Sleep Difficult for Children on Autism Spectrum

By Deborah Jeanne Sergeant

Recent research published in the journal Pediatrics indicates that children with autism spectrum disorders (ASDs) are at double the risk for experiencing difficulties with sleep than children not on the spectrum.

Researcher Ann Reynolds, a physician and associate professor of developmental pediatrics at University of Colorado School of Medicine, found that children between the ages of 2 and 5 are more likely to delay bedtime, struggle getting to sleep, feel anxious about sleep, awaken during the night and have night terrors, all of which can mean fragmented sleep.

Children need sleep for their own mental health benefits.

“Just like with anyone, having impaired sleep can exacerbate behavior problems,” said Henry S. Roane, Ph.D. “If you’re cranky in the morning no matter what, not sleeping makes that worse.”

Roane is SUNY Upstate professor of pediatrics and division chief of Center for Behavior, Development, and Genetics.

He said that among children with special needs and typically developing children, a lack of sleep causes three negative outcomes. The first is heightened psychological stress.

“They’re more reactive to environmental stresses,” Roane said. “They may be less consolable.”

The second is temporary impairment of the ability to take in and process information.   

“The person might be impaired anyway, but lack of sleep makes it that much worse,” Roane said. “They might have difficulty in understanding what they’re supposed to do or a change in routine. That can trickle down to behavior.”

In turn, that altered behavior can cause difficulty with others. Roane said that teachers and caregivers may lessen their expectations for the child or they could look at other causal factors.

The problem may continue for a long time if the child is unable to express how he or she slept or why good sleep isn’t happening.

“You have two effects because the parent can’t sleep well, either,” Roane added.

Uncertain causes

So why do kids on the spectrum experience sleep disturbances? It’s not entirely clear.

Angela Saturno, director of the Kelberman Center in Syracuse, said that medical issues, such as gastrointestinal problems, psychological issues or medication could worsen sleep.

“The first thing you do is look at the medical, medication and psychiatric,” she said. “Try to rule those things out before you go on a behavioral track.” They would have to undergo psychological testing to determine their concerns.

Examining and exploring those variables could help mitigate and manage their effects. Saturno advises parents to keep a sleep diary for their child to see what may affect their sleep positively and negatively. Sensitivity issues prevalent with people on the autism spectrum may affect sleep quality and quantity.

Just before bedtime isn’t a good time for vigorous activity; however, sufficient activity earlier in the day may improve sleep. Quieting the household before bedtime can assist in easing into the transition to sleep.

Saturno recommends a regular nighttime routine, illustrated by a picture board or other display with times listed for older children. For example, a picture of a toothbrush, toilet, sink, storybook and bed in a row could symbolize the order of use of these objects. The display should be located where children can reach it so they can check off each item as they complete it.

Saturno also advises limiting vigorous activities 30 to 60 minutes before bedtime starts and doing some relaxing activities just before bedtime or as part of the routine.

Breaking down bedtime to a set of rules may seem harsh or controlling, but it’s actually what children need–and want.

“Rules are comforting to them so they feel safe,” said Sarah Marsh, a pediatrician at St. Joseph’s Primary Care Center. “It gives them some control. They can decide to follow them or not and know the consequences.

“If they don’t have rules, they have to find the boundary all the time. Routine is key.”

Roane said that environmental factors conducive to good sleep are highly individual for those on the autism spectrum. For example, for some children, the same pajamas, teddy bear, blanket or other objects associated with sleeping help them settle because they’ve added them to the routine.

Those who are noise sensitive may find white noise or a fan unbearable, as well as ambient sounds from outside the room. Thick carpeting, soft wall hangings and sound-absorbing ceiling material can help absorb sounds from the rest of the household with a later bedtime.

Consider the room’s temperature, as well as the bedclothes and pajamas. It’s difficult to sleep in an overly warm bedroom.

“Create a behavior chain that will work for the family, not one the child has made that involves night terrors or sleeping with mom,” Roane said.

For children who get up in the night Roane recommends issuing one “Get Out of Bed Free” pass that’s good for only one night. Once they use their pass for a drink or extra cuddle, it’s gone. If they still have the pass by morning, they may turn it in for a reward, such as access to a preferred activity or favorite fruit.

If children get out of bed after using the pass, Roane recommends prompting them to go to bed with as little fanfare as possible.