Sleep & Autism
Sleep problems are pervasive in the autism community with an average range of 60-80% of families reporting some level of sleep challenges with their child. This leads some to believe that children with autism will never sleep well. However, rest assured (pun intended) this is simply not true. Children diagnosed with autism have just as much potential for healthy sleep as other children, and a diagnosis of autism does not mean a life-sentence of poor sleep and tired days.
It is important to know that sleep problems in children are quite common, in general. We know an average of up to 50% of families report some level of sleep challenges with their child, absent of an autism diagnosis. Where we see the difference between the two populations is with age-related sleep problems; children who are not diagnosed with autism seem to adopt healthier sleep rhythms as they reach the age of 4 or 5 years, while children diagnosed with autism seem to carry their sleep problems further into childhood and adolescence. Even into adulthood in some cases. Why might this be?
First, some children diagnosed with autism seek sensory experiences to calm themselves down and regulate their sensory system. This type of self-regulation can be very helpful throughout the day and may even be recommended as a therapeutic strategy for learning. For example, it is not unusual for occupational, speech, or behavior therapists to engage a child in spinning, jumping, or deep pressure prior to or during learning opportunities. For many children, sensory input can help with focus and skill acquisition in addition to calming the learner down during new or novel experiences. For this reason, many caregivers implement a variety of sensory strategies before bedtime to “get the wiggles out” or “burn off energy” thinking this will tire their child out and help them sleep. However, it can have the opposite effect. Jumping, crashing, bouncing, and running sabotage even the best sleep efforts. Up-and-down vestibular motion is known to be alerting to the sensory system, not calming, and therefore can prevent efficient sleep onset. In addition, these high-impact and cardio-intensive experiences tend to raise the core body temperature at a time when the core temperature needs to be cooling off a few degrees for the body to prepare for sleep. The result is difficulty falling asleep and exceedingly late bedtimes.
A second factor in sleep problems within the autism population can be screen dependence. This relatively new variable began to emerge around 2010 when iPads were introduced to the broader population and smart phones began functioning as entertainment devices. The use of smart devices as a learning tool for children on the autism spectrum also increased exponentially within treatment teams. While the benefits were vast, screen time slowly crept its way into the late evening and bedtime routines in many homes. Because LED screen technology emits what is commonly known as “blue light,” we see a greater difficulty with falling asleep. Why? Blue light wavelengths are similar to the sun’s, and in the presence of sunlight the brain does not produce melatonin; the hormone that signals sleep in the brain. When we view blue light in the form of smart screen use close to bedtime, the result is a delay in melatonin production; as much as 3 hours past our natural secretion of the hormone. As you may be thinking, this is not a problem unique to the autism population, as many people currently struggle with sleep; excessive screen time after dark to blame for it. The difference typically comes down to the undesired behaviors (often appearing as self-injury, aggression, or property destruction) when caregivers attempt to terminate their autistic child’s screen time in exchange for the boring (or even aversive) task of going to bed.
A third variable (which is usually a result or by-product of the former two variables; not being able to fall asleep quickly) is caregiver assistance at bedtime. When we observe that our children are not falling asleep at their “usual” time or are having a difficult time falling asleep, many caregivers (regardless of diagnosis) resort to helping their children fall asleep at bedtime. This may look like a caregiver laying down with the child. It may also look like the child falling asleep in one space and being transferred to their bed after they have fallen asleep. Or possibly, it looks like a caregiver lying on the floor or sitting next to the child as they fall asleep. A bottle of milk, perhaps, to help them drift off…
All of these strategies have one thing in common: they are gone once the child falls asleep. Parents tip-toe out of the room. We slide like a ninja from the bed, desperate for our child not to notice. We gently slip the bottle from their lips and sneak out without a sound. And then, a few hours later, our child wakes up calling for us or appears at our bedside looking to be put back to sleep.
Why does this happen?
It is a widely adopted misconception that we fall asleep at bedtime and wake up in the morning. That is not how sleep works! Throughout the night we cycle through light and deep phases of sleep, alternating in and out of dream and non-dreaming sleep, all night long. In our deep phases of sleep, we are unaware of our surroundings. But in our light phases of sleep, we all wake slightly and then put ourselves back to sleep. We wake, and fall asleep, multiple times per night. When children are unable to put themselves to sleep independently without any adult support at bedtime, they are therefore unable to exhibit that skill throughout the night. As caregivers, we perceive bedtime sleep as the endpoint: the child is asleep and therefore should stay asleep. But this, as you now can see, is not the case.
So, my tired reader, what are the solutions? How do we achieve healthy, on-time bedtimes and independence with falling asleep so we ALL can sleep better through the night? There is no one-solution, but let me offer a few tips that can take you very far in achieving your sleep goals:
Offer only calming sensory input within 2 hours of bedtime. This can include rocking, swinging, deep pressure, massage, etc. Avoid jumping, bouncing, running, or any activities that raise body temperatures or elicit sweating.
Avoid screen-time within 2 hours of bedtime. Instead, offer other pleasing activities such as sorting, matching, bead-stringing, building, stacking, coloring, puzzles, put-in activities, cars/trains, quiet play, or pretend play. If your child has difficulty transitioning away from their screen-time, transition first to a pleasing activity such as a bath or shower, snack, massage, or even some television in a well-lit room. Avoid transitioning from screen time directly to bedtime. Offer a sequence of other enjoyable activities before lights-out.
Make sure the time you are offering “lights-out” is appropriate for your child’s age and how long they have been awake. After the age of about 3.5-4.0 years, a nap is no longer needed. Napping after this age will lead to very late bedtimes in many cases. In early childhood (3y-5y) your child will most likely accept bedtime and fall asleep quickly if offered lights-out about 12-13 hours after they wake in the morning. As your child gets older, they will be able to tolerate much more awake time and will likely require a later bedtime across their lifetime. Late morning wake ups mean late bedtimes; best to keep morning wake up times consistent, allowing for later bedtimes over time. By the time your child is about 12 or 13 years old, they will be able to tolerate about 15 hours awake before being able to fall asleep again.
Try your best to be out of the room when your child falls asleep if excessive night awakenings are a problem. The more awake, aware, and alone your child is as they are falling asleep, the more likely they are to stay in bed and connect their sleep cycles independently throughout the night. Fading yourself out of the falling-asleep sequence will help everyone in your home get the healthy amounts of sleep they need.
