Sleep Disorders and Treatment in Children with ASD

written by: Craig Marrer, M.S., BCBA, LBA

 

Children and adolescents with ASD struggle with sleep problems, particularly insomnia, at a higher rate than typically developing children. Research suggests that between 40% to 80% of children and adolescents diagnosed with ASD experience some form of sleep disruption. In addition to insomnia, children and adolescents diagnosed with ASD also commonly present with difficulties falling asleep, remaining asleep, and early morning awakenings.

As is true for any child, the benefits of a good night’s sleep cannot be overstated. Poor sleep is associated with increases in challenging behaviors along with corresponding decreases in social skills and academic performance. Untreated sleep disorders in childhood have been linked to childhood and adult obesity, adolescent behavioral and emotional problems, anxiety in adulthood, and the persistence of sleep problems into adulthood.

 

Causes of Sleep Problems
While there is no single cause for sleep disruption in children and adolescents diagnosed with ASD, a combination of biological, behavioral, and environmental factors likely contributes to the development of problematic sleep. From a behavioral perspective, sleep disruptions have been linked to factors such as inconsistent pre-sleep routines, problematic sleep dependencies, and problematic sleep contingencies.

 

Pinpointing Sources of Sleep Disruption
When trying to discover the reasons for your child’s problematic sleep, it is best first to recognize how much sleep your child should be getting each night based on their age. The table below shows the recommended sleep and nap durations for children ages 2 to 18.

 

Age	Total Sleep	Night Sleep	# Naps
2	11 hr. 30 min	9.5 hours	1 (2 hr.)
3	11 hr. 15 min	10 hours	1 (1hr15min)
4	11 hr.	10 -11 hours	0-1
5	10 hr. 45 min
6	10 hr. 30 min
9	10 hr.
12	9   hr. 45 min
15	9   hr. 15 min
18	9   hr.

 

With this information, you can determine what time your child should be in bed sleeping based on what time they wake in the morning. Additionally, this will allow you to figure out what time you need to start the bedtime routine.

Pre-sleep Routines. It is best to establish a consistent sequence of events that occur every night before putting your child to bed. These routines often include baths, brushing teeth, reading, etc. In addition to having a set routine, it is best practice to  limit access to over-stimulating activities such as bright screens, reduce the amount of liquids and foods consumed an hour before bedtime, and create an environment that encourages sleep (e.g., reducing light levels, setting a cooler temperature in the home, and reducing physical activities).

Sleep Dependencies. Sleep dependencies are items/people that are physically present during the process of falling asleep. These items/people can help in the process of falling asleep; and, over time, they can become required for remaining asleep or falling back asleep upon waking in the middle of the night.  Healthy sleep dependencies for children can include a favorite blanket or stuffed animal, a nightlight, or a white noise machine.  Unhealthy or problematic sleep dependencies often include one or both parents needing to be present for sleep to occur. A parent’s presence can become problematic when a child wakes in the middle of the night and leaves their bed to seek out a parent.  When choosing sleep dependency items, identify items that can be present throughout the entire night so that your child will not need to leave their bed.

Competing Sleep Contingencies

Several common competing sleep contingencies can interfere with a child’s sleep. These include engaging in behaviors that delay the onset of sleep, engaging in behaviors that recruit attention from a preferred person, and engaging in behaviors to gain access to preferred items. While every situation is unique, and might require some additional support from your child’s BCBA, the following are best practices to manage competing problematic sleep contingencies. First, it is essential that the activities and items available during awake hours not be available during sleep hours; this will create clear differentiation for your child about what is and is not available during bedtime. Second, if your child tends to get out of bed during the night to play with toys in their bedroom, it might be best to remove or limit access to these items during sleep time. Third, if your child leaves their bed frequently to seek attention, minimize the quality of your attention, and bring your child back to bed. Lastly, if your child tends to get out of bed to ask for certain things, like water, place a cup of water on your child’s nightstand, so they do not need to leave their bed in the middle of the night.

 

Establishing Optimal Sleep

1. Develop an ideal sleep schedule based on the recommended number of hours your child should get each night and on their age.
2. Habitualize nighttime routine. This will eventually evoke sleepiness from your child as these activities become more associated with sleep.
3. Manage problematic sleep dependencies and support the development of favorable ones.
4. Address sleep interfering behavior. If needed talk to your child’s BCBA or another trained professional to help.

 

Click here for a one page summary (PDF) of this blog.

 

 

 

References

Devnani, P. A. & Hedge, A. U. (2015). Autism and sleep disorders. Journal of Pediatric Neurosciences, 10, 304-307.

 

National Institute of Child Health and Human Development, Office of Communications (2019). How much sleep do I need? Retrieved from: https://www.nichd.nih.gov/health/topics/sleep/conditioninfo/how-much

 

Practical Functional Assessment. Tutorials: Functional assessment and treatment of sleep problems. Retrieved from: https://practicalfunctionalassessment.com/presentations/