Children with Autism - Sleep Fact Sheet Autism and Sleep Autism is a diagnosed condition. It is recognised that many children with autism will experience sleep difficulties. There are a number of reasons for this: Social and Communication impairment o If communication is difficult either in the understanding of, or use of it, this can affect the child s understanding of what is happening now and next. When relating this to sleep this can be as simple as not understanding why and when to sleep. o The child may not recognise their own sleep need or when they are tired. o They may have difficulties understanding or interpreting external cues for preparation for going to bed, this may in turn affect settling to sleep and sleep onset. o Planning and sequencing may be difficult and this may lead to confusion about what is happening and about to happen. Restricted/repetitive behaviours o If a child is locked into a routine, it can be hard to change this o Many autistic children find transition from one activity to another difficult, thus change for daytime activities to sleep time may be tricky. Sensory Issues o Bedtime routines can be full of many different sensory inputs and this can be confusing and sometimes cause night-time problems. For example a child who does not like to have buttons on pyjamas or a child who will only sleep when wrapped up tightly in a sheet. The autistic child may be very sensitive to light, noise and touch, and all these can impact on sleep. Anxiety o Many children can be anxious, but autistic children can get particularly anxious if particular routines are not carried out or change, or worry about things they don t understand. Melatonin o There has been much research around melatonin production in children with autism. The theory is that as many children with autism may suffer from delayed
sleep onset problems and this could be due to reduction in melatonin production. (1) Many trials have been carried out to test this theory and vary in the results. A few trials have demonstrated that using melatonin supplement for children with Autism has improved sleep. (2) However, a large study carried out in the UK, found that there was strong evidence that melatonin does not improve total sleep time.(5) Support When managing sleep problems with a child with autism it is important to understand the child and then identify the sleep problem. Giving clear messages is often the key to successfully resolving sleep problems. Clearly setting the routines and when it is time to sleep and wake up will help increase both the child s understanding of what is expected and also help set their circadian rhythm. Social Stories Social stories are a well-established method to help autistic children understand particular social situations. They are used to explain and guide. The story is devised which is descriptive, meaningful, physically and socially safe for the child. They are written in the first person. It allows them improve their understanding and expectations of the situation. It does not just tell them what to do. Carefully writing a social story around bedtime and sleep can be hugely effective. (3)There are many books available to help create social stories. Visual Timetables Using a visual timetable can help reinforce new routines. Verbal communication aided with a visual cue will strengthen the child s understanding and what is expected. These are particularly helpful for supporting a good bedtime routine. It allows the child to see what is about to happen. There are many online support templets for visual cards and timetables. Here is an example using a variety of pictures to illustrate what is available. It is always best to use similar types of symbols or pictures rather than a mixture as below: These demonstrate a timeline for a simple bedtime routine. BATH- BRUSH TEETH- PYJAMAS ON-INTO BED-STORY-THEN TO SLEEP. Use pictures which your child will understand, recognise and be able to relate to. The timetable should be simple and meaningful for the child. To help you put together a bedtime time line, talk to your speech and language therapist or specialist health visiting team.
Timers and clocks Timers and clocks are very effective in supporting the timing of activities and helping a child to prepare for transition to the next activitiy. These are both visual cues to help with communication. Even if a child is unable to tell the time, there are man varaiations now available which will help childrn to know when it is time to be in bed and time to be awake. Below is one example of a clock, which changes from a star on a blue background to a yellow sun. Light and Dark As with everyone the circadian rhythm is partially governed by light and dark. Autistic children may be ultra-sensitive to both, thus needing longer reduced exposure to light devices to aid melatonin production (the sleepy hormone produced to aid sleep onset). They may also be very anxious in total darkness. Therefore having a small nightlight or lava lamp in a safe place may give them some light, but also a focal point when going to sleep. Bedtime routines It is really important to get a good bedtime routine in place as early as possible. This will support the child going to sleep now and in the future. Putting together a routine that is tailor made to meet the child s sensory, learning, communication, understanding needs is imperative in getting the best night s sleep. Using a combination of the above ideas and a structured routine will help. Dealing with sleep problems using behavioural techniques have also been found to be successful. Sensory calming activities Many autistic children have sensory processing difficulties and are either very sensitive or sensory seekers. There are a number of activities that can help calm and relax an autistic child in preparation for bed. Often these may need to be trialled first to see if they are effective. For example; using pressure or deep massage before bed has shown to be very effective. Some children like to roll on a large gym ball, again using pressure. Some children may find these activities too stimulating before bed and would have the opposite effect.
Above are a few exercises that are recommended for autistic children to help with calming, using a variety of sensory input. These are based on the book by J Horwood Sensory Circuits for children.(4) There are many books, support groups and forums available which offer lots of helpful advice around supporting a child with sleep problems and autism. References 1. Melke J et al 2008; Abnormal melatonin synthesis in Autism Spectrum Disorders; Molecular Psychiatry (2008) 13, 90 98 2. Rossignol Daniel A, Frye Richard E; Melatonin in autism spectrum disorders: a systematic review and meta-analysis; Development medicine and child neurology; Volume 53, Issue 9; September 2011 Pages 783 792 3. Gray C; The new social story book; Future horizons firm; Oct 2015 4. Horwood J; Sensory Circuits; LDA publishing; 26 March 2009 5. Appleton RE, Gringras P, Mends: the use of melatonin in children with neuro-developmental disorders and impaired sleep a randomised, double-blind, placebo-controlled, parallel trial Archives of Disease in Childhood 2011;96:A1.