A Longitudinal Study of Sleep Disturbance and Parent Stress in Children with ASD at 4 and 6 Years of Age: A Mediational Model

Background: It is estimated that 70% of 2-6 year olds with ASD experience sleep disturbances, a rate two to three times that of typically developing 2-6 year olds (15-40%). Emerging evidence suggests young children with ASD may suffer from sleep-onset difficulties, frequent night awakenings, irregular sleep patterns, and reduced sleep duration in comparison to children with developmental delays and typical development. Early childhood is particularly important for establishing healthy sleep patterns to support rapid physical growth, cognitive development, and self-regulation skills. Untreated sleep disturbances are known to pose significant adverse consequences including cognitive deficits and daytime sleepiness in typically developing children, and may exacerbate symptoms and negatively affect social interactions in children with medical problems. Parents may also be negatively impacted by child sleep disturbances. Little is known about the impact of sleep disturbances on cognitive and behavioral functioning in children with ASD or the impact of child sleep disturbances on stress in parents of children with ASD.

Objectives: To examine 1) the nature and extent of parent-reported sleep disturbances in children with ASD longitudinally at ages 4 and 6, 2) the association of sleep disturbances with child cognitive abilities and problem behaviors, and 3) whether the association between child sleep disturbances and parenting-related stress is mediated by increased problem behaviors.

Methods: Participants were a sample of children (n = 38 at age 4; n = 36 at age 6) who met DSM-IV criteria for a Pervasive Developmental Disorder based on direct assessment (ADI-R, ADOS) by research reliable examiners using all available information. All participants had data from the Child Sleep Habits Questionnaire (CSHQ), a parent-report of a child’s sleep behavior over the previous week. Child cognitive ability (Mullen Scales of Early Learning age 4; Differential Abilities Scale age 6), child problem behavior (Aberrant Behavior Checklist), and parenting-related stress (Questionnaire on Resources and Stress) were assessed when children were age 4 and 6.

Results: Over 73% of children met criteria for sleep disturbance at age 4 (28/38) and over 83% at age 6 (30/36). Longitudinally, 22/30 children (73%) showed sleep disturbances at both time points. Cognitive ability was not significantly related to sleep at either age. At age 4, sleep was not related to problem behavior or parenting stress. However, at age 6, sleep disturbance was related to both increased problem behavior and parenting stress. Mediation was not testable at age 4, as child sleep was not related to parenting stress. However, at age 6, problem behaviors completely mediated the effect of sleep disturbance on parent stress (Sobel test: Z = 2.79, p = .005).

Conclusions: Sleep disturbances in children with ASD appear highly stable from age 4 to 6. By age 6, sleep disturbances are related to problem behavior and parent stress. The preschool years may be well-suited for implementing parent-delivered sleep interventions to support the development of adequate, well regulated sleep in young children with ASD and could reduce caregiver stress associated with child sleep disturbances and related problem behaviors.