Abstract
In addition to the core symptoms that define autism spectrum disorder (ASD), many individuals experience broader problem behavior at a level significant enough for families to seek further clinical assessment and intervention. We define “problem behavior” as any significant emotional or behavioral issue captured by the Child Behavior Checklist (CBCL) including anxiety, depression, withdrawal, somatic complaints, problems with socialization, thought or attention, rule-breaking, and aggression. While greater ASD symptom severity and accompanying sleep disturbance have each been linked with more severe problem behavior, there is little understanding about how these two key factors interact; that is, it is unclear whether the severity and type of sleep disturbance an individual experiences differentially influences the relationship between ASD symptom severity and problem behavior. The aim of the current study was, thus, to explore whether the link between greater ASD symptom severity and clinically elevated problem behavior is moderated by the presence/degree of accompanying sleep disturbance. Forty males with ASD, aged 5–12, participated in the study. The Social Responsiveness Scale, CBCL, and Children’s Sleep Habits Questionnaire were administered to obtain information about ASD symptom severity, problem behavior, and sleep habits, respectively. Results indicated that the relationship between ASD symptom severity and problem behavior differed among individuals with ASD depending on the degree of sleep disturbance they experienced. Specifically, there was a significant positive relationship between ASD symptom severity and problem behavior for individuals with no sleep disturbance or milder sleep disturbance (i.e., in these cases, individuals with severe ASD symptoms experienced clinically elevated problem behavior, while those with milder ASD symptoms experienced milder problem behavior). In contrast, there was no significant relationship between ASD symptom severity and problem behavior for individuals with moderate-to-severe sleep disturbance; rather, clinically significant problem behavior was apparent across all individuals irrespective of ASD symptom severity. Follow-up analyses indicated that disturbances in sleep duration, disordered breathing, and daytime sleepiness were related to clinically elevated problem behavior even among those with milder ASD symptoms. These findings emphasize the importance of routinely assessing for accompanying sleep disturbance in this population regardless of whether individuals present with mild, moderate, or severe ASD.
Highlights
Autism spectrum disorder (ASD) is a heterogenous neurodevelopmental disorder characterized by social deficits and restricted, repetitive patterns of behavior [1]
This study aimed to examine the influence of accompanying sleep disturbance on the established relationship between autism spectrum disorder (ASD) symptom severity and problem behavior in ASD
A significant literature exists on the relationships between ASD severity, sleep disturbance, and problem behavior, relatively little is known about whether ASD severity is related to problem behavior comparably across individuals with varying degrees of accompanying sleep disturbance
Summary
Autism spectrum disorder (ASD) is a heterogenous neurodevelopmental disorder characterized by social deficits and restricted, repetitive patterns of behavior [1]. There is existing research to suggest that many individuals with ASD experience clinically significant internalizing and externalizing problems including anxiety, depression, somatization, rule-breaking, aggression, self-harm, inattention, hyperactivity, impulsivity, and abnormal thought [3,4,5,6,7,8,9]. The term “problem behavior” encompasses any significant emotional or behavioral issue captured by the Child Behavior Checklist (CBCL) including problems with anxiety, depression, withdrawal, somatization, socialization, thought, attention, rule-breaking, and aggression. As is common in ASD research, the nature and severity of these broader problem behaviors vary considerably among individuals on the spectrum; there are some individuals who experience relatively few of these problem behaviors, while many others exhibit one or more problem behaviors that are significant enough to warrant clinical concern [3, 10, 11] and may even result in comorbid diagnoses such as anxiety, depression, conduct disorder, oppositional defiant disorder (ODD), and/or attention deficit hyperactivity disorder (ADHD). Being able to predict who on the spectrum (i.e., individuals of which severities and clinical presentations) is more likely to exhibit clinically significant problem behavior is important, as those with persistent difficulties in this area are at greater risk of long-term mental health issues, poor academic achievement, and future crime and violence [12, 13]
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