Sleep Problems in Children with Autism

By P. Gail Williams, M.D.

Prevalence: Sleep problems are very common in children with autism. Studies indicate that 50 to 80% of children with autism experience sleep difficulties at some time.  This is much higher than the 9 to 50% rate of sleep problems for typically developing children.

Neurobiology: The increased prevalence of sleep disorders among children with ASD is likely due to neurobiologic alterations in the sleep-wake cycle.  Neurotransmitters which have been implicated in ASD sleep problems include Gamma-aminobutyric acid (GABA), serotonin and melatonin.

Impact: Disordered sleep is frequently associated with behavior problems and inattention in typically developing and developmentally disabled children.  Sleep problems in ASD are correlated with increased maternal stress and parental sleep disruption.  Repetitive behaviors and insistence on sameness may also be increased with poor sleep patterns.

Types of sleep disorders: Insomnia is the most commonly reported sleep problem in children with ASD.  Problems falling asleep, increased wakenings, and decreased efficiency of sleep have been reported by parents in numerous studies.  In addition to the neurobiologic  alterations mentioned earlier, children with ASD may have medical conditions such as epilepsy and reflux which interrupt sleep.  Certain medications may predispose to insomnia. Conditions that can be associated with ASD, such as ADHD, anxiety, and depression may also contribute to sleep problems.  Core behavioral concerns such as limited communication and self regulation and strong preoccupations  can lead to difficulty in setting effective bedtime routines.

Other sleep disorders seen with some frequency in autism include sleep disordered breathing, most commonly obstructive sleep apnea (OSA), which may require tonsillectomy and adenoidectomy or other medical treatment.  Children with ASD may also have more parasomnias, including night terrors, sleep walking and confusional arousals.  Children with autism sometimes have rhythmical movements of the head, trunks, or limbs, especially during the transition from wakefulness to sleep.  Restless legs syndrome may also occur. Sleep diaries and sleep questionnaires such as the Children’s Sleep Habits Questionnaire are often useful additions to a complete sleep history.  Specific assessment using actigraphy (wrist device to measure activity levels) or polysomnography (overnight sleep study measuring brain wave activity, heart rate, oxygenation, movement, etc.) may be necessary for diagnosis in some cases but these strategies are often not well tolerated by children with autism.

Treatment

Medical treatment of sleep disrupting conditions: It is critical that underlying medical conditions that interfere with sleep be addressed with appropriate medical management.  These may include gastroesophageal reflux disease, eczema, constipation, seizures, reactive airway disease and dental problems. In addition, restless legs syndrome and periodic limb movement disorder can be associated with iron deficiency which often responds to iron supplements.  Conditions such as anxiety, depression and ADHD may need to be treated with medication in order to assure appropriate sleep patterns.

Sleep practices: Once medical and psychiatric conditions have been adequately treated, healthy sleep practices should be implemented.  These practices should include getting adequate exercise during the day, limiting naps and caffeine and getting adequate exposure to light. In the evening, stimulation should be decreased with an established bedtime routine and minimal exposure to technology.  The sleep environment should be cool, dark and quiet, although a background noise machine may be helpful for some children.

Behavioral treatment: Visual schedules for bedtime routines can be very helpful for children with ASD. For children who fall asleep very late, gradually moving the bedtime to an earlier time may be helpful. Helping the child learn to fall asleep on their own is very important.  This may involve the parent sitting next to the bed but not engaging in eye contact or physical touch and then moving further away from the child’s bed on successive nights until the parent is no longer in the room.  The Bedtime Pass can be helpful for nighttime wakenings.  The child gets one curtain call but then has to turn in the pass; if the pass is not used, it can be turned in the next morning and a reward given.

Melatonin/pharmacology: Several research studies have indicated that melatonin may be helpful in addressing poor sleep onset in children with autism. Melatonin is usually given 30 minutes before bedtime, generally in a dose range of 1 to 6 mg.  Melatonin seems safe and effective in the short term; long term studies are not currently available.  An extended release form of melatonin may be helpful to sustain sleep. In some instances, other medications for sleep may be required.

Helpful resources: Strategies to Improve Sleep in Children with Autism Spectrum Disorders (Autism Treatment Network toolkit available for free download at Autism Speaks website)

Sleep and Autism: Helping Your Child (available at autism.org.uk)

Gail Williams, M.D. is an Associate Professor for the University of Louisville Department of Pediatrics and Clinical Co-Director of the University of Louisville Autism Center.  She is a board certified developmental/behavioral pediatrician and works in a multidisciplinary setting seeing children of all ages with such concerns as autism, learning disabilities, attention deficit hyperactivity disorder, Tourette syndrome, and mental retardation.  Dr. Williams is also the director of the STAR (Systematic Treatment of Autism and Related Disorders) biomedical clinic.  While her primary responsibilities are clinical, she also engages in clinical research and has authored several articles on autism and other developmental topics.