Autism and sleep

Close-up of a tired kid sleeping with his head rested on a table with a book.

World Autism Day is April 2

Make no mistake about it: The physical and mental health benefits of sleep are endless. With a good night’s sleep, you may find yourself getting sick less often, you can stay at a healthy weight, lower your risk for diabetes and heart attacks, reduce stress and improve your mood, and even think more clearly.

But a new study out of the University of Colorado School of Medicine in Aurora has found that all sleep is not created equal — especially for kids on the autism spectrum. The study, published in the March issue of the journal Pediatrics, found that young children who have autism are more than twice as likely to have sleep problems than typical kids or those with other developmental delays. With April being National Autism Awareness Month, now is a great time to explore this issue.

According to lead researcher Dr. Ann Reynolds, an associate professor of developmental pediatrics at the University of Colorado, several factors profoundly impact the sleep of 2- to 5-year-olds with ASD. They’re more likely to resist their bedtime, have trouble getting to sleep, suffer from anxiety over sleep, wake up in the middle of the night and experience night terrors.

“We know a lack of sleep or poor sleep impacts consolidation of memories, learning, sustained attention and how we respond to challenging situations that will inevitably occur,” says Dr. Anson Koshy, a developmental and behavioral pediatrician at the University of Texas Health Science Center’s McGovern Medical School in Houston.

"If we now factor in a young child with autism spectrum disorder who may already have some challenges with daytime behaviors, a lack of efficient sleep will likely only exacerbate those baseline behaviors and further limit the child’s overall frustration tolerance,” Koshy says. “This can manifest as tantrums, irritability or a labile mood, which can make daily routines more challenging.” 

Behind the study

It was already well known that children who have autism struggle with sleep. Studies have consistently found that more than half, possibly as many as four in five, have at least one chronic sleep problem, according to research from Autism Speaks, an autism advocacy and awareness organization.

“There are multiple reasons why children on the autism spectrum have sleeping issues, ranging from genetics to lack of melatonin to sensory issues such as the inability to block out noises or vibrations that are disrupting their sleep,” says Dr. Daniel Coury, medical director of the Autism Treatment Network at Autism Speaks and a developmental behavioral pediatrician at Nationwide Children’s Hospital in Columbus, Ohio.

Reynolds and her team want to look deeper into the issue to see what sleep problems appeared to be more impacted by autism symptoms. They also wanted to compare children with ASD to kids who didn’t have ASD and to those who have other disorders that cause developmental delays. The researchers recruited nearly 2,000 children between ages 2 and 5 across the country. They included more than 500 kids diagnosed with ASD, more than 200 with developmental delays that included aspects of autism, more than 500 with developmental delay unrelated to autism and about 700 children with no developmental delays.

Parents of participants completed a questionnaire about their child’s sleep habits. Researchers tallied up the scores and then compared how well the four groups fared when it was time to go to bed. They discovered that children with ASD were more than twice as likely to have serious problems getting quality sleep as kids without autism symptoms. Kids with autism were also 45 percent more likely to have moderate sleep problems than children with other forms of developmental delays and 75 percent more likely than kids with no developmental delays.

“Lack of sleep exacerbates the symptoms and challenging behaviors associated with ASD, as well as reduces cognitive and adaptive performance,” says Jeff Skibitsky, founder and president of Alternative Behavior Strategies, headquartered in Salt Lake City, which provides services to children with ASD. “This can include shorter attention spans, hyperactivity, more compulsive or ritualistic behavior, higher levels of aggressive behavior, poorer social interactions and more self-injurious behavior.”

According to the study, children with symptoms of autism scored worse in nearly all aspects of sleep. They appeared to have about the same level of difficulty as other kids in just sleep apnea and daytime sleepiness. And kids with ASD were also more likely to have anxiety or attention-deficit hyperactivity disorder, which can also affect sleep. Those who have autism might have problems with their sleep/wake cycle, have seizures that disturb sleep, or have decreased levels of the sleep hormone melatonin, according to Autism Speaks.

“Many children with autism spectrum disorder struggle with sleep issues, either falling asleep or staying asleep,” Skibitsky says. “This lack of sleep can contribute to making their symptoms worse. Sleep plays an integral role in the healthy development of children. It serves multiple functions including energy conservation, brain growth, memory consolidation and cognition.”

Sleep soundly

A sign that a child with ASD is having sleep problems includes resistance to their bedtime routine, according to Skibitsky.

“Frequently, the child may have heightened anxiety or excessive worrying or perpetual thought patterns before going to bed — including increased tantrums and avoidance of routine bedtime prep activities,” he says. “This can include hyperactivity or underactivity prior to bedtime.”

Another sign of a sleep problem is making requests that create stimulation, such as turning on the lights, playing with toys or watching TV before bed, he says.

“The child may also request the presence of others once they are in bed,” Skibitsky says. “Once asleep, ASD children may show they are having sleep problems by frequently awakening from bad dreams and fears, and/or needing to go to the bathroom.”

But if you’re a parent, family member or caregiver with a child with ASD, you can help them get in a good routine and get a better night’s rest.

According to Coury, parents should establish good sleep hygiene for their children with autism by creating a space that is dark, quiet and cool.

“Maintaining a consistent sleep schedule through the week and weekend is also important, as is avoiding naps and caffeine in the afternoon — particularly close to bedtime,” Coury says.

Skibitsky suggests focusing on scheduled wakings and faded bedtimes. “Scheduled waking is a strategy used to treat chronic night terrors and involves parents waking and consoling their child about 30 minutes prior to a typical night terror episode,” he says. “The parent then soothes the child to return to sleep.”

Faded bedtimes are used to help children initiate and maintain sleep. This intervention involves systematically setting bedtime earlier and earlier, while waking the child at the same time each morning and not allowing naps until the desired bedtime is reached.

“Fading the bedtime creates the opportunity to monitor the child’s state of fatigue prior to sleep and awake the child to create normalized circadian rhythms,” Skibitsky says.

He and Coury both say a melatonin vitamin can be another helpful sleep tool for children with autism.

“It is available without prescription, and most families report having tried it before they mention their child’s sleep concerns to me,” Coury says. “Studies to date indicate it is safe in the amounts recommended.”

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