Sleep Guidance for Children With Autism Spectrum Disorder (ASD)

Autism spectrum disorder (ASD) is a term used to describe a range of conditions that affect communication, social interaction and behaviour. This includes Asperger syndrome. ASD is relatively common, with around 1 in every 100 people affected by the condition to some degree. The causes of ASD are not yet well understood, although it is believed that the condition is caused by a complicated interaction of genetic and environmental factors. Boys are significantly more likely to be diagnosed with ASD than girls.

ASD is a wide-ranging condition, and every individual will be affected in different ways. Some people with ASD may not display instantly-recognisable signs of the condition while others may have significant cognitive and language delay. Most people with ASD have problems with social interactions and may struggle to understand social cues involved in activities such as conversation. ASD can also cause repetitive behaviours and a pre-disposition to prefer set routines.

However, it’s important not to generalise and assume when it comes to ASD traits because people with the condition are individuals. ASD usually becomes apparent in early childhood before the age of 3, and some people will show clear signs before 18 months. A small number of people will not be diagnosed until adulthood, especially if their social communication difficulties are not easily noticeable to others.

Problems with sleep are extremely common in children and adults with ASD. In particular, many people with autism have trouble falling and staying asleep. Their sleep is more likely to be disturbed and of generally low-quality. For some people, this can make the difficulties they experience as a result of ASD harder to manage.

For example, poor quality sleep can exacerbate hyperactivity or lack of focus the next day. Of course, quality sleep is just as important for the health of people with ASD as it is for the rest of the population. For this reason, many parents of children with ASD are keen to find ways to improve their sleep.

Fortunately, there are various techniques that can be used to help children and adults with ASD fall asleep more quickly and have better-quality sleep when they do.

How does ASD affect sleep in children and adults?

ASD can affect sleep in a variety of ways. As a rule, children and adults with ASD take significantly longer to fall asleep and generally get less sleep in total per night than unaffected individuals. ASD increases a person’s overall risk of developing a range of sleep problems and sleep disorders. Sleep issues most likely to affect children and adults include:

• An unwillingness to go to bed
• Insomnia (difficulty falling or remaining asleep)
• Problems with breathing during sleep
• Problems waking up
• Feelings of tiredness or fatigue during waking hours

ASD and Sleep Disorders

ASD causes various common sleep disorders. Although many people with these disorders don’t have ASD, people with ASD are statistically more likely to be diagnosed with them. These include:

Sleep apnea

Sleep apnea affects a person’s breathing while they’re asleep. People with the condition stop breathing for short periods of time during the night. This is because the airway becomes temporarily obstructed, leading to low blood oxygen levels. This can cause the person to snore or seemingly gasp for breath while they sleep. Children who have sleep apnea alongside their ASD are more likely to experience episodes of bedwetting, feel tired during the day and exhibit challenging behaviour. A recent Japanese study has found that treating sleep apnea can help to treat behavioural symptoms of ASD.

Sleep-onset insomnia

Sleep-onset insomnia refers to difficulties falling asleep at the appropriate time, such as when you get into bed at night. For some people, this may only happen in the short term or may be episodic. However, other people will develop chronic, long-term insomnia. ASD greatly increases the likelihood of developing sleep-onset insomnia.

Sleepwalking and night terrors

Sleepwalking causes a person to get up and walk around during the night despite being fast asleep. It’s more common in boys than girls. Night terrors cause a person to wake suddenly from sleep and usually is accompanied by a feeling of intense fear, confusion, disorientation and other symptoms of stress. Both conditions can negatively affect sleep quality and may contribute to insomnia because they increase anxiety around going to sleep.

Rhythmic movement disorder

Rhythmic movement disorder (RMD) is a neurological condition. People with RMD tend to experience repetitive body movements before they fall asleep or at the point of nodding off. These movements are most likely to affect the upper body, neck and head. The condition is most likely to affect children, especially those with ASD. Most, although not all, people with RMD will stop experiencing symptoms without treatment in early childhood, usually before they reach 5 years old.

Restless leg syndrome

Restless leg syndrome causes a skin-crawling or tingling sensation in the legs at night which is highly unpleasant. This can lead to an uncontrollable urge to move the legs around to try and relieve the feeling. The condition is sometimes referred to as Willis-Ekbom disease. Women are more likely to develop restless leg syndrome than men.

Nocturnal enuresis

Nocturnal enuresis is the involuntary release of urine while a person is asleep. Most children will be dry at night by the time they reach the age of 5. If bedwetting persists beyond the age of around 7, this may require treatment. Bedwetting is extremely common in children, and a child is even more likely to be affected if they also have ASD. For some people with ASD, bedwetting will persist beyond the age of 10 and even into adulthood.

Hypersomnia

If a person has hypersomnia, they will be far more sleepy than usual during the day or may sleep for far longer than is normal. This can make it difficult for the affected person to remain awake during the day and may cause them to fall asleep at inappropriate moments. This can lead to behavioural and mood problems.

Although these sleep disorders affect many people without ASD, people with the condition are likely to experience the symptoms more severely. Research also suggests that the severity of the person’s social communication difficulties are directly linked to the severity of their sleep problems. The more intense the sleep symptoms, the more likely they are to have problems with behaviour, repetitive movements, inattention and mental health problems.
ASD is also linked to various other health conditions including epilepsy and digestive issues. While these problems are not sleep disorders, they can directly impact the quality of a person’s sleep in a negative way.

Why does ASD affect sleep?

It’s not fully understood why people with autism have problems with sleep and are more likely to develop sleep disorders. However, some possible reasons are currently being researched.

Some sleep experts believe that brain abnormalities could be to blame for disrupted sleep or difficult falling asleep in people with ASD. It is known that children with the condition don’t produce an amino acid called tryptophan at normal levels, which is vital for producing the hormone melatonin. Melatonin helps people to regulate normal sleep cycles. Therefore, people with ASD produce melatonin in a different way to unaffected individuals. In fact, they tend to produce more melatonin during the day, which could explain the difficulties in sleeping at night and potential sleepiness during waking hours.

Another potential reason for sleep issues in children with ASD is their difficulty to understand social signals. While most children will develop habits and understanding around bedtime by observing the nightly behaviour of family members, children with ASD find this more difficult. So, they may not be able to recognize the subtle signs that it’s nearly bedtime.

In addition, children with ASD are more sensitive to stimuli than other children. So, they may find it more difficult to calm down ready to go to sleep than others. They may also be more easily woken by noise or action during the night than unaffected children, who can tune small stimuli out while they sleep.

In general, young children gradually adapt their sleep habits as they get older until they sleep almost exclusively at night, perhaps with short naps during the fay. Children with ASD may develop these sleeping patterns later than other children of the same age.

Does a child’s age affect their sleep?

Many sleep problems associated with ASD in young children will gradually improve and even resolve entirely as they get older. In particular, sleepwalking, night terrors and rhythmic movement disorder are likely to go away before the child reaches 7 years of age. As there is no treatment for these particular conditions, these will need to be managed until they resolve.

Making sure that the child’s bedroom environment is safe and tidy by keeping a clear floor can help to prevent dangerous trips and falls if they sleep walk. You may need to take extra steps to ensure that doors and windows are totally secure, especially if the child attempts to leave the house in their sleep. Their bed may also need to be adapted if there is a risk of falling from bed. Using rails, padding or mats on the floor can help to keep your child safe until they outgrow their sleep problems.

In general, adults with ASD are less likely to have problems with their sleep, although they experience them more often than the rest of the population. Although problems such as night terrors and rhythmic movement disorder are uncommon in adults, issues such as insomnia can persist into adulthood. Like children, adults with ASD are also more likely to have related health conditions that, although they are not sleep disorders, affect sleep quality and duration.

How can sleeping better help a child with ASD?

In general, children with ASD who get higher quality and enough sleep are less severely affected by behavioural problems and social interaction difficulties than children with sleep problems. They are also less likely to feel tired and struggle to pay attention during the day. For this reason, it’s important to monitor your child’s sleep carefully and report any concerns to your child’s medical team. Many sleep problems and disorders associated with ASD can be improved or even completely alleviated with the right treatment.

In addition, some sleep disorders such as sleep apnea can cause a risk to health or lead to the development of other conditions. So, taking steps to improve sleep in children with ASD is beneficial for their mental, social and physical wellbeing.

Improving sleep in children with ASD doesn’t just benefit them. People who look after children with ASD are also at an increased risk of developing sleep problems and disorders. This may be because of emotional stress associated with being a caregiver or the need to wake up during the night if their child is having problems with sleep. So, by tackling sleep problems in the child, this can also benefit the parents or carers by improving the quality of their sleep too.

How much should my child sleep?

Babies and children need more sleep than adults. The amount of sleep they need gradually decreases as they get older. There are no set rules for how much sleep your child needs, as different children will have individual requirements. For example, children who are very physically active may need more sleep in order to recover at night. As a rule of thumb, here are recommended sleep times for babies, children and adults daily:

• Babies: 14-16 hours
• 1-3 years old: 12-14 hours
• 3-6 years old: 10-12 hours
• 7-12 years old: 10-11 hours
• 12-18 years old: 8-9 hours
• Adults: 7-8 hours

When children are very young, their sleep is split across smaller periods. Gradually, the number of naps they take will decrease until they are sleeping almost entirely at night. Most children will no longer require or want a daytime nap by the time they are 5 years old.

Creating the right sleep environment for children with ASD

Creating a calm and soothing bedroom atmosphere is important for all children when it comes to falling asleep. However, it’s even more vital for children with ASD because they are more likely to be disturbed by external stimuli than unaffected children. Eliminating potentially disturbing light from the room using blackout curtains or blinds can help some children with ASD to sleep better. Removing any electronics or objects that have lights or are tempting to play with at bedtime can also make the environment less stimulating and promote better sleep.

Establishing a bedtime routine

Many of the principles that apply to bedtime routines in children apply to those with ASD. It’s known that bedtime routines are important to help children go to sleep at the right time. Having a routine using the same familiar series of activities every night before bed can help the child to recognize that it’s time to sleep. Bedtime should be kept at very regular times. Varying bedtime, for example by staying up later on the weekend, can be counter-productive when it comes to establishing good sleep habits in children with ASD.

Objects associated with sleep can help some children with ASD to recognize it’s bedtime. Particular clothing or comforting soft toys that aren’t too stimulating and are brought out at bedtime can become cues that it’s time to sleep, especially if the child does not pick up on social cues related to bedtime. Having several of these objects may be helpful, as they could get lost or damaged, preventing the child from settling.

Some children with ASD find the transition from one activity to the other difficult to manage. This can cause stress and anxiety when it’s time to move on to something else, for example at bedtime. It may be helpful to give the child notice that bedtime is coming up so that it’s not sudden. Using the same consistent cue, such as using a sand timer, helps make this part of their regular routine.

It’s also important to avoid activities that are highly stimulating before bedtime. In particular, screens can cause problems with falling asleep and should be avoided for a couple of hours before bed for all children, not just those with ASD. In addition, your child may benefit from relaxing activities before bed that help them to wind down such as massage or soothing music. Keeping these the same every night helps to cue to the child that it’s sleep time.

Lifestyle changes to improve sleep

Some children with ASD ay benefit from changes to their diet and exercise routines in order to improve heir sleep problems. As a rule, children with ASD are more likely to have problems with their digestion and experience sensitivities to certain foods. These can cause painful or uncomfortable symptoms that may disturb their sleep. By eliminating triggering foods from their diet, this can help to improve the quality and duration of their sleep. Limiting caffeinated or sugary beverages can also help your child to sleep better.

If your child wets the bed, this is likely to cause distress and wake them in the night because they feel uncomfortable. Reducing their fluid intake before they go to bed can help to reduce bedwetting incidences and improve sleep. Regular physical exercise can also help your child to feel tired at night and ready to sleep. Ideally, this should not be too close to bedtime or it may be overstimulating and have the opposite effect.

My child will only sleep with me in the room. What can I do?

Many children find it difficult to fall asleep without their parent or caregiver with them. However, this can be even more challenging for children with ASD. It can be tempting to remain in the room while they fall asleep every night to avoid any issues. However, this can have a negative impact in the long-term. Not only is this difficult to maintain as the child becomes older, but if they wake in the night, they may be unable to fall back asleep again if they are used to having you there.

Using visual cues can be helpful in explaining to your child with ASD that going to sleep without mom or dad there is normal and safe. For example, you might show them a photo or drawing of them sleeping without you. Showing what you will be doing at the same time, such as cooking in the kitchen or sitting in the lounge, can also be helpful for them to understand that you are still close by and they are safe.

It’s also important that your child only sleeps in their bedroom, otherwise they could develop the habit of sleeping wherever they choose in the house. Ideally, you want them to associate their bed and bedroom with nodding off to sleep.

If your child finds it difficult to fall asleep without you there, you can withdraw your presence at sleep time gradually so that your child can adjust to sleeping alone a little at a time. Many ASD children struggle to sleep unless their parent is in the bed with them. If this is the case for you, you could start by sitting right next to your child’s bed while they nod off. Once they’ve adjusted to this, you may move your chair a little further away for a few days. After a while, you could sit in a visible location outside the room, then out of sight, until your child can happily fall asleep with no adult there at all.

What can I buy to help a child with ASD fall asleep?

Although routine and lifestyle changes are highly effective ways to help a child with ASD fall and stay asleep, there are also products that you can buy which may be helpful. These help you to create a sleep environment in your child’s bedroom that’s more conducive to restful sleep. There are also products that you can buy to help keep your child safe if they have sleep issues that could cause them to fall in the night.

If your child experiences bedwetting and bad night sleep, you can purchase special organic mattress with waterproof sheets and bedding protectors that help to make it quicker to clean up. This means that your child won’t have to get out of bed for so long while you change their bedding before they can go back to sleep. It also helps to stop bedding from becoming smelly and unpleasant to sleep on and reduces the expense of having to replace bedding or mattresses regularly if they become soiled. Some parents also find using absorbent bed pads or incontinence underwear for their child at night can prevent them from feeling wet, making them less likely to wake. In addition to waterproof bedding, some children find a weighted blanket useful. These can be particularly helpful is they have restless leg syndrome, which is associated with ASD.

Many children with ASD sleep walk or have rhythmic movement disorder. Not only can this cause them to fall, but they may wake up if they make contact with the hard side of the bed if they move around a lot. Using padded bed rails around the edge of the bed can help to prevent this from happening. Rails and safety mats on the floor can also help to prevent and limit injuries should your child fall from bed at any point.

If a child with ASD is very sensitive to sounds, the normal sounds from outside or inside the home can be very aggravating and prevent sleep even at a very low level. If this is the case, white noise machines may be helpful. These help to mask any disturbing sounds that may be preventing them from sleeping or waking them up during the night.

Some children with ASD are disturbed by the sound of their own snoring. If this is causing problems with sleep, anti-snoring devices may help to relieve their sleep problems. If your child snores, their dentist may be able to fit them with such a device. If the child has sleep apnea, they may need a continuous positive air pressure machine to help regulate their breathing while they sleep. This is not just important for their sleep quality but for their overall safety during the night.

Supplements for sleep problems in children with ASD

Certain individuals with ASD may benefit from particular supplements to help them sleep better. In particular, children with restless leg syndrome may have an iron deficiency, as this is a known cause of the condition. In this situation, taking additional iron may help your child to sleep better.

Some children with ASD-associated sleep problems may also benefit from taking supplementary melatonin. Studies have shown that taking extra melatonin helps children with autism to fall asleep faster. It also generally increases the overall length of their sleep session.

Before taking any such supplements, it’s important to consult with your child’s doctor. They will be able to advise on the best dose and whether the supplement is likely to be safe and beneficial for your child. Before prescribing or recommending iron supplements, the doctor will most likely check their existing iron levels. This is because taking additional iron with normal iron levels is unnecessary and can cause health problems such as constipation.

Should I try natural or herbal sleep remedies?

There are many ‘natural’ sleep remedies based on traditional herbal medicine that can be bought without prescription in pharmacies or health food shops. If your child is struggling with their sleep, it can be tempting to try these to give them some relief. However, just because something is natural or herbal does not mean it doesn’t have powerful effects. Many of these remedies have the potential to interact with other medications your child is taking or may have unwanted side effects.

In addition, herbal remedies are often sold in adult doses. Therefore, taking even one tablet may be too much for your child, especially if they are very young. In fact, many herbal remedies are not recommended for use by children at all.

This is not to say that alternative or herbal medicines will not be helpful or that they shouldn’t be used. However, they should be approached with some caution. Ideally, you should consult with your child’s doctor before medicating them with anything you’ve bought without a medical prescription. They will be able to advise whether the medicine is safe to take with your child’s current medications and whether there is likely to be any benefit. They will also be able to discuss with you any potential side effects and the correct and safe dosage for a child their age.

The bottom line

Hopefully, you now understand how ASD can affect your child’s sleep and what you can do to help them. By using a combination of routine and lifestyle changes, possibly alongside certain supplements, you can help your child to fall asleep more quickly and stay asleep for long enough to wake up alert and refreshed. If you can help your child to overcome their sleep issues, this can have great benefits in terms of their behaviour, social interactions and overall physical and mental health.

If your child is struggling with sleep, it’s important to seek help from their doctor. Sometimes, sleep issues and disorders can be a sign of a more serious underlying health condition that needs addressing. If your child is non-verbal, they may not be able to tell you that they are in discomfort and their disturbed sleep may be a warning sign that all is not well.

Caring for a child with ASD can be stressful, especially if they have sleep issues that are affecting the quality and duration of your own sleep. Seeking support for yourself and making sure that you get a break can be helpful. Some parents and carers find that they benefit from counselling with a professional with experience in ASD-related sleep disorders.

In addition, joining a support group for parents of children with ASD can be very helpful. Discussing your child’s sleep issues with other people with direct experience and who understand what you’re going through can be very helpful and a great source of support.

Resources:

https://www.autismlinks.co.uk/resources