Most parents have had some experience with a child who has difficulty falling asleep, wakes up frequently during the night, and/or only sleeps a few hours each night. Temporary sleep difficulties are an “expected” phase of child development. Ongoing and persistent sleep disturbances can have an adverse effect on the child, parents, and other household members. Children with autism spectrum disorders experience these sleep disturbances more frequently and intensely than typically developing children. Researchers estimate that 26 to 32 percent of typically developing children experience sleep problems, while estimates for children with an autism spectrum disorder range from 53 to 83 percent (Nath, 2013). A child’s sleeping problems can quickly become a daily parenting challenge.
There are a number of factors to address when establishing a plan to reinforce a positive sleep pattern. First, any underlying medical problems that may be affecting sleep should be assessed. Consider checking for food and/or environmental allergies or intolerances, gastrointestinal disturbances including reflux, and seizures. All of these are more common in persons with autism spectrum disorders. In addition, sleep disturbances can be a side effect of other medications an individual takes and so this should be considered, too. Also, adequate exercise during the day may influence a positive sleep pattern.
Sleep disorders that affect the general population should also be explored for your child with an autism spectrum disorder. Sleep apnea is a disorder that can affect anyone at any age. It is a disorder in which a person experiences pauses in breathing, when the airway becomes obstructed, during sleep. The most common cause for blockage is enlarged tonsils or adenoids. Upper respiratory illnesses and/or allergies can also contribute to the development of sleep apnea. Beside pauses in breathing, symptoms of sleep apnea in children include snoring, mouth breathing, restless sleep, sweating, night waking, and/or frequent coughing or choking while asleep. Other sleep disorders to assess in a child, if appropriate, include sleep terrors and confusional arousals. These both are frequently referred to as parasomnias. Parasomnias are disorders of “partial arousal” that lead to unusual behaviors during sleep. Children with sensory processing difficulties have more problems falling asleep and night waking. An assessment and consultation with an occupational therapist trained in sensory integration may be important to assess relaxation and arousal difficulties, and to help design strategies that address these issues.
After possible medical problems have been addressed, other factors contributing to sleep problems should be considered and strategies for addressing these implemented. Other issues to consider are environmental variables, bedtime routines, and the use of a sleep training method. Each of these three topics is discussed in further detail below.
Environmental Variables
After examining your child’s sleep environment more closely, there may be some adaptations and modifications needed to assist your child’s ability to relax at bedtime.
- Consider whether your child is too hot or too cold. Assess the temperature of the room, bedding, and sleep clothes to decide what combination is best for your child. Remember that your child’s sense of temperature may be different then your own. Recall what temperature your child seems to prefer and/or seek during the day, and consider when making decisions.
- Consider tactile sensitivities that may be affecting your child’s ability to sleep. Certain textures can relax or arouse your child. Look at bedding and pajama textures. Your child may prefer his/her feet covered or uncovered with footed pajamas, socks, and/or even the covers themselves. How tight or loose the clothing fits, and whether or not there is elastic or seams can be an issue for some children. Also, bedding should provide the optimum level of pressure, as this too could affect individuals with autism spectrum disorders.
- Consider noises and how they affect your child. At night, when trying to relax and fall asleep, the noises your child hears may be over powering and impossible to filter out. These noises, such as water running or an animal scratching may not affect you or other household members but can be disrupting for a child with an autism spectrum disorder. Can certain household noises be monitored for the effect on your child? Sometimes a fan, air filter, TV, or soft music in the child’s room can help mask other noises and provide a consistent sound that is comforting and/or soothing for the child.
- Consider visual stimuli that may be causing problems for your child at bedtime. Is your child afraid of the dark? Some children with autism spectrum disorders may seem to prefer dark places during the day but that is different then being expected to sleep in a big room in a bed at night in the dark. Streetlights, the moon, or car lights shining in the room at intermittent intervals may be affecting your child’s sleep. Providing a room that is consistently light (lit with non-LED light) or dark may be very important, depending on your child’s needs.
- Also, consider the effects of the use of tablets, smartphones, and computers that many of us use before bed. Blue light from computer screens, smartphones, and tablets is known to interfere with the brain’s natural sleep cycles especially for children and teens with autism (Doherty, 2014; Rossignol & Frye, 2011). Exposure to light, especially blue light, suppresses the production of the hormone melatonin. Melatonin supports the sleep cycle by reducing alertness and causing drowsiness. To address the effects of blue light exposure at night, the most suggested advice is to turn off digital devices 1-3 hours before bedtime. If it is not possible to turn off the devices, you can dim the brightness of the screen or try a free app (F.lux) that automatically changes the colors on the screen, at sunset, using more reds and yellows, giving the screen a faint orange color. There are also blue light blocking glasses you can buy to help block the effects of the blue light (Schmerler, 2015; Harvard, 2012).
Bedtime Routines
Bedtime routines and rituals are very important for most children in establishing positive sleep patterns, but are extremely critical for children with an autism spectrum disorder.
- Your child will benefit from a set bedtime. Pick a time for bed that is reasonable for your child and which you can consistently provide.
- Children with an autism spectrum disorder need to know what is going to happen next. Establish a bedtime routine that can provide predictability and a comforting, familiar pattern. For further understanding and structure, a visual bedtime schedule can help. The visual schedule can provide reminders and consistency for the whole family.
- A good bedtime routine will help teach a child to calm down, relax and get ready to sleep. For example, if bathing is stimulating or frightening for your child, even though you may want him/her to bathe before bed, it may be best to bathe at a completely different time of the day. Likewise, there may be sensory integration activities that have proven to be relaxing to your child during the day that you can also use as part of the bedtime routine.
- A bedtime routine should be the same every day. Include activities that are pleasant and relaxing as well as special and individualized to fit your child’s needs and interests. A bedtime routine should realistically consist of 4 to 6 steps that do not take more time then is reasonable on a nightly basis.
- Some activities to consider as part of a bedtime routine or ritual include: looking at the same book or story each night, saying good night to favorite objects, toileting, bathing, getting pajamas on, brushing teeth, singing a favorite song or prayer, listening to calming music that the child enjoys, hugging and kissing family members and/or engaging in a calming sensory integration activity.
- On days when you are away from home and/or get home late, it is still important to follow bedtime routines and rituals. You can shorten each step significantly and potentially eliminate nightlong frustrations due to the change. If your child is away from home for a night or two, you may see old sleeping patterns emerge. Even in a temporary new environment, routines may help. Upon returning home, the bedtime routine will continue to be effective, though the excitement from the change may take a night or more to fade depending on your child and how long you have been away.
Sleep Training
After addressing medical issues, environmental variables, and bedtime routines it is time to tackle the hardest piece in establishing positive sleep patterns: teaching your child to sleep through the night. There are various versions of sleep training methods you may have read or heard about. After the bedtime routine is done and your child is in his bed or crib, leave the room without long drawn out words or further attempts at touching the child in any way.
If the child is upset and obviously not sleeping, wait a few minutes and then go back into the child’s room to check on him/her. Checks involve going back into the child’s room and briefly (not more than a minute, preferably less) touching, rubbing, or maybe giving a “high five,” “thumbs up,” or hug for an older child who better responds to these gestures. Gently but firmly say, “It’s okay, it’s bedtime, you are okay” or a similar phrase and then leave the room until it is time for the next check or until the child falls asleep.
Using this technique consistently is generally harder on the parent then it is on the child. It could take a couple of hours the first few nights. It is important to know that it is very likely the child’s behavior will get worse for a few days or more before it improves. This is the child testing the change and trying to bring the old routine back. For some children who are older and not genuinely tired at a reasonable bedtime, a routine of staying in the bed or in the room quietly may be appropriate. Sleep training methods can still be applied in these situations. Also, a gate or other barrier may be needed at the bedroom door to remind the child it is bedtime and the expectation is to stay in your room.
If your child is older and has never consistently slept through the night, you may be totally sleep deprived yourself. Ask for help from your doctor, a psychologist, social worker, or from a case manager if you have applied for Medicaid Waivers. It may not be easy to find a knowledgeable professional but you might start by asking other parents who might know a professional that has helped them in the past. In addition, if your child seems to regress in their sleeping habits, you may need to consult with knowledgeable professionals. Again, it is best to start with a medical assessment and proceed from there. Sometimes if other medical problems are ruled out, a temporary trial of medication taken under a doctor’s care can assist in turning around poor sleep patterns, while working to establish bedtime routines and rituals that work for your child.
Several doctors in the field of autism spectrum disorders have done preliminary research on the short-term use of the over the counter supplement melatonin. Melatonin can help stabilize and promote normal sleep for some children by helping them fall asleep more quickly and stay asleep longer (Malow, Adkins, McGrew et. al, 2012). Researchers suggest additional studies would be helpful to confirm current results and expand the research. Some research suggests that melatonin sometimes stops working and does not usually help those who frequently wake up during the night (Rossignol & Frye, 2011). Some parents have found vitamin supplementation and/or herbal medicine helpful for helping a child get to sleep (Doherty, 2014).
It is extremely common for children with autism spectrum disorders to have difficulty getting to sleep, sleeping for a few hours at a time, and/or staying asleep without frequently waking throughout the night. These poor sleep habits are easily created and can be extremely difficult to change. One issue not yet addressed in this article is the habit of sleeping with the child. This habit may understandably get started when poor sleeping patterns affect not only the child but the parents and the rest of the family as well.
If the child is in the habit of sleeping with a parent and/or in the parent’s bed, the same steps described above should be considered with additional support needed during the examination of the environment and bedtime ritual/routine. For example, a pillow or other item(s) from the parent(s) may help make the environment more comforting to the child as the parent(s) transitions from sleeping with the child. Desensitization to a new bed or room can be added as part of the bedtime routine. Desensitization to a new room or bed can be added as part of a routine done daily for a few days or weeks before also being done as part of the bedtime routine.
It cannot be stressed enough; if possible, the best advice is to avoid creating sleep routines and habits that will have to be broken later.
Checking for medical issues, environmental variables, and then planning and consistently as possible following a bedtime routine and a sleep training method can improve the quality of life for the whole family. It can take time to establish positive sleeping patterns particularly if trying to change a long-standing problem. Families frequently have to make sleeping issues a priority until positive sleeping patterns are established. It is a priority that is worth the effort.
References
Armstrong, K., Rowe, M. & Kohler, W. (2015) Addressing sleep disturbances in children with autism spectrum disorders. Annals of Pediatrics & Child Health, 3(2): 1054-1059.
Cortesi, F. et al. (2012). Controlled-release melatonin, singly and combined with cognitive behavioral therapy for persistent insomnia in children with autism spectrum disorders: A randomized placebo-controlled trial. Journal of Sleep Research, 21: 700-709.
Doherty, S. (2014). Sleep disorders affect 83% of children diagnosed with autism. Retrieved 5/24/21 from http://treatautism.ca/2014/06/16/sleep-disorders-autism/.
Harvard Medical School (2012). Blue light has a dark side. Harvard Health Publications. Retrieved 5/24/21 from https://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side.
Hodge, D. et al. ((2014). Sleep patterns in children with and without autism spectrum disorders: Developmental comparisons. Research in Developmental Disabilities, 35: 1631-1638.
Kotagal, S. & Broomill, E. (2012). Sleep in children with autism spectrum disorder. Pediatric Neurology, 47: 242-251.
Malow, B., Adkins, K.W., McGrew, S.G. et al. (2012). Melatonin for sleep in children with autism: A controlled trial examining dose, tolerability, and outcomes. Journal of Autism and Developmental Disorders, 42(8), 1729–1737.
Malow, B. et al. (2012). A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics, 130: 5106-5124.
Mannion, A. & Leader, G. (2014). Sleep problems in autism spectrum disorder: A literature review. Journal of Autism and Developmental Disorders, 1: 101-109.
Mazurek, M.O. & Petroski, G.F. (2015). Sleep problems in children with autism spectrum disorder: Examining the contributions of sensory over-sensitivity and anxiety. Sleep Medicine, 16: 270-279.
Nath, S. (2013). Sleep problems in children with autism. Interactive Autism Network at Kennedy Krieger Institute. Retrieved 6/6/17 from https://iancommunity.org/cs/simons_simplex_community/sleep_problems.
Rossignol, D. A. and Frye, R. E. (2011), Melatonin in autism spectrum disorders: a systematic review and meta-analysis. Developmental Medicine & Child Neurology, 53: 783–792.
Schmerler, J. (2015). Q & A: Why is blue light before bedtime bad for sleep? Scientific American MIND. Retrieved 6/8/17 from https://www.scientificamerican.com/article/q-a-why-is-blue-light-before-bedtime-bad-for-sleep/
Additional Resources
Katz, T., & Malow, B. (2014). Solving sleep problems in children with autism spectrum disorders:
A guide for frazzled families. Bethesda, MD: Woodbine House.
Tuck Sleep Foundation is an organization which provides general sleep resources and
information for individuals and families: https://www.tuck.com/.
Wheeler, M. (2017). Good night, sleep tight, and don’t let the bed bugs bite: Establishing positive sleep patterns for young children with autism spectrum disorders. The Reporter, First Thursday's Tips and Tools, July 2017. Retrieved from Good night, sleep tight, and don’t let the bed bugs bite