Sleep and Autism Spectrum Disorder (ASD)
by Carin Lamm, MD Associate Clinical Professor of Pediatrics Diplomate American Academy of Sleep Medicine Director Pediatric Sleep Disorders Center Columbia University Medical Center
Sleep problems are very common, reportedly as high as 80% in children with ASD. In typically developing children sleep problems and insufficient sleep can result in daytime sleepiness, learning problems and behavioral issues such as hyperactivity, inattentiveness and aggression. Recent research in children with ASD demonstrates that poor sleepers exhibit more problematic behavior than good sleepers. The most common sleep problems in children with ASD are difficulty falling asleep and repeated awakenings during the night. Some children have very prolonged awakenings or awaken very early for the day. When a child has difficulty sleeping, the sleep of other family members is often impacted.
Many potential reasons exist for poor sleep in children with ASD, including neurological, behavioral, and medical issues. Some early research studies indicate possible abnormalities in brain systems that regulate sleep. Studies are underway in children with ASD evaluating levels of hormones such as melatonin and other chemicals released by the brain known to affect sleep. Behavioral issues such as poor sleep hygiene and limit-setting problems can contribute to insomnia. In addition, medical issues more common in children with ASD such as epilepsy or gastroesophageal reflux can disrupt sleep. Sometimes medications your child might be taking can be alerting and contribute to difficulty falling asleep. Psychiatric issues frequently associated with ASD such as anxiety and/or depression can interfere with sleep. Finally sleep disorders common in the general population such as sleep apnea, sleepwalking, nightmares, restless legs syndrome may impact sleep.
Fortunately, there are several ways parents can improve a child's sleep. First discuss your child's sleep with your health care professional. It can be helpful to know the amount of sleep your child needs. For example the National Sleep Foundation recommends for preschool children (11-13 hrs), school age children (10 -11 hrs) and for adolescents (9 ¼ hrs). ( sleepfoundation.org )
Establishing good sleep hygiene by addressing the following domains is a good first step.
Sleep environment : the bedroom should be dark, quiet and cool. As children with ASD might be particularly sensitive to noises and/or have sensory issues, the environment should be adapted to make sure your child is as comfortable as possible.
Bedtime routine : the routine should be predictable, relatively short (20 - 30 minutes) and include relaxing activities such as reading or listening to quiet music. Avoid the use of electronics close to bedtime such as TV, computer, video games etc. that can be stimulating making it difficult for your child to fall asleep.
Sleep\wake schedule : the schedule should be regular with not much of a difference between the weekday and weekend schedule.
Teach your child to fall asleep alone : It is important that your child learn the skill of falling asleep without a parent present. All children and adults wake briefly during the night but quickly put themselves back to sleep by reestablishing associations used at bedtime. So if your child needs a parent present to fall asleep at bedtime, he might need a parent to help him fall back asleep during the normal awakenings.
Exercise : Daytime exercise can make it easier to fall asleep and children who exercise tend to have deeper sleep. Avoid allowing your child to exercise too close to bedtime as it can make it difficult for him to fall asleep.
Avoid caffeine particularly close to bedtime, which can be alerting making it difficult for your child to fall asleep. Caffeine is found not only in coffee, but also in tea, chocolate and some sodas.
Naps are helpful for preschool children, but should not be taken late in the afternoon as they can interfere with bedtime.
It is important to address medical or psychiatric issues that potentially interfere with sleep. Your child's medications might need adjustment if they affect his sleep. If your child suffers from a sleep disorder such as sleep apnea, sleep walking, sleep terrors, restless legs syndrome, he may need a referral to a sleep specialist. Some children with persistent insomnia will need further behavioral or pharmacological treatment to improve their sleep.
In summary, although sleep problems are common in children with ASD they often can be helped. Better sleep for these children can potentially improve their daytime functioning as well as the sleep of family members.