Elsevier

Sleep Medicine

Volume 13, Issue 7, August 2012, Pages 795-801
Sleep Medicine

Original Article
Comparison of sleep questionnaires in the assessment of sleep disturbances in children with autism spectrum disorders

https://doi.org/10.1016/j.sleep.2012.03.005Get rights and content

Abstract

Background and purpose

The purpose of this study was to compare two parent completed questionnaires, the Modified Simonds & Parraga Sleep Questionnaire (MSPSQ) and the Children’s Sleep Habits Questionnaire (CSHQ), used to characterize sleep disturbances in young children with autism spectrum disorders (ASD). Both questionnaires have been used in previous work in the assessment and treatment of children with ASD and sleep disturbance.

Participants and methods

Parents/caregivers of a sample of 124 children diagnosed with ASD with an average age of six years completed both sleep questionnaires regarding children’s sleep behaviors. Internal consistency of the items for both measures was evaluated as well as the correlation between the two sleep measures. A Receiver Operating Characteristics (ROC) curve analysis was also conducted to examine the predictive power of the MSPSQ.

Results

More than three quarters of the sample (78%) were identified as poor sleepers on the CSHQ. Cronbach’s alpha for the items on the CSHQ was 0.68 and Cronbach’s alpha for items on the MSPSQ was 0.67. The total scores for MSPSQ and CSHQ were significantly correlated (r = .70, p < .01). After first identifying the poor sleepers based on the CSHQ, an area under the curve was 0.89 for the MSPSQ. Using a cut off score of 56 on the MSPSQ, sensitivity was .86 and specificity was .70.

Conclusions

In this sample of children with ASD, sleep disturbances were common across all cognitive levels. Preliminary findings suggest that, similar to the CSHQ, the MSPSQ has adequate internal consistency. The two measures were also highly correlated. A preliminary cut off of 56 on the MSPSQ offers high sensitivity and specificity commensurate with the widely used CSHQ.

Introduction

Autism spectrum disorders (ASD), such as Autistic Disorder, Asperger Disorder, and Pervasive Developmental Disorder, Not Otherwise Specified, affect up to one in 110 children [1]. Core features of ASD include deficits in social interaction and communication as well as repetitive and restrictive patterns of behavior. In addition to these core diagnostic features, children with ASD frequently present with a host of associated behavioral issues. On parent report, sleep disturbances are estimated to occur in 30–86% of this group of children [2], [3], [4], [5], [6]. Studies comparing children with ASD to their typically developing counterparts have demonstrated significantly higher rates of sleep disturbances in ASD [7], [8], [9], [10]. The sleep disturbances identified have primarily been dyssomnias, including delayed sleep onset, difficulty maintaining sleep with night wakings, early morning waking, and decreased total sleep time. Although earlier study samples included children with ASD with co-occurring developmental delays or intellectual disabilities, recent reports of children with ASD and typical cognitive development reported sleep disturbances in 73–82% of the ASD group compared to approximately 50% in typically developing comparison groups [7], [11]. Hence, children with ASD, but without intellectual disability, also appear to have higher rates of sleep disturbances. In a recent report of young children ranging from two to five years, reports of sleep disturbances were found in a group of children with ASD at a rate of 53%, 46% for children with developmental disability, and 32% for children with typical development [12]. Collectively, previous work supports the conclusion that children with ASD are at high risk for sleep disturbances at a level beyond what is observed in their typical counterparts or those with developmental disabilities.

Given the prevalence of ASD and the often co-morbid presence of sleep disturbances, appropriate assessment methods for these sleep disturbances in children with ASD are needed. Research thus far has assessed these sleep disturbances primarily via parent report on various sleep questionnaires or sleep diary measures. A recent review of general pediatric sleep questionnaires makes a strong argument for the development of psychometrically valid instruments to move the field of pediatric sleep medicine forward as a whole [13]. One commonly employed sleep questionnaire for children included in this review is the Children’s Sleep Habits Questionnaire (CSHQ) [14]. This questionnaire has been used in children ranging from preschool age through school age [14], [15]. Furthermore, it has been used in previous research in ASD [7], [9], [16]. This measure is currently used across the 17 North American sites of the Autism Treatment Network (ATN) to systematically assess for and characterize sleep issues in a large sample of children enrolled in the ATN. Spruyt and Gozal [13] described the necessary steps towards the development of psychometrically sound measures. The sequential steps outlined included: (1) purpose of the tool; (2) research question; (3) response format; (4) generate items; (5) pilot; (6) item-analysis non-response; (7) structure; (8) reliability; (9) validity; (10) confirmatory analyses; and (11) standardize and develop norms. The CSHQ was assessed to satisfy five of the 11 steps towards psychometric validity (Steps 1, 2, 3, 8, and 9 above) [17]. Another sleep questionnaire, the Simonds and Parraga Sleep Questionnaire [18], has been less widely used in ASD. However, it was modified (MSPSQ) and used by Wiggs and colleagues [4], [19], [20] in both descriptive studies examining sleep patterns and as a treatment outcome measure in children with a range of developmental disabilities, including children with ASD. However, closer inspection of the previous work reveals varying versions of the questionnaire have been used. For example, the instrument was subjected to a factor analysis in a study of children with Down’s Syndrome, but only 12 items were included in this analysis of 91 participants [21] while Maas et al. [22] used all items but employed a seven point scale, as did Wiggs and Stores [4]. Nonetheless, this measure achieved comparable steps towards psychometric validity as the CSHQ, as outlined in the Spruyt and Gozal review [17], and in fact was assessed to meet the additional fourth step of generation of items. The MSPSQ has strong potential for clinicians to more easily address sleep disturbances in children with ASD, as it probes for more qualitative information about the nature of sleep disturbances compared to the CSHQ. In particular, items inquiring about children’s night wakings, parasomnias, and sleep disordered breathing are more detailed and specific. For example, two of the CSHQ questions related to parasomnias are: “Child awakens during the night screaming, sweating, and inconsolable,” and “Child awakens alarmed by a frightening dream.” These same questions on the MSPSQ are “Wakes during the night screaming in terror. Anxiety may be so bad that sweating, gasping or trembling may happen. This usually happens during the first half of the night. He/she is not aware of their surroundings and will not remember it the next day,” and “Wakes in the night complaining of nightmares or frightening dreams and seems quite anxious. This usually happens in the last half of the night.” This added detail helps the clinician differentiate between agitated night wakings and physiological nightmares and sleep terrors.

Additionally, the MSPSQ includes several items inquiring about previous attempts to treat sleep disturbances as well as parents’ perception of their child’s disturbances. This allows for an assessment of parents’ histories of addressing sleep disturbances as well as willingness to attempt new interventions. Additionally, open-ended questions are included that inquire about others impacted by the child’s sleep disturbances, as well as family history of sleep disturbances. Both the CSHQ and MSPSQ were of particular interest to us given their prior use in ASD. The goals of the current study were to further assess the reliability and validity of these two measures in an ASD sample. Specifically, we extended previous work by (1) developing similar subscales for the MSPSQ as previously reported for the CSHQ; (2) determining the internal consistency of the two measures in a relatively large sample of children with ASD; (3) examining the convergent validity between the MSPSQ and the CSHQ; and (4) determining the predictive validity of the MSPSQ in identifying children with ASD and co-occurring sleep disturbances.

Section snippets

ASD subjects

A total of 124 subjects with ASD (mean age = 6.58 years, SD = 3.73, range 2–16 years) completed the study. There was a preponderance of males (86.3%) compared to females. The study was approved by the University of Pittsburgh Institutional Review Board and all families signed study consent forms prior to participation. Diagnoses were established based on Diagnostic and Statistical Manual-IV Text Revision [23] (DSM-IV-TR) criteria and corroborated by the Autism Diagnostic Observation Schedule (ADOS)

Sleep measure scores

Table 3 provides means and standard deviations of the scores on the factors for both the CSHQ and MSPSQ. For the CSHQ, the mean total score was 49.06 (SD = 8.95, range 35–73). The mean total score for the MSPSQ for this sample was 67.12 (SD = 15.23, range 38–104). Of the total sample, 78% (N = 97) were identified as having a sleep disturbance based on the recommend total cutoff of 41 for the CSHQ [14]. Of this group of children identified as poor sleepers on the CSHQ, the mean MSPSQ score was 71.24

Discussion

In this sample of children with ASD, 78% were identified as having a sleep problem based on the cutoff score on the CSHQ. This is consistent with what has been reported by Couturier et al. [7] but is more than the 66% reported by Souders et al. [9]; both studies also used the CSHQ in a sample of children with ASD. This group of poor sleepers, based on the CSHQ cutoff, had a MSPSQ mean total score of 71.24 and a standard deviation of 14.16. The internal consistency findings of the subscales for

Financial disclosures

None.

Conflict of Interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2012.03.005.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

Acknowledgements

This study was supported by funding from a National Institute of Mental Health (R34 MH082882-01A2) award to the first author, Autism Speaks (Autism Treatment Network), Autism Service, Education, a Research and Training (ASERT) Grant from the Pennsylvania Bureau of Autism Services, Department of Public Welfare, and the National Institute for Research Resources (2ULRR024153-06).

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    The views expressed in this article are those of the authors and do not necessarily reflect the official position of the National Institute of Mental Health, the National Institute of Research Resources, the National Institutes of Health, or any other part of the US Department of Health and Human Services. NIMH encourages publication of results and free scientific access to data. There were no financial conflicts of interest.

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