Malow publishes paper on sleep issues and aggressive behaviors in children with autism

Young boy yawning

Vanderbilt Kennedy Center (VKC) investigator Beth Malow, M.D., M.S., recently co-authored a paper* published in the journal Research in Developmental Disabilities focusing on how clinicians can predict sleep issues in a child with autism spectrum disorder (ASD), and how those issues may affect aggressive behavior.

Commonly-seen traits in children diagnosed with ASD include difficulty falling and staying asleep in addition to aggressive behavior, sometimes causing injury to the child or others. Research is being conducted on whether the two traits are in some way connected.

Malow, who serves as Burry Chair in Cognitive Childhood Development, Professor of Neurology and Pediatrics, and director of the Vanderbilt Sleep Disorders Division, secured a sample of child participants from the Autism Speaks Autism Treatment Network (AS ATN) registry whose parents volunteered them for the research study.

“We classified children as having sleep problems based on a yes/no response on a registry survey that asked parents what concerns they had about their children, which included sleep problems,” said Malow. After the study participants were assembled, they were randomly split into “training” and “test” samples.

“The training and test groups refer to a method of analysis in which the data were analyzed in two steps,” Malow added. “The data had been collected between 2008 and 2016 and were entered into a registry. The first step was to identify possible predictors of sleep problems—this was the ‘exploratory’ or training sample. The second step was to test these predictors that came out of the first step in a more rigorous way – this was the test sample.”

Researchers used a multivariable model to determine that aggressive behavior among children with no sleep problems reported at baseline was associated with having more sleep problems at the first annual follow-up visit. This model performed with high sensitivity and accurate prediction of low risk in the test sample.

Conclusions from the study indicated that, among children with ASD, aggressive behavior independently predicted sleep problems.

“Aggressive behaviors in children with ASD range from self-injurious behavior, like picking at one’s skin for example, to being aggressive to other children or adults, or to objects,” said Malow. “We don’t know if aggression was mitigated after better sleep was established as this was not an interventional study. However, this study did document a relationship between aggressive behavior and sleep problems, raising the possibility that these factors are related.”

Researchers are optimistic that the model’s high sensitivity for identifying children at risk and its accurate prediction of low risk can help with eventual treatment and prevention of sleep problems. Further data collection may provide better prediction through research methods with larger samples of participants.

For any parent who thinks his or her child might be struggling with sleep issues, Malow advises sharing concerns with medical professionals and making small changes at home before more seeking more substantial measures like medication to address the problem.

“For any child, we recommend that parents talk with their child’s health care provider so that any medical conditions can be evaluated for and addressed. Once this step has been completed, there are many different approaches to promote sleep, including those that emphasize behavioral strategies,” said Malow.

“We try to limit medication use whenever possible. Turning off screens, implementing a calming bedtime routine, and ensuring that the child has sufficient exercise during the day can all help. These methods have also been successful in our work with children on the spectrum. Different models are being developed to help parents learn these behavioral strategies, including online educational materials, and working with community therapists.”

The Vanderbilt Kennedy Center has several free printable resources on the topic of autism and sleep available on its Topical Resources webpage, including Strategies to Improve Sleep in Children with Autism Spectrum Disorders: A Parent’s Guide and Sleep Strategies for Teens with Autism Spectrum Disorder: A Guide for Parents. These two informational booklets were produced by the Autism Speaks ATN and the Autism Intervention Research Network on Physical Health (AIR-P).

Click here for more information on the Autism Speaks Autism Treatment Network.

Elizabeth Turner is associate program manager for VKC Communications.


*Shui, A.M., Katz, T., Malow, B.A., & Mazurek, M.O. (2018). Predicting sleep problems in children with autism spectrum disorders. Research on Developmental Disabilities.(2018 Dec). 83:270-279. doi: 10.1016/j.ridd.2018.10.002. Epub 2018 Oct 27.

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