45 percent (Malow, M.D. et al. 2006) to 53 percent (Krakowiak) of children with autism spectrum disorder (ASD) experience trouble with sleep.
Sleep problems are a somewhat mundane complaint of all parents, but only 32 percent of typically developing (TD) children present with difficulty sleeping (Malow, M.D. 2007). When children cannot fall asleep it causes stress for both them and their parents. Between the struggle to keep the child in their bed, to the taxing effects on the child’s ability to function during the day, sleep problems generate an uncomfortable family environment.
The most common issues for children with ASD are: difficulty falling asleep (53%), restless sleep (40%), and unwillingness to fall asleep in own bed (40%) (Gail). All of these result in what is known as lower sleep efficiency and prolonged sleep latency. In regards to lower sleep efficiency, this means that children with ASD are asleep for less time that they are in bed than TD children. Prolonged sleep latency translates to the fact that children diagnosed with ASD take longer to go from being fully awake to falling asleep. These problems could be a result of increased affective and attentional problems as well as higher scores on the anxiety/depression scale (Malow, M.D. 2007). Even though 51 percent of children with ASD (from a study with a median age of 8.4 years) average eight to nine hours of sleep per night (Gail), the time it takes for them to fall asleep contributes to these disruptive results during the day. In addition, school age children should be obtaining ten to eleven hours of sleep per night to reach optimal functioning during the day (Morgenthaler, M.D.)
All of these struggles demand an answer to the sleep problem. Here are five strategies to improve your child’s sleep (Wheeler) (Malow, M.D. 2007):
Provide An Optimal Sleeping Environment
• Determine what temperature is comfortable for your child, and what bedding is most comfortable. This sounds simple, but being too hot or cold can contribute to your child’s inability to fall asleep. Furthermore, some textures of bedding can be arousing to your child. Find blankets that offer a comfortable pressure on your child and sheets that consist of fabric that does not irritate your child.
• As with your child’s bedding, ensure that your child’s nighttime clothing is not arousing. Some children are bothered by clothes with seams or elastic bands.
Establish and Maintain a Regular Bedtime Schedule
• Your child’s schedule should consist of four to six activities that remain the same every night. Here are some activity ideas: “looking at the same book or story each night, saying good night to favorite objects, toileting, bathing, getting pajamas on, brushing teeth, having a glass of water, singing a favorite song or prayer, listening to calming music that the child enjoys, hugging and kissing family members and/or engaging in a calming sensory integration activity.” (Wheeler)
• Even if you know you are going to be coming home late, your child isn’t with you at their bedtime, or your family is traveling, try to keep your child’s bedtime schedule the same. Children with ASD often do better when they know what is going to happen next, so creating a physical copy of the schedule that they can see will also aid in the process.
Keep Your Child in Their Own Bed
• A common battle for parents of all children is ensuring that their child actually goes to bed when their child goes to their room. To reinforce the concept of staying in bed at night, you can put a gate against the door, or simply attaching a small bell to the door that will alert you if your child is leaving their room. This will limit the number of times your child gets up throughout the night, thus solidifying the idea that once you get into bed, you stay in bed.
• It is important that your child sleeps in their own bed, but it can be difficult to make this transition. To facilitate this transitional period, allow your child to keep an object from your room to take with them to bed. Allow the process to occur in small steps, and the transfer will occur.
Reward Systems
• Reinforcement System: To positively reinforce your child’s sleep, you can reward them each morning that they sleep through the night and in a timely manner. Whether it is a sticker, privilege, or small candy, the reward will eventually perpetuate the behavior.
• Bedtime Pass is a behavioral method that allows a child one-trip out of the bedroom after being put to bed. This method requires more research, but is showing positive results.
• Extinction: is a behavioral method that consists of planned parental ignoring until the child stops the behavior; although found effective, it is typically difficult for parents to implement as behaviors often worsen before they get better, and it can be accompanied by temporary bedtime resistance.
Consult with Professionals
• When behavioral treatments and environmental changes are difficult, find support. A behavioral interventionist can help! Many insurance companies are covering the cost of home therapies. Professionals can help you implement strategies, help to set up a routine, and get pictures schedules in place.
• Although research on sensory treatments is limited and not a promising practice. Many occupational therapists can help with advice on textured blankets & clothing, etc.
• Your doctor can help if given the strategies above you still struggle. Many studies have researched the use of melatonin on children with ASD who experienced trouble sleeping. In one retrospective study, “113 children with ASD (were) treated with 1-6 mg melatonin before bedtime…parents reported improved sleep in 89%” (Andersen). In one prospective study, “15 children with Asperger disorder, treated with 3 mg melatonin 30 minutes before bedtime for 2 weeks, showed a 50% reduction in sleep latency” (Paavolen). While melatonin is not guaranteed to help all children, it is an option you should bring up with your child’s doctor if you come to a point where you believe medication is necessary.
With all of these strategies one central concept must be kept in mind: things aren’t going to change overnight. Getting your child to sleep better and fall asleep faster takes time. Things commonly get worse, even, before the treatment(s) begin to work. Do not lose faith, and know that there is a way for your child to finally sleep without continuous problems. If a behavior has worked for a child for several months or years, it will take time and consistent behavioral strategies before a consistent change occurs. Be contingent and be consistent!
References:
Andersen IA, McGrew SC, Kaczmarska J, Malow BA (2006). Therapeutic use of melatonin in autism spectrum disorder. SLEEP 29:A297,
Friman PC, Hoff KE, Schnoes C, Freeman KA, Woods DW, Blum N (1999) The bedtime pass: an approach to bedtime crying and leaving the room. Arch Pediatr Adolesc Med 153(10): 1027-1029.
Gail Williams, P., Sears, L. L. and Allard, A. (2004), Sleep problems in children with autism. Journal of Sleep Research, 13: 265–268. doi: 10.1111/j.1365-2869.2004.00405.x
KRAKOWIAK, P., GOODLIN-JONES, B., HERTZ-PICCIOTTO, I., CROEN, L. A. and HANSEN, R. L. (2008), Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: a population-based study. Journal of Sleep Research, 17: 197–206. doi: 10.1111/j.1365-2869.2008.00650.x
Malow BA; Marzec ML; McGrew SG et al. Characterizing sleep in children with autism spectrum disorders: a multidimensional approach. SLEEP 2006;29(12):1563-1571.
Malow M.D., M.S., Beth A. “Promoting Sleep in Children with Autism Spectrum Disorder”. Vanderbilt Sleep Disorders Center. Nashville. Powerpoint. 30 Jan 2007. Web. 29 Aug 2012.
Morgenthaler, M.D., Timothy. “Question: How many hours of sleep are enough for good health?.” Mayoclinic. Mayo Foundation for Medical Education and Research, 4 Dec 2010. Web. 5 Sep 2012.
Paavonen EJ,.von.Wendt T. Vanhala NR, Aronen ET and von Wendt L. (2003) Effectiveness of melatonin in the treatment of sleep disturbances in children with Asperger disorder. Journal of Child and Adolescent Psychopharmacology 13: 83-95.
Wheeler, M. (2003). Good night, sleep tight, and don’t let the bed bugs bite: Establishing positive sleep patterns for young children with autism spectrum disorders. The Reporter, 8(2), 1-5, 6.
