All parents intermittently deal with children who have difficulty falling asleep or staying asleep. These temporary sleep difficulties are normal. However, children with autism spectrum disorder (ASD) appear to have more ongoing sleep-related difficulties. The number of families affected varies from study to study, but significant sleep problems can occur in 40%—80% of children with ASD.
Sleep is a critical component of health. Although we do not understand all its functions, sleep is essential to grow, to restore our body and immune system and to enhance and solidify memory and learning.
For children with ASD, insufficient sleep appears to impact daytime behaviors, making challenging behaviors worse. In addition, sleeping difficulties for the child lead to sleeping difficulties for parents and sometimes siblings, adding to the stress and challenges of parenting a child who has autism. No one can function at their best when they are sleep deprived.
What Causes Sleep Difficulties in Children with Autism
The most common reasons for sleep difficulties in all children are environmental influences or inadvertent behavioral shaping. For example, parents may assist a child in falling asleep by rocking or holding them and then placing them in bed while asleep. But when children awake naturally later in the night, they do not have access to the things in their environment that are associated with sleep and so are unable to get back to sleep by themselves. Another common cause of sleep difficulties is putting a child to sleep in a bedroom where he or she engages in stimulating play activities during the day.
For children with autism, there appear to be more challenges. There are studies that suggest children with ASD are more likely to have circadian rhythm (natural wake/sleep cycles) disturbances and may have abnormal melatonin regulation. Melatonin is a hormone that regulates the wake/sleep cycle. In addition, children with autism may be more anxious about the bedtime routine and may have difficulty with the social cues that signal bedtime. They are also more sensitive to sensory experiences such as light, touch or sound.
There are medical problems that interfere with sleep, and children with ASD may be more likely to experience them. For example, medical problems such as gastro esophageal reflux, allergies, sleep apnea, night terrors or seizures can interrupt sleep. Mental health problems such as bipolar disorder or severe anxiety can disrupt sleep and may be difficult to identify when a child with autism cannot communicate.
What to Do
One of the most important steps parents can take is to keep a sleep diary, keeping track of time of sleep and number of nighttime awakenings. A sleep diary allows families to become aware of patterns and environmental situations that may be inadvertently contributing to sleep problems and to monitor progress. It also is invaluable when working with experts such as sleep specialists.
Routines that encourage sleep are important. For children with autism, it can be helpful to create a visual schedule to inform and reassure them of the expected steps in a bedtime routine.
Families should consider the activities that precede bedtime and their effect on calming or stimulating children. Children with autism learn best in small bites with plentiful opportunities to feel successful. When establishing a routine to improve sleep, remember that new learning takes time and reinforce small steps in a positive way.
There are no medications approved by the Food and Drug Administration (FDA) for the treatment of pediatric sleep disorders, but there are some medications that have been used in controlled studies and have been found effective. Families should consult their physician for advice and guidance related to these treatments.
When to Seek a Specialist’s Care
Families should consider a behavior specialist when there are challenges in establishing a bedtime routine or when changes to promote a routine provoke challenging behaviors.
Consider a sleep specialist when improving sleep hygiene (creating a bedtime routine and providing a calming environment) does not lead to better sleeping or when there are suggestions of medical or neurologic problems associated with sleep.
Whatever strategy is used to help a child with autism sleep better at night, it’s important to remain consistent in the approach. Finally, remember there are thousands of other parents going through similar experiences every day. Seek help and support organizations and talk to other parents whenever possible.