Research in Autism Spectrum Disorders 5 (2011) 1223–1229

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Research in Autism Spectrum Disorders

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

Sleep is associated with problem behaviors in children and

adolescents with Autism Spectrum Disorders
Suzanne E. Goldman a,*, Susan McGrew b, Kyle P. Johnson c, Amanda L. Richdale d,
Traci Clemons e, Beth A. Malow a
a
Vanderbilt University Medical Center, Department of Neurology – Sleep Disorders Program, Nashville, TN 37232-2551, United States
b
Vanderbilt University Medical Center, Center for Child Development, 3401 West End Avenue, Suite 460 W, Nashville, TN 37203, United States
c
Oregon Health & Science University, Mail Code CR 139, 3181 SW Sam Jackson Park Road, Portland, OR 97239, United States
d
Olga Tennison Autism Research Centre, School of Psychological Science, La Trobe University, Bundoora, VIC, Australia
e
EMMES Corporation, Rockville, MD, United States

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

Article history: Multiple sleep problems have been reported in children with Autism Spectrum Disorder
Received 5 January 2011 (ASD). The association of poor sleep with problematic daytime behaviors has been shown
Received in revised form 13 January 2011 in small studies of younger children. We assessed the relationship between sleep and
Accepted 13 January 2011 behavior in 1784 children, ages 2–18, with confirmed diagnosis of ASD participating in the
Available online 12 February 2011 Autism Treatment Network. Sleep problems were identified using the Children’s Sleep
Habits Questionnaire (CSHQ). The Parental Concerns Questionnaire (PCQ) was used to
Keywords: evaluate behavioral concerns and to define good or poor sleepers. Poor sleepers had a
Sleep problems
higher percentage of behavioral problems on all PCQ scales than good sleepers. Over three-
Behavior problems
fourths had problems with attention span and social interactions. Further delineation of
Parental Concerns Checklist
Children’s Sleep Habits Questionnaire
this phenotype will help guide future interventions.
Autism Spectrum Disorder ß 2011 Elsevier Ltd. All rights reserved.

Autism Spectrum Disorders (ASD) are a group of neurodevelopmental conditions characterized by deficits in three major
domains: social interaction, communication, and restricted interests and/or stereotyped and repetitive behaviors. Sleep
concerns are common, among children with ASD, with prevalence rates estimated to range from about 50–80% (Couturier
et al., 2005; Krakowiak, Goodlin-Jones, Hertz-Picciotto, Croen, & Hansen, 2008; Richdale, 1999). Sleep-onset insomnia and
nocturnal awakenings have been found to be the most frequent and consistent findings (Richdale & Schreck, 2009). Recent
research by Goldman, McGrew, Clemons, and Malow (2010) has shown sleep problems in children with ASD persist into
adolescence with adolescents experiencing problems with sleep onset, shorter sleep duration and daytime sleepiness.
Associations between sleep disorders and problematic daytime behaviors, such as aggression and hyperactivity, have
been found in typically developing children. Similar associations have been reported in small populations of children
with ASD (Goldman et al., 2009; Malow et al., 2006). Studies to date have shown associations between sleep
disturbances and autism severity, hyperactivity, mood variability, and aggression (Mayes & Calhoun, 2009); inattention
and hyperactivity, compulsive and ritualistic behavior (Goldman et al., 2009); affective problems (Malow et al., 2006)
and attention deficit hyperactivity, inattentive and hyperactive impulsive behaviors, and oppositional behaviors
(DeVincent, Gadow, Delosh, & Geller, 2007). Behavioral symptoms may be causal or contributory factors to sleep
disturbances in ASD, but may also result from (or be exacerbated by) the sleep disturbance itself. Symptoms may also

* Corresponding author at: Vanderbilt University Medical Center, Department of Neurology – Sleep Disorders Program, 1161 21st Avenue South, Room
AA0232B, Nashville, TN 37232-2551, United States. Tel.: +1 615 322 0283; fax: +1 615 936 0223.
E-mail address: suzanne.e.goldman@vanderbilt.edu (S.E. Goldman).

1750-9467/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2011.01.010
1224 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229

vary with age, with less severe restricted interests and stereotyped behaviors being displayed in older children
(Esbensen, Seltzer, Lam, & Bodfish, 2009). This raises the possibility that sleep disturbance or its impact on behavior may
change with age.
As the core symptomatology of ASD are behavioral deficits, understanding the sleep-behavior paradigm holds promise to
improve the quality of life of these individuals and their families. The goals of our study were (1) to determine whether
parental report of sleep concerns relates to parental reports of problematic daytime behaviors in children with ASD across
early childhood through adolescence, (2) to estimate the relative risk and variability of poor sleepers having a behavioral
problem, and (3) to identify variations in the sleep-behavior paradigm across this age-span. To accomplish these goals, we
utilized validated sleep and behavior questionnaires from a large well-characterized clinical cohort of children with ASD
across the age span from toddlers through adolescence.

1. Methods

1.1. Participants

The study population was 1784 children participating in the Autism Treatment Network (ATN) whose parents completed
the Children’s Sleep Habits Questionnaire (CSHQ) and the Parental Concerns Questionnaire (PCQ) at their first visit. The ATN
is a registry collecting data on children with ASD across 14 sites in the United States and Canada. All children/adolescents
have a clinical diagnosis of ASD (American Psychiatric Association, 2000) At least 90% of the children/adolescents enrolled in
the Registry from each site must meet Autism Diagnostic Observation Schedule (ADOS) criteria for ASD (Lord et al., 2000).
Based on the DSM IV classifications, 67.2% children had a diagnosis of Autism, 9.8% Asperger’s syndrome and 23.0% Pervasive
Developmental Disorder not otherwise specified (American Psychiatric Association, 2000). These diagnoses were combined
for analyses to be consistent with the proposed revision to the DSM-V where a single diagnostic category will be used to
define ASD (American Psychiatric Association, 2010). Protocols were approved by the Institutional Review Board at each site
with parents providing consent and children providing assent.

1.2. Sleep measures

Sleep behaviors were derived from the Children’s Sleep Habits Questionnaire (CSHQ) and the Parental Concerns
Questionnaire (PCQ). The CSHQ is a validated parental questionnaire that consists of 45 items relating to sleep complaints
over the past month. The majority of questions are answered on a 3-point scale (1 = rarely, 2 = sometimes, 3 = usually). The
CSHQ has been used in children with a variety of conditions, including ASD (Goldman et al., 2009; Malow et al., 2006). A total
score is calculated, as well as subscale scores that measure insomnia-related aspects of sleep including sleep anxiety, sleep
duration, sleep onset delay, night wakings, bedtime resistance and other dimensions such as sleep disordered breathing,
parasomnias, and daytime sleepiness (Owens, Spirito, & McGuinn, 2000).

1.3. Behavioral measures – Parental Concerns Questionnaire

Developmental and behavioral symptoms were derived from the PCQ, a screening instrument designed and validated for
children with ASD (McGrew et al., 2007). The PCQ is a series of 13 questions designed to identify common problems and
behavioral concerns. The questions address the patterns of abnormal development in the social interaction, verbal and
nonverbal communication, and restrictive and repetitive activities. Other symptoms addressed included anxiety, obsessive/
compulsive behaviors aggression, self-injurious behaviors, mood swings, hyperactivity and attention issues, and sleep
disturbances. The questions ask the parent to describe the extent to which the behavior has been a problem over the previous
week with responses: 1 as no concern, 2 mild concerns, 3 moderate concerns, and 4 severe concerns. Based on extensive
clinical use of the PCQ by one of the authors (SGM) and previous clinical research using this questionnaire (Malow et al.,
2006) we collapsed the responses, on all questions, into none-mild and moderate-severe by combining the no concern and
mild concerns questions to constitute good sleepers and the moderate and severe concerns questions to constitute poor
sleepers.

1.4. Statistical analysis

Descriptive statistics were performed on all major variables with means and standard deviations for continuous data and
percentages for categorical data. The primary analysis examined the differences between the behavioral questions on the
PCQ with the parent report of whether or not they perceived the child to be a good or poor sleeper using the Pearson’s Chi-
square test was used to examine the differences between the behavioral questions on the PCQ by sleep status; e.g. good
sleeper or poor sleeper by parent report. To evaluate the association of age with problematic behavior, by good sleeper and
poor sleeper, the cohort was divided into four age groups based on clinical cut-points commonly seen in a pediatric
population: <5 years, 5 to <7 years, 7 to <11 years, and 11 years. The relative risk and the 95% confidence interval (CI) of a
parent reporting a child having a specific problem on the PCQ based on parental report of a sleep problem was estimated
using log-binomial models adjusted for age (Greenland, 2004). The association was further evaluated using stepwise logistic
regression analysis to determine which CSHQ subscales were the most predictive of having a problem behavior. The possible
 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229 1225

Table 1
Percent of parents responding their child had problems on a specific PCQ question by good sleeper–poor sleeper1.

PCQ question Good sleeper (n = 1200) Poor sleeper (n = 584) Total (n = 1784)

Language use and understanding 60.6 69.5 63.5

Compulsive behavior 32.2 47.6 37.2
Anxiety 40.9 61.2 47.5
Sensory issues 41.2 63.2 48.4
Aggression 20.3 37.3 25.9
Hyperactivity 41.7 66.8 49.9
Attention span 56.1 77.7 63.2
Mood swings 25.7 47.8 32.9
Eating habits 44.8 57.9 49.1
Social interactions 53.9 75.4 60.9
Self-stimulatory behavior 36.2 55.1 42.4
Self-injurious behavior 9.9 23.5 14.4
1
All scales were significant between good sleepers and poor sleepers at p < 0.001.

interaction between age and sleep parameter was examined with the addition of a quadratic term in the respective models. A
p-value of <0.05 was used for hypothesis generation, therefore no adjustment was made to the Type I error. Analyses were
performed using SAS V9 (Cary, NC), SPSS V17 (Chicago, IL), and STATA V11 (College Station, TX).

2. Results

2.1. Participants

Children ranged in age from 3 to 18 years with a mean age (standard deviation) of 6.7 (3.5) years. The population was
84.5% male, race and ethnicity were by self-report with 85% Caucasian and 8.5% Black. Parents of 1200 (67%) children
reported their child to be a good sleeper, and 584 (33%) reported their child as a poor sleeper.

2.2. Developmental and behavioral problems associated with good and poor sleepers

Developmental and behavioral problems, as reported by the parents on the PCQ, were prevalent. In this cohort over 60% of
the children had problems with language use and understanding, attention span, and social interactions; and almost 50% had
problems with anxiety, sensory issues, hyperactivity, and eating habits (Table 1). Across all PCQ questions a higher
percentage of poor sleepers were reported as having problems on any question than the average percent score for the entire
group; and the good sleepers had a lower percentage of individuals being reported with the problem behavior than the
average for the entire group. In the poor sleepers more than 50% of these children were reported to have problems with
attention, social interaction, language, hyperactivity, sensory issues, anxiety, eating behaviors, and self-stimulatory
behavior; while good sleepers only were reported to have problems in three areas language, attention and social interaction
in more than 50% of cases. The difference between the good and poor sleepers was significant for all problem areas of the PCQ,
with the poor sleepers having a higher prevalence of problems overall.
In log-binomial models, children reported to be poor sleepers (compared to good sleepers) had a higher likelihood of
being reported as having problems with a specific behavior on the PCQ (Table 2) for all behaviors than the good sleepers. In
age-adjusted models, a poor sleeper had a 20.4% higher likelihood of having problems with self-injurious behavior, and over

Table 2
Parental report of PCQ problematic behavior in poor sleepers by age category.

PCQ item <5 years (total 5–<7 years (total 7–<11 years (total 11 years (total Total n = 1784,
n = 734, % poor n = 400, % poor n = 401, % poor n = 249, % poor % poor sleepers
sleepers = 31.5) sleepers = 29.5) sleepers = 34.4) sleepers = 39.0) = 32.7 p = 0.06
% poor sleepers % poor sleepers % poor sleepers % poor sleepers p

Language use and understanding 51.1 17.5 18.5 12.8 <0.001

Compulsive behavior 42.4 22.1 20.7 14.9 0.14
Anxiety 36.4 21.0 25.5 17.1 0.28
Sensory issues 39.1 22.3 24.2 14.4 0.19
Aggression 42.7 25.2 18.8 13.3 0.01
Hyperactivity 72.7 75.4 59.4 52.6 <0.001
Attention span 38.2 21.2 24.3 16.3 0.51
Mood swings 41.2 21.9 20.1 16.9 0.26
Eating habits 43.9 21.4 21.4 13.4 0.01
Social interactions 39.4 19.4 23.7 17.4 0.73
Self-stimulatory behavior 41.9 17.4 24.2 16.5 0.27
Self-injurious behavior 43.1 22.6 19.7 14.6 0.43
1226 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229

Table 3
Relative risk of parental report of problematic sleep in poor sleepers compared to good sleepers.

PCQ question RR (95% confidence interval)a

Language use and understanding 1.1 (1.1, 1.2)

Compulsive behavior 1.5 (1.3, 1.7)
Anxiety 1.5 (1.3, 1.6)
Sensory issues 1.5 (1.4, 1.7)
Aggression 1.7 (1.6, 2.2)
Hyperactivity 1.6 (1.5, 1.8)
Attention span 1.4 (1.3, 1.5)
Mood swings 1.9 (1.6, 2.1)
Eating habits 1.3 (1.2,1.4)
Social interactions 1.4 (1.3, 1.5)
Self-stimulatory behavior 1.5 (1.4, 1.7)
Self-injurious behavior 2.4 (1.9, 3.0)
a
Adjusted for age in years.
Reference category is good sleeper.

a 10.5% higher likelihood of mood swings, aggression and compulsive behavior problems. There was an inverse relationship
between age and language, sensory issues, aggression, hyperactivity, and eating problems. Younger children who were poor
sleepers were more likely to have problems with language, aggression, hyperactivity and poor eating habits than older poor
sleepers (Table 3). In the younger children (under 5 years of age) over 40% of the poor sleepers had problems in these areas.

2.3. Developmental and behavioral problems associated with sleep behaviors

Stepwise logistic regression analyses were used to examine the contribution of each CSHQ sleep subscale score to
individual behavioral problems reported on the PCQ (Table 4). All CSHQ subscales were associated with at least one PCQ
behavior. The CSHQ parasomnia scale was the scale that most consistently remained as a sleep problem in individual
multivariate logistic regression models. For a one-unit increase on the parasomnia scale, there was approximately a 20%
increase in the odds of the parent reporting a problem on the anxiety, sensory issues, aggression, hyperactivity, attention,
mood swings, and self injurious behavior questions when all other variables in the model are held constant (Table 4).

3. Discussion

In this study, we examined a large and well-characterized cohort of children with ASD for the relationship between sleep
problems and problem daytime behavior. Our findings support previous studies showing an association of sleep and daytime
behavior (Goldman et al., 2009; Malow et al., 2006; Mayes & Calhoun, 2009; Patzold, Richdale, & Tonge, 1998; Schreck,
Mulick, & Smith, 2004) with a much larger population and expand the field of knowledge to include an older age group, ADOS
confirmed diagnoses of ASD, and documentation of behavior with an autism specific questionnaire.
Our study showed a higher risk of having problematic behaviors on all PCQ scales except for language use and
understanding if the parent reported the child to be a poor sleeper. This finding is consistent with previous reports on the
association between developmental and behavioral problems and disturbed sleep in children with ASD using both objective
measures, as well as parental report (DeVincent et al., 2007; Goldman et al., 2009; Goodlin-Jones, Tang, Liu, & Anders, 2009;
Liu, Hubbard, Fabes, & Adam, 2006; Malow et al., 2006; Mayes & Calhoun, 2009). In a study using parental report the authors
reported on 477 children with ASD age (6.5 (3.0) years, mean (sd)) and found hyperactivity, mood variability and aggression
to be strong predictors of a sleep disturbance. In a study of 112 preschool children with PDD, those who had more sleep
problems exhibited more severe symptoms of attention-deficit hyperactivity disorder and oppositional defiant disorder than
children without sleep problems (DeVincent et al., 2007). In a slightly older age group of 167 children with ASD [8.8 (4.0)
years] behavioral problems of hypersensitivity to stimulus and ADHD were found associated with sleep problems (Liu et al.,
2006).
Objective studies looking at sleep parameters and parental report of sleep and daytime behaviors in children with ASD are
limited. With overnight polysomnography, Malow et al. (2006) found an association between parent report of good and poor
sleep and PSG sleep parameters that included sleep latency and sleep efficiency. Further, children with ASD who were
classified as poor sleepers by parent report on the PCQ, had higher scores on the Child Behavior Checklist (CBCL) and more
problems on the ADOS social interactions scale than children classified as good sleepers. Using wrist actigraphy to measure
sleep in the home setting, Goldman et al. (2009) found poor sleepers had more inattention and hyperactivity, as measured by
the CBCL; and more restricted/repetitive behavior, as measured by the RBS, than children classified as good sleepers. In
another study using both wrist actigraphy and parental report, the authors found parent reports of sleep problems to be
associated with daytime performance (Goodlin-Jones et al., 2009).
Overall the children in our study with poor sleep were more likely to have behaviors associated with the third area of the
autism triad, restrictive and repetitive behavior. That is poor sleepers more likely had self-stimulatory behavior. Behaviors
commonly reported as co-morbid with ASD, sensory issues, eating habits hyperactivity, and anxiety were also more common
 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229
Table 4
Association odds ratio (95% confidence interval) of a behavioral problem with CSHQ scales: stepwise multivariate logistic regressiona,b,c.

PCQ question Night Bedtime Sleep delay Sleep duration Sleep anxiety Parasomnias Sleep disordered Daytime Age
waking resistance breathing sleepiness (years)

Language use and 1.2 (1.1, 1.3) 1.1 (1.0, 1.2) 1.1 (1.0, 1.2) 0.8 (0.8, 0.9) 0.8
understanding (0.8, 0.9)
Compulsive behavior 1.1 (1.0, 1.1) 1.1 (1.0, 1.1) 1.1 (1.1, 1.2) 1.1 (1.0, 1.3)
Anxiety 0.9 (0.9, 1.0) 1.2 (1.1, 1.4) 1.3 (1.2, 1.4) 1.2 (1.1, 1.3) 1.1
(1.0, 1.1)
Sensory issues 0.9 (0.9, 1.0) 1.1 (1.0, 1.2) 1.2 (1.1, 1.3) 1.2 (1.2, 1.3) 1.0 (1.0, 1.1)
Aggression 1.1 (1.1, 1.2) 1.2 (1.1, 1.2)
Hyperactivity 1.2 (1.1, 1.4) 1.1 (1.0, 1.2) 1.2 (1.2, 1.3) 0.9
(0.9, 1.0)
Attention span 1.2 (1.0, 1.4) 1.1 (1.0, 1.2) 1.1 (1.0, 1.1) 1.2 (1.1, 1.2) 1.0
(1.0, 1.1)
Mood swings 1.1 (1.1, 1.2) 1.2 (1.1, 1.2) 1.1 (1.0, 1.3) 1.0 (1.0, 1.1)
Eating habits 1.1 (1.0, 1.3) 1.1 (1.1, 1.2) 1.1 (1.0, 1.1) 0.9
(0.9, 1.0)
Social interactions 1.5 (1.3, 1.7) 1.1 (1.1, 1.2) 1.0
(1.0, 1.1)
Self-stimulatory behavior 1.4 (1.2, 1.6) 1.1 (1.1, 1.2)
Self-injurious behavior 1.1 (1.0, 1.1) 1.1 (1.0, 1.2) 1.2 (1.1, 1.4) 1.0 (1.0, 1.1)
a
Each PCQ variable is a separate model. Model is predicting the odds of having problem behavior.
b
All CSHQ scales were entered into the model for stepwise regression analyses. Only variables included in the final model are shown.
c
All models adjusted for age.

1227
1228 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229

in poor sleepers. These associations existed across the age-span of childhood through adolescence. The inverse relationship
between age and behavior problems is consistent with previous research of symptom changes reported over time in children
and adolescents with ASD (McDuffie et al., 2010; Seltzer et al., 2003).
Of all the behaviors measured on the PCQ, a poor sleeper had the highest overall risk of exhibiting self-injurious behaviors
even after the model was adjusted for age. Self-injurious behavior was reported in almost a fourth of the poor sleepers and
the relative risk of being a poor sleeper rather than a good sleeper if the child had such behavioral problems was 10%. The
association between self-injurious behaviors, and disturbed sleep, has been noted in children with ASD and other
developmental disabilities, (DeLeon, Fisher, & Marhefka, 2004) as well as in adults with developmental disabilities (Symons,
Davis, & Thompson, 2000). DeLeon et al. (2004) reported on a 4 year old with ASD who displayed self-injurious behavior
occurring within 1 h of waking. Direct observation indicated an association between nighttime awakenings and these
behaviors. Adults with profound intellectual disability who exhibited self-injurious behaviors were reported to have shorter
sleep duration with the authors proposing the possibility of a common neurochemical pathway (Symons et al., 2000).
In multivariate logistic regression models, we found the parasomnia scale to be associated with the majority of behavioral
problems evaluated by the PCQ. Indeed, after adjusting for age there was a 10–20% increase in the odds of a parent reporting a
problem on any of the PCQ scales. As a category, parasomnias constitute a vast array of symptomatology. The International
Classification of Sleep Disorders (ICSD-2) (American Academy of Sleep Medicine, 2005) describes 30 different parasomnias,
many of which occur in children (Stores, 2009). The CSHQ parasomnia scale contains 7 items consisting of bed wetting, sleep-
talking, restless sleep, sleep-walking, bruxism, awakening screaming or sweating, and alarmed by a scary dream. We elected
to analyze the full scale, rather than looking at each item separately, to maintain consistency with the other scales and other
research studies using the CSHQ. Parasomnias have been reported in several studies of children with ASD with incidence
rates varying from low to high (Liu et al., 2006; Patzold et al., 1998; Richdale & Prior, 1995; Schreck & Mulick, 2000;
Thirumalai, Shubin, & Robinson, 2002). In our study, we confirmed the prevalence of parasomnias in ASD and showed them
to persist across the age range from early childhood through adolescence.
The high association between the parasomnia scale and behavioral problems warrants further investigation to clarify this
relationship in children with ASD. Restlessness during sleep has been cited as one of the major sleep problems in children in
this population (Mayes & Calhoun, 2009). Indeed, 34% of the poor sleepers were reported to have problems with restlessness
compared to only 9% of the good sleepers. Screaming during the night is also common in ASD – 19% of the poor sleepers were
found to have problems waking and screaming during the night compared with 3% of the good sleepers. Identifiable reasons
are not always apparent as actions such as waking up screaming from sleep may reflect sleep behaviors other than
parasomnias, such as anxiety (Richdale, 1999). In addition, children with ASD have been noted to have a high rate of enuresis
(Miano et al., 2007) with 25% of the poor sleepers in our study having a problem with this compared to 16% of the good
sleepers. The sleep duration scale was also associated with a large number of behavioral problems. Previous reports on
problematic sleep duration in children with ASD have varied. Short sleep duration has been reported in some studies (Oyane
& Bjorvatn, 2005; Paavonen et al., 2008; Patzold et al., 1998; Wiggs & Stores, 2004) while other authors reported no
difference in sleep duration between children with ASD and controls (Polimeni, Richdale, & Francis, 2005; Schreck & Mulick,
2000). The sleep duration scale on the CSHQ consists of three items; sleeps too little, sleeps the right amount, and sleeps the
same amount each day. In our population parents endorsed more problems with sleeping too little with 27% of all parents
reporting they felt their child slept too little, with 61% of the parents of poor sleepers reporting they felt their child slept too
little.
The strengths of this study include its large well-characterized nationally obtained cohort, with over 90% of the children
having an ADOS-confirmed diagnosis. Validated questionnaires were used and behavior was measured with a questionnaire
specifically designed for the ASD population. The study was limited in its cross-sectional design and lack of objective
measurements of sleep and behavior, an inherent limitation of large descriptive cohort studies.
In summary, consistent with previous reports, our findings support an association between parental report of poor sleep
with that of more problematic behavior in children with ASD and extend this finding to adolescents with ASD. We have
shown that across both childhood and adolescence poor sleepers are at a higher risk for behavioral problems than good
sleepers. Our work cannot determine directionality, e.g. whether sleep problems influence behavior or whether
developmental and behavioral problems contribute to poor sleep. Future work should focus on refining the sleep-behavior
phenotypes to provide the foundation for focused studies targeting treatment of sleep and behavior in ASD.

Acknowledgements

Financial support: This research was conducted as part of the Autism Treatment Network (ATN), a program of Autism
Speaks. Further support came from a cooperative agreement (UA3 MC 11054) from the U.S. Department of Health and
Human Services, Health Resources and Services Administration, Maternal and Child Health Research Program, to the
Massachusetts General Hospital. The views expressed in this publication do not necessarily reflect the views of Autism
Speaks, Inc. The authors acknowledge the members of the ATN for use of the data. The Autism Treatment Network includes
these members:
Clinical Coordinating Center, Mass General Hospital for Children: James Perrin, MD Dan Coury, MD
Data Coordinating Center, EMMES Corporation: Traci Clemons, PhD
Baylor College of Medicine: Diane Treadwell-Deering, MD Daniel Glaze, MD
 S.E. Goldman et al. / Research in Autism Spectrum Disorders 5 (2011) 1223–1229 1229

Bloorview Kids Rehab, Surrey Place Center and The Hospital for Sick Children: Wendy Roberts, MD Alvin Loh, MD
Cincinnati Children’s Hospital Medical Center: Patricia Manning-Courtney, MD Cynthia Molloy, MD, MS
Columbia University Medical Center: Agnes Whitaker, MD Reet Sidhu, MD
Kaiser Permanente Medical Care Program Northern California: Lisa Croen, PhD Pilar Bernal, MD
Kennedy Krieger Institute and Marcus Institute: Rebecca Landa, PhD Stewart Mostofsky, MD
Oregon Health & Science University: Robert Steiner, MD Darryn Sikora, PhD
University of Arkansas and Arkansas Children’s Hospital: Jill James, PhD Jill Fussell, MD
University of Colorado Denver, School of Medicine and The Children’s Hospital: Cordelia Robinson, PhD, RN Ann Reynolds,
MD Susan Hepburn, PhD
University of Missouri: Judith Miles, MD, PhD Stephen Kanne, PhD
University of Pittsburgh: Nancy Minshew, MD Cynthia Johnson, PhD Benjamin Handen, PhD
University of Rochester: Susan Hyman, MD Tristram Smith, PhD
Vanderbilt University Medical School: Beth Malow, MD
The views expressed in this publication do not necessarily reflect the views of Autism Speaks, Inc.

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