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Research in Developmental Disabilities 33 (2012) 1408–1417

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Research in Developmental Disabilities

Sleep disruption as a correlate to cognitive and adaptive behavior


problems in autism spectrum disorders
Matthew A. Taylor a, Kimberly A. Schreck a,*, James A. Mulick b
a
777 W. Harrisburg Pike, W311 Olmsted Building, Middletown, PA 17036, USA
b
The Ohio State University, Nationwide Children’s Hospital Developmental Assessment Program, 187 West Schrock Road, Westerville, OH 43081, USA

A R T I C L E I N F O A B S T R A C T

Article history: Sleep problems associated with autism spectrum disorders (ASD) have been well
Received 1 February 2012 documented, but less is known about the effects of sleep problems on day-time cognitive
Accepted 6 March 2012 and adaptive performance in this population. Children diagnosed with autism or pervasive
Available online 21 April 2012 developmental disorder-not otherwise specified (PDD-NOS) (N = 335) from 1 to 10 years of
age (M = 5.5 years) were evaluated for the relationships of Behavioral Evaluation of
Keywords: Disorders of Sleep (BEDS; Schreck, 1998) scores to measures of intelligence and adaptive
Autism behavior. Results suggested that children who slept fewer hours per night had lower
Sleep
overall intelligence, verbal skills, overall adaptive functioning, daily living skills,
Adaptive behavior
socialization skills, and motor development. Children who slept fewer hours at night
Intelligence
Sleep disorders
with waking during the night had more communication problems. Breathing related sleep
problems and fewer hours of sleep related most often to problems with perceptual tasks.
The results indicate that quality of sleep – especially sleep duration – may be related to
problems with day-time cognitive and adaptive functioning in children with autism and
PDD-NOS. However, future research must be conducted to further understand these
relationships.
! 2012 Elsevier Ltd. All rights reserved.

1. Introduction

In 1964, 17-year-old Robert Gardner broke the world record for sleep deprivation by staying awake for 264 h without the
aid of stimulants (Ross, 1965). This lack of sleep greatly impaired Mr. Gardner’s ability to function. Gardner began to have
trouble focusing his eyes by the second day of wakefulness. On day three, he experienced mood changes, nausea, and
difficulty saying tongue twisters. In addition to his irritability, on the fourth day, Gardner experienced cognitive problems
including difficulty concentrating and lapses in memory. Hallucinations and delusions followed, including mistaking a street
sign for a person and believing that he was a famous football player being berated by fans. Throughout the rest of his
marathon period of wakefulness, Gardner continued to experience these symptoms in addition to fragmented thinking,
slurred speech, and blurred vision.
Similarly, sleep disruption has been shown to impair typically developing (TD) children’s and adolescents’ day-time
functioning. Schreck (2010) reviewed the diagnostic relationships of sleep problems to day-time behavior for children and
adolescents finding significant relationships. Research has supported Schreck’s (2010) review, indicating that young children
who sleep fewer hours per night continually experience more difficulty with perceptual tasks and cognitive ability measures

* Corresponding author at: Penn State Harrisburg, 777 West Harrisburg Pike, W311 Olmsted Building, Middletown, PA 17057-4898, USA.
Tel.: +1 717 948 6048.
E-mail addresses: mat5386@psu.edu (M.A. Taylor), kas24@psu.edu (K.A. Schreck), mulick.1@osu.edu (J.A. Mulick).

0891-4222/$ – see front matter ! 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2012.03.013
M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417 1409

than children who sleep more (Gruber et al., 2010). The impact of sleep deprivation on children’s intellectual functioning also
has been shown to impair their academic performance (Fredriksen, Rhodes, Reddy & Way, 2004; Wolfson & Carskadon, 1998).
In addition to lack of sleep in general, specific sleep problems have been shown to have negative effects on cognitive
functioning and academic performance in TD children and adolescents. For example, TD children diagnosed with or at risk for
sleep-disordered breathing have exhibited more difficulty (a) defining vocabulary words (Suratt et al., 2007); (b) sustaining
attention (Blunden, Lushington, Kennedy, Martin, & Dawson, 2000; Owens, Spirito, Marcotte, McGuinn, & Berkelhammer,
2000; Suratt et al., 2007), (c) planning and problem solving (Karpinski, Scullin, & Montgomery-Downs, 2008), (d) inhibiting
behavior (Karpinski et al., 2008), (e) performing in school (Montgomery-Downs, Jones, Molfese, & Gozal, 2003; Urschitz et al.,
2003), and (f) remembering (Blunden et al., 2000). Like children with sleep disordered breathing, individuals with other sleep
problems (e.g., insomnia) also have experienced difficulties with concentration and memory (Fernandez-Mendoza et al.,
2009). O’Brien (2009) has asserted that sleep problems (e.g., poor sleep hygiene, sleep restriction, circadian rhythm
problems, sleep-disordered breathing, restless legs syndrome, narcolepsy, and insomnia) also have consistently impaired
children’s attention. With the exception of restless leg syndrome, these sleep problems have also been associated with poor
school performance (O’Brien, 2009).
The understanding of the impacts of sleep problems on day-time functioning becomes more vital for children with
developmental disabilities (DD), because they tend to have more sleep problems than TD children (Cotton & Richdale, 2006;
Goodlin-Jones, Tang, Liu, & Anders, 2009; Richdale, Francis, Gavidia-Payne, & Cotton, 2000). The increased amount of sleep
problems for this population in combination with the deficits associated with DD (e.g., cognitive deficits) may result in an
even more significant impact of sleep problems on day-time behavior. For example, Wiggs and Stores (1996) have reported
that children with DD who have experienced more bed-time settling problems, night waking, and early morning waking
have displayed a greater intensity and number of disruptive day-time behaviors than those without sleep disturbances.
Like children with DD in general, children with Autism Spectrum Disorders (ASD) have consistently been diagnosed with
sleep problems (Couturier et al., 2005; Honomichl, Goodlin-Jones, Burnham, Gaylor, & Anders, 2002; Malow, Marzec, et al.,
2006; Polimeni, Richdale, & Francis, 2005; Richdale & Prior, 1995; Souders et al., 2009). In fact, research has suggested that
those with ASD have more sleep problems than TD children and those with other DDs (Allik, Larsson, & Smedje, 2006b;
Giannotti et al., 2008; Krakowiak, Goodlin-Jones, Hertz-Picciotto, Croen, & Hansen, 2008; Miano et al., 2007; Paavonen et al.,
2008; Schreck & Mulick, 2000; Souders et al., 2009; Tani et al., 2003). When compared with TD children, these problems have
resulted in inefficient sleep, such as night waking or lack of sleep (Allik, Larsson, & Smedje, 2008; Bruni et al., 2007; Couturier
et al., 2005; Elia et al., 2000; Giannotti et al., 2008; Goldman et al., 2009, 2011; Krakowiak et al., 2008; Limoges, Mottron,
Bolduc, Berthiaume, & Godbout, 2005; Miano et al., 2007; Øyane & Bjorvatn, 2005; Paavonen et al., 2008; Patzold, Richdale, &
Tonge, 1998; Schreck & Mulick, 2000; Souders et al., 2009; Wiggs & Stores, 2004).
One category of sleep problems common in children with ASD, insomnia, presents as difficulty initiating or maintaining
sleep (see Richdale & Schreck, 2009). Children who have ASD have been known to engage in escape behavior at bedtime in
attempts to avoid having to go to sleep (Allik, Larsson, & Smedje, 2006a; Bruni et al., 2007; Giannotti et al., 2008; Goldman,
Richdale, Clemons, & Malow, in press; Goldman et al., 2009; Paavonen et al., 2008). Even when children go to bed when
asked, they often experience difficulty falling asleep (Allik et al., 2006a, 2006b; Allik et al., 2008; Bruni et al., 2007; Giannotti
et al., 2008; Goldman et al., 2009, in press; Honomichl et al., 2002; Hoshino, Watanabe, Yashima, Kaneko, & Kumashiro,
1984; Limoges et al., 2005; Miano et al., 2007; Paavonen et al., 2008; Patzold et al., 1998; Richdale, 2001; Richdale & Prior,
1995; Segawa, 1985, as cited in Segawa, Katoh, Katoh, & Nomura, 1992; Souders et al., 2009; Takase, Taira, & Sasaki, 1998;
Tani et al., 2003; Wiggs & Stores, 2004; Williams, Sears, & Allard, 2004). Remaining asleep also poses a challenge for this
population, as most research has suggested that children with ASD often wake up during the night or early in the morning
(Allik et al., 2006a, 2006b, 2008; Bruni et al., 2007; Giannotti et al., 2008; Goldman et al., 2009, in press; Honomichl et al.,
2002; Hoshino et al., 1984; Limoges et al., 2005; Miano et al., 2007; Paavonen et al., 2008; Patzold et al., 1998; Richdale, 2001;
Richdale & Prior, 1995; Segawa, 1985 as cited in Segawa et al., 1992; Souders et al., 2009; Takase et al., 1998; Tani et al., 2003;
Wiggs & Stores, 2004; Williams et al., 2004).
In addition to insomnia, children with ASD may experience circadian rhythm sleep disorders (i.e., delays in falling asleep,
waking in a confused state, feeling sleepy during the day, and waking early in the morning). As discussed above, individuals
with ASD often have difficulty maintaining and initiating sleep, suggesting problems establishing appropriate sleep-wake
cycles. Preliminary research has supported this notion (Giannotti et al., 2008; Segawa et al., 1992). Children in this
population have experienced other sleep-quality problems. These sleep-quality problems, such as parasomnias (e.g.,
confusional arousal, bedwetting, sleep walking, sleep terrors, nightmare disorders), sleep movement disorders (e.g., restless
leg, teeth grinding, periodic leg movements, and stereotypic movements), and sleep disordered breathing likely have
contributed to night-waking in ASD (Schreck, in preparation; Schreck & Mulick, 2000). These night waking episodes have
disrupted sleep for children with ASD more so than children who are TD or have other DDs (Couturier et al., 2005; Goldman
et al., 2011; Giannotti et al., 2008; Polimeni et al., 2005; Schreck & Mulick, 2000; Souders et al., 2009).
These types of sleep problems associated with ASD have received considerably more attention from researchers than
clarification of their day-time implications. Therefore, knowledge regarding the influence of sleep problems on cognition and
adaptive functioning in this population has remained limited. Preliminary research has suggested that a history of decreased
sleep duration or poor sleep quality for children with ASD has correlated with nonverbal intelligence deficits (Elia et al.,
2000; Gabriels, Cuccaro, Hill, Ivers, & Goldson, 2005), communication problems (Schreck, Mulick, & Smith, 2004), and
academic performance difficulties (Paavonen, Nieminen-von Wendt, Vanhala, Aronen, & von Wendt, 2003). However, not all
1410 M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417

researchers have discovered a significant relationship between sleep problems and IQ in a sample of children with autism
(Mayes & Calhoun, 2009).
Most of the research discussed above has focused on the influence of sleep problems on cognition and academic
performance. However, it is also important to examine the impact of these problems on children’s ability to function
pragmatically in their natural environment (i.e., adaptive behavior). In addition, some of the findings discussed (e.g.,
impaired academic performance and cognitive ability) may have been at least partially attributable to social and
communication problems inherent in ASD. For example, scores on intelligence tests may have been lower than individuals’
true abilities due to their behavior during the test or inability to take the test. Thus, understanding of the relationship of
adaptive behavior to sleep problems may help to clarify these relationships. To this date, we have been able to locate only one
study that has investigated these effects of sleep problems to adaptive behavior in children with ASD (Krakowiak et al.,
2008). Results of this study have remained equivocal with sleep and adaptive behavior associated, but not particularly for
young children with ASD.
Although only the previous study has specifically evaluated adaptive behavior, sleep-problems research has suggested
links between sleep problems and adaptive behavior skills. For example, a young girl with ASD and sleep apnea showed great
improvement in both sleep and social communication after undergoing a surgical procedure designed to correct disordered
breathing during sleep (Malow, McGrew, Harvey, Henderson, & Stone, 2006). Additionally, Schreck et al. (2004) found that
specific sleep problems predicted increased expression of autism symptoms that would likely affect adaptive behavior.
Specifically, night waking and sensitivity to stimuli in the environment was significantly related to communication
problems, while shorter sleep duration predicted social interaction problems. In another study, children classified as poor
sleepers had greater social interaction problems than good sleepers (Goldman et al., 2011), suggesting a relationship
between sleep disruption and adaptive behavior deficits.
Although this research has suggested that sleep problems in autism may be related to these children’s cognitive and
adaptive performance, significantly more research with this population must be conducted to understand the effects of these
sleep problems. In fact, a recent special interest group meeting at the 2011 International Meeting for Autism Research
(IMFAR) concluded that while sleep disturbances remain prevalent and significant in ASD, more research must be conducted
to determine the impact of sleep disturbance on cognition and daily functioning in this population (Baker, 2011). The
purpose of this study was to provide the initial steps toward meeting the IMFAR special interest group recommendations by
delineating the relationships between the sleep behavior in children with ASD and subsequent day-time cognitive and
adaptive performance.

2. Method

2.1. Participants

Participant data was collected from a database of diagnostic testing for children seen at a pediatric hospital-affiliated
disability assessment clinic. Children with a primary diagnosis (by a licensed psychologist) of Autism or PDD-NOS at the
clinic were initially identified (N = 455). Participants also had scores in the files for the Behavioral Evaluation of Disorders of
Sleep (BEDS; Schreck, 1998; Schreck, Mulick, & Rojahn, 2003). After eliminating participants according to this criterion, the
participant numbers reduced to 335. Of the remaining 335 participants, autism was the most common diagnosis (n = 219),
followed by PDD-NOS (n = 116).
The final sample of children ranged in age from 1 to 18-years-old (M = 5.15 years; SD = 3.27). The majority were male
(male: n = 296; female: n = 39), white (n = 240), and cognitively delayed. Full scale IQ scores were obtained for 300
participants and ranged from standard scores of 8 to 128, with a mean of 61.55 (SD = 19.05). Mean verbal IQ score for the
sample was 67.09 (n = 106; SD = 18.31; range = 40–106), while the mean performance IQ score was 76.33 (n = 222;
SD = 23.08; range = 32–145).
General adaptive behavior domain scores (i.e., adaptive behavior composite, socialization, communication, daily living
skills, and motor skills) were also collected based on the results of two adaptive behavior measures—the Scales of
Independent Behavior-Revised (SIB-R; Bruininks, Woodcock, Weatherman, & Hill, 1997) and the Vineland Adaptive Behavior
Scale (VABS; Sparrow, Balla, & Cicchetti, 1984). Scores for the adaptive measures included: (a) adaptive behavior composite
(n = 247; M = 57.25; SD = 27.15; range = 0–124); (b) socialization (n = 241; M = 62.78; SD = 25.61; range = 0–113); (c)
communication (n = 235; M = 53.99; SD = 26.25; range = 0–113); (d) motor (n = 236; M = 76.22; SD = 28.31; range = 0–143);
(e) daily living skills (n = 241; M = 60.77; SD = 23.32; range = 0–124).
Formal diagnoses of sleep problems from medical professionals were recorded in official psychological reports for 30
participants. In the psychological reports, the majority of these diagnoses were listed vaguely as ‘‘sleep problems’’ (n = 18),
‘‘dyssomnias’’ (n = 3), and ‘‘rule-out apnea’’ (n = 5). The psychology assessment reports also stated parental report of one or
more of their children’s sleep problems (n = 115), including settling and sleep onset problems (n = 53), night waking (n = 46),
co-sleeping (n = 19), and snoring or apnea (n = 10). Additional parent-report measures (i.e., BEDS responses) estimated that
18% of parents described their child as having a sleep problem. While 94 participants were reportedly taking medication
at the time of evaluation, none were excluded from the present study, as an initial ANOVA (medication status ! total
BEDS score) indicated that children on medications continued to have more sleep problems than children not on medications
[F(1, 275) = 8.52, p < .004].
M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417 1411

2.2. Materials

2.2.1. Intelligence
Several different intelligence tests were used due to differences in the age of the children, language, and cognitive ability.
However, due to the adequate concurrent validity of the tests (see Sattler, 2001), generalized intelligence scores were
recorded from the equivalent domains for the test each individual was administered (e.g., either a WISC-IV; Wechsler, 2003)
full scale score or WPPSI full scale score (Wechsler, 2002) was recorded under a generic variable named ‘‘full scale IQ’’).
Verbal and performance IQ scores were also recorded. See Table 1 for tests and the domains used for each of the general score
designations (i.e., verbal, performance, and full scale IQ). The most commonly administered intelligence tests included the
Leiter International Performance Scale-Revised (Leiter-R; Roid & Miller, 1997) (n = 142), Developmental Profile II (DP-II;
Alpern, Boll, & Shearer, 2000) (n = 132), Mullen Early Learning Scales (Mullen, 1995) (n = 102), and Stanford-Binet
Intelligence Scales, Fifth Edition (Roid, 2003) (n = 60). In cases where multiple tests were administered to a child producing
more than one full scale IQ score, the lowest score was used in the analysis because it would provide the most stringent
estimate of the child’s functioning. In addition, individuals who were administered only nonverbal measures of intelligence
such as the Leiter obtained only nonverbal IQ scores.

2.2.2. Adaptive behavior


Two separate measures of adaptive functioning were administered to children in compiling the database for the study, (a)
SIB-R (Bruininks et al., 1997) (n = 215) and (b) VABS (Sparrow et al., 1984) (n = 38). One or the other measure was usually
administered to children included in this study. General adaptive behavior composite, socialization, communication, daily
living skills, and motor skills scores were recorded from the measure of adaptive functioning that each individual had been
administered. Equivalent domains for the adaptive behavior scales were determined using Wells, Condillac, Perry, and Factor
(2009) (see Table 2 for VABS and SIB-R domains used for each adaptive behavior score as was done with the IQ tests). If
individuals were administered both measures, the lowest scores were included in the analysis.

2.2.2.1. Scales of independent behavior-revised. The SIB-R (Bruininks et al., 1997), a measure of functional independence and
adaptive functioning in school, home, employment, and community settings, can be used with any age group with or without
DD. It assesses areas of adaptive functioning in domains including broad independence, social interaction and
communication skills, personal living skills, motor skills, and community living skills.

2.2.2.2. Vineland adaptive behavior scales. The VABS (Sparrow et al., 1984) assesses adaptive behavior in children and
adolescents from birth to 18-years-old along with low-functioning adults. In addition to an adaptive behavior composite
score, the test yields scores in four behavior domains including communication, daily living skills, socialization, and motor
skills. Normative data was gathered using a sample of 3000 participants aged from birth through 18 years, 11 months.

Table 1
Intelligence tests and domains used for general intelligence scores.

Test Age range FSIQ VIQ PIQ


a
BSID-III Birth–42 months Cognitive Scale Language Scale N/A
DP-IIb Birth–9.5 years Cognitive Language N/A
DP-IIIc Birth–12 years Cognitive Communication N/A
DASd 2.6–17.11 years General Conceptual Ability Verbal Nonverbal
K-ABCe 2.6–12.6 years Mental Processing Composite N/A Nonverbal
Leiter-Rf 2–21 years N/A N/A Leiter Full Scale
Mulleng Birth–68 months Early Learning Composite Expressive Language N/A
Stanford-Binet-Vh 2–89 years Full Scale IQ Verbal IQ Performance IQ
S-BITi 6–20 years N/A N/A Nonverbal IQ
WASIj 6–89 years Full Scale IQ Verbal IQ Performance IQ
WISC-IIIk 6–16.11 years Full Scale IQ Verbal IQ Performance IQ
WISC-IVl 6–16.11 years Full Scale IQ Verbal Comprehension Index Performance IQ
WPPSI-IIIm 2.6–7.3 years Full Scale IQ Verbal IQ Performance IQ
a
BSID-II = Bayley Scales of Infant Development-Third Edition (Bayley, 2005).
b
DP-II = Developmental Profile II (Alpern et al., 2000).
c
DP-III = Developmental Profile III (Alpern, 2007).
d
DAS = Differential Ability Scales (Elliott, 1990).
e
K-ABC = Kaufman Assessment Battery for Children (Kaufman & Kaufman, 1983).
f
Leiter-R = Leiter International Performance Scale-Revised (Roid & Miller, 1997).
g
Mullen = Mullen Scales of Early Learning (Mullen, 1995).
h
Stanford-Binet-V = Stanford-Binet Intelligence Scales, Fifth Edition (Roid, 2003).
i
S-BIT = Stoelting Brief Nonverbal Intelligence Test (Roid & Miller, 1999).
j
WASI = Wechsler Abbreviated Scale of Intelligence (Wechsler, 1999).
k
WISC-III = Wechsler Intelligence Scale for Children-Third Edition (Wechsler, 1991).
l
WISC-IV = Wechsler Intelligence Scale for Children-Fourth Edition (Wechsler, 2003).
m
WPPSI-III = Wechsler Preschool and Primary Scale of Intelligence-Third Edition (Wechsler, 2002).
1412 M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417

Table 2
Adaptive behavior tests and domains used for corresponding general adaptive behavior scores.

Test Age range Adaptive behavior composite Socialization Communication Daily living skills Motor skills
a
VABS Birth–18 Adaptive behavior composite Socialization Communication Daily living skills Motor skills
SIB-Rb Infancy–80+ Broad independence Community Social interaction and Personal living skills Motor skills
living skills communication skills
a
VABS = Vineland Adaptive Behavior Scales (Sparrow et al., 1984).
b
SIB-R = Scales of Independent Behavior-Revised (Bruininks et al., 1997).

2.2.3. Sleep

2.2.3.1. Behavioral evaluation of disorders of sleep. The BEDS (Schreck, 1998; Schreck et al., 2003), a parent-report questionnaire
based on the International Classification of Sleep Disorders (AASM: American Academy of Sleep Medicine, 1991), was
developed for use with children (5–12 years). The BEDS consists of 107 items on a five-point Likert scale (0 = never; 1 = almost
never; 2 = sometimes; 3 = almost always; 4 = always) measuring aspects of sleep quality. In addition to questions regarding
specific sleep behaviors, four additional questions addressed general aspects of children’s sleep, including hours slept per night,
hours slept in the last 24 h, hours napped during the day, and whether or not the parent perceives their child as having a sleep
problem. Parents’ answers on the BEDS reflect their child’s sleep behavior over the last 6 months.
Exploratory factor analyses on the original sample (N = 307) and confirmatory factor analyses of the 107 Likert scale items
resulted in four factors based on 22 of the items. The four scales of the BEDS include Expressive Sleep Disturbances (9 items
measuring behaviors, such as screaming during the night), Sensitivity to the environment (7 items measuring behaviors such
as night-time fears and environmental discomfort), Disoriented Awakenings (4 items measuring behavior such as slow
reaction times when waking), and Apnea (2 items measuring breathing difficulty during sleep). The four factors and BEDS
total score have adequate internal consistency, and the test distinguishes between children with sleeping problems and
those without (Schreck, Mulick, & Rojahn, 2005). See Schreck et al. (2003) for more information on the development of the
BEDS.

2.3. Procedures

Before collecting data, the Internal Review Board at Pennsylvania State University reviewed and approved the study. In
constructing the database, we accessed patient files from 1999 to 2008 from a pediatric hospital-affiliated assessment clinic.
The second author and graduate fellows at the pediatric hospital-affiliated assessment clinic constructed the database by
recording de-identified demographic information (e.g., date of birth, gender, race, medications, past medical history, etc.),
test scores on standardized diagnostic tests (e.g., adaptive behavior, intelligence, etc.), measures of sleep problems (BEDS),
and diagnostic decisions (e.g., diagnoses of autism spectrum disorders, diagnoses of sleep disorders).

2.4. Data analysis

All analyses were computed using the Statistical Package for Social Sciences (SPSS, 2008). Before analyzing the
relationship between sleep and cognitive ability and adaptive functioning, Pearson correlation analyses were conducted to
determine if the BEDS items measuring amount of sleep (i.e., hours slept per night, hours slept in last 24 h, and hours spent
napping during the day), the BEDS Factors (i.e., Expressive Sleep Disturbances, Sensitivity to the Environment, Disoriented
Awakenings, and Apnea), and the BEDS Total score were related to participants’ adaptive behavior (adaptive behavior
composite, socialization, communication, motor skills, and daily living skills) or IQ domains (full scale, verbal, and
performance). These analyses indicated that BEDS items were related to both IQ and adaptive behavior (see Tables 3 and 4 for
the bivariate relationships among the variables).
Because the BEDS items scores were significantly associated with IQ and adaptive behavior scores, we analyzed BEDS
items to determine which BEDS factors and items predicted cognitive and adaptive functioning. Stepwise multiple linear
regression analyses were conducted to determine if BEDS factor scores, BEDS total score, and the three additional BEDS items
(hours of sleep per night, hours slept in the last 24 h, and hours napped per day) predicted intelligence scores (i.e., full scale
IQ, verbal IQ, and performance IQ) and adaptive behavior scores (i.e., adaptive behavior composite, social skills,
communication skills, daily living skills, and motor skills). These analyses were conducted separately for each of the
intelligence scores and adaptive behavior scores.

3. Results

3.1. Intelligence

Stepwise multiple regression analyses indicated that children’s IQ scores across all IQ domains (i.e., verbal, performance,
and full scale) were related to their sleep quantity and sleep quality. We analyzed the predictive ability of BEDS factors (i.e.,
M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417 1413

Table 3
Bivariate correlations for BEDS factors and IQ scores.

Factors IQ BEDS
a b c
Full scale Verbal Perf Hours/nightd Hours/24e Hours Parent BEDS ESDi Sens Dis Apneal
napsf reptg totalh envj awakek

Full scalea – .93** .74** .33** .27** .12 .07 ".14* ".06 ".02 .03 ".11
Verbalb – .76** .38** .29** .22* .07 ".06 .05 ".02 .15 ".20
Perfc – .26** .23** .17* .09 ".11 ".02 ".07 .04 ".18**
Hours/nightd – .58** .14* ".23** ".38** ".19 ".37** ".16** ".06
Hours/24e – .38** ".20** ".31** ".18** ".25** ".09 ".09
Hours napsf – ".08 ".05 ".03 ".11 .01 ".04
Parent reptg – .33** .23** .26** .26** .08
BEDS totalh – .59** .71** .58** .16**
ESDi – .42** .30** .08
Sens envj – .31** .08
Dis awakek – .12*
Apneal –
a
Full scale = full scale IQ.
b
Verbal = verbal IQ.
c
Perf = performance IQ.
d
Hours/night = hours slept per night.
e
Hours/24 = hours slept in the last 24 h.
f
Hours naps = hours napped per day.
g
Parent rept = parent perception of whether their child has a sleep problem.
h
BEDS Total = BEDS Total Score.
i
ESD = BEDS Expressive Sleep Disturbances.
j
Sens env = BEDS Sensitivity to Environment.
k
Dis awake = BEDS Disoriented Awakening.
l
Apnea = BEDS Sleep Apnea.
* p < .05.
** p < .01.

Table 4
Bivariate correlations for BEDS factors and Adaptive Behavior Scores.

Factors Adaptive behavior BEDS


a b c d e
ABC Soc Com DLS Motor Hours/nightf Hours/24g Hours Parent BEDS ESDk Sens Dis Apnea n

napsh repti totj envl awakem

ABCa – .90** .85** .85** .82** .36** .30** .25** ".05 ".21** ".16* ".20** ".18** ".12
Socb – .76** .70** .69** .36** .32** .26** ".02 ".17* ".12 ".11 ".11 ".11
Comc – .70** .52** .28** .21** .16* ".07 ".16* ".22** .02 ".07 ".03
DLSd – .71** .30** .21** .13 ".08 ".17* ".15* ".15* ".16* ".06
Motore – .33** .23** .26** ".06 ".14* ".10 ".21** ".24** ".11
Hours/nightf – .58** .14* ".23** ".38** ".19 ".37** ".16** ".06
Hours/24g – .38** ".20** ".31** ".18** ".25** ".09 ".09
Hours napsh – ".08 ".05 ".03 ".11 .01 ".04
Parent repti – .33** .23** .26** .26** .08
BEDS Totalj – .59** .71** .58** .16**
ESDk – .42** .30** .08
Sens envl – .31** .08
Dis awakem – .12*
Apnean –
a
ABC = adaptive behavior composite.
b
Soc = socialization.
c
Com = communication.
d
DLS = daily living skills.
e
Motor = motor skills.
f
Hours/night = hours slept per night.
g
Hours/24 = hours slept in the last 24 h.
h
Hours naps = hours napped during day.
i
Parent rept = parent perception of whether their child has a sleep problem.
j
BEDS Total = BEDS Total Score.
k
ESD = BEDS Expressive Sleep Disturbances.
l
Sens env = BEDS Sensitivity to Environment.
m
Dis awake = BEDS Disoriented Awakening.
n
Apnea = BEDS Sleep Apnea.
* p < .05.
** p < .01.
1414 M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417

Expressive Sleep Disturbances, Sensitivity to the Environment, Disoriented Awakenings, and Apnea), BEDS total, and number
of hours slept (i.e., hours slept per night, hours slept in the last 24 h, hours napped per day) for full scale IQ, verbal IQ, and
performance IQ scores. Analyses of the relationships between sleep variables and IQ revealed that children who slept more
hours per night had higher full scale and verbal IQ scores (full scale IQ: R2 = .11; p < .01; verbal IQ: R2 = .15; p < .01).
Additionally, hours slept per night in combination with reports of apnea (BEDS Sleep Apnea factor) predicted performance IQ
scores (R2 = .10; p < .01). Fewer hours slept per night coupled with a higher frequency of parent-reported symptoms of apnea
was strongly associated with decreased ability to perform nonverbal tasks.

3.2. Adaptive behavior

Stepwise multiple regression analyses were also conducted to determine which BEDS factors (i.e., Expressive Sleep
Disturbances, Sensitivity to the Environment, Disoriented Awakenings, and Apnea), BEDS total score, and questions
addressing number of hours slept (i.e., hours slept per night, hours slept in the last 24 h, hours napped per day) predicted
specific adaptive behavior domain scores. Parental report of more hours slept per night singularly predicted better daily
living skills (R2 = .09; p < .01). The combination of more total hours slept per night and hours napped during the day
significantly predicted better Adaptive Behavior Composite (R2 = .18; p < .01); motor skills scores (R2 = .16; p < .01), and
socialization scores (R2 = .17; p < .01). More hours slept per night in combination with fewer episodes of night waking with
screaming (BEDS Expressive Sleep Disturbance score) and more sensitivity to sleeping environment disturbances (BEDS
Sensitivity to the Environment scores) significantly predicted children’s higher communication scores (R2 = .14; p < .01). In
other words, children who slept more on average per night without waking showed better developed communication skills.
See Table 5 for stepwise multiple regression.

Table 5
Stepwise multiple regression predicting IQ & adaptive behavior.

Scale scores Predictors

Intelligence Scale Scores


Full scale
F 28.78**
R2 .11
Predictors (1) Hours slept per night
Verbal
F 14.29**
R2 .15
Predictors (1) Hours slept per night
Performance
F 8.54**
R2 .10
Predictors (1) Hours slept per night
(2) Sleep Apnea
General Adaptive Behavior
Adaptive behavior composite
F 19.57
R2 .18
Predictors (1) Hours slept per night
(2) Hours napped
Socialization
F 17.57
R2 .17
Predictors (1) Hours slept per night
(2) Hours napped
Communication
F 9.31
R2 .14
Predictors (1) Hours slept per night
(2) Expressive Sleep Disturbances
(3) Sensitivity to Environment
Daily living skills
F 16.34
R2 .09
Predictors (1) Hours slept per night
Motor skills
F 16.65
R2 .16
Predictors (1) Hours slept per night
(2) Hours napped
*
p < .05.
** p < .01.
M.A. Taylor et al. / Research in Developmental Disabilities 33 (2012) 1408–1417 1415

4. Discussion

By reporting these relationships among specific cognitive skills, adaptive behavior, and sleep factors for children with
ASD, this study took the first step toward meeting the recommendations made by the IMFAR special interest group on sleep.
In this study, children with ASD who slept fewer hours on average per night were more likely to perform worse overall with
respect to intelligence and verbal skills than children who slept longer. This result corroborated Gruber et al.’s (2010)
observations, but was in direct contrast to previous research indicating no relationship or an inverse relationship between
sleep quantity and IQ (Mayes & Calhoun, 2009).
We also determined that sleep disruption impaired more than just overall cognitive ability. Perceptual and verbal skills
also declined with disrupted sleep. For example, children with ASD who slept for fewer hours and suffered from parent-
reported nighttime breathing problems showed less ability to complete nonverbal tasks (e.g., puzzles, mazes, block building,
etc.). Similar relationships among apnea and cognitive ability (i.e., memory, attention, vocabulary, and executive
functioning) have been established for TD children (Blunden et al., 2000; Karpinski et al., 2008; Owens et al., 2000; Suratt
et al., 2007). For children with ASD, only relationships existed between apnea treatment and improvement in social
communication skills and increases in autism symptoms (Malow, McGrew, et al., 2006; Schreck et al., 2004). This study may
be the first to indicate a possible relationship between apnea and perceptual tasks for children with ASD.
The difficulties with cognitive skills (i.e., perceptual and verbal ability) may also generalize to adaptive behavior
problems. Although the one other study evaluating adaptive behavior for young children with ASD did not report a
significant relationship between adaptive behavior and sleep disruption (Krakowiak et al., 2008), our results suggested that a
relationship may exist between sleep duration, sleep problems, and adaptive behavior deficits. Specifically, we found that
children who slept less on average per night displayed more deficits in skills needed to complete typical daily living tasks
(e.g., hygiene, eating, toileting, etc.). To our knowledge, this is the first study to examine the relationship of sleep disturbance
to the ability to complete daily living activities. The children’s difficulties with completing daily living activities, such as
pouring water, brushing hair, may be due to motor difficulties, as those children who slept less on average both at night and
during the day had more difficulty with all adaptive behavior tasks, especially motor and social skills.
Finally, children who slept more on average per night without waking and were less bothered by environmental stimuli
within their sleeping environment (e.g., noises, lights, uncomfortable beds, etc.) showed better ability to effectively
communicate with others during the day. This result remains consistent with Schreck et al. (2004), who reported that
children who awoke more at night and were more sensitive to the night time environmental stimuli showed more
communication patterns during the day typically found with children with an ASD (e.g., echolalia).
This study’s attempt to delineate specific cognitive skills and adaptive behavior influenced by sleep deprivation and
disruption contradicted Krakowiak et al.’s (2008) general evaluation of adaptive behavior for young children with autism.
Our inclusion of specific cognitive and adaptive domains provides a significant stepping stone for future research. Future
research should attempt to correct limitations in this study, such as not verifying parent report of sleep problems and varying
assessment materials. Future researchers also must elaborate on these findings. Specific diagnostic sleep disorders must be
evaluated in conjunction with these types of specific cognitive and adaptive skills. Further analysis of specific motoric, social,
communicative, and daily living skill deficits could be related to verified sleep disorders. Performance on tasks that appear to
be impaired by sleep disruption before and after successful treatment of the sleep disorder will provide the best test of a
causal relation between sleep disruption and the impaired performances suggested by this study.
As these relationships develop among sleep disorders and cognitive ability and adaptive behavior, clinicians and medical
practitioners must be educated on the importance of identifying and treating sleep within the ASD population. With
treatment of sleep problems, children’s day-time functioning improves (Johnson, Giannotti, & Cortesi, 2009; Malow,
McGrew, et al., 2006; Minde, Faucon, & Falkner, 1994; Rooney, Alfano, Walsh, & Parr, 2011). If professionals do not identify
sleep problems as a possible contributor to day-time deficits, treatments for skill development and implementation may be
incomplete and insufficient.

Acknowledgements

The authors wish to express appreciation for their hospitality to the staff and postdoctoral fellows at The Nationwide
Children’s Hospital. Without access to their data, cooperation, and inclusion of sleep assessment in psychological
evaluations, this study would not have been possible. The authors would also like to thank Eric Butter for his assistance with
locating research assistants to enter data. Finally, thank you to Lindsay Knapp and Preeti Kumar for their assistance in
preparation and editing of the manuscript.

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