Sleep Quality Among Adolescents with ASD in Relation to Internalizing and Externalizing Symptoms

Background:  Greater than half (66%) of parents report at least moderate sleep problems among their young children with ASD (Souders et al., 2009). Parent reports of diminished sleep quality continue to persist from early childhood into early adolescence among their children with ASD (Humphreys et al., 2013). The majority of studies regarding sleep quality among children with ASD have relied on parent reports.  However, recent work that extends the measurement of sleep quality to include self-reports of adolescents with ASD corroborates greater sleep problems as compared to typically developing peers (Baker et al., 2013).  The current study adds to the literature by examining emotional and behavioral correlates of self-reported sleep quality among adolescents with ASD.

Objectives:  To examine the associations between self-reported sleep quality of adolescents with ASD and their (1) self-reported internalizing symptoms, and (2) parent-reported internalizing and externalizing symptoms.

Methods:  Participants were 31 adolescents who had been clinically diagnosed with ASD and their mothers. Adolescents were between 12 and 18 years, predominantly male (90%), and were within average intellectual functioning.  Adolescents and their mothers completed questionnaires during study home visits.  Sleep quality was measured with the School Sleep Habits Survey (SSHS; Wolfson & Carskadon, 1998), an adolescent self-report with two subscales:  (1) the Sleepiness Scale and (2) the Sleep/Wake Problems Behavior Scale.  Internalizing and externalizing symptoms were measured using both adolescent and parent questionnaires.  Two adolescent self-reports of internalizing symptoms were used: (1) the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1991) for depressive symptoms and (2) the Multidimensional Anxiety Scale for Children (MASC; March, 1997) for anxious symptoms.  Parent reports of adolescent internalizing and externalizing symptoms were measured using the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001).

Results:  Adolescent reports of greater sleepiness were significantly linked to adolescent reports of greater depressive symptoms (r=.502, p=.004) and anxious symptoms (r=.531, p=.002).  Similarly, adolescent reports of greater sleep/wake problems were significantly related to adolescent reports of greater depressive symptoms (r=.413, p=.023) and greater anxious symptoms (r=.374, p=.042).  In contrast, adolescent reports of sleepiness were not associated with parent reports of adolescent internalizing symptoms.  Whereas adolescent reports of greater sleepiness were significantly linked to parent reports of adolescent externalizing symptoms (r=.462; p=.009), adolescent reports of sleep/wake problems were not related to parent reports of adolescent externalizing symptoms.

Conclusions:  Poor quality sleep is a common problem for adolescents with ASD. This study extends previous work by examining self-reported sleep quality in relation to self- and parent reports of internalizing and externalizing symptoms among adolescents with ASD.  Results show that more sleep problems are linked to self-reports of more internalizing symptoms and parent reports of more adolescent externalizing symptoms.  Differential associations between sleep problems and both self-reported internalizing and parent-reported adolescent externalizing symptoms have clinical implications regarding respondent variability. These findings underscore the importance of obtaining the perspectives of both adolescents with ASD and their parents during evaluations of adolescent sleep, emotional, and behavioral symptomatology, as well as when evaluating responses to interventions directed toward these domains.