Autism and
Sleep
by Dr Avril Brereton
Problems sleeping – does it matter?
The short answer to this question is YES! Sleep problems
in young children impact not only on the child but the
whole family. Loss of sleep for parents usually causes
fatigue, stress and difficulty coping with the tasks
parents have to get through during the day. For the
child, sleep problems can cause excessive daytime
drowsiness, irritability, aggression, depression,
hyperactivity and interfere with learning.
Many parents report that their young children with
autism have difficulty either getting to sleep, staying
asleep or simply don’t sleep very much at all. But not
all children with autism have problems sleeping and it
is not central to diagnosis.
Sleep problems in autism are probably best understood in
light of what happens in typically developing children
and those who have neurological problems, intellectual
disability, or developmental delays, particularly given
that autism is a neurodevelopmental disorder and also
that about 80% of children with autism have
developmental delays.
Richdale (1999) described the establishment of a “mature
sleep-wake rhythm” as a “developmental phenomenon” (p
60), in other words, children learn how to sleep and
wake in a routine as their brain develops and matures.
Typically developing infants move from a pattern of
sleeping and waking that is “polyphasic” when they are
newborn to a more settled pattern of a longer night time
sleep with 2 short naps at about 3 months and then on to
one nap per day by 12 months of age. By 4 years of age
most children have given up their daytime sleep.
Children’s sleep-wake rhythm is usually influenced by
the light-dark cycle and the child’s daily routines such
as eating and social activities. Sleep problems in
typically developing children may include difficulty
settling down to sleep, waking during the night, night
terrors or nightmares and occur in about 30% of
pre-school aged children. Sleep improves during middle
childhood and continuing problems such as night waking
or difficulty settling are usually treated behaviourally
or with progressive rescheduling of the sleep-wake
cycle.
Children who have intellectual disability (ID),
particularly those with severe ID, are reported to
experience higher rates of sleeping problems than
typically developing children, (about 34-80%). They are
also reported to present with these problems with
greater frequency and severity. Studies that reported
sleep onset and sleep maintenance problems in children
with ID found that sleep problems are usually associated
with other behavioural problems and communication
difficulties that affect the development of and
maintenance of sleep-wake routines (Richdale, 1999). It
is thought that children with ID have difficulty in
developing “the calming and necessary rhythms of rest
and activity that allow synchrony with parents and
carers” (Dorris et al., 2008, p. 1).
What about sleep problems in children who
have autism?
Researchers
have been investigating sleep problems in children with
autism for some time now. It is accepted that sleep
problems are more common in autism than most other
developmental disorders but we still do not know why.
Some think that is it because children with autism find
it difficult to learn the normal sleep associations or
respond to changes in their routine or environment. Some
studies have found that parents of children with autism
report that their children sleep long enough but that
the quality of their sleep is different to other
children. Another hypothesis is that the behaviour of
children with autism “may affect the
hypothalamic-pituitary-adrenal axis regulating basic
circadian rhythms and alterations in
hormone/neurotransmitter (melatonin/serotonin)
production (Richdale and Prior, 1995). (Melatonin is
secreted during darkness and makes us sleepy and is
suppressed by exposure to light). The sleep-wake cycle
is a circadian rhythm (light-dark cycle) but humans also
use social cues to entrain circadian rhythms. For
example, social cues and routine are thought to help
infants develop the pattern of having the longest sleep
at night (as for the rest of the family). For children
with autism, it may be that the social and communication
difficulties they have are influencing their ability to
“read” the social cues and understand the instructions
about going to bed and sleeping. Children with autism
are often anxious. It may be that sleeping problems,
particularly insomnia, are due to fears and anxiety in
some children with autism.
Sleep problems
seem to occur in children with autism at all IQ levels
including those who do not have an intellectual
disability. The sleep difficulties reported in children
with autism include problems with: Sleep onset and
maintenance, irregular sleep-wake patterns, poor sleep,
early waking, alterations in sleep onset and wake times
and night waking.
These problems
tend to improve with age but older children with autism
have been found to sleep less at night than other
children. Some children with autism have unusual
routines for settling to sleep and may sleep walk and
have nightmares more than other children.
What can we do?
Richdale (1999)
stated that intervention must begin with history-taking
including the parents giving a detailed description of
the problem and keeping a sleep diary for 1 week to
determine what factors may be leading to cycles of poor
sleep. The sleep history should include an analysis of
the current sleep problem, including:
-
pre-disposing factors, (a clear developmental
history can highlight pre-disposing factors for
sleep problems)
-
precipitating factors (a general health assessment
is important to determine whether the problem may be
associated with a medical condition; do you need to
limit drinks before bedtime? is the sleeping problem
related to food intake?, what does the child do
immediately before bedtime?)
-
perpetuating factors (where does the child sleep?,
does he/she have several naps during the day?, do
you stay in the room with him/her?)
-
as well as
consequences of the sleep problems on the whole
family.
Behavioural
interventions are often used to treat sleeping problems.
Putting bedtime routines in place, using reinforcement
(rewards), effective instructions and partner support
have been shown to be successful. A simple social story
about going to bed and going to sleep may be helpful.
(Examples of social stories can be found in Carol Gray
My Social Stories Book, Jessica Kingsley
Publishers, 2002). This could include information that
everyone goes to bed and sleeps at night time.
If the sleeping
problem is anxiety related, relaxation training (deep
breathing, muscle relaxation, massage, a warm bath, soft
music or story tapes) to reduce tension at bedtime
together with teaching the child positive
self-statements (to try to build the child’s confidence
that they can go to sleep by themselves) can be helpful.
The Developmental Behaviour Checklist (Einfeld and
Tonge, 2002) can be helpful to ascertain levels of
anxiety and other emotional and behavioural problems
(see Fact sheet 9).
If the sleeping
problem is associated with circadian rhythm, sleep
scheduling (setting a regular sleep/wake time with no
daytime nap) can help. Also delaying bedtime can help
reset the circadian clock so that the child goes to bed
when he/she is very sleepy or tired. Melatonin has been
shown to be effective for some children, particularly
when combined with a behaviour intervention programme.
Sometimes a
sleeping problem can be related to a sensory
disturbance. For example some children may be disturbed
by light, the breeze through an open window, the type of
fabric of pyjamas or even the weight and type of bed
linen and blankets. Sound sensitivity may also keep
children awake at night. Careful observation and
knowledge of the child’s sensory profile may help to
assess whether or not sensory issues may be contributing
to the sleeping problem.
Improving
‘sleep hygiene’ is another popular intervention. This
involves monitoring sleep routines before setting a
specific time for going to bed and developing a bedtime
routine that includes relaxing, quiet activities before
going to bed and not playing in the bedroom so that it
is associated with going to bed and sleeping rather than
a place to play in.
Whatever the
intervention, it must be tailored to suit the individual
child and parents must be supported during the
intervention phase. Care must be taken to ensure that
the intervention is acceptable to the family and that
parents understand the intervention and can commit to
it.
References and further reading:
Dorris, L.,
Scott, N., Zuberi, S., Gibson, N. amd Espie, C. (2008)
Sleep problems in children with neurological disorders.
Developmental neurorehabilitation. 1-20, iFirst
Richdale AL,
Prior MR. (1995). The sleep-wake rhythm in children with
autism. European Child and Adolescent Psychiatry. 4:
175-186
Richdale, AL.
(1999). Sleep problems in Autism: Prevalence, cause and
intervention. Developmental Medical Child Neurology.
41: 60-66
The National
Autistic Society “Sleep and Autism: helping your child”.
www.nas.org.uk (Has examples of sleep
diaries)
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