Investigating Sleep Behaviors in Autistic Infants

Autism Spectrum Disorder (ASD) is defined by social, emotional, and learning deficits. Past research suggests that ASD and sleep problems often co-occur. The goal of this research was to investigate sleeping behaviors in autistic infants in comparison to typically developing infants (TD). The data of this study has been acquired at the University of California San Diego Autism Center of Excellence. One main goal of this center is to identify early indicators of ASD in infants (1-3 years of age), which could lead to earlier treatment and better therapy techniques. The current study used a sleep questionnaire to compare parent-reported sleeping behaviors in young autistic infants and in healthy controls. The results showed that autistic infants had significantly more difficulty getting to sleep at night, woke from sleep screaming or confused more often, and had more difficulty waking up in the morning, compared to TD infants. Future research should further investigate the treatment options for sleep problems in autistic infants, and examine whether autistic infants with epilepsy have more sleeping abnormalities than autistic infants without epilepsy. Keywords: Autism Spectrum Disorder, infants, sleep problems, sleep questionnaire ASD INFANT SLEEP BEHAVIORS 3 Investigating Sleep Behaviors in Autistic Infants Sleep problems during early childhood have been shown to be comorbid with disturbances in executive functioning, along with behavioral and mood issues (Beebe & Gozal, 2002, as cited in Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). Sleep disturbances diminish children’s quality of life, as well as the lives of their parents or caregivers (Mindell et al., 2006). Investigating these sleep issues is essential because it may lead to improvements in a child’s functioning, health, and overall happiness. Past research provides insights into sleep variables that are commonly impacted in children with sleep disturbance, as well as potential behavioral and medical treatments for sleep issues (Mindell et al., 2006). According to parent reports, children experience the most sleep problems during the time of preschool suggesting that sleep problems have a young onset (Stein, Mendelsohn, Obermeyer, Amromin, & Benca, 2013). These disturbances included parasomnias such as nightmares, snoring, insomnia, bed-wetting, noisy sleep, and tiredness during the day. The children with sleep disturbances at age two were more at risk to continue having sleep disturbances years later (Stein et al., 2013). Further, detecting sleep problems early in childhood may help to predict later emotional and behavioral problems (Gregory & O’Connor, 2002). Using a longitudinal study from age four to mid-adolescence, the researchers found that sleep problems at age four, reported by parents, predicted the development of depression/anxiety, attention problems, and aggression in mid-adolescence. Thus, sleep disturbances may put children more at risk for having psychological and behavioral problems later in development (Gregory & O’Connor, 2002). However, this association between sleep abnormalities and psychopathology needs to be further tested through sleep treatments. ASD INFANT SLEEP BEHAVIORS 4 There is evidence that children who have difficulty sleeping at night also suffer cognitive deficits (Konen, Dirk, & Schmiedek, 2015). To test the relationship between working memory and sleep, elementary school students practiced a numerical and spatial working memory task on smartphones. The researchers used sleep diaries and found that student performance of the task at school was correlated with sleep quality at night, bedtime, and level of tiredness during the day (Konen et al., 2015). Students with less quality sleep, a later bedtime, and more tiredness, performed worse on the working memory task. This suggests that sleep disturbances are related to impairments in cognition. The researchers also discuss how cognition in children is important because it is crucial for their social and emotional functioning (Konen et al., 2015). In fact, McQuade et al. (2013) showed a link between working memory and peer acceptance (as cited in Konen et al., 2015). These findings demonstrate that sleep problems in children have effects beyond tiredness. Research shows that sleep disturbance is related to behavioral, psychological, emotional, and cognitive problems in children. Autism Spectrum Disorder (ASD) is defined as a range of developmental disorders that include deficits in social communication, emotionally relating to others, and in some cases repetitive or restricted behaviors (American Psychiatric Association, 2013). Earlier findings suggested that children with ASD have a more difficult time with sleep (Krakowiak, GoodlinJones, Hertz-Picciotto, Croen, & Hansen, 2008). Using a parent-reported questionnaire, the researchers discovered that ASD children (ages 2-5 years) had longer sleep latencies, slept for a shorter amount of time, and had more night awakenings in comparison to typically developing (TD) children of the same age. These sleep problems are also correlated with cognitive and adaptive impairments, thus, determining the causes of these sleep disturbances may lead to better behavioral and medical treatment of children with ASD (Krakowiak et al., 2008). ASD INFANT SLEEP BEHAVIORS 5 It is important to target sleep problems early in children. Previous studies investigated sleep problems in regressed and non-regressed autistic children as well as in TD children (Giannotti, Cortesi, Cerquiglini, Miraglia, Vagnoni, Sebastiani, & Bernabei, 2008). Regression refers to the loss of previously learned skills, including communicative and social skills (Giannotti et a., 2008). Both regressed and non-regressed autistic children had significantly more sleep problems before age 2 than TD children. In agreement with Krakowiak et al. (2008), Giannotti et al. (2008) found that children with autism had significantly longer sleep latencies and more night awakenings, in addition to having more sleep anxiety and daytime tiredness. In comparing regressed and non-regressed children, the researchers found that regressed autistic children showed more sleep disturbances. This suggests that sleep problems are exasperated in autistic children who experience a loss of language, social interest, and other communication skills. Other research has confirmed that the higher the severity of autism, the greater the sleep problems (Mayes & Calhoun, 2009). Further, using parent-reports, they suggested that sleep disturbances in autistic children were correlated with maladaptive behaviors, aggression, attention deficit, hyperactivity, anxiety, and depression (Mayes & Calhoun, 2009). Anxiety, a symptom of ASD, may be related to sensory overload. This interaction may be a contributor to sleep problems in ASD children (Mazurek & Petroski, 2015). Using a large sample of autistic children, Mazurek & Petroski (2015) discovered that anxiety and sensory overresponsivity were significantly correlated for young and old autistic children. In addition, anxiety and sensory over-responsivity were each significantly correlated to sleep problems. From ages two to five specifically, more anxiety was correlated with resisting bedtime, shorter sleep length, and more night awakenings. While increases in sensory over-responsivity were also correlated with shorter sleep length and more night awakenings, they were also related to prolonged sleep ASD INFANT SLEEP BEHAVIORS 6 onset. This evidence suggested that treatments for anxiety or hyperarousal might be useful in treating sleep problems in autistic children (Mazurek & Petroski, 2015). To measure wake and sleep activities more directly, actigraphy studies in ASD children use a wristwatch to monitor motor activity. Wiggs and Stores (2004) showed that over a five day period, ASD children had sleep problems including long sleep latencies and more frequent awakenings during the night, even when these behaviors were not parent-reported (as cited in Glickman, 2009). These sleep disturbance patterns propose that ASD children may have circadian sleep disorders (Glickman, 2009). Although there is no consensus from these researchers on the cause of sleep problems, it was suggested that abnormal neuronal activity may account for the inability to develop normal sleeping patterns (Cortesi, Giannotti, Ivanenko, & Johnson, 2009). In a review of sleep literature, the most commonly found sleep problems in children with autism were difficulty falling asleep and sleep restlessness (Mayes & Calhoun, 2009). More recently, a meta-analysis was performed to compare the findings of past research on sleep difficulties in children with ASD in comparison to TD children (Elrod & Hood, 2015). The researchers found that children with ASD on average slept 32.8 minutes less per day, took 10.9 minutes longer to fall asleep, and had 1.9% less sleep efficiency than TD children, suggesting that children with ASD have consistently shown more difficulty falling asleep and staying asleep through the night (Elrod & Hood, 2015). Sleep disturbance may impact the overall quality of life of ASD children. There is new evidence that sleep problems in autistic children are negatively correlated with scores on the Health-Related Quality of Life, an assessment measuring an individual’s overall well-being in addition to physical, psychological, and social functioning (Delahaye, Kovacs, Sikora, Hall, ASD INFANT SLEEP BEHAVIORS 7 Orlich, Clemons, van der Weerd, Glick, & Kuhlthau, 2014). Therefore, investigating and treating sleep problems in autistic children may lead to them developing a better quality of life (Delahaye et al., 2014). While past research demonstrated that children with ASD have sleep problems, most of these studies included older children. Therefore, the current study uses a younger sample population, including infants from the age of 12 to 36 months. Since sleep patterns begin developing at an ea