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SLEEP PROBLEMS AND AUTISM SPECTRUM DISORDER

If your child diagnosed with Autism has a hard time falling and/or staying asleep, you are not alone. Sleep problems are very common in children and more so in children diagnosed with Autism. Over time, accumulated sleep debt from not falling asleep at appropriate times and/or not sleeping through the night impacts children’s ability to focus, to maintain appropriate levels of energy, and regulate their emotions.

Prevalence of sleep problems for children diagnosed with Autism is 80%. Studies correlate such a high prevalence rate of sleep challenges in children with Autism to neurological, medical and behavioural concerns. 

More research is needed to investigate how possible brain differences affect sleep in children with ASD and how possible hormonal differences such as differences in melatonin (responsible for sleep and wake cycles) and cortisol (stress hormone that keeps us awake during the day) are correlated to the sleep problems observed in children with ASD.

This article addresses the behavioural component of sleep problems for children with Autism. From a behavioural perspective, a number of well researched and established factors help address sleep problems in children with Autism. The 5 steps to help your child with Autism fall and stay asleep are outlined below.

The first step to understanding why a child doesn’t fall or stay asleep is to understand a child’s sleep cycle.

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Children go through many of these cycles throughout the night. Good sleep hygiene and a good sleep environment helps children link these cycles when they wake up.

The stage correlated with night wakings in children with Autism is Stage 5 (REM “Rapid Eye Movement”). The REM stage is when children are dreaming. It is the lightest stage of sleep and so children are more likely to wake up during the REM stage than any other stage. This stage progressively gets longer as the night progresses, making nighttime wakings more common as the morning approaches.

*THE MELATONIN-SLEEP CONNECTION

Melatonin is a hormone released by the pineal gland (small gland in the brain) and starts to be produced when babies are between 8-12 weeks of age. Melatonin helps control sleep and wake cycles. Typically, melatonin levels rise around 7pm (stimulated darkness) and peak around 12am (inhibited by light), remaining high for most of the night. Melatonin levels drop in the early morning as the body prepares for the day.

A child has his/her own internal clock that controls natural cycle of sleeping and waking and in part, a child’s clock controls how much melatonin the body produces; this clock is influenced by the sleep environment and sleep hygiene.

*THE CORTISOL-SLEEP CONNECTION

Cortisol is the hormone that keeps us awake during the day. This hormone is most prevalent in the body around 8am and declines in levels throughout the day. Cortisol is released as a stress signal (fight/flight) and is triggered when children are overtired. It keeps children in the light REM sleep instead of falling in the deeper stages of sleep.

Cortisol and melatonin work in an opposing relationship; when one is up, the other is down, so when there is an imbalance in either levels, sleep is affected and sleep problems in children with Autism develop.

Good sleep hygiene and a good sleep environment helps to establish balanced levels of melatonin and cortisol. It teaches children with ASD how to fall asleep independently so that when they wake up during the REM stage of sleep, they are able to fall back asleep independently and transition into the next cycle of sleep.

5 STEPS TO HELP YOUR CHILD WITH AUTISM FALL ASLEEP AND STAY ASLEEP

Please note, these strategies are general strategies. For personalized advice or coaching specific to your child’s needs and the sleep problems your child is experiencing, please book a no charge service consultation.

STEP 1. Start the “falling asleep process” in own bed/crib.

There are a number of challenges when children fall asleep anywhere but their crib/bed. For starters, the transfer often wakes children up and they struggle to fall back asleep. In addition, even a few minutes of relaxation in another environment can be the same as a micro nap and cause children to have a very hard time to fall asleep for the night. Also, when a child remembers falling asleep in one space but wakes up in another, they get startled (this is the equivalent of you falling asleep on the couch and waking up on the front lawn).

STEP 2. Establish a good sleep environment.

Remove screen time access at least 2 hours before bedtime. The blue light emitted from screens disrupts melatonin production (responsible for wake sleep cycles). If you have a big family that watches TV in the living room, it would be best to bring your child to his/her room or another room in the house, do a few quiet and low stimulatory activities (e.g. reading books), and complete your bedtime routine.

Keep your child’s room (and bed) for sleeping only. This can be tough to achieve, but if possible, until night sleep is consolidated, keep your child’s room (and bed) just for sleeping if possible. Remove all toys from the bedroom and encourage play in other areas of the house and avoid screen use on the bed. Play spaces and screen use stimulate heightened levels of arousal, which is opposite of what we want the sleep space to be. We want to establish an association to the room and the bed as a calm, low-arousal sleep space, so children can fall asleep more quickly and stay asleep for longer periods of time. Keeping the sleeping space free of toys also prevents night waking with the intention to play with the toys.

Maintain a low stimulation sleep environment. When your child should be sleeping, keep the environment as low stimulation as possible (dark, quiet and not too hot). This will stimulate melatonin production. When your child should be awake, keep the environment as high stimulation as possible. This will inhibit melatonin production and stimulate cortisol. Specific factors that stimulate a child depends on the child. For some children, sleep props like white noise machines/lullabies are soothing, for others they are stimulating. For some children, having a parent in the room is soothing, for others it is stimulating.

Utilize sleep props. Appropriate sleep props help form an association with sleep and help decrease children’s baseline arousal level. Some examples of sleep props include weighted or sensory blankets and white noise machines. Some sleep props work better for some children than for others, so be sure to trial a few different options to determine the best one for your child. PRO TIP: Sleep props are a great tool especially if your child has sensory challenges. A consultation with an Occupational Therapist can help determine the types of props you can utilize as per your child’s needs.

Establish bedtime and waking routines. Start your child’s sleep routine at the same time, every night, and wake up your child with a morning routine at the same time, every morning. A great bedtime routine is one that has a series predictable, low arousal, events that lead up to bedtime, such as taking a bath, brushing teeth, putting on pyjamas, and reading a book. A great morning routine is exercise! Exercising early in the day can help children feel more energetic and awake during the day, have an easier time focusing, and help with falling and staying asleep later in that evening. Routines don’t have to be long, but they’re important to trigger melatonin production and Stage 1 (drowsy) of sleep. PRO TIP: If your child does well with visuals, put together a visual schedule so his daily routines and schedules are predictable. This also fosters independence in the long run.

STEP 3: Allow your child to nap or have quiet time during the day.

Contrary to popular belief that children must stay awake in order to fall asleep at night, in reality sleep begets sleep. When children miss naps, they are overtired, and it is much harder for them to fall asleep later due to overproduction of cortisol (stress hormone). In essence children become over stimulated.

The recommended number and length of naps depends on your child’s age. Toddlers (ages 1 to 2) should get between 11-14 hours of sleep over a 24-hour period and usually have two daytime naps (2.5 hours total). Preschool children (ages 3 to 5) should get between 10-13 hours of sleep over a 24-hour period and usually one daytime nap (0-2 hours). All naps should not exceed 2 hours. Older children may not need any naps at all.

The recommended time you child should nap will  depend on whether your child is attending daycare, kindergarten, or school. It is generally recommended all naps occur in the early afternoon and the last nap should be at least 2 hours before the scheduled bedtime

Some children just are not nappers and they sleep great at night, so that is okay too. In that case, it is recommended that you set up a scheduled “quiet time” in your child’s room for your child to relax.

STEP 4: Track daily caloric intake and food consumption.

Your child should consume the right number of calories throughout the day to avoid night waking due to hunger. Consult your paediatrician or dietician on the appropriate number of calories your child should consume in one day.

There are many types of food that act as stimulants, so it is recommended to keep a food log of your child’s commonly consumed foods and the effect each food has on his/her energy level. Foods that act as stimulants should be avoided in the late afternoon and into the evening as they can cause night waking and shallow sleep even if it doesn’t prevent the child from falling asleep. Appropriate (free of stimulants, smaller portion) dinner/all food consumption should be at least 2 hours before the scheduled bedtime.

STEP 5: Keep a diary.

Make note of information will help detect pattens in sleep and arousal levels.

*Time your child wakes up

*Food consumed throughout the day

*Nap time(s) and the length of each nap

*Bedtime routine

*Time you put your child to sleep

*Time your child falls sleep

*Time and duration of all night wakings

PRO TIP: A great application to make tracking sleep a little easier is Huckleberry (found in all app stores) – this app also analyzes sleep patterns and predicts optimal nap and sleep times as per your child’s age.

WHEN IS A MEDICAL INTERVENTION NECESSARY?

Once you have tried all the tips outlined above, consulted with a behaviour consultant that specializes in sleep coaching to address environmental contingencies and sleep associations, and with an occupational therapist to address sensory needs, and your child with Autism is still having sleep problems, a paediatrician evaluation may be beneficial. Your paediatrician may recommend supplementing with melatonin or tryptophan to help regulate your child’s wake/sleep cycles, or alternative medical interventions to help decrease your child’s levels of cortisol and put your child in a calm state at bedtime.