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Sleep Help for Those Diagnosed With ASD
By Brenda Smith Myles and Amy Bixler Coffin 
Autism spectrum disorder (ASD) is a catch-all term for autism, pervasive developmental disorder not otherwise specified (PDD-NOS), and Asperger syndrome. ASD affects about 2 million individuals in the United States, and is 4.5 times more common in boys than in girls.
ASD affects individuals to different extents. Individuals with ASD can be highly gifted or intellectually challenged, but all have some challenges with socializing and communicating with others. Developmental issues associated with ASD are typically diagnosed in early childhood, but can be noticed as early as 18 months.

Between 44 to 83 percent of children with autism spectrum disorder also experience sleep issues. Most commonly, children with autism have difficulty falling asleep and experience disturbed sleep once they do. Problematically, their sleep problems tend to exacerbate other issues characteristic of the disorder. For instance, daytime sleepiness from lack of sleep often results in hyperactivity, inattentiveness, and aggression during the day.

Common sleep disorders affecting children and adults with autism

In general, children with autism tend to sleep 32.8 minutes less per night and take almost 11 minutes longer to get to sleep than their typically developing peers. Children with ASD also have a higher prevalence of sleep issues than their typically developing peers. One study reported the following instances of sleep issues in autistic children:
  • 54% displayed resistance to bedtime
  • 56% experienced insomnia
  • 53% suffered from parasomnias, such as sleepwalking or night terrors
  • 25% experienced sleep disordered breathing, including sleep apnea
  • 45% had difficulty waking up in the morning
  • 31% experienced daytime sleepiness
Common sleep issues for people with autism include:
  • Sleep-onset insomnia describes difficulty falling asleep. Children with autism are two to three times more likely to have insomnia than their typically developing peers. Children with ASD are also more likely to have anxiety or depression, which are co-morbid conditions of insomnia.
  • Sleep apnea is a form of sleep-disordered breathing where the individual literally stops breathing during sleep for up to a few seconds. Obstructive sleep apnea (OSA) is caused by blocked airways that decrease oxygen levels in the blood. Individuals with OSA experience less restful sleep because the apnea episodes rouse them.
  • Sleepwalking, like autism, is more common in boys than in girls. Sleepwalking episodes typically occur during deep sleep in the first half of the night.
  • Children who sleepwalk are also more likely to experience nightmares or night terrors, sudden rousing during the first half of the night accompanied by sweating, rapid heart rate, fear, and confusion.
  • Rhythmic movement disorder describes rhythmic head or body rocking episodes of 15 minutes or less that occur while the person is falling asleep or just after they fall asleep.
  • Restless leg syndrome (RLS) describes an uncontrollable urge to move the lower limbs in order to relieve a tingling sensation while falling asleep. RLS is more common in women than in men.
  • Bedwetting (nocturnal enuresis), while common enough during early childhood, is even more common in children with ASD than their typically developing cheers.
  • Hypersomnia is the opposite of insomnia, and describes excessive sleep of 10 hours or more that isn’t refreshing and leaves the individual tired during the day.

In addition to the sleep disorders above, children with ASD are also more likely to have epilepsy or gastrointestinal problems, both of which can further disrupt sleep.

Unfortunately, when autistic children have sleep issues, they also tend to be more intense than typically developing children. Worse, short sleep duration is highly correlated with social impairment, especially the ability to develop peer relationships, according to recent research. Sleep-deprived children with ASD see decreased IQ scores, and tend to engage in repetitive behaviors and compulsive rituals more often. They also have higher rates of behavioural issues, depressed or anxious mood, and problem paying attention in school. 

Why are children with autism more prone to sleep problems?
While scientists still don’t know why children with autism are more prone to sleep issues, they have advanced a few theories.

Abnormal Melatonin Production

One theory is that children with autism have brain abnormalities that affect their ability to regulate sleep. Children with autism tend to have abnormal levels of tryptophan, which is an amino acid involved in melatonin production. Melatonin is the hormone responsible for regulating sleep. Autistic children don’t produce melatonin at the same time other people do, so their levels are higher during the day and lower at night – which is the reverse of when it should be.

Difficulty Reading Social Cues

Autistic children have difficulty reading social cues. As a result, they may not correctly interpret the actions of their siblings, parents or other family members getting ready for bed. Besides our circadian rhythms, social cues also help us recognize when it’s time for sleep, especially in early development. 

Heightened Sensitivity

Because children with autism have heightened sensitivity (e.g. acute hearing), it can be more challenging for their brain to calm down enough to fall asleep. Plus, they are more prone to be roused by external stimuli during the night, such as a snoring family member or a parent opening a door elsewhere in the house.

Developmental Issues
During infancy and as toddlers, typically developing children sleep throughout the day and wake up to feed. As they age, children continue taking naps but sleep less during the day and sleep more during night, until they eventually sleep primarily at night. Young children with autism may not develop mature sleep patterns at the same rate as their peers, which can cause them to wake more frequently during the night and to be more tired during the day.

Genetic Abnormalities

Children with autism may experience spend 8 to 10 percent less time in REM sleep, which is the critically restorative stage of sleep where dreaming occurs and the brain processes memories and learnings from the day. The reduced REM sleep can negatively impact autistic children’s cognitive performance in school and stymie their development.

Researchers hypothesize that neurotransmitter abnormalities in the brain may be responsible for the reduced REM sleep. They are also currently researching whether a single genetic mutation could cause both insomnia and autism.

How do sleep issues change as my autistic child ages?

Fortunately, many sleep problems affecting autistic children naturally go away with childhood, including night terrors, sleepwalking, and rhythmic movement disorder (RMD).
Night terrors are more common in children between the ages of 3 to 7. Unfortunately, there is no treatment for these, but reassuring your child before bed and whenever they wake up may help calm them.
Children also outgrow sleepwalking, although a 2012 Stanford study estimates 3.6 percent of adults have slept walked within the past year. While you wait for your child to outgrow it, protect against them getting hurt by keeping things off the floor, clearing clutter, and locking doors and windows.
Most cases of RMD go away naturally by age 5. If you notice your child rocking, do not wake them up as it will cause them to just restart the process when they go back to sleep (unless, of course, your child is about to hurt themselves by falling off the bed). Until then, invest in padded bed rails and floor pads to protect your child from injury.
Adults with ASD have significantly fewer sleep problems than children with ASD, but they still experience them at twice the rate of the general population. About 20 percent of adults with ASD have a diagnosed sleep disorder such as sleep apnea, and insomnia can continue into adulthood for autistic individuals. Adults with ASD also have higher rates of psychiatric disorders and other medical conditions, many of which can contribute to or exacerbate sleep issues themselves.

How can I help my autistic child sleep better?

Autistic children who get a better night’s sleep tend to have fewer behavioural problems and better social interactions, according to a 2006 study published in the journal Sleep. If your child has difficulty sleeping, wakes frequently during the night, or wakes up early, they may have a sleep issue. Monitor your child during the night and note anything unusual such as snoring, movements, or breathing problems. You can share this information with your paediatrician or a sleep specialist.
Note that children need more sleep than adults. Here’s an overview of the recommended amount of sleep by age:
  • Toddlers: 14 hours
  • Preschoolers: 12 hours
  • Elementary and middle schoolers: 10 hours
  • Adolescents: 9 hours
  • Adults: 7 to 8 hours
Helping your child sleep better will also help you as their caregiver. Caregivers and parents of children with ASD tend to have more sleep problems than the average adult, whether due to the emotional stress of raising an autistic child or interruptions during the night from their child. Further, parents of autistic children sleep less overall, have worse sleep quality, and wake up earlier than other parents.

Behaviour Changes
Many behavioural changes can completely resolve or at least alleviate sleep issues for children with autism. The following tips have been helpful for parents:

1. Keep the bedroom cool, dark, and quiet.
Children with ASD have heightened sensitivity and can be more sensitive to their environment than other children, so you may want to invest in blackout curtains and remove any stimulating electronics. Limit television time in the hours before bed as it can over-stimulate their already sensitive brains. Instead, focus your child’s attention on quiet activities like drawing, puzzles, or reading.

2. Practice good sleep hygiene and establish a bedtime routine.

Bedtime routines can help children fall asleep faster, according to research by Vanderbilt University. Repeat the same activities in the same order each night 30 minutes before bedtime, including when your child brushes their teeth and if you read a bedtime story together. Have your child go to sleep and wake up at the same time, regardless of whether it’s a weekday or weekend.
Children with autism can show a strong favouritism towards objects. Take advantage of this by using the same pajamas and objects in the bedtime routine. Find a way to include multiple objects (such as two stuffed animals) so your child can still sleep if one item becomes unavailable.
Prepare your child for bedtime by reminding them that it’s coming up, so they don’t get irritated by a sudden transition. Use something consistent, whether it’s a verbal reminder, or a clock that signals the time.
Because autistic children are highly sensitive, you might consider using relaxation techniques in the bedroom routine, such as a gentle massage or lavender oils during bath time.

3. Adjust your child’s diet and exercise.

Watch your child’s diet and take care to remove any foods that they have sensitivity to as an upset stomach can disturb sleep. Children with autism are more likely to have gastrointestinal problems and food allergies or sensitivities, which if ignored, can cause disrupted sleep.
Limit liquid intake before bed to prevent bedwetting. Avoid caffeine (remember that tea, coffee, chocolate, and soda can all be sources of caffeine).
Provide regular exercise earlier in the day so your child can fall asleep better at night.

4. Coach your child to fall asleep without you in the room.

Children with autism can have an even harder time falling asleep without their parents than their typically developing peers. Slowly coach your child to fall asleep without you in the room. In the event they wake up during the night, this will also help them fall back asleep on their own.

First, you can also establish a sense of normalcy around falling asleep alone by showing your child a picture of them asleep in their room while you are doing another activity, or limiting any sleep or nap time to take place solely in their bedroom. Then, go through each of these steps until your child falls asleep, doing one step for a few nights at a time before moving on to the next one:

  • Lie next to your child in bed
  • Lie near the bed
  • Sit on a chair inside the bedroom with the door open
  • Sit outside the bedroom but remain visible to your child
  • Sit outside but out of sight, with the door open
  • Sit outside with the door closed
  • Go to your room and sleep

Sleep products

There are many sleep products designed to help individuals with sensory and developmental disabilities fall asleep better.

Waterproof mattresses and bedding

Autistic children who regularly wet the bed may benefit from waterproof mattresses and bedding. These are made from polyurethane and other materials that are easy to clean and do not develop an odour or stain from repeated incontinence.

Bed rails and floor pads

Bed rails prevent falls for individuals who move a lot during sleep from rhythmic movement disorder, night terrors, or epilepsy. Bed rail pads provide a comfortable surface should your child come into contact with the rails during sleep, and floor pads around the sides of the bed can provide further protection against a fall.

White noise machine

A white noise machine or smartphone app can help calm children to sleep using soothing music, white noises, and nature sounds. It also helps drown out other noise in the house they may be sensitive to.

Anti-snoring devices

Autistic children who snore may find relief from anti-snoring mouthpieces. These are fitted by a dentist to move the lower jaw forward and free up airways during sleep. Less extreme options include anti-snoring nasal plugs or pillows. Alternately, more extreme options for cases of sleep apnea include continuous positive air pressure (CPAP) machines, which fit an oxygen mask over the face during sleep.

Weighted blankets

Weighted blankets soothe the uncomfortable sensations from restless leg syndrome. Choose a blanket that weighs 10 percent of your child’s body weight plus 1 pound. Even an autistic child without RLS may prefer a sleeping bag in their bed, finding comfort in the warm, cocoon-like feeling.
Some individuals may have RLS due to an iron deficiency, in which case taking an iron supplement can relieve symptoms.

Light therapy

If your child suffers from hypersomnia or excessive daytime sleepiness, using light therapy boxes in the morning may help them adjust better to being awake during the day.

Melatonin supplements

Melatonin has been shown to help children with ASD fall asleep 28 minutes faster and sleep for 21 minutes longer. Ask your doctor about giving your child a melatonin supplement. Low doses of 1 to 3 mgs 30 minutes before bedtime can be effective.

Reprinted with permission: https://www.sleephelp.org/autism-asd/

Disclaimer: This document reflects the views of the author. It is Autism Ontario’s intent to inform and educate. Every situation is unique and while we hope this information is useful, it should be used in the context of broader considerations for each person. Please contact Autism Ontario at info@autismontario.com or 416-246-9592 for permission to reproduce this material for any purpose other than personal use. © 2012 Autism Ontario  416.246.9592  www.autismontario.com.