Association between Sleep Problems and Aggressive Behavior, Attention Problems, and Internalizing Behaviors Using Baseline and Follow-up Data in the Autism Speaks-Autism Treatment Network Registry

Background: Sleep difficulties in children with Autism Spectrum Disorder (ASD) have been well established, and studies indicate that 50 to 80% of children with ASD have sleep problems. Aggression has been reported in previous literature as associated with sleep problems among children with ASD in cross-sectional studies. Sleep problems are also associated with increased internalizing and externalizing behavior and hyperactivity. Establishing an association between daytime behaviors and sleep problems over time may help with treatment and prevention of both sleep problems and daytime behaviors.

Objectives: To determine if change in sleep problems is associated with change in daytime behaviors from baseline to first 1-year follow-up among young children with ASD.

Methods: In a sample of children under 6 years-old in the Autism Speaks-Autism Treatment Network (ATN) registry with both baseline and first follow-up Child Behavior Checklist (CBCL) scores available, change scores were calculated from age- and sex-adjusted z-scores by subtracting z-score at baseline (visit 1) from z-score at first follow-up (visit 2). Change scores were calculated for the CBCL syndrome scales: Sleep Problems, Aggressive Behavior, Attention Problems, Emotionally Reactive, Anxious/Depressed, Somatic Complaints, and Withdrawn. The associations between the sleep problems change score and each of the daytime behavior change scores were assessed using adjusted generalized linear models (GLM), controlling for baseline characteristics including demographics and DSM-IV diagnosis. The multiple imputation method was used to address missing data in each model, and a Holm-Bonferroni step-down procedure was applied to the six daytime behaviors to address multiple comparisons. Each adjusted p-value was compared to a significance threshold of 0.05, and nominal p-values prior to the adjustment were also reported.

Results: Of the 3,722 children under age 6 in the ATN registry, 457 had both baseline and first follow-up CBCL scores available. Mean age at baseline CBCL assessment was 3.5 years (SD 0.82), and most children were male (80.7%), non-Hispanic (93.1%), white (83.8%), had caregivers who completed at least some college (82.7%), and had a DSM-IV diagnosis of autistic disorder (68.2%). Adjusting for baseline characteristics and multiple comparisons, aggressive behavior and attention problems change scores were significantly associated with sleep problems change scores. On average, for each unit increase in aggressive behavior change score, sleep problems change score increased by 0.352 (p<0.001); and for each unit increase in attention problems change score, sleep problems change score increased by 0.234 (p<0.001). By contrast, internalizing behaviors were not correlated with increased difficulties with sleep.

Conclusions: Among young children with ASD, worsening aggressive behavior and attention problems were correlated with worsening sleep problems from baseline to first follow-up. These data highlight the importance of evaluating young children’s sleep when aggressive behavior and attention problems are present. Addressing aggressive behavior and attention problems may help with treatment and prevention of sleep problems, and addressing sleep problems may also help with treatment and prevention of aggressive behavior and attention problems. Future research is needed to better understand the association between sleep and aggression/attention to determine if improvements in aggression/attention lead to improvement in sleep or vice versa.