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Child Psychiatry & HumanDevelopment ISSN 0009-398X Child Psychiatry Hum DevDOI 10.1007/s10578-014-0496-9
Frequency and Clinical Correlates of Sleep-Related Problems Among Anxious Youthwith Autism Spectrum Disorders
Joshua M. Nadeau, Elysse B. Arnold,Amanda C. Keene, Amanda B. Collier,Adam B. Lewin, Tanya K. Murphy & EricA. Storch
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ORIGINAL ARTICLE
Frequency and Clinical Correlates of Sleep-Related ProblemsAmong Anxious Youth with Autism Spectrum Disorders
Joshua M. Nadeau • Elysse B. Arnold • Amanda C. Keene •
Amanda B. Collier • Adam B. Lewin • Tanya K. Murphy • Eric A. Storch
� Springer Science+Business Media New York 2014
Abstract Sleep-related problems (SRPs) are common
and problematic among anxious youth but have not been
investigated in anxious youth with autism spectrum disor-
der (ASD). Participants were 102 youth (ages 7–16 years)
with ASD and comorbid anxiety. Youth and their primary
caregiver were administered the Pediatric Anxiety Rating
Scale. Parents completed the Multidimensional Anxiety
Scale for Children–Parent (MASC-P) Report, Social
Responsiveness Scale, and the Child Behavior Checklist
(CBCL). A measure of SRPs was created from items from
the CBCL and MASC-P. Results suggest SRPs were rela-
tively common among youth with ASD and comorbid
anxiety. The number of SRPs endorsed directly associated
with parent ratings of social deficits, internalizing and
externalizing symptoms, and anxiety symptoms, as well as
with clinician-rated anxiety symptoms. Parent-rated inter-
nalizing symptoms predicted frequency of SRPs over and
above social deficits, externalizing symptoms, and parent-
and clinician-rated anxiety symptoms. A subset of 40 par-
ticipants who completed family-based cognitive–behavioral
therapy (CBT) experienced reduced SRPs following treat-
ment. Implications, study limitations, and recommendations
for future research are discussed.
Keywords Autism spectrum disorders � Anxiety � Sleep �Cognitive–behavioral therapy � Obsessive–compulsive
disorder
Introduction
Sleep related problems (SRPs) are relatively common
among typically developing adults [1] and children [2].
With respect to childhood presentation, SRPs can include
nightmares, difficulty falling asleep, difficulty sleeping
away from home, refusal to sleep alone, and general
nighttime fears [3, 4]. SRPs have been associated with
impairments in memory, vigilance, and affect [5, 6], and
may intensify difficulties with behavioral regulation [7].
Additionally, relatively minor amounts of sleep deprivation
result in significant performance decline within higher
cognitive functions, including verbal fluency and abstract
thinking [8]. As such, childhood SRPs have been associ-
ated with impaired functioning in academic, social, and
psychosocial domains [9], and may contribute to poor
outcomes with respect to emotional development [10–12].
Although little is known about SRPs among youth with
ASD and anxiety, several studies have been conducted
among typically developing anxious youth. Findings sug-
gest that youth with anxiety disorders show dispropor-
tionately large prevalence of SRPs, with more than 50 % of
youth endorsing three or more SRPs via parent report
checklists [3, 13]. These findings are similar to those
reported among youth with obsessive–compulsive disorder
(OCD), where more than one-quarter of the sample
J. M. Nadeau (&) � E. B. Arnold � A. C. Keene �A. B. Collier � A. B. Lewin � T. K. Murphy � E. A. Storch
Department of Pediatrics, University of South Florida, 880 6th
Street South, Box 7523, St. Petersburg, FL 33701, USA
e-mail: [email protected]
J. M. Nadeau � E. A. Storch
Rogers Behavioral Health – Tampa Bay, Tampa, FL, USA
E. B. Arnold � A. B. Lewin � E. A. Storch
Department of Psychology, University of South Florida,
St. Petersburg, FL, USA
A. B. Lewin � T. K. Murphy � E. A. Storch
Department of Psychiatry and Behavioral Neurosciences,
University of South Florida, St. Petersburg, FL, USA
123
Child Psychiatry Hum Dev
DOI 10.1007/s10578-014-0496-9
Author's personal copy
endorsed five or more of eight assessed SRPs [14]. Inter-
estingly, although age and gender have not significantly
correlated with SRP endorsement, the number of SRPs
endorsed was positively associated with severity of child-
rated anxiety symptoms [3, 13, 14]. Additionally, evidence
suggests that the increase in frequency of SRPs endorsed
was associated with the specific anxiety disorder diag-
nosed; youth with social phobia and separation anxiety
disorder demonstrated higher rates of SRPs than youth with
other anxiety disorders, although SRP endorsement rates
were higher among youth with any anxiety disorder as
compared to youth without these diagnoses [13]. Of par-
ticular relevance to the current study, treatment of anxiety
symptoms resulted in concomitant reduction of endorsed
SRPs, whether treatment was pharmacological (i.e., flu-
voxamine; [3]) or psychological (i.e., cognitive–behavioral
therapy (CBT); [14]).
Recent research has investigated the nature of SRPs
among youth with psychiatric disorders, with results gen-
erally indicating that SRPs occur at increased rates among
youth with emotional and behavioral problems [14–16].
Disordered sleep has been associated with cognitive per-
formance and behavioral problems in multiple pediatric
populations, including youth with autism spectrum disorder
(ASD; see [17] for a review). The various cognitive, social,
communicative, and behavioral impairments that com-
monly occur among youth diagnosed with ASD suggest
that youth with ASD should endorse increased rates of
SRPs as compared to typically developing youth [18–20].
Findings among youth with ASD consistently suggest
increased rates of SRPs (44–83 %; [21]) as compared to
same-age typically developing peers (32 %; [22]), includ-
ing increased sleep latency, decreased duration of sleep,
and frequent nighttime wakings [8, 21]. Youth with ASD
classified as ‘‘poor sleepers’’ are rated as having more
affective problems on the Child Behavior Checklist
(CBCL), as well as more problems with reciprocal social
interaction on the Autism Diagnostic Observation Schedule
[23], as compared to youth with ASD classified as ‘‘good
sleepers’’ [8]. Increased endorsement of sleep problems, as
well as significantly greater response to medication for
sleep problems, has been reported among youth with aut-
ism and Asperger’s Disorder as compared to typically
developing youth [24]. Tudor et al. [25] found that sleep
latency among youth with ASD was a strong predictor of
communication deficits, stereotyped behaviors, and sever-
ity of core ASD symptoms. Neither cognitive nor adaptive
development was a significant predictor of SRP frequency
or severity among children with autism [22]. Within this
literature, information about the frequency of SRPs among
youth with ASD has been relatively well-represented rel-
ative to typically developing youth; however, no research
exists examining relationships of SRPs with severity of
core ASD symptoms and comorbid anxiety symptoms,
despite the high comorbidity rate of anxiety among youth
with ASD [26–28].
It is clear from existing data that youth with ASD fre-
quently experience SRPs. Similarly, existing data support
elevated rates of SRPs among typically developing youth
with anxiety disorders. However, the magnitude and nature
of relationship between ASD symptoms and comorbid
anxiety symptoms with respect to SRPs remains unclear.
The present study examines the prevalence and correlates
of SRPs in a large sample of children and adolescents with
ASD and comorbid anxiety, and was designed to answer
five research questions. First, what is the frequency of 8
SRPs (i.e., being overtired, sleeping less than other youth,
sleeping more than other youth, talking or walking while
asleep, having trouble sleeping, needing a nightlight to
sleep, co-sleeping, and having nightmares) in youth with
ASD and comorbid anxiety? We expected to find that SRPs
occurred frequently (i.e., more than 60 % of sample)
among anxious youth with ASD. Second, are SRPs related
to age and gender? We hypothesized that younger children
(ages 7–11) and females would endorse more SRPs than
older children (ages 12–16) and males, consistent with
prior findings [3]. Third, what are the associations between
SRPs, ASD symptoms, and anxiety symptoms? We
expected that SRPs would be positively related to ASD
symptoms and anxiety symptom severity. Fourth, do anx-
iety and/or internalizing symptoms predict SRPs above and
beyond ASD symptoms? We hypothesized that anxiety and
internalizing symptoms would significantly predict SRP
endorsement while controlling for ASD symptom severity.
Finally, what effect does CBT modified for youth with
ASD and anxiety have upon SRPs? Given the effectiveness
of CBT for anxiety in youth with ASD [20] and past
findings in typically developing youth with anxiety [29,
30], we hypothesized that a reduction in endorsed SRPs
would be found from pre- to post-treatment assessment.
Method
Participants
Participants were 102 children and adolescents with ASD
and comorbid anxiety disorders (81 males) recruited from
4 completed studies. The first study [31] examined the
efficacy of a modularized CBT protocol, Behavioral
Interventions for Anxiety in Children with Autism [32]
and contributed 44 participants (ranging in age from 7 to
11 years) to the current study. This study examined the
efficacy of 16 sessions of a modular treatment protocol
(BIACA) relative to a treatment as usual (TAU) control
condition. Although the associated publication for the
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study [31] explains the design and participant information
in great detail, use of a modular treatment approach
allowed inclusion of anxiety and non-anxiety symptoms
as treatment goals, as well as the opportunity to address
treatment issues commonly identified among youth with
ASD (i.e., comorbid conditions, low motivation). The
second study was an open trial evaluating a computer-
assisted CBT program, Camp Cope-A-Lot (CCAL; [33])
and contributed five participants (ranging in age from 7 to
11 years) to the current study. The CCAL protocol con-
sisted of six computer-guided and six therapist-guided
sessions over 12 weeks. The computer-guided sessions
focus upon helping youth with anxiety to recognize their
emotions, relax, and modify anxiety-related cognitions.
The therapist-guided sessions are designed to promote
application of learned skills through exposure tasks to
help the youth better manage thoughts, feelings and
behaviors when anxious. The third study [34] examined
use of the BIACA protocol among adolescents with high-
functioning ASD and comorbid anxiety ranging in age
from 11 to 15 years, and contributed 28 participants to the
current study. The fourth study, the manuscript for which
has been submitted for publication consideration, also
examined the use of the BIACA protocol among adoles-
cents, and contributed 25 participants (ranging in age
from 11 to 16 years) to the current study. In the last two
studies (those examining application of the BIACA pro-
tocol among adolescents), the study designs were essen-
tially replications of the first study [31] among adolescent
populations.
Participant descriptive data are provided in Table 1.
Data from the baseline assessment of each study were used
to examine cross-sectional associations among study vari-
ables for the sample as a whole, while post-treatment data
were also used to examine changes in SRP rates for a
subset of this sample (N = 40) completing the associated
course of CBT (i.e., 12 sessions of CCAL or 16 sessions of
BIACA). In any event, participants met inclusion criteria
for the presence of ASD and anxiety based on the Autism
Diagnostic Interview-Revised [35], Autism Diagnostic
Observation Schedule Module 3 [23], and the Anxiety
Disorders Interview Schedule for DSM-IV Parent and
Child versions [36], respectively. At the time of study
entry, participants ranged in age from 7 to 16 years
(M = 10.81 ± 2.3 years). The majority of youth were
Caucasian (87 %), with 7 % reporting as Hispanic, 3 % as
Asian, and 3 % as mixed. Of the sample, 59.1 % of youth
were taking one or more psychiatric medications, with
serotonin reuptake inhibitors (35.4 %), stimulants (32.3 %)
and anti-psychotics (8.2 %) representing the top three
classes of medication. Medication status was not available
for one youth.
Procedure
Study procedures were approved by the local Institutional
Review Board. In the case of each parent study, written
parental consent and child assent were obtained. After
obtaining consent/assent, families completed a 2 day in-
person screening with the 2 days occurring no more than
7 days apart. Anxiety-specific diagnostic assessments were
administered on the first visit, and autism-focused diag-
nostic assessments occurred at the second visit. Those
youth who qualified returned to complete a baseline
assessment, including all clinician- and parent-report
measures. For those participants completing CBT, post-
treatment assessments were completed within 1 week after
the final CBT session.
Measures
Establishment of ASD diagnosis and diagnostic differen-
tiation was accomplished via the use of combined diag-
nostic information from the ADI-R and ADOS-Module 3,
which have demonstrated good diagnostic utility when
used in combination [37]. Administration of the ADI-R and
ADOS were completed by a certified and experienced
doctoral-level evaluator. Independent evaluators, who were
Table 1 Characteristics of study participants
Age (years)
Range 7–16 years
Mean (SD) 10.81
(2.31)
Gender [n (%)]
Male 81 (79.4)
Female 21 (20.6)
Ethnicity [n (%)]
White/Caucasian 89 (87.3)
Hispanic 7 (6.9)
Asian 3 (2.9)
Multi-racial 3 (2.9)
Autism spectrum disorder [n (%)]
Asperger’s disorder (AS) 42 (41.2)
Autistic disorder (AD) 30 (29.4)
Pervasive developmental disorder, not otherwise
specified (PDD-NOS)
30 (29.4)
Primary anxiety disorder [n (%)]
Social phobia (SoP) 42 (35.6)
Generalized anxiety disorder (GAD) 31 (26.3)
Obsessive–compulsive disorder (OCD) 13 (11.0)
Separation anxiety disorder (SAD) 12 (10.2)
Specific phobia (SP) 2 (1.7)
Anxiety disorder, not otherwise specified (ANX-NOS) 10 (8.5)
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blind to participants’ intervention condition and not
involved in treatment, administered all clinician-rated
measures. Prior to the onset of all studies, evaluators
completed instructional training, observed multiple
administrations of measures, and completed measure
administrations under supervision.
Pediatric Anxiety Rating Scale (PARS)
The PARS [38] is a clinician-rated measure of the presence
and severity of anxiety symptoms in youth. Total scores
represent the severity and frequency of anxiety symptoms
as well as associated distress, avoidance, and interference
during the previous week. For the current study, severity of
physical symptoms of anxiety was assessed using an item
from the PARS as rated by the parent, youth, and clinician.
The PARS has acceptable reliability and validity [39] and
has been shown to be acceptable for use among youth with
ASD [40]. Internal consistency ratings for the PARS in the
sample were .53 at baseline, and .80 at post-treatment.
Multidimensional Anxiety Scale for Children–Parent
Version (MASC-P)
The MASC-P [41] is a 39-item parent-report measure of
anxiety symptoms. Items are rated on a four-point Likert
scale (0: never true about my child, 1: rarely true about my
child, 2: sometimes true about my child, 3: often true about
my child) with higher scores corresponding to greater
anxiety. The MASC-P has demonstrated strong psycho-
metric properties [42]. Internal consistency for the MASC-
P in this sample was .87.
Social Responsiveness Scale (SRS)
The SRS [43] is a 65-item scale measuring severity of
autism spectrum symptoms (social awareness, autistic
preoccupations) with excellent psychometrics [44]. Internal
consistency for the SRS in this sample was .81.
Sleep Composite Measure
Similar to previous studies [3, 13, 14, 45], we formed a
composite measure of SRPs by combining six relevant
items from the CBCL (i.e., sleep walks, has nightmares,
overtired, sleeps less than most children, sleeps more than
most children, and trouble sleeping) and two items from
the MASC-P (i.e., keeps the light on at night, sleeps next to
someone from my family). In contrast to utilizing child-
reported anxiety via the MASC [42], the current study used
parent proxy report via the MASC-P. Given that the items
from the MASC-P differ in response format form those of
the CBCL, responses were recoded. However, to provide a
more conservative estimate of sleep problem severity than
in prior studies, response recoding was such that more
positive endorsement of a SRP (i.e., rating of ‘‘2’’ on the
CBCL, rating of ‘‘2’’ or ‘‘3’’ on the MASC-P) was recoded
as ‘‘1,’’ while ‘‘1’’ ratings on both instruments were reco-
ded as ‘‘0.’’ Note that ‘‘0’’ ratings were not recoded. These
eight items were standardized and then summed to create a
composite SRP score.
Anxiety Disorders Interview Schedule for DSM-IV-Child
and Parent Versions (ADIS-C/P)
The ADIS-C/P [36] are clinician-administered, semi-
structured interviews that assess parent and child
endorsement of DSM-IV-TR Axis I disorders. Diagnostic
presence and severity are established using a CSR on a
scale of 0–8, with a score of 4 or more indicating diag-
nostic presence. The ADIS-C/P demonstrates strong reli-
ability and validity among typically developing youth [40]
and treatment sensitivity among youth with ASD [31, 46].
Child Behavior Checklist (CBCL)
The CBCL [47] is a 113-item parent report form used to
assess a wide range of child internalizing and externalizing
symptoms over the past 6 months. Items are rated on a
three-point scale (0: never true, 1: sometimes true, 2: often
or always true). The CBCL has eight individual subscales,
Internalizing and Externalizing Scales, and a Total Score
that is derived by summing the Internalizing and Exter-
nalizing Scales. Numerous studies have supported the
psychometric properties of the updated version of the
CBCL [48, 49]. Internal consistency ratings for the CBCL
in this sample were .82 for the internalizing subscale, and
.92 for the externalizing subscale.
Data Analysis
Missing data were determined to be at random using pro-
cedures provided by Schlomer et al. [50]. As listwise
deletion occurred in variables of interest in less than 5 % of
response opportunities [51], hotdeck multiple imputation
was completed, ensuring that none of the missing data
constituted sleep composite items. Data were analyzed
using SPSS 21.0. Descriptive data and zero-order correla-
tion coefficients were calculated to determine the preva-
lence of SRPs in the current sample, as well as to identify
the relationships between SRPs and other study variables of
interest (e.g., PARS scores, CBCL Internalizing and
Externalizing subscale scores, MASC-P Total Score, SRS
scores). Sleep items were removed from all CBCL scales
and MASC-P scores before calculating internalizing,
externalizing, and anxiety scores to remove overlapping
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items from analyses. To examine possible differences in
overall and individual SRPs due to age and gender, paired
sample t tests and Chi square tests were used. The rela-
tionships between SRPs, SRS scores, parent-rated inter-
nalizing and externalizing symptoms, and parent- and
clinician-rated anxiety symptoms were examined via
backward regression. The dependent variable for the
regression model was overall SRPs. Finally, to examine
treatment effects, data representing a subset of participants
who completed CBT were used. From these data, t tests
were used to test for significant changes in total number of
SRPs endorsed, as well as in individual SRPs endorsed,
from pre- to post-treatment. Given the exploratory nature of
this study, no statistical correction was used to minimize the
chance of obfuscating potentially important relationships.
Results
Associations Between Clinical Characteristics
and SRPs
Table 2 presents descriptive statistics for and correlations
among administered measures. As shown, the total number
of SRPs showed strong positive relationships with parent-
reported ASD-related social deficits, parent-rated internal-
izing symptoms, and child- and clinician-rated anxiety
symptoms. A moderate positive association was observed
between total number of SRPs and parent-rated external-
izing symptoms. Endorsement rates for overall number of
SRPs, as well as for each of the eight SRPs examined, are
presented in Table 4. Less than one-quarter (24.8 %) of the
current sample did not have a SRP, with more than
one-third (35.6 %) of the sample reporting three or more
SRPs. The most commonly reported problems included
needing a night light (54.5 %), and feeling unable to sleep
alone (43.6 %).
Age and Gender Effects
Gender
The difference between the mean number of SRPs for
males and females was not statistically significant
[t(101) = 1.54, p [ .05]. Analysis of individual SRPs
revealed that nightmares [t(101) = 2.60, p = .011]
occurred with greater frequency in female than male
participants.
Age
The difference for the mean number of SRPs between age
groups was not statistically significant [t(101) = .65,
p [ .05]. On individual types of SRP, sleeping less
[t(101) = 2.22, p = .028] and co-sleeping [t(101) = 2.34,
p = .021] were found with greater frequency in younger
versus older youth.
Predictive Utility of ASD and Comorbid Anxiety
Symptoms
Results of the backward regression model are summarized
in Table 3. In step one, the overall model was a significant
predictor of SRP endorsement, accounting for 51 % of the
observed variance (p \ .01); however, investigation of
individual contributions indicated no significant predictors
within the model. Removal of parent-rated externalizing
symptoms in step 2 maintained significant prediction of
Table 2 Correlations, internal consistency, and descriptive statistics for study variables
Variable SRPs ASD symptoms Parent-rated anxiety Parent-rated Clinician-rated anxiety
Internalizing Externalizing
Total SRPs – .456** .446** .590** .271** .453**
Overtired .561** .270* .262* .499** .072 .414**
Sleep less .499** .397** .266* .323** .247* .252*
Sleep more .279** .229 .128 .413** .090 .234*
Sleep walk .404** .207 .050 .285** .140 .206
Sleep trouble .703** .277* .318** .298** .102 .470**
Nightlight .614** .206 .320** .248* .134 .111
Co-sleep .548** -.030 .241* .261** .261** .205
Nightmares .610** .429** .254* .319** .118 .240*
Mean (SD) 2.01 (1.74) 166.78 (18.00) 59.99 (13.66) 22.11 (9.44) 15.93 (11.12) 23.68 (3.41)
Reliability (a) .57 .81 .87 .83 .92 –
* p \ .05; ** p \ .01; *** p \ .001
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SRP endorsement by the model overall (51 %, p \ .01),
although none of the individual variables significantly
predicted variance in SRP endorsement. Clinician-rated
anxiety symptoms were removed in step 3 of the regres-
sion, yielding a non-significant reduction in overall model
predictive utility (50 %, p \ .01); however, no individual
significant predictors of SRP endorsement were revealed.
Step 4 of the regression involved removal of parent-rated
anxiety symptoms. Note that, although overall model pre-
dictive utility exhibited a non-significant reduction (49 %,
p \ .001), parent-rated internalizing symptoms were a
significant individual predictor of SRP endorsement
(p \ .01). Finally, social deficits were removed in step 5 of
the regression, with the result that the parent-rated inter-
nalizing symptoms exhibited significant predictive utility
(46 %, p \ .001) of SRP endorsement.
Treatment Effects
A subsample of 40 youth who completed a full course of
family-based CBT (16 sessions for the 3 studies utilizing
the BIACA protocol; 12 sessions for the CCAL protocol)
was examined. Endorsement rates of SRPs for all partici-
pants at baseline and post-treatment are provided in
Table 4. The youth completing CBT displayed a statisti-
cally significant reduction in overall number of reported
SRPs from baseline to post-treatment [t(39) = 2.30,
p = .027, d = .74]. In terms of specific symptom reduc-
tions, nightmares [t(39) = 2.36, p = .023], overtired
[t(39) = 2.78, p = .008], and sleeps more [t(39) = 2.22,
p = .032] were all significantly reduced in the current
sample (see Table 4). The remaining SRPs, ‘‘talks or walks
in sleep’’, ‘‘sleeps less than other kids’’, ‘‘has trouble
sleeping’’, ‘‘sleeps next to someone in family’’, and ‘‘needs
nightlight to sleep’’ showed no significant reductions in
endorsement rate from baseline to post-treatment among
the treatment-completing subset.
Discussion
This study investigated the incidence and correlates of
SRPs among youth with ASD and comorbid anxiety dis-
orders. While SRPs have been examined separately in
youth with ASD and in typically developing youth with
anxiety, few data have been reported on SRPs in youth with
ASD and comorbid anxiety. Consistent with studies of
anxious typically developing youth [3, 14] and youth with
ASD [8, 21], 75 % of participants in this study endorsed at
least 1 SRP, with 35.6 % of participants endorsing 3 or
more SRPs. Parents most frequently reported problems
with needing a night light and co-sleeping, which is con-
sistent with findings that youth with autism demonstrate
higher frequency of endorsed co-sleeping versus typically
Table 3 Backward regression model for overall sleep-related
problems
Variables R2 R2 change F B (std. error) b
First step .51 – 4.35**
SRS .020 (.02) .20
CBCLext -.009 (.3) -.06
CBCLint .087 (.05) .43
PARS .055 (.11) .10
MASC .015 (.03) .12
Second step .51 .00 5.64**
SRS .019 (.02) .18
CBCLint .085 (.05) .42
PARS .046 (.10) .08
MASC .017 (.03) .13
Third step .50 -.01 7.72**
SRS .020 (.02) .20
CBCLint .088 (.05) .43
MASC .019 (.03) .15
Fourth step .49 -.01 11.60***
SRS .025 (.02) .24
CBCLint .103 (.04) .51*
Fifth step .46 -.03 21.61***
CBCLint .138 (.03) .68***
* p \ .05; ** p \ .01; *** p \ .001
Table 4 Mean scores and percentages for sleep-related problems for
entire sample, and for treatment-completing subset before and after
cognitive–behavioral therapy
Sleep related
problem
Overall
sample (%)
Treatment-completing
subset
Pre-
treatment
(%)
Post-
treatment
(%)
Nightmares 17.8 34.8 12.8*
Overtired 20.8 60.0 17.9**
Sleeps less than other
kids
15.8 15.4 15.4
Sleeps more than other
kids
8.9 13.0 5.1*
Talks or walks in sleep 6.9 8.7 7.7
Has trouble sleeping 32.7 29.2 23.1
Sleeps next to
someone in family
43.6 47.8 38.5
Needs nightlight to
sleep
54.5 48.7 40.0
Total mean SRPs (SD) 2.01 (1.74) 2.75 (1.81) 1.69* (1.59)
* p \ .05; ** p \ .01; *** p \ .001
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developing youth and youth with other disabilities (e.g.,
Prader–Willi Syndrome and Down Syndrome; [52]).
Consistent with findings among typically developing
anxious youth [3, 14, 15], parent-reported internalizing
symptoms, and parent- and clinician rated anxiety shared
significant positive associations with total SRPs. Parent-
rated internalizing symptoms directly predicted SRPs,
consistent with previous research [17]. The association
between SRPs and symptoms of ASD and anxiety may
suggest a complex relationship. Symptoms related to anx-
iety as well as ASD may affect sleep, which in turn reduces
coping, tolerance and behavioral and affective regulation,
which further exacerbates ASD and anxiety presentations
[15, 16, 53]. These findings indicate that symptoms asso-
ciated with anxiety and ASD may impact children’s sleep
in multiple ways. First, anxiety symptoms and ASD
behavioral characteristics may significantly impact the
bedtime routine. For example, if anxiety is centered around
bedtime or its characteristics (i.e., fear of the dark, of
separating from parents, or of experiencing nightmares), or
if behavioral characteristics commonly observed among
youth with ASD are present (i.e., rigidity with respect to
rituals and/or schedules, difficulties with transitions, diffi-
culties identifying social cues related to bedtime), then
youth with anxiety and ASD may seek and receive
increased support and attention from their parents at bed-
time. This reliance on parents, in addition to significantly
extending an anxiogenic routine (going to sleep), may also
hinder self-regulation in mood and sleep. Second, the
physiological symptoms of anxiety (e.g., heart palpitations,
stomachaches, sweating, recurrent use of the bathroom), as
well as evidence suggesting biological abnormalities
associated with ASD (i.e., melatonin synthesis and circa-
dian rhythm; [53]) could contribute to or exacerbate com-
mon difficulties with achieving and maintaining sleep (i.e.,
insomnia, delayed sleep onset, and irregular sleep patterns).
Neither gender nor age was associated with SRPs. This
stands in contrast to Alfano et al. [15], where increased
SRPs were endorsed among adolescents as compared to
children in a sample of typically developing youth. The
high rate of SRPs in this sample suggests that any demo-
graphic-related effects may have been outweighed by
characteristics of diagnostic presentation; specifically,
ASD and comorbid anxiety, both of which have been
consistently associated with elevated rates of impaired
sleep [3, 17, 21, 53].
Sleep related problems were reduced following CBT,
which has been shown in youth with ASD [24] and without
[3]. A relatively straightforward explanation of this may lie
in the hypothesized relationships between ASD and anxiety
symptoms, and SRPs. Beyond the findings that modular-
ized CBT adapted to meet the needs of youth with ASD
and anxiety has been efficacious in reducing symptoms of
anxiety [20], treatment response has also been associated
with reductions in ASD-related social and behavioral
symptom severity and related impairment [31, 54]. It is
possible that reduction of anxiety and/or ASD symptoms,
which are hypothesized to act as maintaining variables for
SRPs, would reduce characteristics generating or exacer-
bating sleep impairments. Beyond attempts at replication
of current findings, future research among this population
should investigate whether CBT-related improvement in
sleep quality subsequently manifests as decreased social
and behavioral issues.
The results of the current study should be considered in
light of several limitations. First, these analyses were post
hoc and subject to multiple hypothesis testing. Second,
internal consistency for the PARS and SRPs were relatively
low, which could impact the conclusions. Although psy-
chometrically sound, the PARS has demonstrated fair
internal consistency in typically developing youth and in
those with ASD [38, 40], which has been suggested to
relate to the associated but not redundant item content.
Third, use of an open trial prevented the incorporation of a
control group with which to compare outcome data.
Finally, the limited number of female participants restricts
the generalizability of the results to all youth with ASD.
Despite these limitations, this study is the first to
examine SRPs in anxious youth with ASD. These findings
indicate that SRPs frequently occur in this population.
Furthermore, ASD symptoms and anxiety uniquely con-
tributed to the presence and frequency of SRPs, suggesting
that anxiety compounds SRPs over and above what may be
expected in youth with ASD. SRPs were reduced following
CBT. Collectively, these data emphasize the importance of
screening for SRPs and evaluating their impact upon
comorbid symptoms in youth with ASD, especially those
who are anxious. Considering the efficacy of CBT with
respect to SRP endorsement in the current study, future
research should examine the possible adaptation of com-
mon sleep interventions for anxious youth with ASD,
whether through behavioral interventions (e.g., increased
sleep hygiene, faded bedtime with response cost), phar-
macotherapy, or a combination of modalities. Particularly
given the evidence of reciprocal relationships SRPs share
with anxiety symptoms and ASD symptoms, there is a
compelling rationale to determine whether easily imple-
mented and effective sleep interventions have the potential
to reduce or minimize impairment associated with anxiety
and ASD symptoms in youth.
Summary
This study reports initial data on the frequency and clinical
correlates of sleep-related problems among 102 anxious
Child Psychiatry Hum Dev
123
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youth with ASD. Frequency of SRPs endorsed was ele-
vated as compared to previous findings among neurotypical
anxious youth and youth with ASD alone. Strong direct
associations were observed between frequency of SRPs
endorsed and parent-rated internalizing and externalizing
symptoms, as well as with parent- and clinician-rated
anxiety symptoms. Further, parent-rated internalizing
symptoms predicted SRP frequency above and beyond
social deficits commonly associated with ASD, parent-
rated externalizing symptoms, and parent- and clinician-
rated anxiety symptoms. Finally, the subset of participants
completing family-based CBT displayed a significant
reduction in frequency of SRPs following treatment.
Although study limitations should be considered, these data
provide information regarding the frequency and clinical
correlates of SRPs among anxious youth with ASD.
Acknowledgments This work was supported in part by grants from
the All Children’s Hospital Research Foundation, the University of
South Florida Internal Grants Program, and the National Institutes of
Child Health and Human Development to Dr. Storch
(5R34HD065274-02). The views of this manuscript do not necessarily
reflect those of the National Institutes of Health.
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