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Autism Spectrum Disorder (ASD) and Sleep

25 Mar 2016

Sleep is a major issue for many adults and children who have been diagnosed with autism spectrum disorder (ASD). Recent studies suggest that up to 80% of young people with ASD also have difficulty falling and/or staying asleep at night. The incidence rate of sleep problems and disorders is also high among adults with ASD, particularly those who are classified as ‘low-functioning’. Lack of sleep can exacerbate some of the behavioral characteristics of ASD, such as hyperactivity, aggression, and lack of concentration. As a result, people with ASD who have a hard time sleeping may struggle at work or in their classroom.

We’ll look at some of the most common sleep issues among adults and children with ASD, as well as some suitable treatment options and tips for managing ASD and sleep on a regular basis. First, let’s look at how the medical and psychiatric communities currently define ASD.

What Is Autism Spectrum Disorder?

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is considered the most authoritative guide for evaluating and diagnosing mental health disorders in the United States. According to the latest definition (last revised in 2013), the diagnostic criteria for autism spectrum disorder (ASD) are as follows:

  • ‘Persistent deficits’ in communication and social interactionthat occur in multiple settings. These deficits may a lack of engagement in back-and-forth conversation, ‘abnormal’ approaches to social interaction, and failure to respond to social invitations. ‘Poorly integrated verbal and nonverbal communication’ is another common deficit; this may be accompanied by irregular eye movements, nervous tics, lack of facial expression, and other physical signs. Finally, people with ASD often have deficits in ‘developing, maintaining and understanding’ different types of relationships.
  • Restricted, repetitive behavioral patterns. These patterns may be manifested in motor movements, speech, or use of everyday objects. Common examples of these tendencies include constantly lining up objects in the same manner, mimicking the speech of others (known as echolalia), or repeating ‘idiosyncratic’ phrases. People with ASD may also be unreasonably rigid about breaking from these patterns, and may express dismay when asked to do so. They also demonstrate ‘highly fixated’ interest on specific subjects, as well as ‘hyper- or hyporeactivity’ to sensory factors in their environment (such as smells and/or sounds).
  • Although many people are diagnosed and treated for ASD as adults,symptoms must be or have been present during the early development period.
  • The symptoms must be serious enough to cause ‘clinically significant impairmentin social, occupational, or other important areas of current functioning.
  • The symptoms are not ‘better explained’ by the presence of another condition, such as an intellectual disability or a global development delay. The DSM-5 notes that ASD and intellectual disabilities are often co-morbid, or simultaneously present, in children and adults. However, both classifications carry different sets of diagnostic criteria.

The latest DSM revisions also note three distinct ‘severity levels’ that can be used to assess how much support (if any) a person with ASD requires on a regular basis.

Severity Level Social Communication Restricted Interests and Repetitive Behaviors
Level 3: Requiring Very Substantial Support ‘Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others’. ‘Preoccupations, fixated rituals and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly’.
Level 2: Requiring Substantial Support ‘Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others’. ‘[Rituals and repetitive behaviors] and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRB’s are interrupted; difficult to redirect from fixated interest’.
Level 1: Requiring Support ‘Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions’. ‘Rituals and repetitive behaviors (RRB’s) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRB’s or to be redirected from fixated interest’.

Previous Definitions

Prior to 2013, ASD was broken down into different autism subtypes based on severity of symptoms. These subtypes were eliminated and omitted from the DSM-5, and their diagnoses have all been absorbed into the ‘ASD’ definition. Although these subtypes are no longer officially diagnosed, they are still widely discussed within the medical and psychiatric communities. Additionally, some are still included on other authoritative lists, such as the International Statistical Classification of Diseases and Related Health Problems (ICD) database maintained by the World Health Organization (WHO). The four most common subdivisions of ASD (as previously defined by the DSM) are:

  • Asperger syndrome:Asperger was once considered the mildest incarnation of ASD. Children and adults with Asperger display symptoms like inability to pick up on social cues, hypersensitivity to sensory stimuli, and preoccupations with hyperfocused areas of interest. However, many people with Asperger are high-functioning.
  • Autistic disorder:This was once considered a middle-of-the-spectrum condition. Symptoms are more intense than those in people Asperger, but less severe than the most debilitating forms of autism.
  • Childhood disintegrative disorder:This was considered the rarest — and most severe — form of autism prior to the DSM-5 revision. Most often diagnosed in children between the ages of two and four, CDD was characterized by strictly limited social, speech, and cognitive abilities. Many children with CDD also developed seizure disorders.
  • Pervasive development disorder, not otherwise specified:PDD-NOS was essentially a term for any autism spectrum condition that didn’t meet strict criteria for one of the three disorders mentioned above. As a result, symptoms for PDD-NOS ranged from milder than Asperger to more severe than CDD.

In addition, some disorders once considered part of the autism spectrum were removed from the ASD diagnostic criteria prior to the DSM-5 revision in 2013. Rett syndrome, for instance, can cause symptoms in children that are similar to those associate with autism; however, Rett syndrome is caused by a genetic mutation, and also carries symptoms not found in other ASD disorders. Social communication disorderis another example; people with SCD often struggle with everyday communication, but the disorder is distinguished from ASD due to a lack of repetitive behavior patterns.

The root cause of ASD remains unknown, though most researchers today believe that both genetic and environmental factors play a major role. Recent studies have pinpointed some genes that are prevalent in people with the disorder, and brain-imaging tests indicate that the brains of people with ASD develop differently than the brains of other individuals. The general consensus is that ASD originates from defects in the brain that affect how the brain grows and communicates with other areas of the body. Studies have yet to identify any specific environmental factors that directly cause or influence the development of ASD. However, the scientific community has debunked and rejected the longstanding belief among parents that child vaccinations lead to a higher incidence rate of ASD in developing children.

How Does ASD Affect Sleep?

A 2009 study published inSleep Medicine Reviewsnoted parents report sleep problems for children with ASD at a rate of 50% to 80%; by comparison, this rate fell between 9% and 50% for children that had not been diagnosed with ASD. The rate for children with ASD was also higher than the rate for children with non-ASD developmental disabilities.

In a recent study titled ‘Sleep Problems and Autism’, UK-based advocacy group Research Autism noted that the following sleep issues are common among children and adults with ASD.

  • Difficulty with sleep onset, or falling asleep
  • Difficulty with sleep maintenance, or staying asleep throughout the night
  • Early morning waking
  • Short-duration sleeping
  • Sleep fragmentation, characterized by erratic sleep patterns throughout the night
  • Hyperarousal, or heightened anxiety around bedtime
  • Excessive daytime sleepiness

The study also pinpointed several underlying causes for these sleep problems that are directly or indirectly related to the individual’s ASD diagnosis. These include:

  • Irregular circadian rhythm:The circadian rhythm is the 24-hour biological clock that regulates the sleep-wake cycle in humans based on sunlight, temperature, and other environmental factors. The circadian rhythm is processed in the brain, and many people with ASD also exhibit irregularities with their sleep-wake cycle. Additionally, some studies have noted a link between children with ASD and irregular production of melatonin, a natural hormone that helps regulate circadian rhythm.
  • Mental health disorders:Conditions like anxiety and depression are often co-morbid with ASD; these conditions often lead to insomnia and other sleep disorders. Studies have also suggested that as many as half of all children with ASD also exhibit symptoms of attention-deficit hyperactive disorder (ADHD), which can cause elevated moods around bedtime.
  • Medical problems:Epilepsy is often co-morbid with ASD, and seizures can greatly impact sleep — even on a regular basis, in severe cases. Other common medical issues among people with ASD include constipation, diarrhea, and acid reflux.

People with ASD often struggle with daily pressures and interactions more than individuals who do not live with the disorder. Lack of sleep can greatly exacerbate the feelings of distress and anxiety that they experience on a frequent basis. As a result, may people with ASD who have trouble sleeping may struggle greatly with employment, education, and social interaction — all of which can impact their outlook on life.

Persistent sleep problems in people with ASD may indicate a sleep disorder. Insomnia is the most commonly reported sleep disorder among adults and children with ASD. Insomnia is defined as difficulty falling and/or remaining asleep on a nightly or semi-nightly basis for a period of more than one month. A study published inSleepfound that 66% of children with ASD reported insomnia symptoms. A similar study from 2003 found that 75% to 90% of adults then-diagnosed with Asperger syndrome reported insomnia symptoms in questionnaires or sleep diaries.

In addition,parasomniassuch as frequent nightmares, night terrors, and enuresis (bedwetting) have been widely reported among children with ASD, particularly those once diagnosed with Asperger syndrome. The child’s inability to express their fears and discomforts upon waking — often due to ASD — can complicate the way parasomnias are addressed and treated. Additionally, children with ASD often wake up in the middle of the night and engage in ‘time-inappropriate’ activities like playing with toys or reading aloud.

Sleep researchers are currently studying the relationships between other sleep disorders and ASD. For example, Dr. Steven Park recently noted a possible connection between ASD and obstructive sleep apnea (OSA), a condition characterized by temporary loss of breath during sleep resulting from blockage in the primary airway that restricts breathing. Dr. Park’s theory suggests that the intracranial hypertension found in many babies and infants with ASD may also cause the child’s jaw to take on an irregular shape, which can lead to sleep-disordered breathing as well. Other studies have explored the link between ASD and disorders like narcolepsy and REM Behavior Disorder. However, insomnia and parasomnias remain the most common sleep disorders among adults and children with ASD.

Next let’s look at treatment options and considerations for adults and children with ASD who are experiencing a sleep disorder.

Sleep Therapy Options

If the preliminary assessment indicates the presence of a sleep disorder in a child with ASD, then treatment will likely be the next step.

The three common therapeutic approaches recommended for improving sleep among children with ASD include: cognitive behavioral therapy, light therapy, and sleep training. By implementing these interventions, studies indicate these can increase the parents “sense of competence and control” which can make it easier to cope with the stress of raising a child with autism—and enable the parent to get better sleep themselves.

Cognitive Behavioral Therapy

Cognitive behavioral therapy for insomnia (CBT-I) has proven fairly effective in alleviating sleep disorder symptoms for young people with ASD. CBT is designed to improve sleep hygiene in patients by educating them about the science of sleep and helping them find ways to improve their nightly habits.

For a child with autism, the therapist will consult with the parent to understand their child’s current sleep behaviors, thoughts and opinions surrounding sleep, and sleep environment. The therapist will then work with parents and children to develop an individualized treatment plan, which may include:

  • Sleep restriction:This approach involves restricting sleep to a strict schedule according to the amount of healthy sleep for your child’s age (e.g. 12 hours for 3 to 4 year olds, 10 hours for 5 to 12 year olds). The child can only stay in bed during that set amount of time, whether they slept the whole time or not. The idea is that with time, the child will associate the bed exclusively with sleep (rather than fitful waking), and entrain themselves to the sleep schedule.
  • Stimulus control:Stimulus control focuses on further developing the association between bed and sleep by eliminating distracting visual cues or activities. For instance, the therapist may recommend keeping your child out of their bed except during times that are designated for sleeping or napping, or removing items like toys and games from the bedroom.
  • Relaxation training:Relaxation training is designed to quiet an overactive mind at night. Activities often include deep breathing, progressive muscle relaxation, and visualization exercises. These can be challenging for a child with autism to learn on their own, so the therapist may practice these with parents to walk through with their children at night in their bed.

Light Therapy

In addition to CBT, light therapy (also known as phototherapy) may also help children with ASD sleep better. This form of therapy is usually conducted using a light-transmitting box kept near the child’s bed.

Light therapy boxes are distinct from traditional lamps. These lights are designed to mimic the 10,000-lux of natural sunlight, but without UV rays. By having your child sit in front of the box for 15 to 30 minutes per day—either early in the morning or afternoon, depending on how their sleep cycle is offset—this therapy can help boost melatonin production and make children feel more alert throughout the day.

Sleep Training

A study published in theJournal of Pediatric Neurosciencenoted that children with ASD are often set in their routines, so establishing a consistent bedtime schedule can be quite beneficial to them. A healthy bedtime schedule might consist of the following:

  • Putting on pajamas
  • Brushing teeth
  • Using the toilet
  • Washing hands
  • Getting in bed
  • Reading a book (or being read to)
  • Shutting off the light

Additional behavioral interventions may help children with ASD improve their difficulties with sleep. According to a ‘Sleep Tool Kit‘ published by the Autism Treatment Network, these interventions include the following:

  • Create a ‘visual schedule checklist’ with pictures, objects and other visual aids that can help a child with ASD grasp the concepts more easily.
  • Keep the bedtime routine concise, and limit it to roughly 30 minutes before bed. Otherwise the child might become overwhelmed with too many commitments.
  • Order the routine so that stimulating activities like television and video games come first, followed by reading and other relaxing activities.
  • Physically guide the child to the schedule at first, and use verbal cues to remind them to check the schedule. Teach them how to cross things off on the checklist themselves.
  • Provide positive reinforcement whenever the child follows the schedule correctly.
  • If the routine must be changed, let the child know in advance so that they can mentally prepare for the disruption. Alter the checklist ahead of time to reflect these changes.

Dietary Supplements

Therapy interventions are often effective, but some children may not respond as well to them. If this is the case, then parents may want to consider certain dietary supplements, the two options below are considered the most suitable route for children with ASD — though parents should not give either of these to their child before consulting a physician:

  • Melatonin:As mentioned above, children with ASD often experience circadian rhythm disruption that can lead to low melatonin levels. Melatonin supplements are widely available over-the-counter, and can help boost deficient melatonin levels. They also carry a low dependency risk and few adverse side effects, though nausea, diarrhea, and dizziness may occur.
  • Other supplements:In addition to melatonin, other natural supplements can help induce sleepiness and improve sleep maintenance in children with ASD. These include iron, kava, valerian root, and 5-Hydroxytryptophan (5-HTP). Multivitamins may also help, as well. These supplements carry no dependency risk, and adverse side effects are minimal.

The Center for Autism and Related Disorders notes that parents should avoid giving certain over-the-counter medications to children with ASD, including sleep-inducing antihistamines like Benadryl that are often erroneously used as sleep aids.

Sleep Management Tips for People with ASD

Therapy can be an effective way to reduce problems associated with sleep disorders and disturbances. However, people with ASD may also experience improvements by simply establishing a healthy nighttime routine and improving their sleep hygiene. Dr. PavanMadan, M.D. of Community Psychiatry says:

“Autism Spectrum Disorder (ASD) can affect sleep in many ways. Stereotypical or ritualistic behaviors can make it difficult to fall asleep within a reasonable amount of time. People with ASD often are very sensitive to touch, noise, and light, which can all affect the ability to fall and stay asleep. Many have co-occurring anxiety, which adds to the problem.

If we can understand the underlying reason for sleep issues in ASD, we can help manage them better. For example, parents can help a child choose the right space for sleep that is dark, cool, and comfortable. They can help children set a separate time for rituals in the evening so that there is less anxiety about not falling asleep. Other sleep hygiene practices can be followed as appropriate, such as taking a warm bath or shower before bed. Certain medications can be helpful for sleep, but these should be considered in consultation with their psychiatrist.”

Read on for more tips on managing sleep problems in those with ASD.

Tips for Adults

Strategies adults can use to minimize sleep issues and get a good night’s sleep on a regular basis include:

  • Create a relaxing bedroom environment that is conducive to sleep. Beds should only be used for sleep and sex, so refrain from activities like eating, watching television, and reading in bed; confining these activities to other areas of the house will help establish a more sleep-friendly atmosphere in the bedroom.
  • Eat balanced dinners and snacks prior to bedtime, and avoid substances like alcohol, nicotine, caffeine, and sugar as much as possible.
  • Electronic devices like TVs, computers, tablets, and smartphones emit ‘blue light’ that can hinder melatonin production and increase sleep latency. Recent studies suggest that people should avoid all electronics for at least one hour before bedtime.
  • Avoid napping for more than thirty minutes during the day, and less than three hours before bedtime.
  • Fluorescent and LED lights also emit blue light, as well as ‘artificial light’, which can also cut down on melatonin production. Outside lights may affect sleep onset and maintenance, as well. For optimal bedroom conditions, consider installing adjustable lights that can be dimmed; this will help boost melatonin production. Also make sure the curtains are drawn in order to block outside lights, as well as daylight when morning arrives.
  • Make sure the bedroom is temperature-controlled, and that the thermostat is set to a comfortable level. Don’t be afraid to adjust the temperature to correspond with seasonal changes.
  • If nightly discomfort is an issue, then it might be time to replace the mattress. Most mattresses need to be tossed out after seven years of consistent use. Sleep position may also be a factor, since people who sleep on their sides and backs tend to be more comfortable on mattresses made of memory foam or latex, which are designed to conform to the contours of the human body and provide spinal support. Innerspring mattresses, by comparison, offer little spinal support or contouring, and are less suitable for most side- and back-sleepers.
  • Follow a consistent sleep schedule every day of the week, including weekends. Go to bed and wake up at the same time every day to naturally entrain the mind to a regular sleep schedule.
  • Develop a daily exercise routine. Exercise can physically tire the body, making it easier to fall asleep at night. If possible, exercise outside in the morning or the first half of the day. The natural sunshine will help reset the circadian rhythms. Avoid exercising past the late afternoon, to prevent over energizing the body too close to bedtime.
  • Keep a sleep diary. This will help track nightly patterns and changes, and can be a useful reference for physicians. Sleep diaries are often required as part of CBT and light therapy.

Tips for Children and Parents

Parents of children who have been diagnosed with ASD and are experiencing sleep problems can also use the strategies listed above to help their kids get enough rest each night. The established bedtime routine schedule discussed in the previous section can also be useful. Additionally, here are a few more tips for parents of sleep-deprived kids with ASD.

  • Many foods naturally induce sleep, and parents can include these in nightly meals and snacks to help their kids rest better. These include nuts, leafy greens, dairy products, and other products that are rich in calcium and magnesium. Tryptophan can also induce sleepiness; this amino acid is found in turkey, chicken, bananas, and beans. For children with low melatonin production, try fruits like sour cherries, grapes, and pineapple that contain high levels of natural melatonin.
  • Daytime exercise can help children feel more naturally tired at night, while physical exertion too close to bedtime can actually hinder sleep. Encourage children with ASD to get exercise during the day, but try to curtail these activities in the hours leading up to bed.
  • Relaxation techniques often do wonders for children with ASD who are experiencing sleep troubles. These include meditation, listening to soft music, reading, or simply laying in bed with the lights off. Parents can also participate in these activities to guide the child along and make sure the techniques are working effectively.
  • Sensory distractions are a major issue for children with ASD at all times of the day, particularly at night. To help them sleep better, test the floor and door hinges for creaking sounds. Other sensory considerations include outside light, room temperature, and bed size.
  • If the child follows an established bedtime schedule, be sure to check on them during the early stages to ensure they are actually asleep when they are supposed to be. If they are awake and seem distressed or upset about not being able to fall asleep, take a minute to reassure them that everything is all right. Many children with ASD respond well to physical touching, so also try patting them on the head, rubbing their shoulders, or giving them a high-five to help ease their worries.

Additional Resources

For more information about the relationship between ASD and sleep difficulties, please visit the following online resources.

ASD in Adults

  • Interactive Autism NetworkThe IAN offers a user-friendly online platform for adults with ASD to communicate and share ideas with one another.
  • Autism SpeaksAdults with ASD can access dozens of blogs, journals, advocacy groups, and other online resources with this comprehensive link list from Autism Speaks.
  • Actually Autistic Blogs ListThis exhaustive list includes hundreds of links to blogs created and maintained by adults who have been diagnosed with ASD.
  • Journal of Autism and Developmental DisordersThis 2015 report outlines the RBQ-2A, one of the first screening questionnaires designed to evaluate adults for ASD symptoms and behaviors.
  • Scientific American: This 2016 article titled ‘Autism — It’s Different in Girls’ looks at some fundamental differences in the way ASD is addressed in male and female patients.

ASD in Children

  • National Autism AssociationEarly detection of ASD is crucial for developing children, and this NTA guide geared toward parents includes common symptoms, tendencies, and information about screening procedures.
  • HelpGuide.orgThis detailed guide is designed to help parents understand the signs and symptoms, behaviors, effects, and treatment options for ASD in children.
  • Scientific AmericanThis article titled ‘The Hidden Potential of Autistic Kids’ looks at certain tendencies — such as strong memories and technological proficiency — that are associated with high-functioning ASD in children.
  • Parents: Writer David Royko penned this heartfelt article (titled ‘What It’s Really Like to Raise a Child with Autism’) about his own experiences with his son Ben.

ASD and Sleep in Adults

  • Research AutismThis guide titled ‘Sleep Problems and Autism’ covers common complaints, risk factors, treatment options, and other information related to people with ASD who are experiencing sleep issues.
  • Psychology Today
  • Musings of an AspieIn a 2012 post titled ‘Wide Awake: Insomnia, Autism and Me’, the author of this long-running blog — a woman in her 40’s previously diagnosed with Asperger syndrome — details her struggles with sleep, as well as some effective solutions she has discovered.
  • Sleep: This 2015 journal article discusses common sleep patterns and problems in adults with high-functioning ASD, including more sleep disturbances at night and lower sleep efficiency than people who do not have ASD.
  • Sleep Intervention for Adults with Autism Spectrum Condition: Published by a team of researchers at the London-based Royal College of Nursing, this paper outlines the effectiveness in group therapy treatment for adults with ASD.

ASD and Sleep in Children

  • WebMDThis guide to helping children with ASD get a good night’s sleep includes causes and side effects of common sleep disorders, as well as some treatment options and sleep hygiene improvement tips.
  • SpectrumIn this comprehensive 2015 report, writer Ingfei Chen explores the medical, psychological, and environmental factors that can cause sleep problems in children with ASD.
  • Autism Treatment Network: Learn about some best-practice behavioral interventions for children with ASD and sleep problems with this useful tool kit from the ATN.
  • Journal of Pediatric Neuroscience: This 2015 report reviews key 20-year findings related to the assessment, diagnosis, and treatment of children with ASD who are experiencing sleep problems.
  • Sleep and Autism Spectrum DisordersThis report published for the 2011 National Autism Conference highlights causes, symptoms, and treatment methods for the most common sleep disorders in children with ASD.

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