Breaking the Cycle: Impact of Physical Activity on Sleep Disorders in Autism-A Five-Year Longitudinal Analysis

Sleep disorders represent a significant health burden among children and adolescents with autism spectrum disorder (ASD), affecting their core symptoms, behavior, and quality of life. While physical activity has shown promise in managing sleep disorders in the general pediatric population, its effectiveness for children and adolescents with ASD remains understudied.

This retrospective cohort study analyzed electronic health records from 132 healthcare organizations, examining 155,860,529 individuals to determine sleep disorder prevalence in ASD populations and evaluate the impact of physical activity interventions. We identified 248,940 children and adolescents with ASD aged 5-18 years, of whom 38,976 had documented sleep disorders. Propensity score matching was performed to compare patients with ASD and sleep disorders who received physical activity interventions with matched controls. Primary outcomes included sleep disorder resolution and medication utilization changes at 1- and 5-year follow-up. Bonferroni correction was applied to secondary analyses to account for multiple comparisons.

The prevalence of sleep disorders was markedly higher in children and adolescents with ASD (19.25%) compared to non-ASD peers (3.37%), with risk ratios escalating from childhood (RR = 5.34, 95% CI: 5.28-5.40) to adolescence (RR = 6.12, 95% CI: 6.05-6.19). After matching, 3709 patients were included in each group. Physical activity interventions were associated with significantly higher sleep disorder resolution at 1 year (-59.9% vs. -5.05%, p = 0.001) and sustained benefit at 5 years (-49.83% vs. +7.26%, p = 0.001). After Bonferroni correction, improvement in sleep apnea at 1 year remained statistically significant (-62.26% vs. +9.39%, Bonferroni-adjusted p = 0.040). Improvements in parasomnia and insomnia did not survive correction and were considered exploratory. Age emerged as a key effect modifier: adolescents (12-18 years) demonstrated sustained improvements in overall sleep outcomes at both 1- and 5-year follow-up that met Bonferroni-corrected thresholds, whereas younger children (5-11 years) showed limited and inconsistent responses. Among comorbidity groups, anxiety-comorbid patients exhibited the strongest overall improvement (-58.7% vs. -12.4%, p < 0.01), while reductions in amphetamine use and changes in melatonin prescribing patterns should be interpreted as exploratory findings requiring prospective confirmation.

This large-scale observational study suggests structured physical activity interventions are associated with sustained improvements in overall sleep disorders among children and adolescents with ASD. While subtype- and subgroup-specific associations were observed, many attenuate after multiple comparison adjustments, highlighting the need for cautious interpretation. Findings support exploring physical activity in comprehensive care plans, with prospective randomized trials needed to confirm causality, optimize protocols, and address multiplicity.