Autism spectrum disorder (ASD), often referred to as simply “autism,” is a developmental and neurological disorder that affects how an individual behaves, learns, communicates, and interacts with others. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), those with autism exhibit challenges when interacting with others, repetitive behaviors, restricted interests and/or symptoms that affect their daily life. Autism can affect any race or gender and may be diagnosed at any age. In 2021, the CDC reported that an estimated 1 in 44 children in the U.S are diagnosed with ASD, and an estimated 5,437,988 (2.25) adults have autism.
Autism is considered a spectrum disorder which means there is significant variation in presented symptoms and severity of symptoms. As a result, symptoms experienced by one individual may not be shared by another, and is why it is aptly called a “spectrum disorder.” Despite this variation there are certain symptoms that are more common than others. For example, making little or inconsistent eye contact and having trouble sleeping.
According to Autism Speaks, 50 – 80% of children with autism have at least one chronic sleep problem. The most common sleep problems experienced by those with autism include:
- Inconsistent sleep routines.
- Restlessness or poor sleep quality.
- Difficulty falling asleep.
- Waking up too early or frequently during the night.
Research has found that insomnia is the most common sleep problem in those with autism. On average, it takes those with autism 11 more minutes to fall asleep, with many waking up frequently in the night.
Why are sleep disorders more prevalent in children with autism?
Despite plenty of research on autism spectrum disorder, there is still no conclusive reason why sleep disorders are more prevalent. That said, there are several theories as to why it occurs. One theory suggests that those with autism have trouble falling asleep because of their challenges with reading social dues. Some researchers believe that although our circadian rhythm plays a role, we also know it’s time to sleep on our shredded latex pillow because of social cues. For example, a child sees their parents getting ready for bed or their siblings getting sleepy and know it is time to go to sleep, but with autism, they may miss these cues, so bedtime comes as a surprise, and they don’t feel ready to go to bed.
A second theory suggests that these sleep struggles are related to melatonin production. Melatonin is a hormone that helps regulates our sleep-wake cycle. For the body to make melatonin, an amino acid called tryptophan is needed, and research has shown that children with autism may have higher or lower than normal levels. Further, some studies have found that children with autism don’t release melatonin at the correct time of day. Studies have shown that in children with autism, melatonin levels are higher during the day and lower at night which makes daytime sleepiness worse and keeps them up at night.
Increased sensitivity may also be responsible for disrupted sleep. Because children with autism can have a heightened sensitivity to touch and sound, they can easily be awoken by noises in their bedroom or home. For example, while the majority of children could remain asleep when a car drives by or when someone walks down the hall, a child with autism could be startled awake and have difficulty falling back asleep.
Some theories suggest that other conditions or medications can cause these sleep struggles. For example, many individuals with autism have other conditions, such as attention deficit hyperactivity disorder (ADHD) or gastrointestinal problems which could keep them up at night. Additionally, many medications for these conditions are stimulants which can cause insomnia and sleep troubles.
Lastly, some believe that increased anxiety is the cause of these sleep problems. Children with autism tend to test higher for anxiety, which could lead to trouble falling asleep and staying asleep throughout the night.
How do sleep struggles impact children with autism?
A lack of quality sleep is detrimental to everyone! Our minds and bodies need rest to function, and a lack of it can be incredibly harmful to a child. Research has found that children with autism who experience sleep struggles are also more likely to experience depression, hyperactivity, aggression, increased behavioral problems, irritability, and poor learning and cognitive performance.
These sleep struggles also impact parents and other siblings. When a child doesn’t sleep, neither does the parent, which affects their functioning and alertness the next day. Haley Bennett’s daughter Bramli has autism and trouble falling asleep each night. It takes Bramli’s parents about two hours, tucking her in six to eight times before she falls asleep for the night. According to Ruth O’Hara, associate professor of psychiatry and behavioral science at Stanford University in California, this is “very, very disruptive to the family.”
Recent research has discovered that children with autism get less rapid-eye movement (REM) sleep which can worsen daytime functioning. REM sleep is vital for memory and learning and can cause many challenges during the day if a child doesn’t get enough. A Stanford study found that, on average, it took children with autism 160 minutes to enter REM sleep, where they spent 15.5% of their sleep. This means that when those with autism sleep, their sleep tends to be less restorative. Sleep deprivation impacts the same areas of the brain affected by autism. O’Hara says, “sleep disturbance impacts cognition, it impacts mood, and it impacts behavior.”
How are sleep problems assessed in those with autism?
A home sleep study is often the best way to determine if a sleep problem exists. Polysomnography is the most common test that will measure a person’s brain waves and eye and limb movements during sleep. Although these measurements are excellent, it can be challenging to get an accurate read because of all the wires and sensors. As mentioned, those with autism are often more sensitive, and being hooked up to one of these machines can make it extremely difficult to sleep. As a result, a less cumbersome test known as actigraphy may be used. Actigraphy is a small device that is fastened to the wrist like a smartwatch. Although it doesn’t capture as detailed information as polysomnography, it does record how much a person is sleeping in the night and can even reveal details on sleep patterns, like how much time they spent in REM sleep.
Reports and records from individuals or their parents can also be helpful. Sleep diaries help doctors and sleep experts understand the type of struggles a person may experience. With a sleep diary, it is also important to track the activities throughout the day so potential causes like stimulating activities, blue light, or caffeine can be ruled out.
How can those with autism sleep better at night?
According to Carin Lamm, Associate Clinical Professor of Pediatrics Diplomate American Academy of Sleep Medicine and Director of Pediatric Sleep Disorders Center Columbia University Medical Center, despite this high prevalence of sleep problems in those with autism, sleep quality and quantity can be improved by focusing on sleep hygiene.
The first step to better sleep hygiene is a suitable sleep environment. Those with autism can be particularly sensitive to noises or sensations, which should be considered when picking out bedding. For example, a shredded latex pillow with a soft bamboo pillow case can provide comfort that won’t distract or cause uncomfortable sensations. Weighted blankets are also said to help improve sleep for those with autism and were specially designed for children with ASD. The bedroom should be adapted to be as comfortable as possible without any distractions.
A bedtime routine is also very important for those with autism. Dr. Lamm suggests a routine be kept to no more than 30 minutes and remains predictable. This bedtime routine could include listening to relaxing music or reading on a meditation pillow. It is also essential to avoid overly stimulating activities such as computer games, electronics, phones, or TV.
The time a child or person with autism goes to sleep and wakes up each day should remain the same. Although it can be tempting to shut off the alarm clock on weekends, having the same bedtime and wake-up time every day of the week will help those with autism fall asleep faster (and more consistently!).
In more extreme cases, a doctor may prescribe medication. These are usually only prescribed as a last resort after a person has tried a natural sleep aid. Natural sleep aids like melatonin can help those with autism normalize their sleep-wake cycle and fall asleep faster.
The key to treating sleep disorders and struggles is determining what is causing them. Doctors cannot assume any sleep troubles are a result of autism and must rule out other potential causes, such as sleep apnea or a poor sleeping environment. Although autism-related sleep problems can cause greater issues or exacerbated symptoms, these sleep struggles can be remedied through good sleep hygiene and a solid sleep routine.