Autism, Asperger’s Syndrome and Sleep

Autism Spectrum Disorder (ASD) is a complex developmental condition. ASD  impacts about 1% of the population. Millions of children and adults with this disorder face lifelong difficulties with communication and nervous system effects. One area of focus for improving symptoms and quality of life for people with autism is sleep.

Sleep impairment is associated with many health effects. These include social strain, learning, and cognitive effects, aggression, and hyperactivity. These traits are also very reflective symptoms of ASD. Among those with autism, poor sleep is further linked with:

• Lower IQ
• More compulsive behavior
• Behavioral issues
• Attention deficits
• Depressed/anxious mood

Sleep is of utmost importance to modern science, with links to nearly every aspect of physical and mental health. However, the brain remains a complex area of study for even the most advanced scientists. That makes studying the links between autism and rest quite challenging. Many factors appear to be at play. But, recent years have shed significant light on this relationship.

In this article, we look at Autism Spectrum Disorder in detail along with its relationship to sleep. We’ll also cover current treatments and good sleep habits that everyone can implement for sweeter dreams.

How Walk Now for Autism Speaks is Helping to Fund Research and Solutions

Autism Speaks is a leading organization that focuses on supporting individuals with autism spectrum disorders and their families. One of their annual events, the Walk Now for Autism Speaks, is dedicated to raising awareness and funding for research related to autism spectrum disorders, including sleep-related issues.

Individuals with autism spectrum disorders may face a variety of challenges related to sleep, such as difficulty falling asleep, staying asleep, or waking up early. These sleep problems can have a significant impact on daily functioning and quality of life. Addressing these challenges is essential to promoting optimal health and well-being for individuals with autism spectrum disorders.

Fortunately, there are several strategies for improving sleep quality that can be effective for individuals with autism spectrum disorders. These strategies may include behavioral interventions, medication, and other therapies. Through the Walk Now for Autism Speaks event, the organization is working to fund research into these and other potential treatments, with the goal of improving sleep outcomes for individuals with autism spectrum disorders.

Autism Spectrum Disorder Defined

Before diving into the links between autism and sleep, it’s helpful to understand exactly what this condition entails. The American Psychiatric Association publishes the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual serves as a reference to criteria for clinical classification of mental health concerns. Mental health professionals use the DSM to diagnose conditions.

DSM-V is the most recent version, published in 2013. The category of Autism Spectrum Disorders includes three levels of severity. The key criteria for assessing ASD include abnormal social development and repetitive behaviors. Both factors must not otherwise be explained by intellectual disability. These symptoms must have started in early childhood and impair daily function.

The newest classification system changes a few previous diagnoses:

• Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS), Autism Disorder, and Asperger’s Disorder is now part of ASD.
• Rett Syndrome is now a distinctly diagnosed disorder.
• Social Communication Disorder is also distinct. Its definition lacks the behavior repetition patterns of ASD.

DSM Criteria for ASD

In assessing patients for ASD, clinicians consider the criteria provided in the DSM. The DSM-V lists five key criteria for autism diagnosis, summarized below:

Lasting impairment to social communication and interactions. Clinicians assess for current presence or history of:

1. Deficits in social-emotional reciprocity. Given examples include failure of normal back-and-forth conversation and reduced sharing of interests and emotions. Abnormal social approaches or failure to engage in social interactions are also traits to look for.
2. Deficits in nonverbal communication. Examples the DSM offers are abnormalities in eye contact, a lack of facial expressions and nonverbal communication, and trouble understanding the use of gestures. Clinicians assess for a general understanding of nonverbal communications and to see if verbal and nonverbal messaging seem to match up.
3. Deficits in relationships. Difficulty initiating and maintaining relationships and interest in peers is another aspect. Here, the doctor considers the person’s ability to understand relationships, engage in social play, and adjust behavior to social contexts.

Restricted, repetitive patterns of behavior, interests, or activities. Clinicians assess for the current presence or history of at least two of the below traits:

1. Repetitive movements, speech, or object use. This is categorized by repeatedly lining up toys, for example, or making repetitive motor movements. It can also appear as a meaningless repetition of phrases or irregular speech patterns.
2. Inflexibility with adhering to routines or ritualized behavior patterns. People with autism tend to have difficulty or extreme distress with changes to routines. They may also show difficulty transitioning activities or with inflexible thought patterns. Another symptom is sticking to similar rituals, such as with greeting patterns, dietary choices, or routes.
3. Fixated and restricted interests. Clinicians look for strong attachments to atypical objects or pervasive preoccupations. This might include abnormally intense or laser-focused fixations on objects or ideas. For example, one might show intense focus on something like trains, dinosaurs, certain numbers, or a shape. Or, they might collect something unusual with great passion.
4. High or low reactivity to sensory stimulation. Both extremes of responsiveness to sensory stimulation in the environment are of interest to clinicians. For example, some people might display hypersensitive reactions to sounds, lights, textures, smells,  or tastes. Others may show little to no reaction to sensory input, displaying hyposensitivity.

Presence of symptoms in early childhood. Regardless of the current age of the patient, clinicians detail childhood behaviors to determine onset.

1. For some, symptoms may not be severe enough to seek treatment early on. But, there should still be a history of the above traits in childhood to make a diagnosis of ASD, as it is considered a lifelong disorder.
2. Adults may also develop coping strategies or hide symptoms. Reviewing childhood behaviors may offer clinicians greater insight.
3. The presented symptoms must cause significant impairment to a person’s life. This might be in social life, work, or other critical domains.
4. Symptoms presented are not better explained “ by intellectual disability (intellectual developmental disorder) or global developmental delay.” Developmental delays and ASD often occur together. Because of this, clinicians are asked to assess several factors, including:
   1. If intellectual impairment is present.
   2. If language impairment is present.
5. Influential medical conditions, genetics, or environmental factors.
6. Other related mental, behavioral or neurological disorders.
7. Presence of catatonia. One study describes symptoms of catatonia in ASD to include: “markedly increased psychomotor slowness, which may alternate with excessive motor activity, apparently purposeless…”

While assessing the DSM checklist, the clinician also assesses the patient’s severity levels. Social communication and repetitive behaviors are classified into three levels using the following criteria:

Level 1

The Level 1 category includes people “requiring support.” This is the lowest severity level of ASD in the DSM-V. The older diagnosis of Asperger Syndrome was assumed in this category.

Social Communication
Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who can speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are odd and typically unsuccessful.

Restricted, Repetitive Behaviors
Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence.

Level 2

The Level 2 category includes people “requiring substantial support.” This is the middle level of ASD in the DSM-V. The older diagnosis of Autistic Disorder was assumed into this category.

Social Communication
Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication.

Restricted, Repetitive Behaviors
Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in various contexts. Distress and/or difficulty changing focus or action

Level 3

The Level 3 category includes people “requiring very substantial support.” This is the highest severity level of ASD in the DSM-V. The older diagnoses of Childhood Disintegrative Disorder and Pervasive Development Disorder were assumed into this category.

Social Communication
Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches.

Restricted, Repetitive Behaviors
The inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action.

Steps in Diagnosing ASD

So, what happens if you suspect your child or yourself may have some of the above symptoms? The first thing doctors do is perform a developmental screening. If problems are identified, then diagnostic tools come in to assess for disorders.

Developmental Screening

During pediatric visits, doctors normally assess child development at specific intervals. Typically, this occurs at 9 months, 18 months, and 24-30 months. This includes observing how the child speaks, behaves and interacts. Doctors look for any warning signs of developmental disorders or disabilities that may require diagnostic screening.

There are numerous screening tools doctors may use. Five of the most popular include:

• Ages and Stages Questionnaires. This survey relies on parent observation. It screens for communication, problem-solving, motor skills and adaptive skills.
• Communication and Symbolic Behavior Scales. This is a parent-completed tool used to screen infants and toddlers. It looks at communication and symbolic aptitude.
• Parents’ Evaluation of Developmental Status. This tool interviews parents on general development and behavior. It’s intended for all ages.
• Modified Checklist for Autism in Toddlers. This checklist for parents aims to assess potential risk factors. It’s intended for toddlers between 16 and 30 months.
• Screening Tool for Autism in Toddlers and Young Children. This interactive skills assessment tool involves play, communication, and imitation. It’s designed to assess developmental issues.

In adults and young adults, screening and diagnosing for ASD can prove difficult. Many of the tools apply specifically to young children. This is because most diagnoses occur during the early development stages. Very few tested tools exist for adults.

Screening for adults usually involves self-reported concerns. Adults may express social or behavioral difficulties. They may also seek screening if family members receive an ASD diagnosis. The clinician may ask the person about their childhood or interview family members.

Making a Diagnosis

If the initial screening process detects potential issues, the next stage is a diagnosis. This may take place with a general physician. Or, your doctor may elect to refer you to a mental health professional for this step. Generally, it’s recommended that doctors use multiple tools for assessment.

There are a few different diagnostic tools used in addition to the DSM-V criteria. These commonly include:

• Autism Diagnosis Interview – Revised (ADI-R)
  • For children and adults with mental ages over 18 months.
  • Assessment of three main areas:
  • Reciprocal social interaction
  • Communication and language
  • Restricted, repetitive interests and behaviors
• Autism Diagnostic Observation Schedule (ADOS)
  • Designed for children, although the ADOS-2, Module 4 may be used for adults.
  • Includes four modules, designed to accommodate different levels of expressive language.
  • Assesses communication, social interaction, imagination and play.
• Childhood Autism Rating Scale (CARS)
  • Designed for children over age two.
  • Measures a broad spectrum of areas related to ASD, including verbal and non-verbal communication, social understanding, emotional expression and regulation, sensory sensitivity, anxiety and more.
  • Helps estimate severity.
• Gilliam Autism Rating Scale (GARS)
  • Designed for ages 3 to 22.
  • Measures items on six subscales: restrictive, repetitive behaviors; social interaction; social communication; emotional responses; cognitive style, and maladaptive speech.
  • Developed for teachers, clinicians, and parents.
  • Helps estimate severity.

• Adult Repetitive Behavior Questionnaire (RBQ-2A)
  • Designed for adults.
  • Relies on self-reported responses from the patient.
  • Assesses restricted and repetitive behaviors.

ASD and Sleep

Now that we know what autism is, let’s look at its relationship with rest. One certainty is that people with ASD are more likely to have sleep problems. A lack of rest may also contribute to symptoms. Together, this makes the connection between autism and sleep deserving special attention.

An incredibly high percentage of children on the spectrum report sleep difficulties. In fact, sleep problems are one of the early warning signs of ASD in young children.

Studies estimate between 50% to 80% of children with autism have problems sleeping. Compared to peers, they are two to three times more likely to have insomnia. Trouble staying asleep and quality of rest also are common concerns. Adults with autism report sleep problems higher than the general population, but are less studied.

Getting inadequate rest affects everyone, but people with autism may be particularly sensitive. Studies show that poor sleep exacerbates many ASD symptoms, like interpreting social cues. It may also increase the risk of co-occurring psychiatric disorders.

Family members of those with autism spectrum disorders also may see impacts. Caregivers tend to report more stress and sleep disturbances. One study found that mothers reported increased stress caring for children with ASD and sleep disturbances. Another found parents of children with ASD reported worse sleep quality than parents of typically-developing children. They also showed less overall rest. Improving the sleep of people with ASD is important for their outcomes. But, it’s also crucial to the wellness of caregivers and family members.

What Types of Sleep Issues are Common with Autism?

Sleep is a complex process that involves numerous stages and cycles. Throughout the night, we cycle through lighter stages and deeper stages. Meanwhile, our bodies work to repair and clean house for the next day. Alterations to these cycles, sleep-related hormones, and numerous other factors influence our quality of rest.

Studies on sleep patterns of people with ASD reveal numerous trends, including:

• Shorter total sleep time.
• Taking longer to fall asleep.
• Higher proportion of time awake after falling asleep
• Increased time in lighter cycles of rest.
• Decreased time in deep, Rapid Eye Movement (REM) sleep.

These complaints can impair daily functioning, becoming clinically significant and requiring treatment. Sleep disorders most often diagnosed with ASD include:

• Insomnia – trouble falling asleep. There are multiple reasons and ways insomnia manifests. These include internal biological disruptions as well as external factors like:
  • Internal Biological Disruptions – hormones and the internal circadian clock can delay tiredness or disrupt sleep.
  • Sleep onset association type – refers to depending on certain objects, people, or conditions to fall or stay asleep.
  • Limit setting type – refers to escalating refusal and stalling behaviors resulting from caregivers’ limit setting.
  • Environmental Factors – daytime social stresses, changes to the environment, routine changes, and other considerations all may affect rest.

• Delayed Sleep Phase – feeling tired much later than normal or later than desirable.
  • A “normal” bedtime depends on the person’s age and their desired wake-up time. For adults waking between 6 AM and 8 AM, normal bedtime is between 10 PM and midnight. In this case, not being tired until 2 AM or later could signal a delay in circadian timing.

• Obstructive Sleep Apnea – obstructed breathing, causing the breath to start and stop during rest. Sleep apnea is linked with non-restful sleep due to frequent awakenings.
  • Symptoms include daytime sleepiness, poor mood, impaired memory, and snoring.
  • The fatigue and mood effects of OSA may exacerbate challenging behaviors and symptoms of ASD.

• Parasomnias
  • Nightmares – frightening dreams or night terrors.
  • Nocturnal Enuresis – bedwetting.
  • Sleepwalking – becoming active while still asleep.
  • Rhythmic Movements – repetitive rocking movements that continue after sleeping.
  • Most parasomnias dissipate with age, primarily affecting young children.

Does Autism Severity Matter?

The majority of studies involving ASD and sleep have one important limitation. Most do not distinguish between the different severity levels. For autism, this is important as the symptom scale is wide. Limited research suggests severe autism symptoms may correlate with more severe sleep disturbances.

However, research also suggests that insomnia remains very common among people with high-functioning autism or Asperger syndrome (AS). One small study compared children diagnosed with AS to those with ASD and typically developing peers. Both autism and Asperger’s syndrome were associated with reduced sleep. But, AS also showed increased shifts between sleep stages. Conversely, ASD showed fewer cycle shifts than typical peers. Authors speculate that the more frequent cycling in AS may relate to high-functioning memories.

So, is autism affecting slumber or vice versa? There is no clear answer here as both are incredibly complex and multi-faceted. Biological rhythms, mental health, and even medications related to ASD all play roles. The complex nature of the brain and the nervous system creates difficulty in studying these aspects in isolation.

Let’s look at key influences on the relationship between sleep and autism. Then, we’ll dig into best practices for reducing this impact.

Circadian Rhythm

The circadian system operates as the body’s internal clock. It oversees the production of hormones related to alertness and drowsiness. The circadian clock uses cues from light, temperature and our behaviors. When functioning normally, it triggers an evening release of melatonin. This, in turn, starts inducing drowsiness around bedtime.

The high incidence of sleep problems among people with ASD means circadian clock function is of key interest to researchers. A review of over 100 studies found numerous associations between ASD and the circadian system:

• Alterations to genes related to the circadian clock and melatonin pathways.
• Higher frequency of sleep disturbances. These include insomnia, shorter rest times, and low sleep quality. The delayed sleep phase was also identified, in which people tend to sleep much later than usual.
• Impaired sleep or altered circadian cycles also correlate to the severity of ASD symptoms. Researchers theorize that poor sleep increases symptom severity. At the same time, more severe symptoms also affect rest.

Melatonin production is of particular interest to researchers. This hormone is associated with drowsiness. Part of the circadian system, it’s released by the pineal gland when cues signal it’s time for sleep.

Numerous trials reveal abnormalities relating to melatonin in those with ASD. The general consensus is that people with both sleep problems and autism are more likely to exhibit higher daytime levels of melatonin and lower nighttime levels of melatonin. Typically, we have the lowest levels of melatonin in the daytime, peaking in the evening.

Social Cues and Interaction

Problems interpreting social cues and forming social relationships are central to autistic disorders. In early childhood development, social cues give us important information. Family members’ expressions, habits, and emotions inform us about routines and expectations.

Children with ASD may not pick up on social behaviors. Signals it’s time to wind down in the evening and get ready for bedtime can be missed or confused. Coupled with the potential for impaired circadian rhythm functioning, they may experience difficulty following a typical schedule.

The connection between sleep and social cues is an important area of research. One study of children with ASD found significant associations between shorter sleep duration and severe social impairment. In particular, the inability to develop peer relationships was noted as a correlating factor.

Researchers link poor sleep with other social side effects as well. For example, sleep-deprived people prove less adept at perceiving humor, sarcasm, and other people’s emotions. Being tired also makes us more aggressive and more likely to argue with people. ASD-specific research indeed links poor sleep with impaired social interaction. It also shows impairment in learning performance and language development.

Co-Occurring Mental Health Disorders

Hyperactivity: Inattentive and hyperactive symptoms are common in children with ASD. An estimated 30% meet the criteria for Attention Deficit Hyperactive Disorder (ADHD). ADHD is linked to insomnia and sleep pattern disturbance. Common ADHD medications show also links to delayed sleep onset. Kids with impaired sleep symptoms and ASD show increased hyperactivity compared to normal sleepers.

Anxiety & Mood Disorders: Rumination and negative thoughts induce cognitive hyperarousal in most people. Anxiety makes it hard to quiet the mind and relax. Compared to neurotypical peers, people with ASD show higher rates of anxiety and depression. One report indicates that about 40% of ASD kids and teens also have at least one other anxiety disorder. This includes obsessive-compulsive disorder, phobias, or social anxiety disorder. Autism-focused studies also identify links between poor sleep and worsened anxiety, as well as between autism and depression.

Co-Occurring Medical Issues

Epilepsy: Epilepsy is a neurological disorder characterized by loss of consciousness, convulsions, and seizures. The exact cause is unknown. But, research has found relationships between sleep and epilepsy. Some neurological symptoms are more likely during certain parts of the sleep cycle.

Sleep deprivation and stress also show links with seizures. Children with ASD are diagnosed with epilepsy much more than peers. This may further influence their sleep quality.

Gastrointestinal Issues: Kids with autism are three times more likely than typically developing peers to report frequent gastrointestinal problems. One study found that among kids with ASD, higher frequency of abdominal pain, constipation, diarrhea, and other issues was correlated with irritability, social withdrawal, and hyperactivity. Physical and mental discomfort certainly can make relaxation more challenging. This can be doubly true for non-verbal children that can’t express their discomfort.

Acid Reflux: Acid Reflux is commonly diagnosed in kids with ASD. This condition occurs when stomach acid flows back into the esophagus. It is commonly known as heartburn. Symptoms can be more pronounced when lying down. This may mean people with reflux feel more pain and discomfort at bedtime.

Allergies: Food and environmental allergies are often seen alongside autism. Food allergies often trigger gastrointestinal discomfort. They can also cause a broad range of health effects. Allergies to dust, plants, pets, and other items may create physical discomfort impairing relaxation.

ASD-Related Medications

Several medications prescribed to mitigate autism symptoms may interfere with rest. Selective Serotonin Reuptake Inhibitors (SSRIs) can cause agitation and hyperactivity. Antipsychotics can cause daytime drowsiness that may impact sleep timing at night. Pharmaceuticals prescribed for co-existing conditions also hold influence. Changes to medications or any concerns about how they influence sleep should be discussed with your doctor.

Heightened Sensory Sensitivity

The experience of the senses is often heightened with autism. Loud or unexpected sounds can be distressing. Smells and tastes can be more intense. Temperatures and textures can feel particularly distracting. What doesn’t bother others can feel overwhelming.

Studies show that those with increased sensory sensitivity may be more likely to have disturbed sleep. Sensory input is significantly associated with multiple sleep problems. This is true for older children in particular. Important things to consider include:

• Visible lights in the home or outside.
• Uncomfortable clothing or bedding.
• Sounds around the home after bedtime.

The sensation of touch may be of particular importance. One study found children with heightened sensitivity to touch experienced the most significant sleep disturbances. This was true for both sensory hypersensitivity (more sensitive) and hyposensitivity (less sensitive).

Assessing Sleep Disorders

Do you suspect that your child or yourself may have a sleep disorder? The first step is typically reaching out to your physician. He or she can conduct a general assessment and refer you to the right specialist if needed.

Screening for potential causes looks at a variety of factors. For example, current medical issues, mental health, medications, food allergies, and other aspects may affect rest. Generally, sleep problems are assessed and measured using a few standard tools. These include diaries, questionnaires, and observational methods.

Sleep Diaries

First, your care provider might ask that you keep a sleep diary. Sleep diaries prove useful for highlighting patterns and trends. A sleep diary involves logging your habits, such as:

• Bedtime and wake time.
• Instances of insomnia.
• Parasomnias like sleepwalking or bedwetting.
• Disturbances during the night.
• Morning and daytime restfulness.

It might also track daily activities, exercise, and meals. For children, this would be kept by their caregiver.

Even before you reach out for help, starting this habit can be a useful idea. The National Sleep Foundation offers an example that anyone can print out.

Questionnaires

There is a wide range of questionnaires doctors might use to assess the sleep habits of people with ASD. For children, parents usually complete their assessments. A few that prove most popular include:

• Children’s Sleep Habit Questionnaire (CHSQ). The CHSQ is the most widely used screening tool for assessing childhood sleep disorders. It looks at a broad spectrum of factors, including sleep timing, bedtime resistance, anxiety, parasomnias, and more. This test applies to children aged four to 10.

• Modified Simonds and Parraga Sleep Questionnaire (MSPSQ). This test works for children aged five to eighteen. The MSPSQ looks at sleep quantity and quality as well as specific disorders. It also gathers information relevant to planning for treatment.
• Family Inventory of Sleep Habits (FISH). This tool was specifically developed for children with ASD. It applies to kids between ages three and 10. FISH assesses daytime behaviors, bedtime behaviors, and the sleep environment. It also looks at parental bedtime habits.

Objective Clinical Assessments

Sometimes, your healthcare provider may seek a more objective assessment of habits. Tools used to scientifically assess sleep include actigraphy, polysomnography, and videosomnography.

• Actigraphy. An actigraph is a watch-like device that measures movement. This, in turn, measures periods of sleep and wakefulness. It allows researchers to collect data on bedtime, sleep duration, and night wakings. Together, these data points provide a clinician with a look at overall sleep efficiency. They do have some drawbacks like the potential for user error and sleeper intolerance.
• Polysomnography. This type of monitoring takes place in a sleep laboratory or clinic. During polysomnography, researchers collect data on brain waves, heart rhythm, breathing, muscle activity and more. It’s used for things that can be hard to assess, like disturbances to sleep stages or sleep apnea. Challenges here include high costs and difficulty adapting to the lab environment.
• Videosomnography. This approach involves taking a time-lapse video recording during the night. Videosomnography gathers data on sleep-wake states, limb movements, breathing, and more. Clinicians may also use it as a tool for providing feedback on parent-child bedtime interactions. This approach may prove useful for children averse to wearing an actigraph or sleeping in a lab.

Treatment of Autism-Related Sleep Problems

The relationship between autism and sleep is clearly complex and multi-dimensional. Because of this, many in the scientific community believe that managing sleep proves important for managing autistic symptoms.

The appropriate treatment protocol will vary based on the type of sleep problems, symptoms, current medical conditions and medications, and many other factors.  Experts often suggest that family sleep education is the desirable first-line approach. Changes to the sleep environment, cognitive therapies and pharmaceuticals are also studied treatments.

Recognizing when it’s time to seek help and implementing good sleep practices at home can be crucial in reducing the impact of this problem.

Sleep Training

Training on healthy sleep practices remains the first line of defense. Studies show that behavioral parent training improves both insomnia and sleep onset timing.

These programs typically include detailed information on sleep difficulties related to ASD to better equip parents. They go into scientifically-proven sleep hygiene strategies, the sleep environment, healthy and unhealthy habits, sleep timing, and more. The goal is to enable caregivers to establish, implement and manage effective bedtime routines. Training may occur as a self-study program, individual sleep coaching, or in group classes.

In order for this method to be effective, caregivers must implement and stick to the strategies learned in training.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is a psychology approach. It involves working with a therapist to change unhelpful thoughts and behaviors. This approach focuses on developing coping strategies and improving emotional regulation.

In particular, Cognitive Behavioral Therapy for Insomnia (CBT-I) targets a person’s attitudes and behaviors toward sleep. It’s typically coupled with patient education on sleep and creating a restful environment. This approach proves one of the most popular for behavior-related insomnia.

CBT-I might begin with keeping a sleep diary and then assessing the patient’s thoughts and behaviors. The doctor works to channel potential negative patterns into more helpful ones. For example, say a child expresses anxiety about darkness or nightmares. Their doctor might discuss the fear with the child to challenge it with logic. They may be able to help create a statement such as, “I am safe here,” to counter the fear.

A critical component of CBT for insomnia is its emphasis on healthy sleep habits. These include training on:

• Creating a relaxing nighttime routine.
• Exercise, nutrition, and avoiding stimulants.
• Improving the bedroom environment.
• The utility of sticking to a schedule.
• Techniques for reducing worry and sleep anxiety.
• Relaxation techniques like guided visualization and deep breathing.
• Partial sleep restriction to reset habits.
• Stimulus control such as avoiding naps, not spending time in bed when not sleepy, and consistent waking times.

Because CBT is a psycho-social approach, it does require the patient to be fairly verbal. It might not apply to all children or adults with ASD. It is showing promising results in initial studies, however.

Light Therapy

Another treatment your doctor might suggest is light therapy. It may help those suffering from circadian phase disorders or seasonal effects.

Light therapy involves daily exposure to a lightbox for a prescribed duration. These devices use certain luminosities and hues to mimic natural light. This is designed to help entrain the circadian clock into a normal 24-hour cycle. As with all treatments, it’s best to use under the supervision of a doctor.

Sleep Medicine Approaches

Currently, no drugs are approved for childhood insomnia by the Food and Drug Administration. For adults, there are several on the market, but many come with risks. From dependency and gastrointestinal problems to interactions with other medications, pharmaceutical sleep aids often have undesirable outcomes.

Melatonin is one supplement that is often studied for autism. This sleep-inducing hormone could be of use to those who naturally produce low levels. It’s also been shown to help ease Delayed Sleep Phase symptoms. However, melatonin is not risk-free. It comes with the potential for increased daytime sleepiness, bedwetting, depression, and seizures. Long-term efficacy is also unknown.

Always consult with a physician or other licensed medical provider before introducing new supplements or medications. It’s best to follow the advice of your pediatrician or medical advisors here! Everyone’s situation is different.

Dr. Vyas of Sleepless in NOLA Sleep Coaching says it is not recommended to start a child on over-the-counter Melatonin without first discussing it with the child’s pediatrician. There are often behavioral modifications that can be made to assist a child in sleeping through the night before medications are instituted.

Sleep Hygiene Tips for People with Autism

As we’ve seen, getting healthy rest is crucial for many aspects of life. In addition to helping mitigate ASD symptoms, quality sleep proves important for the wellness of the whole household.

Sleep hygiene practices are designed to help everyone rest easier. These guidelines utilize modern science to provide a basis for modeling behaviors and routines around healthy sleep.

1. Create a Bedtime Routine

One of the best ways to start the journey to healthier rest is by establishing a consistent bedtime routine.

• Step 1: Determine the correct amount of sleep for you or your child’s needs.
  • For adults, this is typically between seven to nine hours.
  • Teenagers need between eight to 10 hours.
  • Kids aged six to twelve should get nine to 12 hours.
  • Kids aged three to five should get 10 to 13 hours.
  • Toddlers aged one to two years should get 11 to 14 hours.
  • Infants four to 12 months should get 12 to 16 hours

• Step 2: Based on when you need to wake up, determine an appropriate bedtime.
  • For example, an adult that needs to wake up at 6 AM should aim to be in bed by 9 to 11 PM depending on their sleep needs.
  • Alternatively, an eight-year-old child that wakes up at 7 AM should be in bed between 7 and 10 PM.

• Step 3: Make a checklist of evening pre-bed activities to include in your routine.
  • This list might include changing into pajamas, taking a bath, washing your face, having a cup of herbal tea, reading, journaling, and other relaxing actions.
  • Prioritize tasks from least to most calming. Do the most calming ones closest to bedtime. For example, teeth brushing can be distressing to some people with high sensory sensitivity.
  • Integrating favorite objects like stuffed animals, a story, or a favorite blanket might be helpful for some children. Some experts suggest using two or more items for object-responsive kids in case one is unavailable.
  • Your routine should ideally be 30 minutes or less, especially for children.
  • Create a visual checklist of these nighttime to-dos on paper or a whiteboard. For children, explain each step, familiarize them with the list, and empower them to check off each step themselves.

• Step 4: Set a daily start time for your routine, about 30 minutes before your desired bedtime.
  • A reminder an hour or 30 minutes before the routine starts can help ease the transition to night. Being able to wrap up activities may help reduce bedtime resistance.

• Step 5: Utilize positive reinforcement for sticking to the routine. This can mean verbal encouragement or rewarding with a certain story at the end of the routine, for example. Experts also suggest a token system, where kids earn tokens for desirable behaviors that can be cashed in for rewards.

Try to stick to this routine every single evening, even on weekends. Staying consistent with bedtimes and wake times is one of the most helpful strategies for keeping sleep on track.

Occasionally you may need to deviate, for say a social function or to travel. Bedtimes also need to adjust by age and needs. In this case, try to prepare your child in advance. Let them know when and what will change in the routine. Try to visually outline these updates to your checklist in advance as well.

2. Assess the Bedroom Environment

The bedroom environment includes everything from the mattress and sheets to light, temperature, noise, cleanliness, and more. Ensuring the bedroom is set up for optimal rest can help remove common causes of sleep disturbance. These factors prove even more important for people with ASD who tend to have higher sensory sensitivity.

• Bedding: Comfortable, breathable linens can make a big difference.
  • Fabrics – Cotton is considered one of the best fabrics for sleep as it is breathable and moisture-wicking. Fabrics like polyester can trap heat, causing overheating at night. For children, check with them to make sure bedding is comfortable and temperature-appropriate. Scratchier fabrics may also disturb some sleepers.
  • Weighted Blankets – One study of children and teens with ASD took a look at the effects of weighted blankets. There wasn’t a significant difference in sleep time or onset. But, they found that the kids preferred the weighted blankets to typical-weight blankets.
  • Wash sheets, linens, and any plush toys regularly. This keeps the sleep space clean and minimizes allergens like dust.

• Mattresses: Having a bed and pillow suited to your sleep position and body type can make the difference between good sleep and bad. You should wake up well-rested without back pain and soreness. Stiffness or daytime back pain could be a sign that it is not providing support. If you or your child frequently awakens due to painful pressure points, your mattress may lack proper cushioning.
  • Use our free guide on finding the best mattresses to help narrow your search.

• Lighting: Light is important as its presence can delay the sleep-inducing hormone melatonin.
  • In the evening, switch to warm lighting with reddish undertones instead of blue.
  • Start dimming lights as bedtime nears if possible.
  • Use very dim night lights or motion-activated ones if needed.
  • Cover LED indicator lights on electronics with electrical tape if they bother you or your child.
  • Use blackout drapes if your home has light pollution from street lamps and city traffic.
  • Be mindful of lights near a child’s bedroom after you put them to bed.

• Temperature: Studies suggest that the ideal temperature for sleep is between 65 and 72 degrees. Generally, cooler temperatures are more conducive to deep rest. Find a suitable temperature that works for your family. Be mindful of seasonal weather shifts.
• Noise: Some people are very sensitive to sounds at night. This is even more true of people with ASD. Noises like a clock ticking, passing cars, rattling pipes, and family members’ footsteps can impair rest. Earplugs or sleep headphones offer one option for noisy environments. Be conscious of noise levels in the home when people sleep on different schedules.
• Smells: Another area where people with ASD experience increased sensitivity is their sense of smell. Odors other people may not notice can be highly distracting. Some people may respond well to calming scents like lavender. Others may prefer no detectable scents at all.
• Tidiness: A clean, neat room is always more calming and peaceful. Try to keep clutter, dirty clothes, homework, bills, and other distractions out of sight. With children, the first step in the bedtime routine might be putting away toys, for example.

3. Get Activity

One strategy for getting tired at bedtime is to burn off excess energy during the day. For children, ensure they have active playtime in the morning and afternoon. Taper down high-octane activities by the evening to start promoting calm. In adults, regular exercise is shown to help improve sleep. Try to get your sweat session in by midday or at least three hours before bedtime.

4. Be Mindful of Food and Drinks

A distinct relationship exists between diet and sleep. While complex, the basic thing to know is that a varied and balanced diet promotes healthy slumber. A few other helpful tips to keep in mind include:

• Avoid caffeine, sugar, and stimulants, at least in the evening.
• Eating too close to bedtime can cause indigestion and discomfort. Since people with ASD are more likely to experience digestive problems and acid reflux, this is doubly important.
• Limit liquids close to bedtime, especially for kids with bedwetting issues. Encourage water drinking during the daytime and taper down toward the evening.
• Incorporate foods rich in natural calcium, magnesium, tryptophan, and melatonin. Sour cherries, grapes, pineapple, poultry, eggs, seeds, nuts, dairy, and leafy greens are all high in sleep-promoting nutrients.

5. Power Down

Electronics and blue-toned LED lighting show strong connections with insomnia. Blue light emits from televisions, computers, and smartphones. It is believed that this light alters the brain’s melatonin response.

In order to reduce this impact, set an “off-time” for electronics at least one hour before bedtime. For kids and teenagers, keep smart devices outside the bedroom if they are tempted to play.

6. Try Relaxation Techniques

Other useful strategies anyone can try include relaxation techniques. Practices like deep breathing help calm stress and anxiety.

• Deep Breathing: Slow, deep breathing can help slow down the autonomous nervous system. This, in turn, can help induce relaxation. There are several methods of this technique. The 4-7-8 technique is one such method many people find useful.
• Journaling: Keeping a journal can be helpful for both adults and kids. It serves as an outlet to download the day’s worries and clear thoughts. Messages of gratitude and writing down the next day’s to-do list have both been shown to help with insomnia.
• Gradual Self-Soothing: For kids that require high-level parental support to sleep, researchers suggest adopting a gradual approach to teach self-soothing behavior.  This process involves slowly reducing parental presence. If you currently need to be in the child’s bed for them to sleep, this might look like spending one week laying near but not in the bed. Next week, you might move to a chair in the room. Then to a chair outside the room but still in sight. This gradual fading continues until the child can fall asleep independently.