Journal of Autism and Developmental Disorders

, Volume 48, Issue 8, pp 2629–2641 | Cite as

Modification of the Children’s Sleep Habits Questionnaire for Children with Autism Spectrum Disorder

  • Terry KatzEmail author
  • Amy M. Shui
  • Cynthia R. Johnson
  • Amanda L. Richdale
  • Ann M. Reynolds
  • Lawrence Scahill
  • Beth A. Malow
Original Paper


Sleep problems are common in children with autism spectrum disorder (ASD) and adversely impact daytime functioning. Although no questionnaires have been developed to assess sleep in children with ASD, the 33-item Children’s Sleep Habits Questionnaire (CSHQ) is widely used in this population. We examined the factor structure of the CSHQ in 2872 children (age 4–10 years) enrolled in the Autism Treatment Network. A four-factor solution (Sleep Initiation and Duration, Sleep Anxiety/Co-Sleeping, Night Waking/Parasomnias, and Daytime Alertness) with 5–6 items per factor explained 75% of the total variation. Ten items failed to load on any factor. This abbreviated 23-item four-factor version of this measure may be useful when assessing sleep in children with ASD.


Autism spectrum disorder Children’s Sleep Habits Questionnaire Sleep measures Insomnia Parental report 



This research was conducted as part of the Autism Speaks Autism Treatment Network and the Autism Intervention Research Network on Physical Health. Main 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. or The Maternal and Child Health Bureau.

Author Contributions

TK, AMS, CRJ, ALR, AMR, LS, and BAM worked on the conceptualization and design of the study, plan of analysis, interpretation of results, initial draft and revisions of the manuscript, and approval of the final manuscript as submitted. AMS completed all statistical analyses.

Compliance with Ethical Standards

Conflict of interest

Dr. Katz declares that she has no conflict of interest. Ms. Shui declares that she has no conflict of interest. Dr. Johnson declares that she has no conflict of interest. Dr. Richdale declares that she has no conflict of interest. Dr. Reynolds declares that she has no conflict of interest. Dr. Scahill has served as a consultant to Neuren, Supernus, Shire, Bracket and CB Partners. He receives book royalties from Oxford and Guilford. Dr. Malow declares that she has no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th edn., text rev.). Washington, DC: Author.Google Scholar
  2. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders. (5th edn.). Washington, DC: Author.CrossRefGoogle Scholar
  3. Baglin, J. (2014). Improving your exploratory factor analysis for ordinal data: A demonstration using FACTOR. Practical Assessment, Research and Evaluation (a peer-reviewed electronic journal), Vol. 19, no. 5, Accessed January, 12, 2017.
  4. Benabou, M., Rolland, T., Leblond, C. S., Millot, G. A., Huguet, G., Delorme, R., … Bourgeron, T. (2017). Heritability of the melatonin synthesizes variability in autism spectrum disorders. Scientific Reports, 7(1), 17746.CrossRefPubMedPubMedCentralGoogle Scholar
  5. Bentler, P. (2007). On tests and indices for evaluating structural models. Personality and Individual Differences, 42, 825–829.CrossRefGoogle Scholar
  6. Bentler, P. M. (1990). Comparative fit indexes in structural models. Psychological Bulletin, 107(2), 238–246.CrossRefPubMedGoogle Scholar
  7. Bentler, P. M., & Chou, C. P. (1987). Practical issues in structural modeling. Sociological Methods and Research, 16, 78–117.CrossRefGoogle Scholar
  8. Bernstein, I. H., & Teng, G. (1989). Factoring items and factoring scales are different: Spurious evidence for multidimensionality due to item categorization. Psychological Bulletin, 105(3), 467–477.CrossRefGoogle Scholar
  9. Bollen, K. A., & Long, J. S. (1993). Introduction. In K. Bollen & J. Long (Eds.), Testing Structural Equation Models (pp. 1–9). Newbury Park, CA: Sage.Google Scholar
  10. Bonuck, K. A., Goodlin-Jones, B. L., Schechter, C., & Owens, J. (2017). Modified Children’s Sleep Habits Questionnaire for behavioral sleep problems: A validation study. Sleep Health, 3, 136–141.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. Bollen & J. Long (Eds.), Testing structural equation models (pp. 136–162). Newbury Park, CA: Sage.Google Scholar
  12. Charrier, A., Olliac, B., Roubertoux, P., & Tordjman, S. (2017). Clock genes and altered sleep-wake rhythms: Their role in the development of psychiatric disorders. International Journal of Molecular Sciences, 18(5), 938.CrossRefPubMedCentralGoogle Scholar
  13. Chen, F., Curran, P. J., Bollen, K. A., Kirby, J., & Paxton, P. (2008). An empirical evaluation of the use of fixed cutoff points in RMSEA test statistic in structural equation models. Social Methods Research, 36(4), 462–494.CrossRefGoogle Scholar
  14. Chervin, R. D., Weatherly, R. A., Garetz, S. L., Ruzicka, D. L., Giordani, B. J., Hodges, E. K., … Guire, K. E. (2007). Pediatric sleep questionnaire: Prediction of sleep apnea and outcomes. Archives of Otolaryngology–Head and Neck Surgery, 133(3), 216–222.CrossRefPubMedGoogle Scholar
  15. Corbett, B. A., Schupp, C. W., Levine, S., & Mendoza, S. (2009). Comparing cortisol, stress, and sensor sensitivity in children with autism. Autism Research, 2(1), 39–49.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Coury, D. (2010). Medical treatment of autism spectrum disorders. Current Opinion in Neurology, 23(2), 131–136.CrossRefPubMedGoogle Scholar
  17. Couturier, J. L., Speechley, K. N., Steele, M., Norman, R., Stringer, B., & Nicolson, R. (2005). Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: Prevalence, severity, and pattern. Journal of the American Academy of Child and Adolescent Psychiatry, 44(8), 815–822.CrossRefPubMedGoogle Scholar
  18. Elder, G. J., Wetherell, M. A., Barclay, N. L., & Ellis, J. G. (2014). The cortisol awakening response–applications and implications for sleep medicine. Sleep Medicine Reviews, 18, 215–224.CrossRefPubMedGoogle Scholar
  19. Elrod, M. G., & Hood, B. S. (2015). Sleep differences among children with autism spectrum disorders and typically developing peers: A meta-analysis. Journal of Developmental and Behavioral Pediatrics, 36(3), 166–177.CrossRefPubMedGoogle Scholar
  20. Fadini, C. C., Lamônica, D. A., Fett-Conte, A. C., Osório, E., Zuculo, G. M., Giacheti, C. M., & Pinato, L. (2015). Influence of sleep disorders on the behavior of individuals with autism spectrum disorder. Frontiers in Human Neuroscience, 9, 347.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Garrido, L. E., Abad, F. J., & Ponsoda, V. (2013). A new look at Horn’s parallel analysis with ordinal variables. Psychological Methods, 18(4), 454–474.CrossRefPubMedGoogle Scholar
  22. Goldman, S. E., Richdale, A. L., Clemons, T., & Malow, B. A. (2012). Parental sleep concerns in autism spectrum disorders: Variations from childhood to adolescence. Journal of Autism and Developmental Disorders, 42(4), 531–538.CrossRefPubMedGoogle Scholar
  23. Goldman, S. E., Surdyka, K., Cuevas, R., Adkins, K., Wang, L., & Malow, B. A. (2009). Defining the sleep phenotype in children with autism. Developmental Neuropsychology, 34(5), 560–573.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Goodlin-Jones, B. L., Tang, K., Liu, J., & Anders, T. F. (2008). Sleep patterns in preschool-age children with autism, developmental delay, and typical development. Journal of the American Academy of Child and Adolescent Psychiatry, 47(8), 930–938.CrossRefPubMedGoogle Scholar
  25. Hayduk, L. A., & Glaser, D. N. (2000). Jiving the four-step, waltzing around factor analysis, and other serious fun. Structural Equation Modeling, 7, 1–35.CrossRefGoogle Scholar
  26. Holgado-Tello, F. P., Chacón-Moscoso, S., Barbero-García, I., & Vila-Abad, E. (2008). Polychoric versus pearson correlations in exploratory and confirmatory factor analysis of ordinal variables. Quality and Quantity, 44(1), 153–166.CrossRefGoogle Scholar
  27. Honomichl, R. D., Goodlin-Jones, B. L., Burnham, M., Gaylor, E., & Anders, T. F. (2002). Sleep patterns of children with pervasive developmental disorders. Journal of Autism and Developmental Disorders, 32(6), 553–561.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55.CrossRefGoogle Scholar
  29. Humphreys, J. S., Gringras, P., Blair, P. S., Scott, N., Henderson, J., Fleming, P. J., & Emond, A. M. (2014). Sleep patterns in children with autistic spectrum disorders: A prospective cohort study. Archives of Disease in Childhood, 99(2), 114–118.CrossRefPubMedGoogle Scholar
  30. Johnson, C. R., DeMand, A., Lecavalier, L., Smith, T., Aman, M., Foldes, E., & Scahill, L. (2016). Psychometric properties of the Children’s Sleep Habits Questionnaire in children with autism spectrum disorder. Sleep Medicine, 20, 5–11.CrossRefPubMedGoogle Scholar
  31. Li, S. H., Jin, X. M., Shen, X. M., Wu, S. H., Jiang, F., Yan, C. H., … Qiu, Y. L. (2007). Development and psychometric properties of the Chinese version of Children’s Sleep Habits Questionnaire. Zhonghua Er Ke Za Zhi, 45(3), 176–180.PubMedGoogle Scholar
  32. Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism diagnostic observation schedule, second edition (ADOS-2) manual (Part I): Modules 1–4. Torrance, CA: Western Psychological Services.Google Scholar
  33. Malow, B. A., Adkins, K. W., Reynolds, A., Weiss, S. K., Loh, A., Fawkes, D., … Clemons, T. (2014). Parent-based sleep education for children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 44(1), 216–228.CrossRefPubMedGoogle Scholar
  34. Marsh, H. W., Hau, K., & Wen, Z. (2004). In search of golden rules: Comment on hypothesis-testing approaches to setting cutoff values for fit indexes and dangers in overgeneralizing Hu and Bentler’s 1999 findings. Structural Equation Modeling, 11, 320–341.CrossRefGoogle Scholar
  35. May, T., Cornish, K., Conduit, R., Rajaratnam, S. M., & Rinehart, N. J. (2015). Sleep in high-functioning children with autism: Longitudinal developmental change and associations with behavior problems. Behavioral Sleep Medicine, 13(1), 2–18.CrossRefPubMedGoogle Scholar
  36. Mazurek, M. O., Lu, F., Symecko, H., Butter, E., Bing, N. M., Hundley, R. J., … Handen, B. L. (2017). A prospective study of the concordance of DSM-IV and DSM-5 diagnostic criteria for autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(9), 2783–2794.CrossRefPubMedGoogle Scholar
  37. Mazurek, M. O., & Petroski, G. F. (2015). Sleep problems in children with autism spectrum disorder: Examining the contributions of sensory over-responsivity and anxiety. Sleep Medicine, 16(2), 270–279.CrossRefPubMedGoogle Scholar
  38. Mazurek, M. O., & Sohl, K. (2016). Sleep and behavioral problems in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46(6), 1906–1915.CrossRefPubMedGoogle Scholar
  39. Melke, J., Goubran-Botros, H., Chaste, P., Betancur, C., Nygren, G., Anckarsäter, H., … The PARIS study (2008). Abnormal melatonin synthesis in autism spectrum disorders. Molecular Psychiatry, 13(1), 90–98.CrossRefPubMedGoogle Scholar
  40. Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd edn.). New York: McGraw-Hill.Google Scholar
  41. Olsson, U. (1979). Maximum likelihood of the polychoric correlation coefficient. Psychometrika, 44, 443–460.CrossRefGoogle Scholar
  42. Owens, J. A., Spirito, A., & McGuinn, M. (2000). The Children’s Sleep Habits Questionnaire (CSHQ): Psychometric properties of a survey instrument for school-aged children. Sleep, 23(8), 1043–1051.CrossRefPubMedGoogle Scholar
  43. Paavonen, E. J., Vehkalahti, K., Vanhala, R., Von Wendt, L., Nieminen-von Wendt, T., & Aronen, E. T. (2008). Sleep in children with asperger syndrome. Journal of Autism and Developmental Disorders, 38(1), 41–51.CrossRefPubMedGoogle Scholar
  44. Patzold, L., Richdale, A. L., & Tonge, B. (1998). An investigation into sleep characteristics of children with autism and asperger’s disorder. Journal of Paediatrics and Child Health, 34(6), 528–533.CrossRefPubMedGoogle Scholar
  45. Polimeni, M. A., Richdale, A. L., & Francis, A. J. (2005). A survey of sleep problems in autism, asperger’s disorder and typically developing children. Journal of Intellectual Disability Research, 49(4), 260–268.CrossRefPubMedGoogle Scholar
  46. Reynolds, A. M., & Malow, B. A. (2011). Sleep and autism spectrum disorders. Pediatric Clinics of North America, 58(3), 685–698.CrossRefPubMedGoogle Scholar
  47. Richdale, A. L., & Baglin, C. L. (2015). Self-report and caregiver-report of sleep and psychopathology in children with high-functioning autism spectrum disorder: A pilot study. Developmental Neurorehabilitation, 18(4), 272–279.CrossRefPubMedGoogle Scholar
  48. Richdale, A. L., & Prior, M. R. (1995). The sleep/wake rhythm in children with autism. European Child and Adolescent Psychiatry, 4(3), 175–186.CrossRefPubMedGoogle Scholar
  49. Richdale, A. L., & Schreck, K. A. (2009). Sleep problems in autism spectrum disorders: Prevalence, nature, and possible biopsychosocial aetiologies. Sleep Medicine Reviews, 13(6), 403–411.CrossRefPubMedGoogle Scholar
  50. Rodenbeck, A., Heuther, G., Rüther, E., & Hajak, G. (2002). Interactions between evening and nocturnal cortisol secretion and sleep parameters in patients with severe chronic primary insomnia. Neuroscience Letters, 324, 159–163.CrossRefPubMedGoogle Scholar
  51. Sass, D. A., & Schmitt, T. A. (2010). A comparative investigation of rotation criteria within exploratory factor analysis. Multivariate Behavioral Research, 45(1), 73–103.CrossRefPubMedGoogle Scholar
  52. Scahill, L., Bearss, K., Lecavalier, L., Smith, T., Swiezy, N., Aman, M. G., … Johnson, C. (2016). Effect of parent training on adaptive behavior in children with autism spectrum disorder and disruptive behavior: Results of a randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 55(7), 602–609.CrossRefPubMedGoogle Scholar
  53. Schlarb, A. A., Schwerdtle, B., & Hautzinger, M. (2010). Validation and psychometric properties of the German version of the Children’s Sleep Habits Questionnaire (CSHQ-DE). Somnologie, 14(4), 60–266.CrossRefGoogle Scholar
  54. Sikora, D. M., Johnson, K., Clemons, T., & Katz, T. (2012). The relationship between sleep problems and daytime behavior in children of different ages with autism spectrum disorders. Pediatrics, 130(Supplement 2), S83–S90.CrossRefPubMedGoogle Scholar
  55. Silva, F. G., Silva, C. R., Braga, L. B., & Neto, A. S. (2014). Portugese Children’s Sleep Habits Questionnaire—validation and cross-cultural comparison. Jornal de Pediatria (Versao em Portugues), 90(1), 78–84.CrossRefGoogle Scholar
  56. Sneddon, P., Peacock, G. G., & Crowley, S. L. (2013). Assessment of sleep problems in preschool aged children: An adaptation of the Children’s Sleep Habits Questionnaire. Behavioral Sleep Medicine, 11(4), 283–296.CrossRefPubMedGoogle Scholar
  57. Souders, M. C., Mason, T. B., Valladares, O., Bucan, M., Levy, S. E., Mandell, D. S., … Pinto-Martin, J. (2009). Sleep behaviors and sleep quality in children with autism spectrum disorders. Sleep, 32(12), 1566–1578.CrossRefPubMedPubMedCentralGoogle Scholar
  58. Souders, M. C., Zavodny, S., Eriksen, W., Sinko, R., Connell, J., Kerns, C., … Pinto-Martin, J. (2017). Sleep in children with autism spectrum disorder. Current Psychiatry Reports, 19(6), 34.CrossRefPubMedPubMedCentralGoogle Scholar
  59. Spruyt, K., & Gozal, D. (2011). Development of pediatric sleep questionnaires as diagnostic or epidemiological tools: A brief review of dos and don’ts. Sleep Medicine Review, 15(1), 7–17.CrossRefGoogle Scholar
  60. Steiger, J. H. (2000). Point estimation, hypothesis testing, and interval estimation using the RMSEA: Some comments and a reply to Hayduk and Glaser. Structural Equation Modeling, 7, 149–162.CrossRefGoogle Scholar
  61. Steiger, J. H., & Lind, J. C. (1980). Statistically based tests for the number of common factors. Paper presented at the annual meeting of the Psychometric Society, Iowa, City, IA.Google Scholar
  62. Steur, L. M. H., Visser, E. H., Grootenhuis, M. A., Terwee, C. B., Kaspers, G. J. L., & van Litsenburg, R. R. L. (2017). Psychometric properties and Dutch norm values of the Children’s Sleep Habits Questionnaire in toddlers. Sleep Medicine, 34, 57–63.CrossRefPubMedGoogle Scholar
  63. Streiner, D. L., & Norman, G. R. (2008). Health measurement scales: A practical guide to their development and use (4th edn.). Oxford: Oxford University Press.CrossRefGoogle Scholar
  64. Tanaka, J. S. (1993). Multifaceted conceptions of fit in structural equation models. In K. Bollen & J. Long (Eds.), Testing structural equation models (pp. 10–40). Newbury Park, CA: Sage.Google Scholar
  65. Taylor, J. L., & Corbett, B. A. (2014). A review of rhythm and responsiveness of cortisol in individuals with autism spectrum disorders. Psychoneuroendocrinology, 49, 207–228.CrossRefPubMedPubMedCentralGoogle Scholar
  66. Taylor, M. A., Schreck, K. A., & Mulick, J. A. (2012). Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders. Research in Developmental Disabilities, 33(5), 1408–1417.CrossRefPubMedGoogle Scholar
  67. Thorpy, M. J. (1990). International classification of sleep disorders. Diagnostic and coding manual. Diagnostic classification steering committee. Rochester, MN: American Sleep Disorder Association.Google Scholar
  68. Timmerman, M. E., & Lorenzo-Seva, U. (2011). Dimensionality assessment of ordered polytomous items with parallel analysis. Psychological Methods, 16(2), 209–220.CrossRefPubMedGoogle Scholar
  69. Veatch, O. J., Pendergast, J. S., Allen, M. J., Leu, R. M., Johnson, C. H., Elsea, S. H., & Malow, B. A. (2015). Genetic variation in melatonin pathway enzymes in children with autism spectrum disorder and comorbid sleep onset delay. Journal of Autism and Developmental Disorders, 45(1), 100–110.CrossRefPubMedPubMedCentralGoogle Scholar
  70. Wang, G., Liu, Z., Xu, G., Jiang, F., Lu, N., Baylor, A., & Owens, J. (2016). Sleep disturbances and associated factors in Chinese children with autism spectrum disorder: A retrospective and cross-sectional study. Child Psychiatry and Human Development, 47(2), 248–258.CrossRefPubMedGoogle Scholar
  71. Waumans, R. C., Terwee, C. B., Van den Berg, G., Knol, D. L., Van Litsenburg, R. R., & Gemke, R. J. (2010). Sleep and sleep disturbance in children: Reliability and validity of the Dutch version of the child sleep habits Questionnaire. Sleep, 33(6), 841–845.CrossRefPubMedPubMedCentralGoogle Scholar
  72. Wiggs, L., & Stores, G. (2004). Sleep patterns and sleep disorders in children with autistic spectrum disorders: Insights using parent report and actigraphy. Developmental Medicine and Child Neurology, 46(6), 372–380.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PediatricsUniversity of Colorado Denver School of MedicineAuroraUSA
  2. 2.Biostatistics CenterMassachusetts General HospitalBostonUSA
  3. 3.STAR Center for ASD & NDDs, Department of PsychiatryUniversity of CaliforniaSan FranciscoUSA
  4. 4.Department of Clinical and Health PsychologyUniversity of FloridaGainesvilleUSA
  5. 5.Olga Tennison Autism Research Centre, School of Psychology and Public HealthLa Trobe UniversityMelbourneAustralia
  6. 6.Marcus Autism CenterEmory University School of MedicineAtlantaUSA
  7. 7.Sleep Disorders Division, Department of NeurologyVanderbilt University School of MedicineNashvilleUSA

Personalised recommendations