Problem Behavior in Autism Spectrum Disorder: Considering Core Symptom Severity and Accompanying Sleep Disturbance

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.

Differences in Language Ability and Emotional-Behavioral Problems according to Symptom Severity in Children with Autism Spectrum Disorder

“…The behavioral problems that accompany ASD are diverse, and it is very important to predict who is likely to have maladaptive behaviors, as those with ongoing problems in this area are at a higher risk of long-term mental health issues, such as poor peer relationships and academic achievement. 17 Particularly during childhood and adolescent development, problem behavior often overlaps or coexists with other behaviors, rather than presenting as a single symptom or issue. As it can be more difficult to identify the cause of problem behavior and to predict future developmental differences, internalization-externalization classifications are considered useful.…”

Insomnia subtypes and clinical impairment in hospitalized children with autism spectrum disorder

“…A large study of non-ASD adults found that sleep-maintenance insomnia more than doubles the likelihood an individual will experience excessive daytime sleepiness (Hara et al, 2011). Daytime sleepiness has been associated with increased hostility in youth with ASD (Mazurek & Sohl, 2016) and with greater problem behavior in children with mild ASD symptoms (Lindor et al, 2019). Daytime sleepiness has been identified as more common in youth with ASD relative to healthy controls (Allik et al, 2006; Baker et al, 2013; Miano et al, 2007), which may be due to the higher prevalence of insomnia symptoms in this population or a decreased ability to cope with insomnia.…”

Sleep Characteristics and Problems of 2-year-olds with Williams Syndrome: Relations with Language and Behavior

“…There is consistent evidence of an association between sleep disturbance and ADHD symptoms in children [11,[26][27][28][29]. Furthermore, for school-age boys with ASD, decreased total sleep duration and daytime sleepiness have been associated with more behavior problems as measured by the CBCL [30].…”