Dealing with sleep difficulties in children with autism spectrum disorder

ASD and sleep

Like all children, children with ASD can have trouble getting to sleep and staying asleep. Children with ASD can also have sleep difficulties that we don’t see as often in other children. These difficulties include: 

• irregular sleeping and waking patterns – for example, lying awake until very late, or early-morning waking
• sleeping much less than expected for their age, or being awake for more than an hour during the night
• getting up and playing, and making noise for one or more hours during the night
• excessive sleepiness during the day.

Sometimes he wakes up too early and is unable to settle. Because he needs reassurance, he wakes the household.
– Parent of a child with ASD

Why children with ASD have trouble sleeping

Communication difficulties
Many young children with ASD have trouble communicating their wants and needs to others. Your child might be kept awake by something he needs but can’t ask for. Because of their communication difficulties, children with ASD sometimes can’t pick up cues that bedtime is coming up.

Love of routine and bedtime habits
Children with ASD can be very attached to their routines. Your child might settle well if the regular bedtime routine is followed, but not otherwise. Also, children with ASD can get into the habit of falling asleep in a particular place, and they won’t settle anywhere else. Habits like these can be difficult to break for children with ASD.

Favourite objects and associations
Children with ASD might have favourite bedtime objects, or favourite pyjamas they need to wear, or a pillowcase they must have before settling. Without these objects and associations, some children with ASD they can’t settle.

Other reasons: anxiety, hyperactivity, medical issues and medication
Children with ASD can have a lot of anxiety. This can make it hard for them to get to sleep, or get back to sleep after waking. Children with ASD also sometimes have hyperactivity and can stay very active and alert right into the evening.

Like all children, children with ASD can suffer from illnesses – colds or ear infections – that make it hard for them to settle or sleep well. Chronic illnesses such as asthma or epilepsy can also affect children’s sleep. And the side effects of some of the medications used for children with ASD can include trouble sleeping. 

Managing ASD sleep difficulties

Sleep and settling difficulties in children with ASD aren’t always part of having ASD. Some sleep problems are behaviour issues you can manage using strategies you’d use for any other child.

That said, your child with ASD might have difficulty understanding what you want her to do, and accepting any changes that you make. Dealing with your child’s sleep difficulties might need lots of time and patience on your part.

You can also try the following strategies for managing settling and night-waking difficulties:

• Develop a positive bedtime routine you can use wherever you and your child happen to be.
• Set a regular, age-appropriate bedtime for your child. It should be when you know your child will be sleepy, but not overtired. Many parents of children with ASD say that regular bedtimes and wake times are helpful for dealing with sleep problems. 
• Make sure you give your child plenty of warning that bedtime is approaching. If your child doesn’t like to change activities with little warning, your child might get upset if you suddenly decide ‘it’s time for bed’.
• Be consistent in how you warn your child that bedtime is approaching. You could use a cue like a clock or an appropriate picture to show your child it’s nearly bedtime. Choose something you can use or do wherever you are, including when you’re on holidays or at someone else’s house.
• If your child won’t fall asleep without a particular object – for example, a toy, special pyjamas or pillows – try to think of ways to vary this. You might need to phase out the item, perhaps by gradually rotating different items at bedtime. This might help your child from relying on just one.
• Encourage your child to fall asleep in his own bed – not on the couch, in your bed or anywhere else. It’s also important for him to learn to fall asleep by himself. You might need cues to help your child understand that he needs to fall asleep in his bed by himself. These could be things like a picture showing him asleep in bed and you sitting watching TV.
• If your child gets upset and gets out of bed, quietly and calmly put her back to bed. You might need to do this many times, especially if you’re trying to develop a new bedtime routine. Many parents of children with ASD say that returning their child to bed is helpful for dealing with sleep problems.
• If your child experiences anxiety about going to bed or sleeping alone, you could try wrapping your child in a blanket, using a nightlight in the bedroom, and/or playing music in his room when he’s in bed.
• If your child has been ill, she might keep wanting the extra attention she got when she was sick. When your child’s better, try the settling strategies above again. But consult your child’s doctor if you think your child’s poor sleep is related to a medical problem – for example, asthma or epilepsy.
• If your child wakes during the night, or gets out of bed, try the settling strategies above.

Other ASD sleep issues

Night terrors and nightmares
Sometimes children wake up screaming or crying. This could be caused by night terrors, which are normal in children from around 18 months to six years. Nightmares can also wake children up and make it hard for them to get back to sleep. Consult your child’s doctor if you’re concerned or your child’s behaviour seems severe.

Bedwetting and toileting
Late toilet training and difficulties with toilet training are common in children with ASD. If your child isn’t dry at night, he might wake because he’s wetting the bed. Or he might wake to go to the toilet and then won’t go back to bed. 

You might consider getting some help if toilet training and bedwetting are problems for your child. For example, you could start by talking with your child’s early intervention workers. If there’s a persistent problem, also consult your child’s doctor.

Snoring
Like all children, some children with ASD snore. If your child’s snoring is persistent and not associated with a cold or similar illness, consult your child’s doctor. Snoring can sometimes be a sign of sleep apnoea.

Restless sleep
Children with ASD sometimes have more restless sleep than other children. In particular, they might be prone to body-rocking, head-rolling and head-banging. Although quite common, restless sleep can also be a sign of some less common sleep disorders. It’s best to consult your child’s doctor if you’re concerned or your child doesn’t respond to settling strategies such as those above.

Where to go for help

Sleep problems often start to get better after the first 2-3 nights of implementing settling tips such as those above. If you don’t see any improvement, there might be medical reasons for your child’s sleep problems.

You might need the support of a professional to use some of the strategies above, such as those based on gradually changing bedtime and wake time.

You should consult your health professional if the techniques you try don’t seem to help after the first few days. You might be referred to a paediatrician, psychologist or other health professional experienced in treating children’s sleep.

What about medication?
Although medication isn’t the best solution to sleep problems, it can help in extreme cases. For example, some promising research shows that melatonin might help some children with ASD. Melatonin can be prescribed only by a doctor. It shouldn’t be given to a child without medical advice and supervision.

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