Bedtime and Sleep in ASD Individuals                                                                                                                       

7/6/22

It is not uncommon for children with ASD to have difficulty sleeping.  Some of the reasons may be lack of routine, anxiety or sensory overload.  I have worked with several clients who complain that their child is not going to bed at a regular hour or are waking up several times during the night causing them to have difficulty waking up in the morning or falling asleep during the day.  Another common problem presents when the child wants to sleep with their parents; sometimes all night or at some hour during the night.  All of this then impacts the parents sleep and this exhausting cycle can lead to a parent’s desperate cry for help.   From a study published in  2021 by the National Library of Medicine, entitled, A community-based sleep educational intervention for children with autism spectrum disorder it mentions that, Bedtime resistance, anxiety, sleep onset delay and daytime sleepiness may be related to the core symptoms, but not be related to the developmental level in ASD children… sleep hygiene education is as important as the treatment of biological factors.

These sleep problems can cause a series of effects. Sleep disorders may adversely affect children’s daily function, affecting behavior, learning, memory regulation and cognition [17–20]. It may also cause emotional problems such as aggression, irritability, over-reactivity and depression [21, 22]. Moreover, disorders also negatively impact ASD symptoms. For example, ASD children with sleep problems showed more severe social skills deficits, and they scored lower on social tests 

Because it is difficult to know what factors are causing the trouble for your child, you might feel lost.  In 2019 from Bmj Journals comes An evidence based study entitled: Sleeping sound with autism spectrum disorder (ASD): Sleep problems are a characteristic feature of children with autism spectrum disorder (ASD) with 40% to 80% of children experiencing sleep difficulties. Sleep problems have been found to have a pervasive impact on a child’s socio-emotional functioning, as well as on parents’ psychological functioning. 

But there are some changes that you can make to increase the likelihood that your child will sleep successfully and regularly.   The approach that I want to address here is behavioral and follows the idea of creating a set routine for bedtime that encompasses several variables which when done with consistency and being mindful of how your child is reacting you can respond accordingly and lead them in the direction of sleeping alone and sleeping more fully.  When behavior and environmental changes don’t help there may be cause to speak with your physician about a pharmacological approach. 

Again from the 2019 BMJ study, Both behavioral and pharmacological interventions are commonly prescribed to treat sleep problems in ASD; however, we have much to learn about the efficacy of these treatment approaches.

Association for Child and Adolescent Mental Health in March of 2022 relates that

While pharmacological interventions such as melatonin are commonly prescribed to assist families in reducing sleep problems, the National Institute for Health and Care Excellence (NICE) guidelines recommend behaviourally based sleep interventions as a first-line treatment (NICE, 2013). Nevertheless, empirical evidence for the efficacy of behavioral sleep interventions in autistic children is limited.

My first inclination is to create a behavior program that is specifically targeted at changing undesirable behaviors or practices.  That said, when medication or herbal remedies (I am not promoting either) are recommended by a physician, you have to decide what’s best for your child and your family.  Never feel pressured.  It’s all about 2 things; your child’s health and your ability to cope. 

When establishing a set routine for bedtime just be mindful that the longer you wait to do so the harder it will be down the line.  It is an initial sacrifice of time and sleep deprivation to some degree,  but you will get past that by being committed and consistent and your child will adapt. 

Implementation of nonpharmacotherapeutic measures such as bedtime routines and sleep-wise approach are the mainstay of management.

These treatment strategies along with limited regulated pharmacotherapy can help improve the quality of life in ASD children and also decrease the family and parental distress.

It is also common for ASD children to want to sleep with their parents.  The best thing for you to do, if this is a problem, is to encourage your child to sleep in their own bed.  To do that you’ll want to create an inviting and calm environment along with a consistent routine.

It is helpful to acknowledge that you understand that your child does not want to sleep alone and reassure them that sleeping in their room with the door open and your door open means that you are all still connected.  But Mom and/or Dad need(s) to sleep in their bed and they need you to sleep in yours.  And you will help to make this happen.

The following routine is suggested.  You can alter it however you’d like and add in steps that you know will appeal to you child.  

Routine: 

1. Wind down ½ hour before bedtime; no ipads, etc.  
2. Review the routine that can be printed out in steps or read as a Social Story. 
3. Give a 10 minute warning.
4. Proceed with pre-bedtime prep; wash up, change clothes, brush teeth, etc.
5. Dim lights in the room. 
6. If possible (and desired by your child) have some quiet music or environmental sounds playing. 
7. Start a sand timer (20 minutes or whatever you prefer)
8. Read a calming book
9. Foot massage or some kind of relaxing pressure
10. *Lay with her (see below) *#10: In the first several days laying with your child is ok but you will want to gradually, over the course of the coming weeks, move away from your child using a chair, creating distance and giving as little direct contact as you can, according to Andrea Babich from Autism and Sleep. Ten possible strategies: Gradually distance yourself from your child once they have gotten into bed, then keep your visits back to their room brief. Gradually decrease the amount of attention you direct toward your child such as talking, eye contact, facial expressions, etc. while you are increasing your distance away from them.” until you are able to say goodnight and leave the room.
11. When timer runs out you will leave with the door open

Just a quick note about the timer indicates how long you’ll stay with your child before leaving. The 20 minutes encompasses the massage, a story and laying with them. I would start on a Friday night so if you don’t sleep much you have the weekend.  It’s important initially to keep the same routine on the weekends. 

From a study on Autism and Sleep Disorders in 2015, After the bedtime routine is done and the child is in his bed or crib- but is upset and obviously not sleeping, wait a few minutes and then go back into the child’s room to check on him/her. Checks involve going back into the child’s room and briefly (not more than a minute, preferably less) touching, rubbing, or maybe giving a “high five,” “thumbs up,” or hug for an older child who better responds to these gestures. Gently but firmly say, “it’s okay, it’s bedtime, you are okay”

If you are able to get your child into bed and leave the room that’s great but we all know that it isn’t so easy and it’s not overnight. Andrea Babitch again states, Training your child to fall asleep alone should be done gradually over the course of a few weeks. 

A great idea I came across from Autism Speaks is A Bedtime Pass. According to their article on the subject: 

Some children have a difficult time staying in bed. The parent puts the child to bed and, before you know it, the child is crying out or up again. One effective tool to help children learn to stay in bed is the “bedtime pass.”1 A bedtime pass is a card that is given to the child at bedtime that may be exchanged for one “free” trip out of bed or one parent visit after bedtime. If the child does not use the card during the night, he/she may exchange the card for a special reward in the morning. The bedtime pass can be traded for a drink or to get out of bed. If I ask for a drink of water or get out of bed, I have to give them the bedtime pass. When I am able to stay in bed all night, I get to keep the bedtime pass. This is a good thing! In the morning I can trade the bedtime pass for a treat.

Here’s are 4 practices to follow at bedtime: 

1. Set a consistent bedtime each night. 
2. Before bed review the routine and ask your child to retell it to you so they begin to internalize what is expected (if they are non-verbal you can use pictures from their communication device, social story or a picture schedule that you’ve created).  
3. You can ask how they feel each night and again, acknowledge their feelings and assure them that you are there for them.  
4. Building a reward system into bedtime to help with this transition is a great idea. Earning something very special can be highly motivating. 

As mentioned it may be necessary to incorporate a pharmaceutical intervention in more severe cases, but I truly feel that if you can be consistent with an established routine you will see an acclimation in general cases of ASD.  I have attached a link to an Autism Speaks page on tips for improving sleep in your ASD child on the resource page of my website. 

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It’s time now for: A Tip Of The Cap: your Exceptional Needs Parenting Tip 

Today’s tip comes from Autism Speaks and it is related to bedtime routines and Schedule Boards:

Some children are not able to use a visual schedule that uses words, photos, or icons. It may help to use objects instead.

Here’s an example: Here is how to use an object board. A sample bedtime routine might include using the toilet, taking a bath, washing hair, brushing hair, getting a massage, and listening to music. You would then put the following items near the bathroom or bedroom: a roll of toilet paper, a bar of soap, a bottle of shampoo, a hairbrush, a bottle of lotion, and a CD. Your child would get each object before the start of an activity and use this to guide his or her actions. It may be helpful to save a special object just for bedtime. This might be a special blanket, pillow, or stuffed animal. Once your child has this favored object, he or she should go into his or her bed. Even if you do not use objects, write down your child’s schedule so that you are going through the same steps each night and staying with a routine. Use single words or two-word phrases to label or describe what you are doing (“Bath time”, “Wash hair”, “Go sleep”, etc.).

Peace and Keep Rising!