Journal of Autism and Developmental Disorders

, Volume 48, Issue 11, pp 3871–3884 | Cite as

Sleep and Challenging Behaviors in the Context of Intensive Behavioral Intervention for Children with Autism

  • Emily A. AbelEmail author
  • A. J. Schwichtenberg
  • Matthew T. Brodhead
  • Sharon L. Christ


This study examined the associations between sleep and challenging behaviors for average and night-to-night fluctuations in sleep, in 39 children with autism spectrum disorder (ASD) receiving intensive behavioral intervention (IBI). Child sleep was recorded (via actigraphy) for five nights in conjunction with clinician-reported observations of challenging behaviors. Results indicated that on average, poor sleep was associated with higher rates of repetitive behavior, negative affect, and a composite of overall challenging behaviors. These findings suggest that average sleep patterns are important within the context of IBI (rather than night-to-night fluctuations). Interventions aimed at improving overall patterns of sleep may have important cascading effects on challenging behaviors and developmental outcomes for children with ASD and their families.


Autism spectrum disorder Sleep Actigraphy Challenging behavior Repetitive behavior 



First and foremost, we thank the families who generously participated in this study. We also thank Cornerstone Autism Center, Little Start Center, and the Indiana Behavior Analysis Academy for their incredible assistance with both recruitment and data collection. Finally, we thank Kathleen Welling, Amy Barton, and Amelia Reising for their hours of assistance with project management and data entry/preparation.

Author Contributions

EA participated in the design of the study, collected data, conducted analyses, and drafted the manuscript. AJS participated in the design of the study, provided expertise in sleep methodology, drafted sections of the manuscript, and reviewed/edited the manuscript. MB participated in the design of the study, provided expertise in behavior analysis, and reviewed the manuscript. SC advised in the plan of analyses and interpretation of the data and reviewed the manuscript. All authors read and approved the final manuscript.


This Research was supported in part by grants from the Gadomski Foundation, the Purdue University Center for Families, and the Purdue University Graduate Student Government.

Compliance with Ethical Standards

Conflict of interest

The authors report no conflicts of interest.

Ethical Standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all parents or legal guardians at time of enrollment in the study.

Supplementary material

10803_2018_3648_MOESM1_ESM.docx (19 kb)
Supplementary material 1 (DOCX 18 KB)
10803_2018_3648_MOESM2_ESM.pdf (1.1 mb)
Supplementary material 2 (PDF 1100 KB)


  1. Aathira, R., Chakrabarty, B., Dang, N., Gulati, S., Gupta, A., Kabra, M., et al. (2017). Prevalence of sleep abnormalities in indian children with autism spectrum disorder: A cross-sectional Study. Pediatric Neurology, 74, 62–67. Scholar
  2. Adams, H. L., Matson, J. L., & Jang, J. (2014). The relationship between sleep problems and challenging behavior among children and adolescents with autism spectrum disorder. Research in Autism Spectrum Disorders, 8(9), 1024–1030.CrossRefGoogle Scholar
  3. Aeschbach, D., Postolache, T. T., Sher, L., Matthews, J. R., Jackson, M. A., & Wehr, T. A. (2001). Evidence from the waking electroencephalogram that short sleepers live under higher homeostatic sleep pressure than long sleepers. Neuroscience, 102, 493–502.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Allik, H., Larrson, J. O., & Smedje, H. (2006). Sleep patterns in children with asperger syndrome or high-functioning autism. Journal of Autism and Developmental Disorders, 36, 585–595. Scholar
  5. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th edn.). Arlington, VA: American Psychiatric Association.CrossRefGoogle Scholar
  6. Ancoli-Israel, S., Martin, J. L., Blackwell, T., Liu, L., et al. (2015). The SBSM guide to actigraphy monitoring: Clinical and research applications. Behavioral Sleep Medicine, 13, S4–S38.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Anders, T. F., Iosif, A. M., Schwichtenberg, A. J., Tang, K., & Goodlin-Jones, B. L. (2011). Six-month sleep-wake organization and stability in preschool-age children with autism, developmental delay, and typical development. Behavioral Sleep Medicine, 9(2), 92–106. Scholar
  8. Becker, S. P., Sidol, C. A., Van Dyk, T. R., Epstein, J. N., & Beebe, D. W. (2016). Intraindividual variability of sleep/wake patterns in relation to child and adolescent functioning: A systematic review. Sleep Medicine Reviews. Scholar
  9. Bei, B., Manber, R., Trinder, J., & Wiley, J. F. (2016). Beyond the mean: A systematic review on the correlates of daily intraindividual variability of sleep/wake patterns. Sleep Medicine Reviews, 28, 108–124. Scholar
  10. Bertoglio, K., & Hendren, R. L. (2009). New developments in autism. Psychiatric Clinics of North America, 32, 1–14. Scholar
  11. Berument, S. K., Rutter, M., Lord, C., Pickles, A., & Bailey, A. (1999). Autism screening questionnaire: Diagnostic validity. British Journal of Psychiatry, 175, 444–451. Scholar
  12. Chorney, J. M., McMurtney, C. M., Chambers, C. T., & Bakeman, R. (2014). Developing and modifying behavioral coding schemes in pediatric psychology: A practical guide. Journal of Pediatric Psychology, 40, 154–164. Scholar
  13. Cohen, S., Fulcher, B. D., Rajaratnam, S. M., Conduit, R., Sullivan, J. P., St Hilaire, M. A., et al. (2018). Sleep patterns predictive of daytime challenging behavior in individuals with low-functioning autism. Autism Research, 11, 391–403. Scholar
  14. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis. Upper Saddle River, NJ: Pearson Education, Inc.Google Scholar
  15. Cremone, A., de Jong, D. M., Kurdziel, L. B., Desrochers, P., Sayer, A., LeBourgeois, M. K., et al. (2018). Sleep tight, act right: Negative affect, sleep and behavior problems during early childhood. Child Development, 89(2), e42–e59.CrossRefPubMedGoogle Scholar
  16. Crutchfield, S. A., Mason, R. A., Chambers, A., Wills, H. P., & Mason, B. A. (2015). Use of a self-monitoring application to reduce stereotypic behavior in adolescents with autism: A preliminary investigation of I-Connect. Journal of Autism and Developmental Disorders, 45(5), 1146–1155.CrossRefPubMedGoogle Scholar
  17. Davis, T. N., & Rispoli, M. (2018). Introduction to the special issue: Interventions to reduce challenging behavior among individuals with autism spectrum disorder. Behavior Modification, 42(3), 3085–3313.CrossRefGoogle Scholar
  18. Didden, R., Korzilius, H., van Aperlo, B., van Overloop, C., & de Vries, M. (2002). Sleep problems and daytime behaviours in children with intellectual disability. Journal of Intellectual Disability Research, 46, 537–547. Scholar
  19. Doehring, P., Reichow, B., Palka, T., Phillips, C., & Hagopian, L. (2014). Behavioral approaches to managing severe problem behaviors in children with autism spectrum and related developmental disorders: A descriptive analysis. Child and Adolescent Psychiatric Clinics of North America, 23, 25–40. Scholar
  20. Doran, S. M., Van Dongen, H. P., & Dinges, D. F. (2001). Sustained attention performance during sleep deprivation: Evidence of state instability. Archives Italiennes de Biologie, 139, 253–267.PubMedGoogle Scholar
  21. El-Sheikh, M. (2011). Sleep and development: Familial and socio-cultural considerations. Oxford: Oxford University Press.CrossRefGoogle Scholar
  22. Fuligni, A. J., Arruda, E. H., Krull, J. L., & Gonzales, N. A. (2017). Adolescent sleep duration, variability, and peak levels of achievement and mental health. Child Development. Scholar
  23. Gabriels, R. L., Cuccaro, M. L., Hill, D. E., Ivers, B. J., & Goldson, E. (2005). Repetitive behaviors in autism: Relationships with associated clinical features. Research in Developmental Disabilities, 26, 169–181. Scholar
  24. Glickman, G. (2010). Circadian rhythms and sleep in children with autism. Neuroscience & Biobehavioral Reviews, 34(5), 755–768.CrossRefGoogle Scholar
  25. Goel, N., Rao, H., Durmer, J. S., & Dinges, D. F. (2009). Neurocognitive consequences of sleep deprivation. Seminars in Neurobiology, 29, 330–339. Scholar
  26. Goldman, S. E., McGrew, S., Johnson, K. P., Richdale, A. L., Clemons, T., & Malow, B. A. (2011). Sleep is associated with problem behaviors in children and adolescents with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 1223–1229. Scholar
  27. Goldman, S. E., Surdyka, K., Cuevas, R., Adkins, K., Wang, L., & Malow, B. A. (2009). Defining the sleep phenotype in children with autism. Developmental Neuropsychology, 34, 560–573. Scholar
  28. Goodlin-Jones, B. L., Tang, K., Liu, J., & Anders, T. F. (2008). Sleep patterns in preschool-age children with autism, developmental delay, and typical development. Journal of the American Academy of Child & Adolescent Psychiatry, 47(8), 930–938.CrossRefGoogle Scholar
  29. Gruber, R., Anders, T. F., Beebe, D., Bruni, O., Buckhalt, J. A., et al. (2016). A call for action regarding translational research in pediatric sleep. Sleep Health, 2, 88–89. Scholar
  30. Haidet, K. K., Tate, J., Divirgilio-Thomas, D., Kolanowski, A., & Happ, M. B. (2009). Methods to improve reliability of video-recorded behavioral data. Research in Nursing & Health, 32, 465–474.CrossRefGoogle Scholar
  31. Hirata, I., Mohri, I., Kato-Nishimura, K., Tachibana, M., Kuwada, A., Kagitani-Shimono, K., et al. (2016). Sleep problems are more frequent and associated with problematic behaviors in preschoolers with autism spectrum disorder. Research in Developmental Disabilities, 49, 86–99.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Hodge, D., Carollo, T. M., Lewin, M., Hoffman, C. D., & Sweeney, D. P. (2014). Sleep patterns in children with and without autism spectrum disorders: Developmental comparisons. Research in Developmental Disabilities, 35, 1631–1638. Scholar
  33. Hoffman, C. D., Sweeney, D. P., Gilliam, J. E., Apodaca, D. D., Lopez-Wagner, M. C., & Castillo, M. M. (2005). Sleep problems and symptomology in children with autism. Focus on Autism and Other Developmental Disabilities, 20, 194–200. Scholar
  34. Hox, J., & Roberts, K. J. (2011). Handbook of advanced multilevel analysis. New York, NY: Taylor & Francis Group.Google Scholar
  35. Humphreys, J. S., Gringas, P., Blair, P. S., Scott, N., Henderson, P. J., & Emond, A. M. (2014). Sleep patterns in children with autistic spectrum disorders: A prospective cohort study. Archives of Disease in Childhood, 99, 1–5. Scholar
  36. Hundley, R. J., Shui, A., & Malow, B. A. (2016). Relationship between subtypes of restricted and repetitive behaviors and sleep disturbance in autism spectrum disorder. Journal of Autism and Developmental Disorders, 46, 3448–3457. Scholar
  37. Ipsiroglu, O. S., Hung, Y. H. A., Forson Chan, M. L. R., Veer, D., Soo, S., Ho, G., et al. (2015). “Diagnosis by behavioral observation” home-videosomnography: A rigorous ethnographic approach to sleep of children with neurodevelopmental conditions. Frontiers in Psychiatry, 6, 1–15. Scholar
  38. Jenni, O. G., & LeBourgeois, M. K. (2006). Understanding sleep-wake behavior and sleep disorders in children: The value of a model. Current Opinion in Psychiatry, 19(3), 282.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Kamphuis, J., Meerlo, P., Koolhaas, J. M., & Lancel, M. (2012). Poor sleep as a causal factor in aggression and violence. Sleep Medicine, 13, 327–334. Scholar
  40. Kerkhof, G. A., & Van Dongen, H. P. A. (2010). Human sleep and cognition: Basic research. New York, NY: Elsevier.Google Scholar
  41. Klintwall, L., Eldevik, S., & Eikeseth, S. (2015). Narrowing the gap: Effects of intervention on developmental trajectories in autism. Autism, 19(1), 53–63.CrossRefPubMedGoogle Scholar
  42. Krakowiak, P., Goodlin-Jones, B., Hertz-Picciotto, I., Croen, L. A., & Hansen, R. L. (2008). Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: A population-based study. Journal of Sleep Research, 17, 197–206. Scholar
  43. Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Leventhal, B. L., DiLavore, P. C., et al. (2000). The autism diagnostic observation schedule-generic: A standard measure of social and communication deficits associated with the spectrum of autism. Journal of Autism and Developmental Disorders, 30, 205–223. Scholar
  44. Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic interview-revised: A revised version of a diagnostic interview for caregivers of individuals with possible pervasive developmental disorders. Journal of Autism and Developmental Disorders, 24, 659–685. Scholar
  45. Lovaas, I. O. (1987). Behavioral treatment and normal education and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9. Scholar
  46. Lukowski, A. F., & Milojevich, H. M. (2017). Sleep problems and temperament in young children with down syndrome and typically developing controls. Journal of Intellectual Disability Research, 61, 221–232. Scholar
  47. Malow, B. A., Adkins, K. W., Reynolds, A., Weiss, S. K., Loh, A., Fawkes, D., et al. (2014). Parent-based sleep education for children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44, 216–228. Scholar
  48. Malow, B. A., Marzec, M. L., McGrew, S. G., Wang, L., Henderson, L. M., & Stone, W. L. (2006). Characterizing sleep in children with autism spectrum disorders: A multidimensional approach. Sleep, 29(12), 1563–1571.CrossRefPubMedGoogle Scholar
  49. Matson, J. L. (2009). Applied behavior analysis for children with autism spectrum disorders. New York, NY: Springer.CrossRefGoogle Scholar
  50. Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children with autism spectrum disorders: A review. Research in Developmental Disabilities, 28(6), 567–579.CrossRefPubMedGoogle Scholar
  51. Mayes, S. D., & Calhoun, S. L. (2009). Variables related to sleep problems in children with autism. Research in Autism Spectrum Disorders, 3(4), 931–941. Scholar
  52. Mazurek, M. O., & Sohl, K. (2016). Sleep and behavioral problems in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46, 1906–1915. Scholar
  53. Meltzer, L. J., Montgomery-Downs, H. E., Insana, S., & Walsh, C. M. (2012). Use of actigraphy in pediatric sleep research. Sleep Medicine Reviews, 16, 463–475. Scholar
  54. Merikanto, I., Pesonen, A. K., Kuula, L., Lahti, J., Heinonen, K., Kajantie, E., & Räikkönen, K. (2017). Eveningness as a risk for behavioral problems in late adolescence. Chronobiology International, 34(2), 225–234.CrossRefPubMedGoogle Scholar
  55. Mindell, J. A., & Owens, J. A. (2015). A clinical guide to pediatric sleep: Diagnosis and management of sleep problems. Philadelphia: Wolters Kluwer.Google Scholar
  56. Moore, M., Evans, V., Hanvey, G., & Johnson, C. (2017). Assessment of sleep in children with autism spectrum disorder. Children, 4(8), 72.CrossRefPubMedPubMedCentralGoogle Scholar
  57. National Autism Center. (2009). National standards report. Randolph, MA: National Autism Center.Google Scholar
  58. National Research Council. (2001). Educating children with autism. Washington, D.C.Google Scholar
  59. Owens, J. A., Spirito, A., & McGuinn, M. (2000). The Children’s Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep, 23, 1–9. Retrieved from
  60. Peters-Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 5, 60–69. Scholar
  61. Phung, J. N., & Goldberg, W. A. (2017). Poor sleep quality is associated with discordant peer relationships among adolescents with autism spectrum disorder. Research in Autism Spectrum Disorders, 34, 10–18.CrossRefGoogle Scholar
  62. Richdale, A. L., & Schreck, K. A. (2009). Sleep problems in autism spectrum disorders: Prevalence, nature, & possible biopsychosocial aetiologies. Sleep Medicine Reviews, 13, 403–411. Scholar
  63. Sadeh, A., Alster, J., Urbach, D., & Lavie, P. (1989). Actigraphically based automatic bedtime sleep-wake scoring: Validity and clinical applications. Journal of Ambulatory Monitoring, 2, 209–216.Google Scholar
  64. Sadeh, A., Sharkey, K. M., & Carskadon, M. A. (1994). Activity-based sleep-wake identification: An empirical test of methodological issues. Sleep, 17, 201–207.CrossRefPubMedGoogle Scholar
  65. Sannar, E. M., Palka, T., Beresford, C., Peura, C., Kaplan, D., Verdi, M., et al. (2017). Sleep problems and their relationship to maladaptive behavior severity in psychiatrically hospitalized children with Autism Spectrum Disorder (ASD). Journal of Autism and Developmental Disorders. Scholar
  66. Scheithauer, M. C., & Zarcone, J. (2015). Evaluating the relationship between sleep and problem behavior in children with disabilities. Behavior Analysis Practice, 8, 27–36. Scholar
  67. Schreck, K. A., Mulick, J. A., & Smith, A. F. (2004). Sleep problems as possible predictors of intensified symptoms of autism. Research in Developmental Disabilities, 25, 57–66. Scholar
  68. Schwichtenberg, A. J., Hensle, T., Honaker, S., Miller, M., Ozonoff, S., & Anders, T. (2016). Sibling sleep-What can it tell us about parental sleep reports in the context of autism? Clinical Practice in Pediatric Psychology, 4(2), 137–152. Scholar
  69. Schwichtenberg, A. J., Shah, S. E., & Poehlmann, J. (2013). Sleep and attachment in preterm infants. Infant Mental Health Journal, 34, 37–46. Scholar
  70. Schwichtenberg, A. J., Young, G. S., Hutman, T., Iosif, A. M., Sigman, M., Rogers, S. J., & Ozonoff, S. (2013). Behavior and sleep problems in children with a family history of autism. Autism Research, 6(3), 169–176. Scholar
  71. Sikora, D. M., Johnson, K., Clemons, T., & Katz, T. (2012). The relationship between sleep problems and daytime behavior in children of different ages with autism spectrum disorders. Pediatrics, 130, 83–90. Scholar
  72. Sletten, T. L., Segal, A. Y., Flynn-Evans, E. E., Lockley, S. W., & Rajaratnam, S. M. W. (2015). Inter-individual differences in neurobehavioural impairment following sleep restriction are associated with circadian rhythm phase. PLoS ONE, 10, 1–16. Scholar
  73. Smith, C. E., Carr, E. G., & Moskowitz, L. J. (2016). Fatigue as a biological setting event for severe problem behavior in autism spectrum disorder. Research in Autism Spectrum Disorders, 23, 131–144.CrossRefGoogle Scholar
  74. Smith, T., Eikeseth, S., Klevstrand, M., & Lovaas, I. O. (1997). Intense behavioral treatment for preschoolers with severe mental retardation and pervasive developmental disorder. American Journal on Mental Retardation, 102, 238–249. Retrieved from
  75. Souders, M. C., Mason, T., Valladares, O., Bucan, M., Levy, S. E., Mandell, D. S., et al. (2009). Sleep behaviors and sleep quality in children with autism spectrum disorders. Sleep, 32, 1566–1578.CrossRefPubMedPubMedCentralGoogle Scholar
  76. Souders, M. C., Zavodny, S., Eriksen, W., Sinko, R., Connell, J., Kerns, C., et al. (2017). Sleep in children with autism spectrum disorder. Current Psychiatry Reports, 19(6), 34.CrossRefPubMedPubMedCentralGoogle Scholar
  77. Tudor, M. E., Hoffman, C. D., & Sweeney, D. P. (2012). Children with autism: Sleep problems and symptom severity. Focus on Autism and Other Developmental Disabilities, 27, 254–262. Scholar
  78. Van Dyk, T. R., Thompson, R. W., & Nelson, T. D. (2016). Daily bidirectional relationships between sleep and mental health symptoms in youth with emotional and behavioral problems. Journal of Pediatric Psychology, 41, 983–992. Scholar
  79. Veatch, O. J., Sutcliffe, J. S., Warren, Z. E., Keenan, B. T., Potter, M. H., & Malow, B. A. (2017). Shorter sleep duration is associated with social impairment and comorbidities in ASD. Autism Research, 10, 1221–1238. Scholar
  80. Wiggins, L. D., Bakeman, R., Adamson, L., & Robins, D. L. (2007). The utility of the social communication questionnaire in screening for autism in children referred for early intervention. Focus on Autism and Other Developmental Disabilities, 22, 33–38. Scholar
  81. Wild-Hartman, J. A., Wichers, M., van Bemel, A. L., Derom, C., Theiry, E., et al. (2013). Day-to-day associations between subjective sleep and affect in regard to future depression in a female population-based sample. British Journal of Psychiatry, 202, 407–412. Scholar
  82. Wise, M. S., Nichols, C. D., Grigg-Damberger, M. M., Marcus, C. L., Witmans, M. B., et al. (2011). Executive summary of respiratory indications for polysomnography in children: An evidencebased review. Sleep, 34(3), 389–398.CrossRefPubMedPubMedCentralGoogle Scholar
  83. Wolfson, A. R., Carskadon, M. A., Acebo, C., Seifer, R., Fallone, G., Labyak, S. E., et al. (2003). Evidence for the validity of a sleep habits survey for adolescents. Sleep, 26(2), 213–216.CrossRefPubMedGoogle Scholar
  84. Yoder, P., & Symons, F. (2010). Observational measurement of behavior. New York, NY: Springer.Google Scholar

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Authors and Affiliations

  1. 1.Department of Human Development and Family StudiesPurdue UniversityWest LafayetteUSA
  2. 2.Department of Educational StudiesPurdue UniversityWest LafayetteUSA
  3. 3.Department of Counseling, Educational Psychology, and Special EducationMichigan State UniversityEast LansingUSA

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