Cumulative Sleep Loss and Challenging Behaviors during Treatment for Children with Autism

Background: Sleep problems are common in children with autism spectrum disorder (ASD) and can exacerbate challenging daytime behaviors and ASD symptoms. In early childhood, individuals with ASD often receive intensive behavioral interventions using a center-based model, although no published studies have addressed how sleep may influence challenging behaviors in this developmental context.

Objectives: Following models of sleep debt, the present study aimed to address the potential cumulative effects of sleep loss on challenging behaviors occurring in the context of treatment. Specifically, we explored the following research question: On sequential preceding nights in which a child has poor sleep, does he/she exhibit more challenging behaviors the following day? We hypothesized that children with more cumulative sleep loss and/or fragmentation (averaged across all sequential preceding nights of sleep) would exhibit more challenging behaviors on the subsequent day.

Methods: This study included 42 children with ASD (2-10 years). All children had a medical ASD diagnosis and attended a behavioral intervention center five days a week. Sleep was assessed for five, consecutive 24-hour periods (Sunday–Thursday) using an actigraph and a coupled parent-report sleep diary. Daytime behaviors were recorded during the child’s treatment hours by his/her behavioral clinician (Monday–Friday)—in conjunction with the sleep assessment schedule. Daytime behaviors included repetitive behaviors, aggression, negative affect, and self-injury. Partial–interval recording was implemented in five–minute intervals for the entirety of the treatment day, and clinicians indicated whether each behavior was observed within each interval.

Generalized linear mixed effects models were used to assess relations between sequential nights of sleep and each target behavior. Sequential measurements of sleep were calculated by maintaining a running average of sleep estimates over the course of the week. For example, Wednesday’s behavior would be predicted by the average of sleep for Sunday, Monday, and Tuesday. Terms for level of functioning, caregiver education, sex, and age were included in each model. Total sleep time (TST) and wake after sleep onset (WASO) were included in separate models as predictors of each challenging behavior.

Results: Overall, children who slept less at night engaged in more repetitive behaviors and more negative affect during the day (Table 1). For every three hours of sleep missed (on average) over the previous consecutive nights, children engaged in ~one additional repetitive behavior and ~.50 negative affect expressions per hour. Additionally, for every three hours of WASO, children exhibited ~one additional negative affect expression per hour.

Conclusions: Our findings suggest that, in isolation, one night of poor sleep may not be consequential for a child’s challenging behaviors during treatment. Rather, consistent with the theories of sleep debt, unrecovered sleep loss across multiple preceding nights was associated with greater risk for challenging daytime behaviors. Findings from the present study highlight sleep as one potential mechanism to reduce challenging behaviors—particularly when children exhibit extended patterns of maladaptive sleep behaviors.