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J Autism Dev Disord (2013) 43:956–963
DOI 10.1007/s10803-012-1639-0
ORIGINAL PAPER
Relationship Between Children’s Sleep and Mental Health
in Mothers of Children with and Without Autism
Danelle Hodge • Charles D. Hoffman
Dwight P. Sweeney • Matt L. Riggs
•
Published online: 30 August 2012
Ó Springer Science+Business Media, LLC 2012
Abstract The study employed 90 children with autism
spectrum disorders (ASDs) who were matched to 90
typically developing children on age, gender, and
ethnicity. Using structural equation modeling, maternal
sleep and maternal stress mediated the relationship
between children’s sleep and mothers’ mental health for
mothers of children with and without ASDs. Mothers of
children with ASDs reported more problems related to
children’s sleep, their own sleep, greater stress, and
poorer mental health; however, children’s sleep and
maternal sleep were more closely related to maternal
stress for mothers of typically developing children.
Implications of these findings and future directions for
research are discussed.
Keywords Autism Children’s sleep Mothers’ sleep
Mothers’ stress Mothers’ mental health
Introduction
Research suggests that rearing a child with a developmental disability may negatively impact parents’ mental
health (Montes and Halterman 2007; Stoneman 1997). For
parents of children with autistic spectrum disorders
(ASDs), this relationship was supported in a meta-analysis
of 17 studies that found that parents of children with ASDs
D. Hodge (&) C. D. Hoffman D. P. Sweeney M. L. Riggs
Department of Psychology, California State University,
5500 University Parkway, San Bernardino,
CA 92407-2397, USA
e-mail: [email protected]
123
had significantly higher rates of mental health problems
than parents of children with Down syndrome, parents of
children with mental retardation of unknown origins, or
parents of typically developing children (Yirmiya and
Shaked 2005). Recently, it has been suggested that parental
functioning, including psychiatric impairment, is related to
the sleep problems of children with ASDs (Hoffman et al.
2005, 2006; Meltzer 2011). The goal of the present study
was to examine this claim and to explore whether children’s sleep directly impacts mothers’ mental health or
whether the influence on mental health is delivered via the
impact of children’s sleep on the potential mediating
variables of maternal sleep and maternal stress.
Sleep problems are more common among children
with ASDs than among typically developing children
(Krakowiak et al. 2008; Souders et al. 2009; Sivertsen et al.
2012). Research has also shown that parents’ mental health
is associated with the sleep difficulties of typically developing children (Lam et al. 2003; Shang et al. 2006) and
children with ASDs (Meltzer 2011). Although the direction
of any causal relationship between children’s sleep problems and parents’ psychological well-being has not been
conclusively determined, Lam et al. (2003) found that
maternal depression scores, taken when infants were
6–12 months old, did not predict children’s sleep problems
at age 3–4 years. Importantly, in these same mother–child
dyads, children’s sleep problems at age 3–4 years did
predict maternal depression measured at the same time.
This finding suggests that maternal depression is a consequence, rather than a cause, of children’s sleep difficulties.
Moreover, researchers have determined that improvements
in the sleep of typically developing children can lead to
significant improvements in parents’ psychological wellbeing (Hauck et al. 2012; Lam et al. 2003; Hiscock et al.
2008; Mindell et al. 2009).
J Autism Dev Disord (2013) 43:956–963
It may be that the poor quality of children’s sleep
impairs the quality of mothers’ sleep and, consequently,
contributes to higher rates of psychopathology in these
same parents. This speculation is based on the fact that
the quality of parents’ sleep is related to the sleep-quality
of their disabled and non-disabled children (LopezWagner et al. 2008). Additionally, because the sleep of
children with ASDs is more impaired than the sleep of
typically developing children (Krakowiak et al. 2008;
Souders et al. 2009; Sivertsen et al. 2012), it is not
surprising that parents of children with ASDs report more
impaired sleep than parents of typically developing
children (Lopez-Wagner et al. 2008; Schreck et al. 2004).
Thus, the poorer quality of sleep reported by parents of
children with ASDs may contribute to their higher rates
of psychopathology.
Another means by which children’s sleep difficulties
may contribute to parental psychopathology is via the
relationship between sleep and stress. This is in line with
evidence indicating that for parents of children with
developmental disabilities, children’s sleep difficulties are
positively correlated with parental stress (Byars et al. 2011;
Doo and Wing 2006) and that sleep-related behaviors in
intellectually disabled children are particularly stressful to
their parents (Richdale et al. 2000). Furthermore, research
has found that after controlling for maternal sleep and level
of autistic severity, the sleep problems of children with
ASDs continue to predict maternal stress (Hoffman et al.
2008). Similarly, treating children’s sleep problems is
associated with decreased maternal stress for mothers of
typically developing children (Eckerberg 2004; Reid et al.
1999) and mothers of children with severe intellectual
disabilities (Wiggs and Stores 2001). Based on the relationship between stress and mental health (Monroe and
Simons 1991; Zubin and Spring 1977; Zuckerman 1999),
we might expect parents of children with ASDs to report
poorer mental health.
Evidence supports two potential mechanisms via which
children’s sleep may contribute to psychopathology in
parents. Via one mechanism, children’s sleep difficulties
may be impairing parental sleep, which contributes to
poorer parental mental health. An alternate mechanism is
one in which, children’s sleep problems increase parental
stress, which, then contributes to poorer mental health. The
current study extends prior research in this area by testing a
model, depicted in Fig. 1, in which both direct and indirect
paths from the child’s sleep habits to maternal mental
health through maternal stress and sleep-quality are
hypothesized. In testing this model, the present study also
controlled for the level of autistic impairment in participants with ASDs. This precaution is necessary because the
challenging behavioral characteristics of children with
ASDs are correlated with their sleep difficulties (Hoffman
957
et al. 2005; Schreck et al. 2004), maternal stress (Lecavalier et al. 2006), and maternal psychological well-being
(Abbeduto et al. 2004). The analysis also tested for a
possible moderation effect. That is, we hypothesized that
the strength of some path coefficients (direct or indirect)
may differ depending upon whether the data are from
parents of children with ASDs or parents of typically
developing children.
The Model Proposes the Following Hypotheses
Hypothesis One
Direct effects will exist for each sample (ASD and nonASD) between child’s sleep habits and both maternal
parenting stress and maternal sleep quality (Fig. 1 paths A1
and A2). In turn direct effects will exist for each group
between both maternal sleep and stress and the ultimate
criterion of maternal mental health (Fig. 1 paths B1 and
B2).
Hypothesis Two
It was predicted that for mothers of children with ASDs
and mothers of typically developing children, maternal
parenting stress and maternal sleep quality would partially
mediate the relationship between children’s sleep problems
and maternal psychopathology (Fig. 1 path C).
Hypothesis Three
The proposed model also tested for moderation effects
based upon sample (i.e., mothers of children with ASDs
versus mothers of typically developing children). Moderation would be demonstrated if the nature of either direct or
Maternal
Parenting Stress
Maternal
Mental Health
Child’s
Sleep Habits
Maternal
Sleep Quality
Note: Direct effects indicated with solid lines.
Indirect effect indicated with a dashed line.
Fig. 1 Proposed hypothetical model of direct effects and the indirect
effect in which maternal sleep and maternal stress are the proposed
mediators, and group membership is the proposed moderator of the
relationship between children’s sleep problems and maternal mental
health
123
958
indirect (mediated) relationships in the model differs significantly between mothers of children with ASDs when
compared to mothers of typically developing children.
Because prior research has not investigated this topic, no
specific predictions were made regarding exactly where
these moderation effects might exist; consequently, differences between all path coefficients for mothers with and
without children with ASDs will be compared for significant differences in magnitude.
The present research focuses on maternal mental health
because mothers of developmentally disabled children
generally bear the primary responsibility for childcare
(Gray and Holden 1992; Heller et al. 1997) and they
experience greater impairment of their psychological
functioning than do other family members (Hastings 2003;
Piven and Palmer 1999). Further, because differences in
sleep patterns have been found across groups based on age
(Murphy et al. 2000), gender (Fredriksen et al. 2004;
Shang, et al., 2006), and ethnicity (Jean-Louis et al. 2001;
Profant et al. 2002), in the present investigation, the
comparison sample of typically developing children was
matched on these characteristics.
Method
Participants
A total of 180 mother–child dyads participated in this
research. These participants were selected from a larger
dataset of families participating in a program of research
being conducted at a treatment center located on the campus
of a university in southern California. The university’s
institutional review board approved this research. Mothers
of children with ASDs were selected for inclusion if their
children were between the ages of 4 and 12 years and
had received an independent diagnosis of autism. Ninety
mothers of children with ASD met these criteria. Diagnoses
of ASDs were made by licensed mental health professionals
(e.g., psychiatrists or psychologists). Additionally, to ensure
eligibility for the program each child was reviewed or
assessed by the referring agency according to the regulations
of the State Department of Developmental Services.
Mothers of typically developing children were selected from
a sample of more than 700 participants from the community.
From this dataset of typically developing children, the first
child to match a child with an ASD on age, ethnicity, and
gender was selected for inclusion.
Each group contained mothers of 71 boys and 19 girls.
Children’s ages ranged from 4 to 12 years. The mean age
for children with ASDs was 7.49 years and the mean age
for typically developing children was 7.43 years. In each
group 43 % of participants were Caucasian, 18 % were
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J Autism Dev Disord (2013) 43:956–963
Hispanic, and 17 % were African-American, 4 % were
Asian, 1 % were Middle Eastern, and 1 % were Native
American. The remaining 16 % of participants were selfidentified as belonging to some other ethnic group or were
of mixed ethnicity.
Materials
Materials employed in this study were selected because
they have been standardized and demonstrate strong psychometric properties. Though not all have been specifically
validated in ASD populations, each is widely used in the
ASD literature.
Gilliam Autism Rating Scale—Second Edition
(GARS-2; Gilliam 2005)
The GARS-2 was used to assess autistic symptomology
and control for the effect of level of autistic impairment.
The Communication, Stereotyped Behavior, and Social
Interaction subscales of the GARS-2 yield an Autism Index
(AI) which represents the degree of autistic symptomology.
The GARS-2 manual provides normative data from
a nationwide sample of 1,107 children and young
adults (ages 3–22 years) diagnosed with autism. Internal
reliability coefficients ranged from 0.84 to 0.94, with
test–retest reliability for the AI score reported at 0.84.
Children’s Sleep Habits Questionnaire
(CSHQ; Owens et al. 2000)
The CSHQ provides an overall measure of children’s sleep
quality (i.e., Total Sleep Disturbance scale), with higher
scores indicating more disturbed sleep. Based on a sample
of 495 elementary school children and 154 children from a
pediatric sleep clinic, internal consistency coefficients for
the entire scale were 0.68 for the community sample and
0.78 for the clinical sample. The measure demonstrates
adequate test–retest reliability, with coefficients ranging
from 0.62 to 0.79. The CSHQ is the most widely used
parent-report measure of sleep in children with ASDs
(Hodge et al. 2012).
Parenting Stress Index (PSI; Abidin 1995)
The PSI is a standardized measure designed to evaluate
stress in parent–child systems that are at risk for parenting
problems or child behavioral problems. The PSI yields a
Total Stress Score, which encompasses stress originating
from child characteristics or behavioral problems and stress
relating to parents’ functioning. The PSI was normed on a
sample of 2,633 mothers. Reliability coefficients for
J Autism Dev Disord (2013) 43:956–963
subscales of the Child Domain ranged from 0.79 to 0.93.
For the Parent Domain subscales, alphas ranged from 0.55
to 0.80. Internal consistency obtained for the entire scale
was 0.95 and test–retest reliability for Total Stress ranged
from 0.69 to 0.96.
959
analyses using the GARS-2 scores as predictor of all other
variables within the ASD sample and saving the raw
regression residuals for use in the subsequent path analysis.
Results
Pittsburgh Sleep Quality Index (PSQI; Buysse et al.
1989)
Maternal sleep was assessed using the PSQI. The PSQI
yields a global PSQI score where higher scores denote
more impaired sleep. Based on a sample of 62 patients with
primary insomnia, 54 patients with depression, and 52
healthy participants, Buysse et al. (1989) report internal
reliability of 0.83, and a test–retest reliability of 0.85. In
this population, the global PSQI score correctly identified
88.5 % of patients and controls; yielding a sensitivity of
89.6 % and specificity of 86.5 %.
The Symptom Assesment-45 Questionnaire
(SA-45; Maruish 1999)
The SA-45 was employed as a measure of maternal mental
health. The SA-45 yields a Global Severity Index which is
derived from the subscales of Somatization, Obsessive–
Compulsive, Interpersonal Sensitivity, Depression,
Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and
Psychoticism. The SA-45 was normed on a non-clinical
sample of more than 1,600 adults and adolescents, and a
clinical sample of more than 15,000 adults and adolescents
(Strategic Advantage, Inc. [SAI], 1998). Coefficients for
internal consistency range from 0.74 to 0.87 for the nonclinical participants and 0.73 to 0.91 for the clinical
participants. Test–retest reliability, for the non-clinical
sample, yielded Cronbach’s alphas in the 0.80 s (SAI
1998). Construct validity was demonstrated by Viswesvaran (2001), who reported high intercorrelations between the
SA-45 and the Symptom Checklist-90 (Derogatis et al.
1973) and the Brief Symptom Inventory (Derogatis and
Spencer 1982), each a measure of psychopathology.
Analyses
The hypothesized model was tested by means of a path
analysis, conducted using EQS software, version 6.1.
Effects were decomposed in order to assess both the direct
and indirect (mediated) effects proposed in the model.
Moderation effects were tested by stacking the models in
order to evaluate any coefficient differences between the
ASD and non-ASD samples. Because one sample had no
ASD symptoms, the variable of autism severity was controlled by running a series of preliminary regression
Table 1 presents univariate statistics and bivariate correlations for key variables. All key variables were significantly correlated. On each of these variables, mothers of
children with ASDs reported higher scores than mothers of
typically developing children. As the proposed model
represents a preliminary investigation of the relationships
between children’s sleep, maternal sleep, maternal stress,
and maternal mental health, overall assessments of these
constructs were utilized; therefore, no analyses were conducted on the subscales for any of the measures employed.
All variable met basic univariate assumptions for parametric statistics (approximating normality, absence of
extreme outliers, and independence of observation), but the
test of multivariate kurtosis (as conducted by the EQS
software) indicated a violation of this assumption for the
non-ASD sample. Consequently, results reported are based
upon the Satorra-Bentler Chi-Square and robust fit indices.
Results from the initial stacked model indicated a less
than optimal fit of the model to the covariance matrix for
the combined samples (CFI = 0.93, RMSEA = 0.08). The
Lagrange Multiplier Test for releasing constraints indicated
that the path from Child’s Sleep Habits to Maternal Parenting Stress (Fig. 1 path A1) was statistically different
between the two samples, supporting a moderation effect.
This constraint was released, and the resulting model fit the
data well (CFI = 0.98, RMSEA = 0.04). The results of
this final analysis are represented in Fig. 2. Statistically
significant coefficients are in bold. Significant moderation
effects between sample coefficients are indicated with an
asterisk (*).
All direct effects are statistically significant and moderate to large in magnitude. The paths from Child’s Sleep
Habits to Maternal Mental Health through Maternal Parenting Stress (Fig. 1 paths A1 and B1) are generally larger
than those through Maternal Sleep Quality (Fig. 1 paths A2
and B2). The strength of relationships between variables
was comparable across groups, with the exception that the
direct path from Child’s Sleep Habits to Maternal Parenting Stress for the ASD group was moderate in magnitude
(0.31) compared to a large coefficient for the non-ASD
sample (0.61). The indirect (mediated) effect between
Child’s Sleep Habits and Maternal Mental Health through
Maternal Parenting Stress and Maternal Sleep Quality was
statistically significant for both groups. Though the difference in magnitude was not statistically significant,
once again, the association was relatively larger for the
123
960
J Autism Dev Disord (2013) 43:956–963
Table 1 Univariate and bivariate statistics for key variables
CSHQ: child’s sleep
Entire sample (N = 180)
M = 45.42
SD = 9.47
Mothers of children with ASDs (N = 90)
Mothers of typically developing children (N = 90)
M = 6.50
SD = 3.95
M = 47.74
M = 7.59
SD = 10.04
SD = 4.19
M = 43.10
SD = 8.29
Mean differences by group
PSQI: mother’s sleep
t = 3.38*
d = 0.49
M = 5.41
SD = 3.39
t = 3.84*
d = 0.55
PSI: mother stress
M = 248.48
SD = 59.59
M = 279.60
SD = 48.20
M = 217.36
SD = 53.48
t = 8.20*
d = 1.04
SA-45 mother’s
mental health
M = 70.04
SD = 24.05
M = 73.36
SD = 22.61
M = 66.72
SD = 25.11
t = 1.86
d = 0.28
Correlations
CSHQ: child’s sleep
0.38*
PSQI: mother’s sleep
PSI: mother’s stress
0.53*
0.44*
0.33*
0.45*
0.61*
*p 0.001
Maternal
Parenting Stress
.61
.31*
.61
.55
.36
-.03*
.45
.26
Child’s
Sleep Habits
.29
.28
Maternal
Sleep Quality
Maternal
Mental Health
.27
.32
Satorra-Bentler χ² = 6.72; df = 5
CFI = .98
RMSEA = .04
Note: Top Coefficient = Community Control Sample
Bottom Coefficient = Autism Sample
Statistically significant coefficients in bold
Significant moderation indicated with *
Fig. 2 Results from the path analysis of the hypothesized model
non-ASD group (0.45) compared to that of the ASD sample
(0.26). A difference of …
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