Autism Spectrum Disorder and Sleep
Many adults and children who have been diagnosed with autism spectrum disorder (ASD) experience difficulties with sleep. Research suggests that as much as 80% of young people with ASD have difficulty falling asleep and/or staying asleep during the nighttime. Although not quite as high, adults with autism spectrum disorder likewise have high rates of sleep disturbances. Lack of quality sleep can exacerbate existing symptoms of ASD, including difficulty concentrating, hyperactivity, and aggression.
This article will cover autism spectrum disorder, the most common sleep issues among children and adults with ASD, treatment options, and tips for managing sleep.
What is Autism Spectrum Disorder?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is the guide for diagnosing mental health disorders in the United States. If you wish to read the full DSM criteria, I recommend clicking that link in the sentence above! The most recent version, the DSM-V, lists the diagnostic criteria for autism spectrum disorder as:
“Persistent deficits” in communication and social interaction that occur across contexts, not accounted for by general developmental delays. This may include a lack of engagement in two-way conversations, atypical approaches to social interaction, lack of sharing of interests, difficulty making eye contact, and/or failure to respond to social invitations. Individuals diagnosed with AS may also have difficulty developing and maintaining relationships.
Restricted, repetitive patterns of behavior, interests, or activities. These patterns can be found in many different ways. Symptoms may manifest in motor movement, speech patterns, or use of everyday objects.The individual may also desire excessive adherence to routines or express excessive resistance to change. Also included in this section is hyer or hypo-reactivity to sensory input.
Although ASD may be diagnosed at any point in an individual’s life, the DSM clarifies that symptoms must be or have been present during the early development period.
Additionally, the presence of symptoms must cause clinically significant impairment when it comes to social, occupational, or other areas of functioning.
Finally, symptoms must not be better explained by the presence of another condition or disorder. Although individuals with ASD may also experience another disorder, the symptoms of autism spectrum disorder must be diagnosable independent of the other condition.
A new addition to the DSM-V were the severity levels of autism spectrum disorder:
Previous Definitions
Before the DSM-V was released in 2013, autism spectrum disorder was broken down into subtypes based on severity of symptoms. These are terms you may still hear being used, but have actually been absorbed into the ASD diagnosis in the most recent manual. Four common subdivisions from the previous DSM are:
Asperger’s Syndrome: Asperger’s was generally the mildest of the ASD subtypes. Individuals with Asperger’s syndrome may display symptoms like difficulty picking up social cues, hypersensitivity to stimuli, and preoccupations with their interests. Generally, people with Asperger’s syndrome are high functioning.
Autistic Disorder: This was essentially the middle-of-the-spectrum condition. Symptoms may be more clinically significant than in individuals with Asperger’s Syndrome, but not as significant as the following subtype.
Childhood Disintegrative Disorder: CDD was the most severe on the spectrum. Often diagnosed in young children (2-4 years old), it was characterized by strictly limited social, speech, and cognitive abilities. Many of these children were non-verbal.
Pervasive Development Disorder, Not Otherwise Specified: This was the term for any autism spectrum condition that did not strictly meet the criteria for the other three disorders.
The Cause of ASD
The cause of autism spectrum disorder is somewhat unclear. According to the Mayo Clinic, both genetics and environmental factors may play a role. Researchers have identified several genes and mutations which may be involved. These genetic changes may increase the risk of ASD, while others may determine the severity of symptoms. Some of these genetic mutations may be inherited, while others are not hereditary.
There is a lot of ongoing research about the environmental factors in autism spectrum disorders. Researchers are looking at things like viral infections, medications, pregnancy complications, and air pollutants as potential factors. One thing that is important to note is that there is no reliable research to even suggest a link between autism spectrum disorder and childhood vaccines.
Risk Factors
Cases of autism spectrum disorder in children are on the rise, and researchers are not quite sure why. Part of this is due to better detection and reporting. Here are a few known risk factors:
Sex - Boys are about four times as likely to develop ASD than girls.
Family History - Families with one child with ASD have an increased risk of having a second child with ASD.
Other Disorders - Children with certain conditions have a higher risk of autism spectrum disorder. These conditions include fragile X syndrome, Rett Synrdome, and tuberous sclerosis.
Premature Babies - Babies born before 26 weeks of gestation have a higher risk of developing an autism spectrum disorder.
Age of Parents - Research has suggested that older parents may increase the risk of ASD, but more research is needed.
How Does ASD Affect Sleep?
Research has repeatedly shown that between 50 and 80% of children with ASD experience some sleep-related issues. By comparison, the rate is between 9 and 50% for children not diagnosed with an autism spectrum disorder. Multiple studies have looked at the experiences individuals with ASD have in regards to their sleep. The most common issues are:
Difficulty falling asleep (sleep onset)
Difficulty staying asleep through the night (sleep maintenance)
Waking early in the morning
Sleeping for short durations
Erratic sleep patterns during the night
Hyperarousal around bedtime
Excessive daytime sleepiness.
These sleep problems that may be directly or indirectly related to an ASD diagnosis may have underlying causes. These include:
Irregular Circadian Rhythm: The circadian rhythm, our 24-hour biological clock that helps regulate sleep-wake cycle, may have irregularities in individuals with ASD. A process in the brain, individuals with autism spectrum disorder often experience an atypical sleep-wake cycle. One theory is that individuals with ASD have an irregular production of melatonin, which is a hormone that helps regulate the circadian rhythm.
Mental Health Disorders: Many people with ASD have a comorbid mental health disorder. Research suggests around 25% of people with autism spectrum disorder have depression. Many also exhibit symptoms of ADHD. These other mental health conditions are closely linked with insomnia and sleep disorders.
Medical Conditions: Other medical conditions may also play a part in sleep issues among people with autism spectrum disorder. Common medical issues among people with ASD include epilepsy, constipation, diarrhea, and acid reflux.
Side Effects of Medications: Most all medications can have unintended side effects. It’s important to talk with your doctor about medications and side effects. SSRIs can cause agitation and hyperactivity before bedtime. Antipsychotics may cause excessive drowsiness during the day. Again, please talk to your doctor before making any changes to medications.
Those with ASD may struggle with daily pressures and interactions much more than individuals who live without the disorder. Poor sleep quality can exacerbate the discomfort, stress, and anxiety they experience on a daily basis. Because of this, those with ASD and sleep issues may struggle with daily tasks, employment, education, and social interaction.
The most common sleep disorder reported among those with ASD is insomnia. Insomnia is defined as difficulty falling and/or remaining asleep on a regular basis for a period of more than one month. A study in the journal Sleep found that 66% of children with ASD reported symptoms of insomnia.
In addition, parasomnias such as night terrors, frequent nightmares, and enuresis (bed wetting) are widely reported among children with autism spectrum disorder. Children may also awake in the middle of the night and engage in time-inappropriate activities like playing with toys or reading aloud.
Many researchers are currently studying the relationship between sleep disorders and ASD. For example, Dr. Steven Park has a theory that the sleep issues are caused by a link between ASD and sleep apnea. This is still being researched. The theory suggests that intracranial hypertension in infants and babies with ASD may cause an irregular shaped jaw, which might exacerbate sleep disorders.
Treatment Options for ASD-related Sleep Issues
Let’s start again by saying it clearly: Please speak to your doctor about medications.
Generally speaking, prescription medications have been used to treat insomnia and other sleep disorders over the last 50 or so years. Sedative-hypnotic z-drugs, or nonbenzodiazepines, are currently the most popular choice among physicians. These medications include zolpidem (Ambien), zopiclone (Lunesta), and zaleplon (Sonata) and do not generally disrupt sleep architecture. Benzodiazepines like alprazolam (Xanax) and diazepam (Valium) may disrupt sleep in the long term according to research.
Some prescription medications, including z-drugs, may have some side effects. They carry some dependency risk, may cause acid reflux and constipation in some individuals. Additionally, these drugs may interact with other medications individuals with ASD take. So make sure to talk with your doctor! It is important to schedule a preliminary assessment with a doctor so physicians can rule out other factors and investigate the sleep disorder.
Side Effects of Common ASD Medications
There are many medications used to relieve symptoms of ASD. The table below contains some of the most commonly prescribed medications, along with a few side effects they may cause. Remember to speak with your doctor before stopping or altering any medication in yourself or your child.
Sleep Therapy
If a preliminary assessment indicates a sleep disorder in a child with autism spectrum disorder, treatment options come next. Cognitive Behavioral Therapy, or CBT, has proven fairly effective in working with sleep disorder symptoms in young individuals with ASD. CBT can help people improve sleep hygiene, educate individuals about the science and habits, and build new patterns of thinking and behaving around bedtime. A study in the Journal of Pediatric Neuroscience found that establishing a consistent bedtime routine can be quite beneficial. You might consider including:
Putting on pajamas
Brushing one’s teeth
Using the bathroom
Washing hands and face
Getting in bed
Reading a book or having a parent read a book
Singing songs
Mindfulness meditation
Shutting off the light.
Autism Speaks has a great Sleep Tool Kit that offers various interventions and suggestions you may find useful. These include:
Creating a visual schedule checklist with drawings or photos, objects, and visual aids. This can help children with ASD grasp the concepts of the bedtime routine more easily.
Keeping the bedtime routine concise, limiting it to about 30 minutes before bed. Too many commitments can feel overwhelming.
Ordering the routine to decrease in stimulation. For example, cutting off TV and video game time and moving toward reading or singing.
Guiding the child in learning the schedule. Teaching the child to cross things off the checklist themselves.
Providing positive reinforcement with each step.
Pharmacological Treatments
Therapeutic interventions are effective for many, but some children may not be as responsive. Parents may consider pharmacological treatments. Below are a few medications known to help some individuals with ASD and sleep disorders, but be sure to talk to your physician before taking anything.
Melatonin - Because of circadian rhythm irregularities, melatonin may be useful in helping individuals with ASD sleep. With a low dependency risk and relatively few side effects, it may be something to discuss with your doctor.
Clonidine - An anti-hypertension medication generally used to treat tic disorders, ADHD, and high blood pressure. As it lowers blood pressure, it may induce sleepiness. A 2008 study found that clonidine helped reduce sleep latency and nighttime awakening specifically in children with ASD.
Mirtazapine - A tetracyclic antidepressant, mirtazapine can alleviate insomnia symptoms in children and young adults. Antidepressants carry a risk of side effects, especially in adolescents.
Sleep Management Tips
There are many things we can do to help establish a healthy nighttime routine and improve sleep hygiene. Here are a few tips you may consider:
Create a relaxing bedroom environment. Beds should only be used for sleep or sex in the case of adults. Do not eat, watch TV, read, talk on the phone, etc. in bed. This will help your brain associate the bed with sleep only.
Watch what you eat during the day, especially in the afternoon and evening. Avoid mind-altering substances including nicotine, alcohol, caffeine, and sugar. Consider adding nuts, leafy greens, dairy, and foods rich in magnesium, calcium, and tryptophan.
Reduce exposure to blue light before bed by steering clear of TVs, tablets, computers and phones for at least one hour before bedtime.
If possible, avoid napping for more than 30 minutes during the day. You should also aim to not nap in the three hours leading up to bedtime.
Cut down on fluorescent and LED lights. Make the bedroom dim, and install blackout curtains if there is outside light flooding in.
Make your bedroom a comfortable temperature. Being too hot or too cold can lead to sleep disturbances.
Get adequate exercise during the day. Being physically tired can encourage sleep, while overexertion can actually hinder sleep. Make sure to curtail activities a few hours before bedtime.
Be aware of sensory distraction. Things like moving lights, creaky hinges, or incorrect bed size may hinder sleep quality.
Additional Resources
For more information about the relationship between ASD and sleep difficulties, please visit the following online resources.
ASD in Adults
Interactive Autism Network: The IAN offers a user-friendly online platform for adults with ASD to communicate and share ideas with one another.
Autism Speaks: Adults 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 List: This exhaustive list includes hundreds of links to blogs created and maintained by adults who have been diagnosed with ASD.
Journal of Autism and Developmental Disorders: This 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 Association: Early detection of ASD is crucial for developing children, and this NTA guide geared toward parents includes common symptoms, tendencies, and information about screening procedures.
Pharmacy and Therapeutics: This 2015 study includes up-to-date information about the different prescription and over-the-counter pharmacological treatment methods for children with ASD.
HelpGuide.org: This detailed guide is designed to help parents understand the signs and symptoms, behaviors, effects, and treatment options for ASD in children.
Scientific American: This 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 Autism: This 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.
Musings of an Aspie: In 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
WebMD: This 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.
Spectrum: In 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 Disorders: This report published for the 2011 National Autism Conference highlights causes, symptoms, and treatment methods for the most common sleep disorders in children with ASD.