Correlation between sleep problems and physical activity in children with autism spectrum disorder

Introduction

Autism spectrum disorder (ASD) comprises a group of heterogeneous neurodevelopmental disorders characterized primarily by social communication deficits and restricted, repetitive patterns of behavior. The global prevalence of ASD has been increasing, with recent estimates of as high as 1 in 31 children (1). Comorbidities are common, with sleep problems being particularly prevalent, affecting an estimated 50% to 80% of children with ASD (2-4). These disturbances—which include difficulties in initiating sleep, frequent nocturnal awakenings, and reduced total sleep duration—are significantly more severe than those in their typically developing peers (5,6). Adequate sleep is crucial for brain development and cognitive function.

Similarly, regular physical activity (PA) is a cornerstone of healthy physical and psychological development (7). However, children with ASD consistently demonstrate lower levels of PA, often attributed to motor skill impairments and social-behavioral challenges, which in turn elevates their risk for conditions like obesity (8). Although PA has been shown to improve executive function (9), social communication (10) and sleep in this population (11), research specifically examining the link between specific PA intensities and the full profile of sleep disturbances in newly diagnosed, intervention-naive children with ASD is limited.

Therefore, this study aims to systematically investigate the relationship between sleep problems and PA status in children with ASD, with the goal of providing scientific evidence to inform effective, family-centered interventions. This relationship is best understood through the ‘24-hour movement framework,’ where sleep and PA are viewed as codependent behaviors that collectively influence neurodevelopmental outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0071/rc).

Methods

Participants

This cross-sectional study enrolled 312 children newly diagnosed with autism spectrum disorder (ASD) at the Department of Developmental-Behavioral Pediatrics of the Children’s Hospital, Zhejiang University School of Medicine, between January and December 2024. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Children’s Hospital, Zhejiang University School of Medicine (No. 2025-IRB-0293). Written informed consent has been obtained from all participants’ legal guardians prior to participation in this study.

Inclusion criteria

(I) Aged 2.5–12 years; (II) met the diagnostic criteria for ASD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5); (III) no prior professional ASD intervention before the initial diagnosis; and (IV) informed consent provided by parents or legal guardians.

Exclusion criteria

Children with cerebral palsy, visual or hearing impairments, Down syndrome, epilepsy, or fragile X syndrome, other psychiatric disorders or organic brain diseases. And, currently receiving pharmacological treatment for sleep (e.g., melatonin, sedatives) or psychotropic medications.

Assessment of PA

PA was assessed using a structured parent-report questionnaire adapted from World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) activity definitions for children. PA data were reported by the guardians or primary caregivers of the enrolled children. The assessment captured the following dimensions of PA based on typical daily activities:

• Average daily PA (APA) duration: this referred to the total time spent in various physical activities per day, including foundational movements such as walking, running, jumping, throwing, and kicking.
• Moderate-intensity PA (MPA) duration: this was defined as the time devoted to activities that induce a noticeable increase in heart rate and breathing, examples of which included cycling, brisk walking, dancing, stair climbing, swimming, and gymnastics.
• Vigorous-intensity PA (VPA) duration: this encompassed the time spent in activities that result in substantial increases in heart rate and breathing, such as running, rollerblading, rope skipping, mountain climbing, martial arts, and the long jump.

Assessment of sleep problems

Sleep problems were assessed using the Children’s Sleep Habits Questionnaire (CSHQ), a parent-report instrument designed to screen for sleep disturbances in children. The CSHQ is a widely recognized tool for screening sleep disturbances in the ASD population, with demonstrated high reliability and validity in previous clinical studies. Parents or primary caregivers completed the CSHQ to evaluate their child’s sleep habits over the previous week. The questionnaire comprises 41 items, of which 33 are scored across eight subscales: bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night wakings, parasomnias, sleep-disordered breathing, and daytime sleepiness. Each item is rated on a 3-point Likert scale based on the frequency of specific sleep behaviors, with higher scores reflecting more severe disturbances. The total score ranges from 33 to 99, and a score of ≥41 was used as the cutoff to identify the presence of significant sleep problems in this study.

Quality control

To ensure the reliability and consistency of the study, a rigorous quality control protocol was implemented. All clinical diagnoses and assessments were conducted by experienced clinicians from the Department of Developmental-Behavioral Pediatrics at the Children’s Hospital of Zhejiang University School of Medicine. Prior to the study, all participating clinicians received unified, standardized training to ensure consistent evaluation procedures. Following each assessment, a dual-person verification process was carried out to guarantee the completeness and accuracy of the collected data. Finally, each diagnosis of ASD was systematically reviewed and confirmed within the hospital’s clinical database.

Statistical analysis

Statistical analysis was conducted using SPSS software (version 22.0; IBM Corp., Armonk, NY, USA). Categorical data are summarized as numbers and percentages (n, %). Continuous variables are presented as mean ± standard deviation (SD), provided they followed a normal distribution; otherwise, non-normally distributed continuous data are expressed as median with interquartile range. Analysis of variance (ANOVA) was applied to compare sleep parameters across different daily exercise durations. The associations among various sleep dimensions were assessed using Pearson correlation analysis. Spearman’s rank correlation was employed to examine the relationships between PA levels (including daily exercise duration and intensity) and sleep dimensions. A two-sided P value of less than 0.05 was considered statistically significant.

Results

Demographic characteristics and PA status

A total of 312 children with ASD were included in this study. The sample comprised 262 boys (84.0%) and 50 girls (16.0%), with a mean age of 4.69 years. A history of preterm birth was reported for 39 children (12.5%). In terms of family socioeconomic status, over 70% of the parents had attained an education level of an associate degree or above, and the majority of families reported a monthly post-tax household income exceeding 10,000 RMB. The investigation into PA levels showed that 57.7% of the children engaged in an average of 1–3 hours of exercise daily. However, in terms of intensity, 81.4% of the participants performed less than one hour of MPA per day, and 77.9% engaged in VPA for less than 0.5 hours daily. The detailed demographic and clinical characteristics of the participants are summarized in Table 1.

Comparison of sleep status across different daily exercise durations

To address developmental differences, the sample was stratified into toddlers (2.5–3 years, n=130) and school-aged children (4–12 years, n=182), indicating that the overall low-compliance rate was driven primarily by the older age group, for whom the 60-minute MVPA guideline is applicable. While total APA was similar, school-aged children were significantly less likely to meet the 60-minute MVPA recommendation compared to the active play levels of the younger group (P<0.05). Comparative analysis using ANOVA demonstrated that among the various dimensions of the CSHQ, only bedtime habits showed a statistically significant difference across groups with varying daily exercise durations (F=3.898, P=0.02). Notably, as the daily exercise duration increased, scores for bedtime habit problems showed a downward trend, suggesting that increased PA may mitigate issues related to sleep-related behaviors. No significant differences were observed across other dimensions, such as sleep anxiety, night wakings, or the total CSHQ score, in relation to exercise duration (P>0.05) (Table 2).

Correlation analysis between PA and sleep problems

The average daily physical activity (APA) duration demonstrated a significant positive correlation with bedtime habits (r=0.144, P<0.05). In contrast, the average daily moderate-intensity physical activity (MPA) duration was negatively correlated with both daytime sleepiness (r=−0.156, P<0.001) and the total CSHQ score (r=−0.114, P<0.05). However, no significant correlations were observed between vigorous-intensity physical activity (VPA) duration and any of the sleep dimensions or the total CSHQ score (P>0.05). Correlation analyses are summarized in Table 3.

Discussion

Association between sleep problems and PA in children with ASD

This study found that over 40% of children with ASD engaged in less than one hour of moderate-to-vigorous physical activity (MVPA) per day on average. However, it is important to note that for children under age 5, guidelines prioritize total active play throughout the day rather than a specific hour of MVPA. This finding is concerning, as the Physical Activity Guidelines for Americans recommend that children should engage in at least 1 hour of MVPA daily for optimal health (12). Despite the known benefits of regular PA, previous literature suggests that most children fail to meet these minimum daily recommendations (13). Our analysis further demonstrated that average daily exercise duration in children with ASD was positively correlated with bedtime habit scores, while moderate-intensity exercise duration was negatively correlated with both daytime sleepiness and the total CSHQ score. While existing research generally suggests that regular PA exerts a positive influence on sleep quality and duration in children (11,14), a recent systematic review indicates that the relationship between PA and sleep is complex and bidirectional. This relationship exhibits significant daily variability and is influenced by individual differences as well as the frequency, intensity, duration, and type of activity (15). However, evidence suggests that achieving optimal child health requires a balance of appropriate levels of PA, screen time, and sleep duration. For example, while these specific benchmarks do not apply to the toddler subgroup (aged 2.5–3 years), Canada published the “24-Hour Movement Guidelines for Children and Youth Aged 5-17” in 2016, recommending that children aged 5 to 13 engage in 260 minutes of MVPA daily, limit recreational screen time to no more than 2 hours per day, and get 9 to 11 hours of sleep per night (16). While objective measures provide precise data on movement intensity, parent-reported tools like the CSHQ and our PA questionnaire capture the behavioral and habitual aspects of a child’s routine that may be less apparent in short-term device-based tracking. Our cross-sectional data provide a broader epidemiological snapshot of these correlations in a large, newly diagnosed sample. This highlights the potential of PA as a foundational lifestyle factor that aligns with the outcomes of more intensive clinical interventions.

Common interventions for comorbid sleep disorders in children with ASD

Although the etiology of sleep disturbances in children with ASD remains incompletely understood, several interventions have been identified as potential strategies to improve their sleep problems. Previous studies, including our own, have demonstrated that supplementation with melatonin, zinc, iron, and certain dietary supplements can be beneficial (2). Other interventions, such as GABA, are also considered potential methods for improving sleep in children with ASD (17). However, regarding specific treatment strategies for sleep problems in children with ASD, research indicates that clinicians should educate parents on strategies to improve sleep habits and prioritize behavioral interventions as the first-line treatment. If behavioral strategies prove ineffective after addressing relevant co-existing conditions and medications, melatonin supplementation should be considered, with attention to starting at a low dose (18). Another study also found functional behavioral analysis-based interventions effective for sleep problems in children with ASD (19). As an effective lifestyle intervention, PA programs are low-cost, easy to implement, and provide an enjoyable, child-friendly approach. Recent research indicates that PA interventions can substantially improve general sleep problems. Compared to no-treatment control groups, these interventions show positive effects on sleep resistance, sleep efficiency, number of nighttime awakenings, and total sleep duration (11,20). Additionally, a 12-week morning running intervention (twice weekly, 30 minutes per session) demonstrated positive effects on sleep efficiency in children with ASD and increased melatonin levels (21). A potential explanation is that PA improves sleep quality by influencing circadian rhythms and promoting melatonin production. Furthermore, the implementation of these common interventions must account for the individual clinical heterogeneity of children with ASD. For instance, children with higher ASD severity often exhibit significant sensory hypersensitivities, which may lead to oral aversion or difficulties in swallowing pills and supplements. Such sensory barriers can limit the compliance and effectiveness of pharmacological treatments. In this context, PA emerges as a crucial non-pharmacological alternative, as it is non-invasive and less likely to be hindered by the sensory or behavioral challenges common in more severe cases.

Limitations and future perspectives

There are several limitations in this study. First, the cross-sectional design precludes the determination of a causal relationship between PA and sleep; to better clarify the directionality and causal nature of the relationship between PA and sleep, future research should employ more robust longitudinal designs. Specifically, prospective cohort studies could track changes in sleep patterns alongside developmental shifts in PA levels over time. Furthermore, randomized controlled intervention studies (e.g., structured exercise programs) are needed to determine whether increasing PA intensity directly leads to improvements in specific sleep dimensions in children with ASD. Second, the PA data were parent-reported, which may introduce recall bias. The reliance on parent-reported questionnaires rather than objective measures, such as accelerometry, is a limitation. In the current study, objective measures were not employed primarily due to the large sample size and the significant practical burden they would place on families of newly diagnosed children, as well as the associated high costs. Subsequent research should utilize wearable objective devices (e.g., actigraphy) to obtain more precise PA metrics. Third, our study sample was recruited from a single specialized hospital in China, which may limit the generalizability of the findings to other geographical regions or diverse cultural and socioeconomic contexts. Children with ASD in different settings may have varying access to PA resources and different parental sleep-related cultural practices. Therefore, future multi-center studies involving diverse populations are warranted to confirm these correlations and enhance the external validity of our results.

Conclusions

In summary, children with ASD exhibit high prevalence of sleep problems, with school-aged children showing particularly insufficient levels of PA relative to international guidelines. There exists a close relationship between sleep disturbances and PA levels. Interventions involving PA have been shown to significantly improve sleep issues in children with ASD, thereby supporting their healthy development.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0071/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0071/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0071/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0071/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Children’s Hospital, Zhejiang University School of Medicine (No. 2025-IRB-0293). Written informed consent has been obtained from all participants’ legal guardians prior to participation in this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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