinson R. Rapid eye movement sleep behavior disorder in children with autism. J Child Neurol. 2002;17:173-178.
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- Randazzo AC, Meuhlbach MJ, Schweitzer PK, Walsh JK. Cognitive function following acute sleep restriction in children ages 10-14. Sleep. 1998;21:861-868.
- Stores G. Children’s sleep disorders: modern approaches, developmental effects, and children at special risk. Dev Med Child Neurol. 1999;41:568-573.
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- Hoffman CD, Sweeney D, Gilliam JE, Apodaca DD, Lopez-Wagner MC, Castillo MM. Sleep problems and symptomology in children with autism. Focus on Autism and Other Developmental Disabilities. 2005;20(4):194-200.
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- Segawa M, Katoh M, Katoh J, Nomura Y. Early modulation of sleep parameters and its importance in later behavior. Brain Dysfunction. 1992;5(3-4):211-223.