Sleep Problems—Autism Toolkit
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What should we know about sleep problems?
Sleep problems are common in children with and without autism spectrum disorders (ASDs). One-third to half of children with ASDs have sleep problems. This can lead to daytime problems with paying attention, being irritable, and displaying more repetitive behaviors. The amount of nighttime sleep needed by preschoolers in general is typically 10 to 13 hours. It decreases with age to 8 to 11 hours by 13 years. Sleep problems can end up affecting parents and caregivers as well as the child with an ASD because they often lose sleep themselves caring for the child who is awake.
What are some reasons for sleep problems?
Children with ASDs may have many reasons for sleep problems. The causes may be medical, behavioral, or both. Medical reasons for sleep problems may include allergies, breathing problems, and gastrointestinal reflux (stomach discomfort). Medications can also affect sleep.
Sleep normally has cycles with different brain-wave patterns. These patterns may be different in some people with ASDs. Typical sleep patterns include lighter sleep and dreaming later in the night. That is when night waking often happens. The hormone melatonin is made by the brain to control sleep. Some scientific studies have shown that people with ASDs may not have the same amount or action of this hormone.
Some sleep problems include
Trouble falling asleep. Children may have a hard time falling asleep if there is a lot of activity in the household, if they eat foods with caffeine, or if they are hyperactive. It may be that they do not connect bedtime with falling asleep or that they want to be with the family.
Night waking. Children who wake up in the middle of the night may stay awake if they don't know how to fall back to sleep alone or don't understand that nighttime is for sleeping. They may stay awake because they are used to getting food, attention, or other reinforcement when they wake up. Some children wake up when soiled or wet.
Early waking. Children may wake up early because of abnormal sleep cycling or melatonin production or because of problems with falling back to sleep when they wake up. They may also wake up early because their sleep needs have been met.
Nightmares, sleep terrors, and sleepwalking. These occur in the first few hours of the sleep cycle in children with or without ASDs and are related to brain activity during sleep.
How are sleep problems assessed?
Your child's doctor can do a general physical examination and gather a history of health and sleep problems. Try to keep a sleep diary for a while to help the doctor understand your child's sleep habits. The pediatrician may also run laboratory tests if the history or physical examination suggests medical reasons for sleep problems.
What can we do to help our child sleep better?
Studies have shown that behavioral strategies help more than medication to improve sleep problems.
Some basic suggestions include
First Step: Sleep Schedule (Use for 2 Weeks)
Set a regular time for going to bed and getting up for the day.
Start a relaxing routine leading up to bedtime. Try to do this the same way each night.
Make sure your child's bedroom is set up for sleep. It should be quiet and dark, without TV or music. The rest of the household should be quiet at bedtime.
Make sure your child knows that the bed and bedtime are for sleep only, not for play or time-out.
Consider white noise or soft, calming music.
Establishing good sleep hygiene sometimes works all by itself to help sleep problems, but other steps may be needed.
Next Step: Promoting Desired Behavior
Many children with ASDs will respond to structure and rewards when trying to change behavior. Review what is expected with your child ahead of time and again each night. Consider using a picture schedule or social story to describe the schedule for bedtime routine and expectation for staying in bed. Provide a reward in the morning if your child has remained in bed, such as a preferred treat, game, or TV time.
Next Step: Ignoring Problem Behavior
If sleep problems continue after setting up a good sleeping area and routine for your child, you may want to add the step of ignoring sleep protests. When leaving your child in the bedroom, say “good night” and praise your child for going to bed. Then check in at times you have decided on (usually a few minutes) and ignore protests between checks. Increase the time between checks during the night and over the next several days. When checking, briefly look in the bedroom. If your child is awake, tell him to go to sleep, and then leave.
It is very important that all caregivers are consistent in this step. Protests and tantrums from the child may get worse for the next several days, but it is essential you follow through on this routine and do this the same way for at least 2 consecutive weeks. Families may need ongoing support to carry this out, as it can be trying emotionally and physically on parents and caregivers.
Some children with ASDs need supervision at all times to ensure safety because of their behaviors. If your child is at risk for injury when not being supervised and tends to wake during the night, consider the following safety measures:
Make sure the child's bedroom is safe with no objects she can pull over on herself or ingest.
Consider placing a lock on your child's door if she tends to wander to other parts of the house; a doorbell can be installed inside the room for the child to be able to get your attention if necessary.
Some families use a half-door or a baby monitor so they are alerted if the child leaves the bedroom; a video monitor is also an option.
Protect windows from being able to be opened or broken with a window guard.
Another Potential Step: Medication
Your child's pediatrician may suggest prescription or over-the- counter medications to be used along with behavioral training.
Other Behavioral Approaches to Night Waking and Delayed Sleep Onset
If you have used the approaches described previously in a consistent fashion for 2 weeks and your child still has disturbed sleep, you should discuss further with your child's pediatrician. There are other behavioral interventions that can be used. Particularly difficult problems will need consultation from a sleep expert.
American Academy of Pediatrics HealthyChildren.org: www.HealthyChildren.org
Durand VM. Sleep Better! A Guide to Improving Sleep for Children with Special Needs. Baltimore, MD: Paul H. Brookes Publishing Co; 1997
Ferber R. Solve Your Child's Sleep Problems: New, Revised, and Expanded Edition. New York, NY: Fireside; 2006
Family handout from Autism: Caring for Children With Autism Spectrum Disorders: A Resource Toolkit for Clinicians, 2nd Edition, developed by the American Academy of Pediatrics (AAP) Council on Children With Disabilities Autism Subcommittee (ASC).
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