Sleep problems are common amongst children. For children with autism, sleep can be even more challenging. Studies show that up to 80% of children with autism have some sort of sleep difficulties. Most often it is due to difficulty falling and/or staying asleep. The goal of this article is to review sleep hygiene and discuss behavioral approaches to help promote a better night’s sleep.
No discussion about sleep should begin without first talking about the foundation for sleep—good sleep hygiene. What exactly is sleep hygiene? Simply put, sleep hygiene is a combination of our behaviors and the things around us that can help or hurt our sleep. There are four basic elements of good sleep hygiene.
- Sleep Routine: Every child should have a set nighttime routine. A sleep routine consists of a series of activities that are performed the same way and begin at the same time every night leading to bedtime. These activities should help your child wind down. Children with autism may be particularly driven towards routines, so once the nighttime routine is established, it will hopefully be easy to continue. I recommend parents have a visual representation of the nighttime routine to help the child learn the components and the sequence of steps. Once each part of the routine is complete, the visual chart is shown to the child again to indicate which step is next. The final step should be lying the child in bed and the parent saying goodnight. The goal is to have quiet activities that avoid too much light exposure and mental/physical stimulation. A good routine should be about twenty to thirty minutes in length. It is important to avoid TV, tablets and smartphones during this time. This can be tricky as some children use these tools to help calm themselves and prepare for bed. I encourage parents to move these activities earlier in the evening and to avoid bright light from these types of devices for at least one hour prior to bed. Light exposure can change the brain’s pattern of melatonin secretion, an important hormone for sleep. For children with autism, studies show that their melatonin secretion may be prone to dysfunction at baseline. Light exposure before bed can make this even worse.
- Appropriate Sleep Schedule: How many hours of sleep does a child need? How many naps should a child take? It is evident that many children with autism do not seem to sleep as much as other children, nor do they take as many naps, yet seem to stay awake without appearing fatigued during the day. In order to get a rough idea of how much sleep your child needs, below is a chart I use for all children. Please remember that children with autism may fall out of this range completely, but the chart will hopefully give you a reference point.
|Age||Average Sleep Needed||# of Naps|
|0–3 Months||12–18 hours||3+|
|3–12 Months||14–15 hours||2-4|
|1–3 years||12–14 hours||1-2|
|3–5 years||11–13 hours||0-1|
|5–10 years||10–12 hours||None|
|10–17 years||8.5–10 hours||None|
Source: My Child Won’t Sleep. Kansagra S, Createspace Publishers, South Carolina: 2014.
The take-away message is that the duration of normal sleep is a range, and every child is different.
- A Comfortable Environment: This is obvious, but the environment should be a comfortable temperature and free from excessive noise. Body temperature drops during sleep, and being too warm can inhibit the ability to fall asleep. Therefore, I typically recommend keeping the room on the slightly cooler side and dressing warmly instead of the opposite. However, children with autism can have certain sensory preferences, such as preferring more blankets or certain types of clothing. It is important to cater to whatever makes the child comfortable. Some parents have found success using weighted blankets for children with autism. They can provide an additional sense of security and sensory stimuli for children. Keep in mind that a recent study in children with autism did not show improvement in sleep with a weighted blanket, yet children and parents still seem to prefer them. It is worth trying if you feel your child may benefit.
- Avoidance and Treatment of Sleep Disruptors: One major sleep disruptor is caffeine. Even morning caffeine in the form of coffee, tea, soda, or chocolate can disrupt nighttime sleep. As a rule, I recommend that children do not consume any substances with caffeine, regardless of whether or not there is a sleep issue. Medical problems can also disrupt sleep, including nasal congestion from allergies, eczema, sleep apnea, restless leg, and Gastroesophageal reflux (heartburn). These should be treated by your pediatrician.
Once you have the basic foundation of good sleep hygiene in place, you are ready to move on to some focused behavioral therapies for specific problems.
“My child won’t fall asleep without me”
There are two main reasons for children only sleeping with parental presence. The first is anxiety, which can be quite prominent in children with autism. Usually parents can see that the child is anxious at nighttime based on behavior. If your child is excessively anxious, please consider evaluation by your physician. For anxious children, the transition to sleeping independently should be a slow and steady one. I usually recommend placing the child in his/her room after the routine, and then actually staying in the room until the child falls asleep. Over time, parents should move further and further towards the door of the room while the child falls asleep, with the goal of both decreasing nighttime anxiety and encouraging the child to fall asleep independently.
The second reason for needing parents to fall asleep is due to sleep associations. Children quickly learn what is in their environment when they transition from wake to sleep. They often become dependent on this aspect of their environment to fall asleep. For example, an adult who always goes to bed with the fan on will have a hard time going to sleep without it. In this example, the fan is an example of a sleep association. Similarly, a child who always goes to bed with a parent present will learn this is the way they fall asleep. If the parent then leaves prior to the child falling asleep, they will protest until the parent comes back. The parent is the sleep association. The key is to teach the child to transition to sleep independently without any associations that will not be present when they wake up. There are many methods to this, such as “graduated extinction” (leaving the child in bed after the routine, but then returning at set intervals to help calm them) and “fading” (slowly distancing the parent from the child over the course of weeks to months in a gradual fashion). The key is finding a method that is most comfortable for you and your child.
“My child wakes up frequently at night”
Sleep associations are also a common reason for nighttime awakenings. All children wake up at night. It is a normal part of sleep. Children who have sleep associations will wake up and look for their association. If they are accustomed to falling asleep with a parent, they will look for the parent. If they typically fall asleep with an iPad, they will turn on the iPad. Children who don’t have these associations are more likely to simply fall back to sleep after waking up in the middle of the night. Decreasing a child’s dependence on parents to fall asleep may help the child sleep longer at night.
You can also add in positive sleep associations for the child. For example, some children enjoy white noise in the background while they fall asleep at night. The sensory input from such a device can be calming. Similarly, a favorite stuffed animal or blanket can work just as well for children. These associations can stay with the child the entire night, so may actually prevent long awakenings.
“My child wakes up too early”
This is one of the most challenging problems to treat. The first question is how the child behaves and feels upon awakening. If the child is wide awake and functions well throughout the day, chances are the child simply has a decreased need for sleep and may not sleep more regardless of what you do. In this situation, if the child is waking at a time that is too early for the other members of the household, and the child is safe to play independently in the room, then I recommend trying to have a visual cue that signals the child when it is time to leave the room. A light on a timer typically works well. Children can then be taught to play independently in their room and leave once the light turns on. Alternatively, you can slowly move back the bedtime by 10 minutes each day in hopes the wake time also moves later, so long as this is more conducive to the family’s schedule.
However, if it is clear the child is capable of sleeping longer but just won’t remain in bed, the timed light can also work as a visual cue, in combination with returning the child to bed consistently until they fall back asleep. This can take many attempts (sometimes over 50!) on the first few nights. The key is the consistent response from parents. Over time, the child should learn that the response to leaving the bed too early will be exactly the same from parents. This helps children learn to stay in bed until the visual cue to leave is seen. Positive reinforcement for nights your child stays in the room can be helpful for some children. Having a chart on the door to track which nights went well is a helpful tool.
If you’ve done everything in regards to sleep hygiene and taught your child to fall asleep independently, but sleep is still a major problem, talk to your pediatrician. You may need to see a sleep specialist. There are a variety of supplements and medications (such as melatonin) that can also help, but always talk to your healthcare provider first.
Sujay Kansagra, M.D. is the author of the book “My Child Won’t Sleep,” a step-by-step guide for parents that presents ALL of the scientifically-proven techniques to help children sleep. He is the director of the Pediatric Neurology Sleep Medicine Program at Duke University in Durham, NC.
This article was featured in Issue 34 – Autism Sleep, Bedtime and Hygiene Routines