Sleep Problems—Autism Toolkit

ICD10

F84.0

What should I know about sleep problems?

Sleep problems are common in children with and without autism spectrum disorder (ASD). One-half to one-third of children with ASD have sleep problems. This can lead to daytime problems with paying attention, being irritable, and showing more repetitive behaviors. The amount of nighttime sleep needed by preschoolers in general is usually 10 to 13 hours. It goes down with age. By age 13 years, the usual amount needed is 8 to 11 hours. Sleep problems can affect parents and caregivers as well as their child because parents lose sleep caring for a child who is awake.

What are some reasons for sleep problems?

Children with ASD may have many reasons for sleep problems. The causes may be medical, behavioral, or both. Medical reasons for sleep problems may be allergies, breathing problems, and acid reflux (stomach discomfort).

Medications can also affect sleep. Behavioral reasons for sleep problems could be changes in daily or bedtime routines, stress at home or at school, changes in caregivers, or anything else that breaks your child's regular pattern.

Sleep has cycles with different brain-wave patterns. These patterns may be different in some people with ASD. People with ASD may have lighter sleep and less 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 show that people with ASD may not have the same amount or action of melatonin.

Some sleep problems include

Trouble falling asleep . Children may have a hard time falling asleep for several reasons. Falling asleep may be hard if there is a lot going on at home, if children eat or drink caffeine, if they spend a lot of time on screens in the evening, if they do not have a regular bedtime routine, if they have excess daytime napping, or if they are hyperactive. Children with ASD, in particular, may have more trouble going from being awake to being asleep or may have more anxiety about being away from parents or caregivers.
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 or attention when they wake up. Some children wake up when soiled or wet or because they need to use the bathroom.
Early waking . Children may wake up early because of problems with sleep cycles or melatonin production or because they have problems falling back to sleep when they wake up. They may also wake up early because they have slept enough and are not tired.
Nightmares, sleep terrors, and sleepwalking . These occur in the first few hours of sleeping. They are related to brain activity during sleep. Although they can be scary, they are unlikely to be harmful to your child, and children usually don't remember them in the morning.

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 your child's doctor understand your child's sleep habits. Let your child's doctor know if your child is snoring loudly or has breathing problems at night and about any other health conditions your child has. Your child's pediatrician may ask for tests if the history or physical examination findings suggest medical reasons for sleep problems.

What can I do to help my child sleep better?

Studies have shown that behavioral strategies help more than medication to improve sleep problems. Here are some steps to help.

First Step: Sleep Schedule (Use for 2 Weeks)

Set a regular time for going to bed and getting up for the day. Try to stick to that schedule, even if your child has a "bad night."
Start a relaxing routine leading up to bedtime. Do the routine the same way each night. Routines are especially important for children with ASD.
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 only for sleep, not for play or time-out.
Try white noise (like from a fan) or soft, calming music.
Limit screen time in the evening. The blue light from TV and video games tells children's bodies that it is time to wake up.
If your child wakes up often to go to the bathroom, do not let him drink very much after dinnertime and at night.

Creating good sleep habits sometimes works all by itself to help sleep problems, but other steps may be needed.

Second Step: Encouraging Wanted Behavior

Many children with ASD will respond to order and rewards when trying to change their behaviors. Go over what you hope your child will do ahead of time and again each night. Think about using a picture schedule or story to describe the bedtime routine. Give a reward in the morning if your child has remained in bed, such as a treat he likes, a game, or a little bit of screen time.

Third Step: Ignoring Problem Behaviors

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 your child when she calls for you from bed. 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 every few minutes) and ignore her between checks. Increase the time between checks during the night and over the next several days. When checking, briefly look into the bedroom. If your child is awake, tell her to go to sleep and then leave. It is OK if your child falls asleep on the floor.

It is very important that all caregivers stick to this step, so talk with your family members about this plan ahead of time. If you live in an apartment or a condominium, you might want to talk with your neighbors too. Cries and tantrums from your child will get worse for the next several days but will improve over time. It is essential that you follow through on your plan and do it the same way for at least 2 weeks back-to-back to see a difference. You may need extra help to do this, as it can be hard and tiring for parents and caregivers.

Safety

Some children with ASD need to be watched at all times to keep them safe because of their behaviors. If your child is at risk for getting hurt when not being watched and wakes a lot at night, try the following safety measures:

Make sure your child's bedroom is safe with nothing she can pull over on herself or eat. Make sure all large objects, cords, and electrical appliances are safe.
Protect windows from being able to be opened or broken, with a window guard.
Consider placing a baby gate, alarm, or lock onto your child's door if she wanders to other parts of the house.
A doorbell or baby monitor can be used inside the room for your child to get your attention.
You can also use a video or audio baby monitor to make sure your child is safe without entering the room.

Another Potential Step: Medication

Your child's pediatrician may suggest prescription or over-the-counter medications to be used along with behavioral training. You should talk with your child's doctor before trying any medications or herbal supplements for your child.

Other Choices for Night Waking and Trouble Falling Asleep

If you have used this advice every day for 2 weeks and your child still has trouble with sleep, you should talk to your child's pediatrician. There are other behavioral interventions that can be used.

Very difficult problems will need consultation from a sleep expert.