Research in Autism Spectrum Disorders 6 (2012) 1337–1344

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Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Review

Methods for assessing sleep in children with autism spectrum disorders:

A review
Danelle Hodge *, Andrea M.N. Parnell, Charles D. Hoffman, Dwight P. Sweeney
California State University, San Bernardino, CA, United States

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

Article history: A literature review completed by Bauer and Blunden (2008) determined that compared to
Received 28 February 2012 objective measures, subjective assessments of sleep for typically developing children (e.g.,
Received in revised form 23 May 2012 parental reports) were of limited utility. No comparable literature review has been
Accepted 24 May 2012 undertaken to determine whether subjective measures are appropriate for assessing sleep
in children with autism spectrum disorders (ASD). Such a review is necessary as children
Keywords: with ASD have more sleep problems than typically developing children and children’s
Autism sleep difficulties can negatively affect the child and other family members. It is, therefore,
Sleep
important to have measures of sleep for children with ASD that can reliably detect sleep
Polysomnography
problems and track improvements in sleep. This literature review described frequently
Actigraphy
Videosomnography
used measures of children’s sleep and evaluated their utility for assessing sleep in children
with ASD. It was determined that, with the exception of sleep latency, parents’ reports of
children’s sleep are not consistently associated with objective measures of children’s
sleep. This was true for single-item parent-reports and for a widely used multi-item
parent-report measure of children’s sleep. Limitations of objective sleep measures (e.g.,
polysomnography, actigraphy), including the inability of children with ASD to tolerate
such methods, are described.
ß 2012 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1338
2. Objective measures of children’s sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1338
2.1. Polysomnography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1338
2.2. Actigraphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1339
2.3. Videosomnography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1339
3. Subjective measures of children’s sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
3.1. Sleep diaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
3.2. Single-item responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1340
3.3. Children’s sleep habits questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1341
4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1342
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1342

* Corresponding author at: Department of Psychology, California State University, San Bernardino, 5500 University Parkway, San Bernardino, CA 92407-2397,
United States. Tel.: +1 909 537 3566; fax: +1 909 537 7003.
E-mail address: dhodge@csusb.edu (D. Hodge).

1750-9467/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.rasd.2012.05.009
1338 D. Hodge et al. / Research in Autism Spectrum Disorders 6 (2012) 1337–1344

1. Introduction

There is consensus that the majority of children with autism spectrum disorders (ASD) also have sleep difficulties (Arbelle
& Ben-Zion, 2001; Johnson, 1996; Richdale & Schreck, 2009; Richdale, 1999, 2001; Stores & Wiggs, 1998). Although not part
of the diagnostic criteria for ASD, the co-occurrence of ASD and sleep problems is sufficiently common to suggest that sleep
difficulties may be a characteristic of the ASD phenotype (Limoges, Mottron, Bolduc, Berthiaume, & Godbout, 2005; Richdale
& Prior, 1995). Further, research reports significant correlations between the sleep problems of children with autism and the
severity of autistic symptomology (Hoffman et al., 2005; Schreck, Mulick, & Smith, 2004). Significant consequences have
been associated with sleep difficulties. For instance, it has been demonstrated that children’s sleep problems affect working
memory (Steenari, Vuontela, & Paavonen, 2003), increase the risk for physical injury (Owens, Fernando, & Mc Guinn, 2005),
and can lower school achievement and motivation (Blunden, Lushington, & Kennedy, 2001; Gozal, 1998; Meijer & van den
Wittenboer, 2004).
The impacts of children’s sleep problems are not limited to the child. The sleep problems of children with ASD have been
associated with impaired parental sleep (Lopez-Wagner, Hoffman, Sweeney, Hodge, & Gilliam, 2008), minor parental
psychopathology (Shang, Gau, & Soong, 2006) and parental stress (Becker, Chang, Kemeshima, & Bloch, 1991; Doo & Wing,
2006; Hoffman et al., 2008; Kataria, Swanson, & Trevathan, 1987; Norton & Drew, 1994; Patzold, Richdale, & Tonge, 1998;
Scott & Richards, 1990). Likewise, improvements in children’s sleep are associated with improvements in parents’ sleep
(Robinson & Richdale, 2004; Wiggs & Stores, 2001), psychological well-being (Adams & Rickert, 1989; Durand & Mindell,
1990) and stress (Wiggs & Stores, 2001).
Given that children with ASD struggle with sleep difficulties that can affect the child and other family members, it is
important to have valid means for assessing sleep in these children. Further, to understand the nature of children’s sleep and
plan effective interventions for sleep difficulties, it is important to have measures of sleep that can reliably detect sleep
problems and track improvements in sleep. However, assessing the sleep of children with ASD presents unique methodological
challenges that have not been fully addressed by researchers. The goal of this literature review was, therefore, to describe
frequently used measures of children’s sleep and to evaluate their utility for assessing sleep in children with ASD.
Bauer and Blunden (2008) reviewed research published after 1992 and assessed the validity of subjective reports of sleep
for typically developing children. The authors concluded that subjective methods are valid for screening, but are not reliable
indicators of the time taken to fall asleep (i.e., sleep latency), the frequency or duration of waking after sleep onset (WASO), or
actual duration of sleep. Because the sleep of children with ASD differs from that of typically developing children, it is not
clear whether the conclusions of the Bauer and Blunden review will hold for children with ASD. Despite the fact that a
number of researchers have questioned the ability of sleep measures to assess children with ASD (e.g., Goodlin-Jones, Tang,
Liu, & Anders, 2008b; Goodlin-Jones et al., 2009; Hering, Epstein, Elroy, Iancu, & Zelnik, 1999; Meltzer, 2011; Oyane &
Bjorvatn, 2005; Sitnick, Goodlin-Jones, & Anders, 2008; Wiggs, Montgomery, & Stores, 2005; Wiggs & Stores, 2004), no one
has systematically addressed the issue.
In undertaking this project, we utilized a two-stage review process. In the first stage, a literature search for scholarly (peer
reviewed) journals was conducted via EBSCOhost utilizing the search terms of children, sleep, autism spectrum disorder.
This process yielded 176 articles. In the second-stage, a graduate research assistant reviewed each article to determine
whether it provided information on the rates or types of sleep problems experienced by children with ASD. Fifty-two articles
met these criteria. Of these 52 articles, 11 presented information that allowed for a comparison across two or more methods
of assessing sleep.

2. Objective measures of children’s sleep

2.1. Polysomnography

Polysomnography (PSG) is the gold standard for assessing sleep. PSG provides information on sleep stages and the
physiologic activities that occur during sleep (e.g., eye movements, muscle activity, brainwave activity, oxygen saturation
levels). PSG can identify narcolepsy, sleep paralysis, apnea, hallucinations, and sleep-related problems that are not
detectable via other methods. Because PSG requires the application of sensors and must be conducted overnight in a
laboratory, children with ASD are often unable to tolerate the procedure (Arbelle & Ben-Zion, 2001). Due to the highly
selective nature of the subpopulation of children with ASD who can be assessed with PSG, studies using this form of
assessment suffer from small sample size and limited generalizability (e.g., Diomedi et al., 1999; Elia et al., 2000; Thirumalai,
Shubin, & Robinson, 2002).
The optimal number of nights for PSG recordings for children is unclear. In order to avoid a first-night effect (Le et al., 2001;
Toussaint et al., 1995), during which children’s sleep may be atypical due to the novelty and stress of their surroundings,
research employing children with ASD has examined night-two PSG data after a first night of adaptation (Miano et al., 2007).
Other researchers have suggested a catch up effect in which night-two data for children with ASD may be atypical because
children are catching up on missed sleep caused by anxiety associated with the first night of PSG recording (Malow et al.,
2006). It has been proposed that three nights of PSG may be needed to capture children’s typical sleep patterns (Malow et al.,
2006). In our literature searches, we did not identify any studies in which PSG data were gathered on children with ASD for
three or more nights. Therefore, studies utilizing PSG are not reviewed in detail. It appears that studies using PSG produce
 D. Hodge et al. / Research in Autism Spectrum Disorders 6 (2012) 1337–1344 1339

objective data on sleep patterns and sleep quality; however, these data may not accurately reflect the sleep children with
ASD typically experience in their own homes.

2.2. Actigraphy

Actigraphy is an objective measure of sleep that is less invasive than PSG and can be conducted in the home. By
monitoring nighttime movement of the limbs, actigraphy estimates sleep–wake cycles. This procedure requires that a small
watch-like device (i.e., an actigraph) be worn. The most appropriate placement of the actigraph for recording sleep is unclear,
but it is usually placed on the child’s wrist or ankle (Acebo et al., 2005; Littner et al., 2003; Sadeh, 1996; Sadeh & Acebo, 2002).
Based on the pattern and intensity of movements recorded by the actigraph, a computer analysis is used to infer sleep and
wake states (Sadeh, Acebo, Seifer, Ayturs, & Carksadon, 1995a). It has been suggested that actigraphic data be collected for at
least five nights (Acebo et al., 1999). No standardized procedure has been adopted regarding which brand of actigraph or
which scoring algorithm is optimal for assessing sleep in children with ASD. Typically, the algorithms used in actigraphy
have not been validated against PSG (Sadeh & Acebo, 2002). Moreover, evidence indicates that different algorithms for
actigraphy should to be used at different ages (Sadeh, Hauri, Kripke, & Lavie, 1995b; So, Buckley, Adamson, & Horne, 2005).
For these reasons, it is recommended that researchers employing actigraphy become familiar with the scientific literature
before determining their research protocol (Sadeh & Acebo, 2002) and, when publishing, report detailed information
indicating the specific actigraph and algorithm used in the study (Littner et al., 2003).
Because it relies on movement to identify sleep–wake patterns, the ability of actigraphy to detect WASO has also been a
concern (Ancoli-Israel et al., 2003; Pollak, Tryon, Nagaraja, & Dzwonczyk, 2001; Sitnick et al., 2008; So et al., 2005; Tryon,
2004). Lying awake quietly, termed contented sleeplessness, has been reported by parents in their children with ASD (Wiggs &
Stores, 2004) and in the laboratory where children with ASD were observed to lie awake and perseverate on a topic,
sometimes for hours (Malow et al., 2006). Research has shown that, compared to PSG, actigraphy accurately detected sleep
92% of the time, but detected wakefulness only 48% of the time (Kushida et al., 2001). This discrepancy was attributed
primarily to actigraphy’s inability to detect wakefulness in participants who were lying awake quietly. Given that they are
prone to contented sleeplessness, actigraphy may significantly underestimate the frequency and duration of WASO in
children with ASD.
The inability of actigraphy to detect WASO is not limited to instances of contented sleeplessness. In research that included
children with autism, children with developmental delays, and typically developing children, it was reported that when
children were observed on video to sit up and look around, actigraphy recorded the instance as awaking only 27% of the time
(Sitnick et al., 2008). Thus, actigraphy may overestimate the total amount of sleep and sleep efficiency (i.e., amount of sleep
as percent of the time in bed). Conversely, actigraphy may also underestimate sleep time. Sleep can be misidentified as
wakefulness when it entails movement, such as when a child is sleeping in a vehicle or being rocked by a parent (Sadeh,
Sharkey, & Carskadon, 1994).
Though less invasive than PSG, studies have noted that between 10% and 33% of children with ASD are unable to tolerate
actigraphy (Hering et al., 1999; Oyane & Bjorvatn, 2005; Wiggs & Stores, 2004). For instance, Hering et al. (1999), report that,
after simulating actigraphy in order to desensitize children, 18% of participants were still unable to tolerate the actual
actigraph for the length of the study. Souders et al. (2009) present an alternative methodology. After conducting a pilot study
with typically developing children demonstrating that an actigraph placed in a hidden pocket in the upper arm-sleeve of
snug-fitting pajamas was as accurate as placing the actigraph on the child’s wrist, the method was employed in their
research. Souders et al. report that only two children, about 3% of their ASD sample, were unable to tolerate the actigraph. To
date this technique has not been systematically applied; nonetheless it may offer promise for increasing the numbers of
children with ASD who can be assessed via actigraphy.
Actigraphy offers a means of objectively assessing the sleep of children with ASD who cannot tolerate assessment via PSG.
However, researchers need to be mindful that a small, but not insignificant, number of children are unable to tolerate even
the fairly non-invasive placement of the actigraph on a wrist or ankle. Further, actigraphy’s relative insensitivity for
identifying WASO may compromise assessments of total sleep time and sleep efficiency. Therefore, the most appropriate use
of actigraphy is for assessing sleep schedule variables (e.g., time taken to fall asleep, time of morning waking).

2.3. Videosomnography

Videosomnography is an objective measure of sleep in which a portable time-lapse video recording system is placed in
the bedroom (Anders & Sostek, 1976). Sleep–wake states, percentage of time spent sleeping, number of WASO and duration
of WASO can be determined by observers upon reviewing the tapes. Important advantages of videosomnography over PSG
and actigraphy are that videosomnography is well tolerated by children with ASD and, in a sample that included children
with ASD, video recordings successfully identified WASO that were not recorded via actigraphy (Sitnick et al., 2008).
In their study, Sitnick et al. (2008) report that videosomnography and actigraphy were significantly correlated on a
variety of sleep domains (e.g., sleep latency, total sleep time, WASO). The correlations ranged from .26 for number of night
awakenings to .96 for sleep onset time. Conversely, paired t-tests for assessments via actigraphy and videosomnography
indicated significant differences for all domains of sleep that were assessed (i.e., sleep onset time, sleep latency, total sleep
time, morning awakening time, number of WASO, total time of WASO). The authors suggest that differences across the two
1340 D. Hodge et al. / Research in Autism Spectrum Disorders 6 (2012) 1337–1344

methods of assessing sleep were due to methodological limitations associated with actigraphy. That is, videosomnography
was selected as the standard to which actigraphy was compared. This choice was based on the fact that, using multiple raters,
specific aspects of sleep (e.g., WASO) could be reliably identified on video and using actigraphy as the standard would have
necessitated relying on nonverifiable data.
Unfortunately, our review of the literature did not identify any other studies that compared the accuracy of
videosomnography to other methods for assessing sleep. Additionally, videosomnography is limited by the fact that children
may be preoccupied by, distracted by or hide from the camera. Also, as cameras are limited to detecting activity in a
predetermined location (i.e., the child’s bed), they cannot record nighttime behavior that occurs away from the child’s bed.
Nevertheless, because it is well tolerated and is relatively sensitive to WASO, videosomnography, alone or as an adjunct to
actigraphy, may be a preferred tool for objectively assessing sleep in children with ASD.

3. Subjective measures of children’s sleep

Most research on sleep in children with ASD has utilized subjective parent-report measures. Although research
documents better agreement between actigraphy and children’s reports of their own sleep than for actigraphy and parents’
reports of children’s sleep (Gruber, Sadeh, & Raviv, 1997), a reliance on parent-report is necessitated because ASD often
entails communication problems and co-occurring mental retardation, which makes self-reported information difficult to
obtain. Despite its widespread use, several researchers have noted parental-reports as a methodological limitation in
research on sleep in children with ASD (e.g., Arbelle & Ben-Zion, 2001; Johnson, 1996; Richdale, 2001; Schreck & Mulick,
2000; Wiggs & Stores, 1998).
Parents can only provide their subjective opinions of children’s sleep problems and parents may be unaware of some
sleep difficulties (Sadeh, 2008). For instance, it has been documented with typically developing children that, unless children
somehow alert their parents, parents are often not aware of their children’s sleep difficulties (Anders, 1978; Anders, Halpern,
& Hua, 1992; Sadeh, 1994; Sadeh, Lavie, Scher, Tirosh, & Epstein, 1991). Similarly, it has been suggested that for children with
ASD the primary differences between those parentally identified as good sleepers and those parentally identified as poor
sleepers, is that the latter group has made their parents aware of their sleep problems (Wiggs & Stores, 2004). Thus, relying
on parents’ reports may mean that research has focused on the issues that parents find problematic, rather than on actual
sleep problems in their children.

3.1. Sleep diaries

Sleep diaries, sometimes called sleep logs, require parents to report daily (for a period of one to two weeks) on their
children’s sleep for the previous night. Information recorded typically includes bedtimes and waking times, the time of
sleep onset, night waking, subsequent returns to sleep, and daytime napping (Allik, Larsson, & Smedje, 2006; Oyane &
Bjorvatn, 2005; Patzold et al., 1998; Richdale & Prior, 1995; Wiggs & Stores, 2001). Sleep diaries are a recommended
adjunct to actigraphy (Acebo et al., 1999; Littner et al., 2003; Sadeh & Acebo, 2002). To ensure validity, the need to
collect at least 14 days of sleep recording has been indicated (Stores, 2001). This may be problematic, as research with
typically developing children suggests that over time parents respond to fewer sleep diary questions (Sadeh, 1994;
Wolfson et al., 2003).
Studies of typically developing children have found that diary and actigraphy recordings are in good agreement with
regard to children’s sleep schedule variables (e.g., sleep start, minutes of sleep), but are not accurate measures of sleep
quality (Sadeh, 1996; Werner, Molinari, Guyer, & Jenni, 2008). The ability of sleep diaries to assess sleep schedule variables in
children with ASD has some support. Allik et al. (2006) indicate that diary reports of weekend sleep phase delay (i.e., children
went to bed and woke up later on weekends) and shorter sleep latency on weekends compared to weekdays were each
confirmed by actigraphy.
In general, studies including children with ASD report strong correlations between parents’ diary reports and actigraphic
data (Allik et al., 2006; Goodlin-Jones, Sitnick, Tang, Liu, & Anders, 2008a; Goodlin-Jones et al., 2008b). Across two datasets,
the correlations between sleep diaries and actigraphy for sleep latency were .43 (Goodlin-Jones et al., 2008a, 2008b) and .80
(Allik et al., 2006). For total sleep time the correlations for sleep diaries and actigraphy ranged from .16 (Goodlin-Jones et al.,
2008a) to .73 (Allik et al., 2006). Goodlin-Jones et al. (2008b) report that in their study actigraphy and diary data were
significantly correlated. However, they also note that, based on mean values, diaries tended to underreport sleep latency
times, as well as the number and duration of WASO. As with typically developing children, these findings suggest that
parental diary reports may be accurate for assessing the time at which children fall asleep and awake in the morning, but are
less accurate for gauging other aspects of sleep.

3.2. Single-item responses

Researchers sometimes use a single, parent-reported, item (e.g., ‘‘In your opinion does your son/daughter have sleep
problems?’’) to identify children with global sleep difficulties. Studies comparing this method of parent-report to objectively
obtained criteria (i.e., cutoff scores for activity) have yielded contradictory results. Specifically, two studies found that more
parents of children with ASD reported that their child had a global sleep problem than were objectively confirmed via
 D. Hodge et al. / Research in Autism Spectrum Disorders 6 (2012) 1337–1344 1341

actigraphy (Goodlin-Jones et al., 2008b; Hering et al., 1999) and two studies indicate that caregivers reported fewer children
to have a global sleep problem than were identified via actigraphy (Oyane & Bjorvatn, 2005; Wiggs & Stores, 2004).
Parents’ responses to a single item seem to be poor indicators of objectively assessed global sleep problems in children
with ASD; however, parental reports may reflect some specific aspects of children’s sleep. For instance, three studies indicate
that parents who affirmed a global sleep problem in their children, had children with longer sleep latencies recorded via
actigraphy (Allik et al., 2006; Goldman et al., 2009) and PSG (Goldman et al., 2009; Malow et al., 2006). Conversely, in the
same three studies, parents’ reports of global sleep problems were not objectively confirmed by actigraphy or PSG with
respect to total sleep quantity. Thus, children with ASD who are perceived by their parents to have sleep problems are not
receiving less sleep than their counterparts. Other objectively measured aspects of sleep (i.e., efficiency, number and
duration of WASO) were inconsistently related to parents’ reports of global sleep problems (Allik et al., 2006; Goldman et al.,
2009; Malow et al., 2006). Because sleep latency is the only sleep variable that consistently differs for children who are
reported to have global sleep problems and those who are not, a potential interpretation of these three studies is that when
parents are responding to a single question about global sleep problems, they focus on sleep latency and ignore or are
unaware of other specific aspects of sleep (i.e., WASO, quantity of children’s sleep).

3.3. Children’s sleep habits questionnaire

Structured questionnaires are another means of gathering parents’ perceptions of children’s sleep. The children’s sleeps
habits questionnaire (CSHQ; Owens, Spirito, & McGuinn, 2000) is widely used to study sleep in typically developing children
(e.g., Miller, Palermo, Powers, Scher, & Hershey, 2003; Seifer, Sameroff, Dickstein, & Hayden, 1996) and the CSHQ is the most
commonly used standardized measure of sleep problems for children with ASD (e.g., Doo & Wing, 2006; Goldman et al.,
2009; Goodlin-Jones et al., 2008b; Hoffman, Sweeney, Gilliam, & Lopez-Wagner, 2006; Hoffman et al., 2008; Honomichl,
Goodlin-Jones, Burnham, Gaylor, & Anders, 2002a; Honomichl, Goodlin-Jones, Burnham, Hansen, & Anders, 2002b; Malow
et al., 2006; Meltzer, 2011; Souders et al., 2009). With this measure parents rate how frequently (usually, sometimes, rarely)
their school-aged children displayed specific sleep behaviors during the preceding week. The CSHQ is a 45-item measure, of
which 33 items are used to derive a total sleep disturbance score and scores for eight subscales (i.e., bedtime resistance, sleep
onset delay, sleep duration, sleep anxiety, night waking, parasomnias, sleep disordered breathing, and daytime sleepiness).
Based on a sample of 495 elementary school children and 154 children from a pediatric sleep clinic, internal consistency
coefficients for the entire scale are .68 for the community sample and .78 for the clinical sample (Owens et al., 2005). The
measure demonstrates adequate test–retest reliability, with coefficients ranging from .62 to .79, (Owens et al., 2005). In a
sample 104 children with ASD and 162 typically developing children the internal consistency of the CSHQ was demonstrated
by Cronbach’s alpha of .80 for the ASD group and .85 for the typical group (Giannotti et al., 2008). In the same study alpha
coefficients for the subscales ranged from .70 to .91 for both groups. Further, in a sample of 100 children with pervasive
developmental disorders, the CSHQ subscales were found to be stable across three assessments over 12 weeks (r = .56–.84;
Honomichl et al., 2002a, 2002b).
Because the CSHQ queries parents about specific aspects of children’s sleep, it is possible to compare parents’ responses to
objective sleep data and determine which aspects of children’s sleep may be accurately assessed by parents. In two studies
the sleep of children with ASD was assessed by parent identification of good or poor sleep, the CSHQ and by PSG (Malow et al.,
2006) or by actigraphy and PSG (Goldman et al., 2009). Parent identified poor and good sleepers differed significantly on
sleep latency as assessed by the CSHQ subscale of sleep onset delay and objectively by actigraphy and PSG (Goldman et al.,
2009; Malow et al., 2006). Good and poor sleepers also differed on the CSHQ subscale for WASO which was confirmed by
significant differences across groups on actigraphy-assessed WASO (Goldman et al., 2009), but not by PSG-assessed WASO
(Goldman et al., 2009; Malow et al., 2006). Although good and poor sleepers differed significantly in terms of duration of
sleep as assessed by the CSHQ, the difference was not objectively confirmed by actigraphy or PSG (Goldman et al., 2009;
Malow et al., 2006).
In the Goldman et al. (2009) and Malow et al. (2006) studies, only sleep latency in parentally reported good and poor
sleepers differed consistently for both the CSHQ and the objective measures. These studies reveal that, as was the case for
single-item responses, when completing the CSHQ, parents’ reports can be objectively confirmed for sleep latency, but not
for the total amount of sleep children are receiving. Because parent-identified poor sleepers received lower scores on the
CSHQ’s subscale for sleep duration, which was not objectively verified, it suggests that when parents are responding to
single-items, they are not ignoring their children’s sleep duration, but may be erroneously reporting shorter sleep duration
for children they believe to have sleep problems.
Based on the nascent body of research, it seems that for children with ASD only the CSHQ’s subscale of sleep onset delay is
reliably verified via objective methods. Subscales aside, the CSHQ total sleep disturbance score, which is the sum of all
subscales, may be superior to single-item parent-reports for assessing children’s overall sleep quality. Souders et al. (2009)
found that, using a cutoff score of 41 on the CSHQ total score, 66% of children in their ASD sample were identified as having a
sleep problem and 67% of the same sample met actigraphy requirements for a sleep problem. Moreover, Goodlin-Jones et al.
(2008b), Goodlin-Jones et al. (2009) reported that total scores from the CSHQ were associated with actigraphy-based criteria,
whereas single-item parent-reports were not. Another potential strength of the CSHQ is that across three points of data
collection (at three-month intervals), the CSHQ demonstrated good congruence with the actigraphy-based criteria regarding
the persistence of sleep problems (Goodlin-Jones et al., 2009).
1342 D. Hodge et al. / Research in Autism Spectrum Disorders 6 (2012) 1337–1344

4. Conclusion

An earlier review concluded that parental reports of sleep in typically developing children were appropriate for screening,
but were not valid indicators of sleep latency, WASO, or sleep duration (Bauer & Blunden, 2008). This appears to be the case
for children with ASD, with the notable exception that parents of these children are accurate reporters of sleep latency.
Parents of children with ASD may, in fact, be focused on latency to the extent that it overshadows other relevant aspects of
sleep. This potentially leads to over identification of sleep problems in children with ASD who have difficulty falling asleep
(i.e., long sleep latencies), but who sleep well once asleep. Conversely, children with ASD who fall asleep quickly, but who
have difficulties remaining asleep, may be erroneously identified by their parents as good sleepers.
On the whole, limitations relating to the use of objective measures of sleep (e.g., expense, standardized procedures) are
the same for populations of children with and without ASD. For children with ASD special attention is warranted as tolerating
actigraphy or PSG may be particularly difficult. The night-to-night variability evidenced in some research on children with
ASD (e.g., Malow et al., 2006) may suggest that even for children with ASD who can tolerate PSG, the conditions under which
PSG is conducted (e.g., in the lab with sensors attached) lead to atypical sleep; thereby undermining the utility of the
approach in this population. The procedure adopted by Souders et al. (2009) in which an actigraph was placed in a pajama
sleeve shows promise for increasing the numbers of children with ASD who can be assessed via actigraphy. Nonetheless,
researchers need to be mindful that there may be a greater tendency for contented sleeplessness in children with ASD, which
actigraphy can erroneously record as sleep. Therefore, when WASO is relevant, researchers need to consider using
videosomnography as an alternative or adjunct to actigraphy.
To the greatest extent possible, researchers interested in studying sleep in children with ASD are encouraged to use
multiple and objective measures of children’s sleep. Researchers who opt, out of necessity or practicality, for parental-
reports, should appreciate that parents of children with ASD may over-rely on sleep latency as an indicator of overall sleep
problems. This is premised on the consistent associations between objectively assessed sleep latency and both parent
responses to single items and standardized measures (i.e., the CSHQ) and, additionally, by a lack of consistent associations
between other aspects of sleep recorded via objective and subjective means. There is modest evidence to suggest that a
holistic parent-report measure, such as the CSHQ, can be superior to single-item responses for gauging the overall quality of
children’s sleep. Clearly more research is needed. Until additional insight is gained, the greatest utility of parent-report
measures is for gathering parental perceptions of children’s sleep. The problems with objective approaches for assessing
children’s sleep notwithstanding, with the exception of sleep latency, there is scant evidence to support that subjective
measures are valid indicators of any specific aspect of the sleep of children with ASD or of their overall sleep quality.

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