Sleep and Autism

Although sleep problems are not part of the diagnostic criteria for autism, sleep problems seem to go hand in hand with autism. Many parents report this as a problem in their children with autism. However, there is some confusion about what constitutes a sleep problem. Using a broad definition of sleep problems, researchers have noted that anywhere between 56% (Clements, Wing, & Dunn, 1986) and 83% (Richdale & Prior, 1995) of persons with autism experience some sleep difficulties. Sleep problems may include: refusing to go to bed, getting out of bed, tantrums at bed-time, early waking, requiring a parent to sleep with the child, hyperactivity at night, etc. However, one study found that parents may be oversensitive to the sleep problems of children with autism and that the sleep of children with autism was similar (except for some "early night arousal") to that of children without autism (Hering, Epstein, Elroy, Iancu, & Zelnik, 1999). Since this article is not a scientific study, we will side with the parents on this one. Parents have been blamed too much for problems associated with autism, so we will not add to their burden here. Instead, let's discuss some solutions for sleep problems (Outlined in more detail in Schreck, 2001):

1. Establish a bed-time routine - Children with autism tend to create their own routines and may thrive on routines. In my home we started with a purposely-named ritual known as the "Night-night snack". In essence, to accept the snack meant acceptance of the process of going to bed. Start with a set time to go to bed and stick to it. Then initiate a standard bed-time routine or ritual. A typical bed-time routine may include: a. Snack; b. Bath; c. Pajamas; d. Brush hair and teeth; e. Read a story; f. Lights out; g. Get in bed. In order to establish this as a routine, it would have to be consistently practiced for at least three weeks. The idea is that as the child sees this as an inevitable occurrence each night just prior to sleep, the routine will soon be associated with sleep. Above all, pray. The Lord knows all about sleep and will always help. Psalm 4 is known as the "Sleep Psalm" and it may be a good thing to read with your child at night - it will remind him or her that God has everything under control, even while we sleep.

2. Non-Graduated Extinction - This may also be known as the "cold turkey" method. It involves ignoring any sleep disruption after going through the bed-time routine and placing the child in bed. The parents are to ignore the child by not talking to him, not touching him (except to return him to bed), and not looking at him. The child is placed in bed, if he gets up, he is put back in bed and (optionally) the door may be closed as a form of consequence. Be prepared, however, for an "extinction burst", that is, if he was used to you letting him stay up or is used to you sleeping with him, he will have a big tantrum to try to get that to happen again. This may last for an hour or so. Remember, it always gets worse before it gets better. If you consistently ignore him and never give in to him and let him stay up, etc. then he will eventually sleep on his own.

3. Graduated extinction - Some parents just cannot be "mean" enough (read: tough enough) to use the "cold turkey" method so they use a more gradual approach. Continue to use the bed-time routine. Once you place the child in bed, if he gets up, tantrums, or cries, ignore him for five minutes. If he continues after five minutes, go in to his room and settle him down with as little attention as possible, and then leave the room. Wait for a little longer time before going in the next time (say 10 minutes) and gradually increase the amount of time you let him cry. The key to both graduated methods is that the child never is allowed to get up or have you stay with him due to his tantrum behavior.

4. Stimulus fading - This method is especially good with children who have trapped their parents into sleeping with them. In essence it involves gradually moving the parent further and further away from the child's bed. Add a bed or mattress to the child's room. The first night the parent sleeps in the bed right next to the child's bed. Night after night the parent's bed is moved further and further away from the child's bed, until it is out of the room and, finally, the parent is transferred back to the parent's bed (boy, will your spouse be happy!).

General Recommendations:

Make sure your child is screened by his physician for any medical conditions that may interfere with sleep (allergies, asthma, pain, sleep apnea, etc.) prior to beginning any of these recommendations. Part of the bed-time routine should include a cessation of exciting activities about an hour before bed time. Give your child a warning before starting the bed-time routine (e.g., "Bobby, in five minutes it will be time to get ready for bed."). Remember, children with autism may have difficulty shifting from one activity to another, so warn him when one activity is about to stop and another begin. Make sure there are no sensory distractions to bed time. Check out unusual smells, sounds, sights, the feel of the sheets and blankets, the temperature, etc. to be sure they are not interfering with sleep - correct any problems. Set a time to go to bed and a time to get up - oversleeping one day may lead to difficulty going to bed that night. Avoid caffeine in drinks and food. Try not to use sleep medications. Some children with autism do respond to the synthetic hormone, melatonin, as an aid to sleep. It is believed that some children and adults lack sufficient amounts of the hormone. Limit fluid intake after 6:00 pm or so. Keep track of successful bed-times and praise your child for going to bed so well, for staying in bed all night, etc. Make sure your child has an active day-time schedule to include periods of vigorous exercise. Make the bedroom sleep-friendly by removing exciting toys, televisions, etc. and adding favorite blankets or stuffed animals (not too many). Use a night light if necessary but generally keep the room dark with the curtains drawn. Night-night! ;-)

Note: "Romero," one of our Autism Home Page Moms, recommends the following: when her child got up at night, she began simple ABA drills with him. It wasn't long before he decided he would rather sleep! (Of course, it didn't hurt Romero's feelings either).

Sleep-Related Links:

Bedtime - Some practical tips on why children may not want to sleep, how to help them sleep, and a chart that lists how much sleep children need at each age (State of Oklahoma web site).

Melatonin, The Sleep Master - Center for the Study of Autism

Too Much Television Viewing May Lower Melatonin Levels & Hasten Puberty! - New Scientist

Physical Exercise and Autism - Center for the Study of Autism

Book: Sleep Better!: A Guide to Improving Sleep for Children With Special Needs - Amazon.com.

Sleep, Baby, Sleep - Autism Today article.

Sleep Problems in Asperger's Syndrome - A journal article on PubMed that indicates that sleep problems may be a common concern for adults with AS as well.

Coping With Night Terrors - The Healthy Place.com web site article has some great information on this problem and some great, practical suggestions on how to treat it.

Sleep Problems - The Kids Health web site discusses the various types of sleep disturbances that children may have and also offers some good solutions.

References:

Clements J, Wing L, & Dunn G, 1986. Sleep problems in handicapped children: a preliminary study. Journal of Child Psychology and Psychiatry 27(3): 399-407.

Hering E, Epstein R, Elroy S, Iancu DR, & Zelnik N, 1999. Sleep patterns in autistic children. Journal of Autism and Developmental Disorders 29(2): 143-147.

Richdale AL & Prior MR, 1995. The sleep/wake rhythm in children with autism. European Child and Adolescent Psychiatry 4(3): 175-186.

Schreck KA, 2001. Behavioral treatments for sleep problems in autism: Empirically supported or just universally accepted? Behavioral Interventions 16: 265-278.

Disclaimer: The information on this page and from the links are not intended as medical advice. Do not make any changes in your child's treatment without first consulting your child's physician.