How Does Poor Sleep Affect Children With Autism or ADHD?

Study researchers sought to address the gap in research regarding the association between poor sleep and executive function in children with ASD, ADHD, or typical development

Children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) frequently experience sleep-related problems, and these disturbances can impact cognition and behavior. Higher scores on the Children’s Sleep Habits Questionnaire (CSHQ) were associated with poorer executive function (EF) on all Behavior Rating Inventory of EF (BRIEF) scales after adjusting for demographic factors, stimulant medications, and IQ, according to study results published in Sleep Health.

The main objective of this study was to assess whether the association between poor sleep and EF would remain after adjusting for various factors, such as medication.

Study researchers recruited 735 children, aged 8 to 12 years old (323 who were typically developing [TD], 177 with ASD, and 235 with ADHD), through studies at the Kennedy Krieger Institute. They excluded children with a history of neurologic illness or injury, genetic disorders, seizures, intellectual disability, major depression, bipolar disorder, and conduct disorder.

Children with ASD or ADHD were asked not to take stimulant medications the day of and the day before study participation. Children with ASD were able to continue other psychotropic medications.

Children with ASD or ADHD showed higher CSHQ total scores – and scored higher on all scores except sleep-disordered breathing – on average relative to TD children, even after adjusting for age, sex, race, ethnicity, socioeconomic status, use of stimulant medications, and General Ability Index (GAI) from the Wechsler Intelligence Scale for Children (WISC)-IV or WISC-V (CSHQ total: TD, 41.0; ASD, 46.4; ADHD, 46.2, P <.05 for ASD and ADHD groups, relative to TD).

After adjusting for Child Behavior Checklist (CBCL) Anxiety Problems T score, CSHQ total score was significantly associated with the BRIEF Emotional Control score among children with TD (0.12; 95% CI, -0.03 to 0.28) and ADHD (0.16; 95% CI, -0.04 to 0.35), but not children with ASD (0.15; 95% CI, -0.08 to 0.37; P <.05).

After adjusting for anxiety, CSHQ total score was significantly associated with the BRIEF clinical scores among all 3 groups of children across 4 BRIEF “metacognition” scales (Initiate, Working Memory, Planning/Organization, and Organization of Materials; P <.05).

After adjusting for the Conners Inattention and Hyperactivity Scores, the association was not significant among children with ASD, but significant associations remained for the Initiate and Working Memory scores in the ADHD group (P <.05).

Limitations of the study included the CSHQ’s dependence on parent recognition of symptoms, the exclusions of certain patients (which reduced the generalizability of the findings), and the low proportion of children with the “hyperactive/impulsive” ADHD subtype in the analytic sample.

According to the study researchers, targeting these symptoms among children with ASD may help address the impact of sleep dysfunction on behavioral regulation and metacognition components of executive function. They concluded, “We were able to demonstrate strong links between poor sleep and executive dysfunction in children with typical development, ASD, and ADHD, and demonstrate that co-occurring symptoms of anxiety, inattention, and hyperactivity or impulsivity appear to account for the associations between sleep and executive function among children with ASD.”

Disclosure: One study author declared an affiliation with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Holingue C, Volk H, Crocetti D, Gottlieb B, Spira AP, Mostofsky SH. Links between parent-reported measures of poor sleep and executive function in childhood autism and attention deficit hyperactivity disorder. Sleep Health. Published online January 15, 2021. doi:10.1016/j.sleh.2020.12.006