GOOD NIGHT, SLEEP TIGHT
, & DON'T LET THE BED BUGS BITE: establishing positive sleep
patterns for young children with autism spectrum
by Marci Wheeler
Most parents have had some experience with a child
who has difficulty falling asleep, wakes up frequently during the
night, and/or only sleeps a few hours each night. Temporary sleep
difficulties are an “expected” phase of child development. Ongoing
and persistent sleep disturbances can have an adverse effect on
the child, parents and other household members. Children with Autism Spectrum Disorders appear to experience these sleep disturbances
more frequently and intensely than typically developing children.
A child’s sleeping problems can quickly become a daily parenting
There are a number of factors to address when
establishing a plan to reinforce a positive sleep pattern. First,
any underlying medical problems that may be affecting sleep should
be assessed. Consider checking for food and/or environmental allergies
or intolerances, gastrointestinal disturbances, and seizures.
All of these are more common in persons with Autism Spectrum Disorders.
Also sleep disturbances can be a side effect of other medications
an individual takes and so this should be considered, too.
Sleep disorders that affect the general population
should also be ruled out for your child with an Autism Spectrum Disorder. Sleep apnea is a disorder that can affect anyone at any
age. It is a disorder in which a person experiences pauses in breathing
when the airway becomes obstructed during sleep. The most common
cause for blockage is enlarged tonsils or adenoids. Upper respiratory
illnesses and/or allergies can also contribute to the development
of sleep apnea. Beside pauses in breathing, symptoms of sleep apnea
in children include: snoring, mouth breathing, restless sleep, sweating,
night wakings, and/or frequent coughing or choking while asleep.
Other sleep disorders to assess in a child, if appropriate, include
sleep terrors and confusional arousals. These both are frequently
referred to as parasomnias. Parasomnias are disorders of “partial
arousal” that lead to unusual behaviors during sleep. Children with
sensory processing difficulties have more problems falling asleep
and night waking. An assessment and consultation with an occupational
therapist trained in sensory integration may be important to assess
relaxation and arousal difficulties, and to help design strategies
that address these issues.
After possible medical problems have been addressed,
other factors contributing to sleep problems should be considered
and strategies for addressing these implemented. Other issues to
consider are: environmental variables, bedtime routines and the
use of a sleep training method. Each of these three topics is discussed
in further detail below.
After examining your child’s sleep environment
more closely, there may be some adaptations and modifications needed
to assist your child’s ability to relax at bedtime.
Consider whether your child is too hot or too
cold. Assess the temperature of the room, bedding and sleep clothes
to decide what combination is best for your child. Remember that
your child’s sense of temperature may be different then your own.
Recall what temperature your child seems to prefer and/or seek during
the day, and consider when making decisions.
Consider tactile sensitivities that may be affecting
your child’s ability to sleep. Certain textures can relax or arouse
your child. Look at bedding and pajama textures. Your child may
prefer his/her feet covered or uncovered with footed pajamas, socks
and or even the covers themselves. How tight or loose the clothing
fits, and whether or not there is elastic or seams can be an issue
for some children. Also bedding should provide the optimum level
of pressure, as this too can affect individuals with Autism Spectrum Disorders.
Consider noises and how they affect your child.
At night, when trying to relax and fall asleep, the noises your
child hears may be over powering and impossible for the child to
filter out. These noises, such as water running or an animal scratching
may not affect you or other household members but can be disrupting
for a child with an Autism Spectrum Disorder. Can certain household
noises be monitored for the effect on your child? Sometimes a fan,
air filter, TV or soft music in the child’s room can help mask other
noises and provide a consistent sound that is comforting and/or
soothing for the child.
Also consider visual stimuli that may be causing
problems for your child at bedtime. Is your child afraid of the
dark? Some children with Autism Spectrum Disorders may seem to prefer
dark places during the day but that is different then being expected
to sleep in a big room in a bed at night in the dark. Streetlights,
the moon, or car lights shining in the room at intermittent intervals
may be affecting your child’s sleep. Providing a room that is consistently
light or dark may be very important, depending on your child’s needs.
Bedtime Routines & Autism Spectrum Disorders
Bedtime routines and rituals are very important
for most children in establishing positive sleep patterns, but are
extremely critical for children with an Autism Spectrum Disorder.
Your child will benefit from a set bedtime. Pick
a time for bed that is reasonable for your child and which you can
Children with an Autism Spectrum Disorder need
to know what is going to happen next. Establish a bedtime routine
that can provide predictability and a comforting, familiar pattern.
For further understanding and structure, a visual bedtime schedule
can help. The visual schedule can provide reminders and consistency
for the whole family.
A good bedtime routine will help teach a child
to calm down, relax and get ready to sleep. For example, if bathing
is stimulating or frightening for your child, even though you may
want him/her to bathe before bed, it may be best to bathe at a completely
different time of the day. Likewise, there may be sensory integration
activities that have proven to be relaxing to your child during
the day that you can also use as part of the bedtime routine.
A bedtime routine should be the same everyday
and should include activities that are pleasant and relaxing as
well as special and individualized to fit your child’s needs and
interests. A bedtime routine should realistically consist of 4 to
6 steps that do not take more time then is reasonable on a nightly
Some activities to consider as part of a bedtime
routine or ritual include looking at the same book or story each
night, saying good night to favorite objects, toileting,
bathing, getting pajamas on, brushing teeth, having a glass of water,
singing a favorite song or prayer, listening to calming music that
the child enjoys, hugging and kissing family members and/or engaging
in a calming sensory integration activity.
On days when you are away from home and/or get
home late, it is still important to follow bedtime routines and
rituals. You can shorten each step significantly and potentially
eliminate nightlong frustrations due to the change. If your child
is away from home for a night or two you may see old sleeping patterns
emerge. Even in a temporary new environment, routines may help.
Upon returning home the bedtime routine will continue to be effective,
though the excitement from the change may take a night or more to
fade depending on your child and how long you have been away.
Sleep Training & autism
After addressing medical issues, environmental
variables and bedtime routines it is time to tackle the hardest
piece in establishing positive sleep patterns: teaching your child
to sleep through the night. There are various versions of sleep
training methods you may have read or heard about. Basically after
the bedtime routine is done and your child is in his bed or crib,
leave the room without long drawn out words or further attempts
at touching the child in any way.
If the child 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” or a similar phrase and then leave
the room until it is time for the next check or until the child
Using this technique consistently is generally
harder on the parent then it is on the child. It could take a couple
of hours the first few nights. It is important to know that it is
very likely the child’s behavior will get worse for a few days or
more before it improves. This is the child testing the change and
trying to bring the old routine back. For some children who are
older and not genuinely tired at a reasonable bedtime, a routine
of staying in the bed or in the room quietly may be appropriate
for these children. Sleep training methods can still be applied
in these situations. Also a gate or other barrier may be needed
at the bedroom door to remind the child it’s bedtime and the expectation
is to stay in your room.
If your child is older and never consistently
slept through the night, you may be totally sleep deprived yourself.
Ask for help from your doctor, a psychologist, social worker or
from a case manager if you have applied for Medicaid Waivers. It
may not be easy to find a knowledgeable professional but you might
start by asking other parents who might know a professional that
has helped them in the past. Also if your child seems to regress
in their sleeping habits, you may need to consult with knowledgeable
professionals. Again, it is best to start with a medical assessment
and proceed from there. Sometimes if other medical problems are
ruled out, a temporary trial of medication taken under a doctor’s
care can assist in turning around poor sleep patterns, while working
to establish bedtime routines and rituals that work for your child.
melotonin , sleep & Autism Spectrum Disorders
Several doctors in the field of Autism Spectrum Disorders have done preliminary research on the short-term use of
the over the counter supplement melatonin. Melatonin can help stabilize
and promote normal sleep for some children by helping them fall
asleep more quickly. The few studies currently available do caution,
however, that melatonin sometimes stops working and does not usually
help those who frequently wake up during the night. In addition,
the long-term effect of taking melatonin has not been established.
Some parents have found vitamin supplementation helpful for helping
a child get to sleep.
It is extremely common for children with Autism Spectrum Disorders to have difficulty getting to sleep, sleeping
for a few hours at a time, and/or staying asleep without frequently
waking throughout the night. These poor sleep habits are easily
created and can be extremely difficult to change. One issue not
yet addressed in this article is the habit of sleeping with the
child. This habit may understandably gets started when poor sleeping
patterns affect not only the child but the parents and the rest
of the family as well.
If the child is in the habit of sleeping with
a parent and/or in the parent’s bed, the same steps described above
should be considered with additional support needed during the examination
of the environment and bedtime ritual/routine. For example, a pillow
or other item(s) from the parent(s) may help make the environment
more comforting to the child as the parent(s) transitions from sleeping
with the child. Desensitization to a new bed or room can be added
as part of the bedtime routine. Desensitization to a new room or
bed can be added as part of a routine done daily for a few days
or weeks before also being done as part of the bedtime routine.
It can’t be stressed enough, the best advice is
to avoid creating sleep routines and habits that will have to be
broken later, if at all possible.
Checking for medical issues and environmental
variables and then planning and consistently as possible following
a bedtime routine and a sleep training method can improve the quality
of life for the whole family. It can take time to establish positive
sleeping patterns particularly if trying to change a long-standing
problem. Families frequently have to make sleeping issues a priority
until positive sleeping patterns are established. It is a priority
that is worth the effort.
Dodge, N.N. & Wilson, G.A. (2001). Melatonin
Reduces Sleep latency in children with developmental disabilities.
Journal of Child Neurology, 16, 581-584.
Durand, V.M. (1998). Sleep better! A guide to improving sleep for
children with special needs. Baltimore, MD: Paul H. Brookes Publishing.
Hayashi, E. (2000). Effect of melatonin on sleep-wake rhythm: The
sleep diary of an autistic male. Psychiatry and Clinical Neuroscience,
54 (3), 383-4.
Mindell, J.A. (1997). Sleeping through the night: How infants, toddlers,
and their parents can get a good night’s sleep. New York, NY: Harper
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