Pain, Sleep and ASD

father and sleeping babyThis article examines the relationship between pain and sleep problems in children with Autism.
Research published in the February issue of Autism, suggests that a full assessment of pain and sleep problems in young people with Autism Spectrum Disorders may provide crucial information for medical and behavioural treatment planning.1
Health related problems (e.g. gastro-intestinal problems and asthma) are often found to co-exist with Autistic Spectrum Disorders and may be more prevalent in young people with ASD than in typically developing children. Previous research has suggested that pain and sleep problems are highly co-occurring and may increase the likelihood of a young person with ASD experiencing functional impairments and impact upon their quality of life. Research has shown that sleep problems increase when pain is present in young people with physical and intellectual disabilities.

The study is the first to examine the sleep-pain relationship in young people who are considered by their parents to have ASD, specifically looking at whether children with pain-related behaviours  are more likely to have sleep problems. Researchers anticipated that more pain-related behaviours would predict more sleep problems, as previous research has found for typically developing young people and those with developmental disabilities. Researchers also examined whether the way in which the young person expressed the pain could predict sleep problems.

To investigate these relationships, researchers recruited 63 young people (aged 3-18 years) with Autistic Spectrum Disorders (ASD) to the study. They used the non-communicating children’s pain checklist revised (NCCPC-R), a widely used parent-report measure of pain in individuals with communication difficulties, to identify pain behaviours. Subscales used to measure pain included vocal, social (e.g. seeking comfort), facial, activity (e.g. agitation), body (e.g. protecting body part), physiological (e.g. sweating) and eating/ sleeping (sleep problems or disinterest in food). The Children’s Sleep Habits Questionnaire (CSHQ), a parent report measure, was used to measure behavioural and medical sleep problems, such as bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias (e.g. nightmares/night terrors) and sleep disordered breathing.

Sleep problems predicted by pain related behaviours

The analysis of the NCCPC-R and CSHQ data found extremely high levels of both pain and sleep problems in the young people with ASD who took part, with over 90% of respondents scoring at clinically significant levels on both measures. The researchers’ hypothesis proved largely correct: the study found thatmore pain-related behaviours experienced during the previous week indeed predicted more over­all sleep problems. However the study also suggested that not all sleep problems can be predicted by pain related behaviours consistently. The types of sleep problems most consistently predicted by pain related behaviours were problems with sleep duration, parasomnias and sleep disordered breathing.

Pain communication type as a predictor of sleep problems

Sleep problems could be predicted by particular ways of communicating pain. Problems with sleep duration were predicted by social communication of pain, for example comfort seeking. However, the researchers suggest that the social communication of pain may predict shorter sleep duration because of the nature of the social communication behaviour interfering with getting off to sleep.

The presence of parasomnias (nightmares/night terrors) could be predicted by facial communication of pain (the most common observable form of pain behaviour). However the researchers suggest it is possible that the grimacing and gnashing that takes place during parasomnias may increase the likelihood of mothers reporting such behaviour. It is suggested that future research examining this relationship in more depth would be useful.

Sleep disordered breathing was predicted by vocal communication of pain. However like parasomnias, the behavioural presentation of sleep disordered breathing (e.g. gasping), may have some overlap with pain behaviours communicated vocally. The researchers suggest that future studies should further examine how pain-related behaviours are communicated among young people with ASD and various respiratory complaints as compared to those without respiratory complaints.

Clinical implications

Despite the limitations to the study, such as the relatively small sample size, lack of a comparative group and the reliance on parents’ data collection and diagnosis of ASD, the authors suggest that the relationship between sleep problems and pain behaviours has important medical and clinical implications for young people with ASD. Health problems that cause pain or discomfort in young people with ASD may hinder any response to behavioural interventions and pharmacological treatments as well as their day to day functioning. The research suggests that paediatricians and clinicians should take pain-related behaviours into account when assessing and planning treatment for young people with ASD.

The findings are also useful for parents as they may benefit from taking note of their child’s sleep health if the child also has high levels of pain-related behaviour, because sleep disordered breathing, parasomnias and shorter sleep duration tend to be more prevalent in young people with ASD and can have a negative effect on daytime functioning.

The recognition of the relationship between pain and sleep in young people with ASD may help in the design of interventions based on indicators of pain, for example identifying a young person’s socially communicated pain could assist parents and clinicians design interventions (e.g. to improve the young person’s self-soothing abilities).

Future directions

Future studies would benefit from collecting data over multiple time periods. This could help to understand any causal relationships between pain and sleep problems and help to identify factors which may affect them, such as parenting style or parental stress. Utilising comparison groups would also indicate if the relationships between pain and sleep identified are actually unique to young people with ASD. Additionally, more investigation of how pain and sleep problems relate to each other and the effect on daytime functioning of young people with ASD would be able to further inform assessment procedures, and have an impact on the young people’s qual­ity of life.

  1. Tudor, M.E., Walsh, C.E., Mulder, E.C., Lerner, M.D. (2014) Pain as a predictor of sleep problems in youth with autism spectrum disorders. Autism [Online] Available fromhttp://aut.sagepub.com/content/early/2014/01/30/1362361313518994

If you are interested in sleep and Autism, you may find this webinar by Dr Ruth O’Hara, shown on Sfari, an informative watch.

http://sfari.org/sfari-community/community-blog/webinar-series/2013/webinar-ruth-ohara-on-sleep-disorders-in-autism