A Closer Look

Sleep concerns…

Jack’s mother started the office visit with concerns about his sleep. How does sleep impact a child with ASD and his family?
Sleep

Sleep is a very common issue that all parents have to deal with on a day-to-day basis. Thirty percent of typically developing children are reported to have sleep disorders. Children on the autism spectrum appear to have a higher prevalence, as well as more severe sleep disturbances, compared with typically developing children.
On average, children with ASD are reported to have sleep problems 50%-80% of the time. They experience a wide array of sleep problems, including:

  • Difficulty falling asleep
  • Restlessness or disrupted sleep patterns
  • Early morning awakening
  • Sleep parasomnias
  • Snoring
A young boy in class
Sleep in children with ASD

Successfully addressing these issues is critical because quality of sleep is known to affect a child’s overall functioning.

  • Lack of sleep makes it difficult to pay attention and focus and has a negative impact on one’s learning capacity.
  • Disrupted sleep results in irritability and mood disturbance, further aggravating an already predisposed dysregulated behavior pattern, as commonly seen in children with ASD.
  • Lack of sleep affects quality of life for the family as a whole. Parents themselves experience a disrupted sleep pattern, an additional strain on their already overwhelming task as caregivers.

Sleep Disorders video icon

How would you approach the child’s sleeping problem?

Sleep Disturbance

Sleep disturbance is caused by an interplay of intrinsic and extrinsic factors that need to be identified and addressed accordingly.

Pinpointing the physiologic and environmental elements that affect a child’s ability to sleep well is essential in addressing the root of the problem. This could be done by obtaining a detailed sleep history, keeping in mind children with ASD generally have more variations in their sleep patterns and more elaborate sleep rituals than their typically developing peers.

It is important to have a clear idea of the child’s bedtime routine, sleeping habits and sleep environment.

  • Parents usually employ a variety of tricks and techniques to help a child fall asleep more easily.
  • Children themselves may have certain attachments or self-soothing strategies to fall asleep.
  • Parents who co-sleep may not openly share this fact as they are wary of their doctor’s disapproval. A thorough, but diplomatic approach is needed to identify all sleep-related factors.

Sleep disturbance may take the form of sleep talking, sleep walking, restlessness, arousal, night terror, or nightmares. Parents are usually able to describe such events in full detail.

Finding out if the child snores or has disrupted breathing patterns is crucial in determining whether further workup is necessary.

The bottom line is to figure out if the child is getting adequate and restful sleep. This can be determined in part by the ease with which a child wakes up in the morning and whether any daytime drowsiness is observed.

Monitoring Sleep

Documentation of a child’s actual sleep schedule is important in determining how much sleep a child is getting in a 24-hour period. Ask about a child’s bedtime, wake-up time, and nap-time.

  • It is important to differentiate between the time the child is put to bed and when he actually falls asleep.
  • Prolonged nighttime awakenings can significantly lessen the total amount of nighttime sleep a child is actually getting.
  • It is important to identify any day-to-day variations in a child’s sleep schedule, such as comparing weekdays to weekends, as this may be the reason why a child has difficulty falling asleep.

What type of questions would you ask parents regarding a child’s sleep?

A tired young boy about to fall asleep
Can you describe your child’s sleeping environment?

What is your child’s sleep schedule?

  • What time do you put your child to bed? What time does he or she actually fall asleep?
  • Does your child wake in the middle of the night? How long does it take before he or she falls back to sleep?
  • What time does your child wake up in the morning? How easy is it for you to wake him or her up?
  • Does he or she spontaneously wake up?
  • Does your child take any naps during the day? What time and how long are his or her naps?
Bedtime Routine

What is your child’s bedtime routine? Does he or she need any specific toy or object to fall asleep?

Sleep Disturbances

Do you notice your child having any sleep disturbances?

  • Does he or she sleep talk or walk? Does your child have nightmares or night terrors?
  • Is your child a restless sleeper?
  • Does he or she snore? Do you notice any breathing difficulties while your child is sleeping?

How much sleep does a child need?

A little boy outside on a fall day in a jacket

Parents commonly complain that their child is not getting enough sleep. Inappropriate parental expectations about sleep requirements may feed into a child’s disrupted sleep pattern.

Putting a child in bed earlier than the natural time they are likely to fall asleep or enforcing a nap when a child is outgrowing this habit is counterproductive. This practice ends up in an unpleasant power struggle, placing additional strain on the parent-child interaction and further disrupting the child’s sleep pattern. Having a clear understanding and realistic expectations of how much sleep a child needs to function optimally is crucial in avoiding this struggle.

Some children with ASD reportedly have a lower sleep requirement. This emphasizes the importance of obtaining a comprehensive sleep history to determine whether a child is getting sufficient sleep. If parents have a difficult time describing a child’s sleep pattern, recommend they use a sleep diary/chart to help provide clear documentation of a child’s day-to-day sleeping schedule.

Are there specific workups needed for sleeping issues?

Further workup is generally not indicated for the majority of sleep disturbances except for a number of clinical scenarios.

  • Report of snoring or any sleep-disordered breathingdefinitely warrants further investigation with possibly a referral to an otolaryngologist or a sleep study to rule out obstructive sleep apnea (OSA). Vigilant surveillance for OSA is becoming even more important with the increasing prevalence of obesity among children. OSA is said to affect as many as 4% of children; it is as high as 20% – 30% in children who are obese.
  • relationship between sleep disturbance and iron deficiency in children with ASD has been reported. Iron therapy, in turn, has been shown to improve overall sleep in such situations. Therefore, for a child with ASD reported to be restless during sleep, check the complete blood count, serum iron, total iron binding capacity, and ferritin level.
  • For other sleep parasomnias, such as nightmares, sleep terrors, somnambulism, or sleep talking, further workup is unnecessary unless the presentation is indistinguishable from that of a seizure. Given the higher prevalence of epilepsy in autism, it is important to rule out seizures.

What specific advice…

Sleep Hygiene

The cornerstone of quality sleep is proper sleep hygiene. This includes creating an environment conducive to sleeping and following positive bedtime routines and a regular sleep schedule. Nevertheless, establishing proper sleep hygiene can be particularly difficult for children with ASD because of the challenging behavioral patterns specific to their diagnosis.

  • Safety is a key component in creating the proper sleeping environment. This is especially true for a child with ASD who has a tendency to wander or sleep walk. Suggest parents consider removing potentially harmful furniture, constructing a gate by the doorway, and using alarm systems.
  • Minimizing distractions is also essential in establishing the proper sleep environment. Children with ASD tend to be very sensitive to auditory stimuli, so “white-noise machines” may be helpful to block out noises that can potentially disrupt a child’s sleep. Lights may be distracting for children with ASD, so a dark room can be helpful; a small nightlight can be used for a child who is afraid of the dark. Encourage parents to take some time with trial and error and use creative strategies.
  • positive bedtime routine is one that involves a quiet, calming activity like listening to music or reading a book. It should be brief, lasting no more than 20 minutes.
    • Although a fixed routine is ideal, children with ASD have a tendency of becoming overly fixated on routines to the point of refusing to go to sleep unless the specific routine is followed. It is therefore important to introduce minor variations to the routine every now and then to encourage flexibility.
  • children with ASD tend to become dependent on inappropriate sleep associations, like the presence of their parents, in order to fall asleep. It is essential for a child to learn to fall asleep independently and to be able to self-soothe and remain in bed for the entire duration of the night.
Sleep Advice

Children with ASD have been found to have a disrupted sleep schedule for a variety of reasons. They have an increased sleep onset delay, more frequent and longer nighttime awakenings, and decreased overall sleep duration.

  • Inform parents of the importance of keeping a strict sleep schedule to increase the child’s sleep efficiency. Bedtime, wake-up time, and naptimes should be kept the same from day-to-day. There should be no more than an hour’s difference between weekdays and weekends, as any variation in timing can potentially affect sleep latency.
  • Bedtime should be set close to the time a child is most likely to fall asleep, keeping in mind a child’s actual sleep requirement and the fact that some children with ASD tend to require less sleep. Ideally, the child should fall asleep within 15 minutes of being put to bed. Sleep latency of an hour or more is possibly an indication that the bedtime is too early.
  • A child with ASD who wakes up very early in the morning should not be left in bed lying awake for a prolonged period of time, as it can lead to more fragmented sleep during the night. If the family is not yet ready to start the day, safe games and activities can be made available in the room for the child to play quietly once he or she is awake.

Setting the stage for proper sleep entails a whole process; however, once it becomes a habit, things tend to flow smoothly and the process becomes second nature. This is particularly helpful for children with ASD given their preference for having fixed schedules. Ultimately, given the proven effectiveness and benefits of having good sleep hygiene, the effort and investment involved in establishing it is a worthwhile endeavor.

What medications may be helpful in addressing sleep issues?

Medications

Medication is rarely the first line of treatment; neither is it used in isolation when addressing sleep issues. Nevertheless, a trial of medication in conjunction with nonpharmacologic strategies is reasonable for refractory sleep issues after behavioral interventions have been exhausted.

When parents request medication to help with their child’s sleep, be sure to discuss with them that there are no Food and Drug Administration (FDA)-approved medications for pediatric insomnia. That being said, research has been done on the pharmacological agents melatonin and clonidine, supporting their effectiveness in improving the sleep of children with ASD.

Melatonin

Melatonin is neurohormone secreted by the pineal gland that is known to organize the body’s circadian rhythm and thus help promote sleep.

  • A number of studies have shown that melatonin shortens sleep initiation latency, increases total sleep time, and improves sleep efficiency in children with ASD.
  • Given that it is relatively safe, well-tolerated, and readily available, it is something parents are generally willing to try. At most, the reported side effects are morning drowsiness and headaches.
  • Melatonin has a relatively short half-life and should be given approximately 30 minutes before the desired outcome. For children with sleep-maintenance difficulties, controlled-released formulations are available. Liquid formulations and dissolvable strips are available for children who are unable to swallow pills.
Clonidine
A girl sleeping on her caregiver's shoulder

Clonidine, a centrally acting alpha-2 agonist, is another medication that has been studied to reduce sleep initiation latency and night awakening in children with ASD.

  • Clonidine should be used with caution because it can potentially cause bradycardia and hypotension. An EKG is usually done before initiation to ensure proper cardiac functioning. Once a child is on clonidine, it should not be discontinued abruptly because of possible rebound hypertension.
  • Transdermal patches are available for children who are unable to swallow pills; however, caution is warranted for children who have a tendency to eat nonedible items because of the risk of patch ingestion.