The Impact of Physical Activity on Sleep in Children with Autism Spectrum Disorder: Exploring Gender Differences

Date Submitted: 3/23/2025

Date Accepted: 9/1/2025

Sleep efficiency and physical activity (PA) are both critical for overall health and may be positively correlated, particularly in children with autism spectrum disorder (ASD). Sleep plays a vital role in child development, influencing cognitive, emotional, and physical well-being. However, children with ASD often experience sleep difficulties, such as increased wake after sleep onset (WASO) and longer sleep onset latency.(1) WASO is the measured, total amount of time that a person is awake after initially falling asleep. For example, if someone wakes up once during the night and is awake for 15 minutes, their WASO is 15 minutes. Sleep onset latency is the amount of time it takes for a person to fall asleep after actually going to bed. It is measured in minutes from the moment lights are turned off until onset of sleep, which is the first 30 seconds of non-REM (rapid eye movement) sleep. Shorter sleep latency means that a person falls asleep after just a few minutes of laying down, while longer sleep latency means it takes more than 20 or 30 minutes to fall asleep.(2)

Sleep disturbances not only affect a child’s functioning but also their families and their everyday lives. Both pharmacologic and non-pharmacologic interventions exist, but there is increasing focus on investigating PA as a potential means to improve sleep quality without relying on medication. Despite established PA recommendations and guidelines, most children, especially those with ASD, do not meet recommended activity levels, which may impact their sleep, daily activities, and overall development.(3) Notably, while PA is generally beneficial, children with ASD may have distinct preferences regarding daily activity and movement, making it essential to consider individual cues when designing interventions. 

ASD is a complex neurodevelopmental disorder characterized by social communication impairments, repetitive behaviors, and restricted interests. Symptoms appear differently across individuals, leading to misconceptions about the spectrum’s variability. Additionally, language and communication difficulties in ASD carry over into physical and motor difficulties, which further complicates interactions. Research on ASD has previously overlooked girls, despite evidence suggesting sex differences in symptoms.

A study published in 2024 titled "Sex Differences in Sleep and Physical Activity Patterns in Autism Spectrum Disorder" looked at this very topic and addresses gaps in research by examining the relationship between sleep and PA in ASD, with a particular focus on sex differences.(5) Using both objective tests like accelerometer data, and subjective approaches like questionnaires, researchers tracked sleep and PA patterns in 14 children with ASD over the span of seven days. Participants, all with IQs above 70, wore accelerometers on their right triceps to measure sleep efficiency, WASO, total sleep duration, sleep latency, and PA levels. This study provides valuable insight into how PA might serve as a non-pharmacologic sleep aid for children with ASD.

The results revealed significant differences between girls and boys in both sleep patterns and PA levels. Specifically, girls with ASD spent more time in bed and had more WASO compared to boys. High WASO, which reflects more nighttime awakenings, is generally unfavorable, while lower WASO is associated with better sleep quality. The difference in WASO between girls and boys was statistically significant. Consequently, girls also had statistically significantly lower sleep efficiency, meaning they spent a smaller proportion of time asleep compared to the total time in bed. Additionally, boys clustered with higher sleep efficiency and fewer awakenings, while girls tended to cluster with lower sleep efficiency and more frequent awakenings. Both groups reported sleep issues based on the sleep questionnaire scores.

Regarding PA, girls with ASD took statistically significantly fewer daily steps and engaged in less vigorous and less very vigorous PA compared to boys. A detailed analysis further revealed that alterations in sleep patterns were associated with being female and participating in less vigorous PA. 

The study concluded that girls with ASD experience major disruptions in both sleep and PA, with lower PA levels potentially contributing to their sleep difficulties. While PA is generally considered a beneficial, non-medical approach to improving sleep, personalized interventions might be necessary for girls with ASD to address their unique challenges. 

Another study also focused on the often underrepresented population of girls with ASD, examining eating disturbances (ED) using both parent and self-reports. This is relevant since the study discussed above also highlighted the historical under-representation of female participants in ASD research. The second study, by Bitsika and Sharpley (2017), aimed to address the lack of data on ED in young girls with ASD and compared reports from mothers and daughters aged 6 to 17 years.(6) They found a low prevalence of severe ED in their sample (around 11%). Notably, this study emphasizes the importance of collecting data directly from girls with ASD through self-reports, in addition to parent reports, to gain a more comprehensive understanding of their experiences. This resonates with the first study's use of accelerometry as an objective measure of sleep and PA, potentially providing insights beyond parent questionnaires. 

This research emphasizes the importance of studying sex differences, and underscores  the complex connection between sleep efficiency and PA among children with ASD. In other words, the study discusses and evaluates the challenges that are created for these children and calls for more research to better understand the female presentation of ASD.

The findings of this study have important real-world implications. Healthcare providers should recognize the sex-based differences in sleep and PA patterns among children with ASD in clinical settings. Sleep assessments and interventions may need to be customized for girls. While PA shows promising results in being associated with better sleep, it is essential to tailor the types of approaches to individual preferences, recognizing that not all children with ASD respond to increased motor activity in the same way. Parents, caregivers, and educators can encourage structured and more consistent, while still flexible, PA routines tailored to a child’s comfort and desired level, which may help increase improvement in sleep patterns. Developing personalized PA interventions that cater to the interests and motivations of girls with ASD could be key to improving their sleep quality.

The research emphasizes the need to update the existing gaps in research, particularly in understanding sex differences in ASD. By improving these gaps, we can move toward more effective and accessible solutions for sleep-related challenges in ASD, ultimately improving quality of life for children with ASD.

Authors: (alphabetical by last name):

• Regina Bass: reginab5@bu.edu Boston University

• Valerie Ann Rosario: valrosz@bu.edu Boston University

References 

1. Souders MC;Zavodny S;Eriksen W;Sinko R;Connell J;Kerns C;Schaaf R;Pinto-Martin J; “Sleep in Children with Autism Spectrum Disorder.” Current Psychiatry Reports, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/28502070/. Accessed 19 Mar. 2025. 

2. Pacheco, Danielle, and Anis Rehman. “Sleep Latency.” Sleep Foundation, 18 Jan. 2023, www.sleepfoundation.org/how-sleep-works/sleep-latency.  

3. Healy, Seán, et al. “Meeting the 24-HR Movement Guidelines: An Update on US Youth with Autism Spectrum Disorder from the 2016 National Survey of Children’s Health.” Autism Research : Official Journal of the International Society for Autism Research, U.S. National Library of Medicine, June 2019, pmc.ncbi.nlm.nih.gov/articles/PMC6867706/#:~:text=P%20%3C%200.01.-,Physical%20Activity,TD%20children%20%5B22.18%25%20vs.  

4. National Institute of Mental Health. Autism spectrum disorder. National Institute of Mental Health. Published February 2025. https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

5. Bricout VA, Covain S, Paterno J, Guinot M. Sex Differences in Sleep and Physical Activity Patterns in Autism Spectrum Disorder. Clocks Sleep. 2024;6(4):764-776. Published 2024 Nov 18. doi:10.3390/clockssleep6040049 

6. Bitsika V, Sharpley CF. Using parent- and self-reports to evaluate eating disturbances in young girls with Autism Spectrum Disorder. Int J Dev Neurosci. 2018;65:91-98. doi:10.1016/j.ijdevneu.2017.11.002   

7. Alexandra Z. Sosinsky, Janet W. Rich-Edwards, Aleta Wiley, Kalifa Wright, Primavera A. Spagnolo, Hadine Joffe, Enrollment of female participants in United States drug and device phase 1–3 clinical trials between 2016 and 2019, Contemporary Clinical Trials, Volume 115, 2022,106718, ISSN 1551-7144, https://doi.org/10.1016/j.cct.2022.106718 (https://www.sciencedirect.com/science/article/pii/S1551714422000441)