Behavioral Treatments for Sleep Disturbances in Children with Autism Spectrum Disorders

By: Abbey Herringshaw, Rachel Christensen, Sabrina Riera & Suzi Naguib, Psy.D.

Is getting your child who is diagnosed with an Autism Spectrum Disorder (ASD) to sleep at night a struggle for your family? If so, you are not alone. Research shows that sleep disturbances are more common and pronounced in children with disabilities (Christodulu and Durand, 2004). These sleep problems can have negative consequences not only for the child but also for the family as a whole, often creating additional stress (Doo & Wing, 2006). Further, poor sleep in children with ASD has been shown to be associated with more challenging behaviors during the day (Christodulu and Durand, 2004).

Medication is the most common form of treatment for sleep disorders in both children and adults; however, studies have shown that using medication is only marginally effective in improving children’s sleeping behaviors. Thus, for many families, behavioral interventions can be a safer and more effective alternative to pharmacological treatments. Several recent studies have outlined behavioral methods for reducing bedtime troubles and night awakening in children with ASD (Christodulu and Durand, 2004). So exactly how can you reduce these behaviors in your child? Included below are descriptions of some behavioral interventions that have been found to be effective:

Positive Bedtime Routines
Positive bedtime routines are parents’ first line of defense in correcting sleep problems, as any other type of intervention is likely to be ineffective without this step. A positive bedtime routine is just as simple as it sounds- a relaxing routine that you can do every night with your child at bedtime. Below are a few guidelines for parents to follow in constructing their routine (Christodulu & Durand, 2004):

  • Create and implement a nightly routine that starts at least 30 minutes before bedtime.
  • Activities to do during this routine should include things like changing into pajamas, washing, brushing teeth, and reading.
  • Try to keep the timing and order of routines about the same each night.
  • Try to avoid activities that might cause conflict for your child, such as picking out clothing for the next day or cleaning up.
  • Avoid watching television during this time as T.V. can be disruptive to children’s sleep.
  • Try not to extend the time of the routine, which would push back bedtime.
  • Avoid getting into bed or letting your child get into bed with you.
  • Include small variations in your routine each night (e.g., read a different book or wear different pajamas) so that the routine does not become an unbreakable ritual.

Graduated Extinction
Graduated Extinction is a method in which parents try to allow their child to resolve his or her sleep problems independently. Thus, in this method a parent would put their child to sleep and ignore problem behaviors, such as crying, for a predetermined amount of time with which the parent is comfortable (many parents start with about 5 minutes).  After this time, if the child is still awake and upset the parents can get up and resettle their child in bed.  The resettling should still aim to be quick and involve minimal comforting. Parents should then increase the amount of time that they will not attend to their child by a couple of minutes each night until their child is able to fall asleep independently.  Although graduated extinction has shown to be effective, there are some important downsides to this method that parents should consider.  When first implemented, graduated extinction tends to make problem behaviors worse before they get better.  Parents should expect this temporary worsening and realize that this may not be the best choice for them if they find it too distressing to hear their child upset for an extended period of time or if their child tends to engage in self-injurious behaviors when upset (Durand et al., 1996).

Sleep restriction
Sleep restriction involves temporarily reducing the amount of time that a child sleeps each night by 10%. To do this, one would begin by first monitoring how many hours your child sleeps on average every night. Once an average time has been found, multiply this number by .9 to find your child’s new target sleep time. Next, adjust bedtimes and waking times so that your child sleeps only this target amount of hours.  Once sleep disturbances have been significantly reduced for seven consecutive days, bedtime can be set 15 minutes earlier. This is repeated until the desired sleep schedule is achieved.  Sleep restriction is a good choice for parents who find it hard to hear their children cry for an extended period of time (Christodulu & Durand, 2004).

Scheduled Awakenings
Scheduled Awakenings is a method that is mostly used to specifically treat chronic night-terrors in children with ASD.  A night terror is characterized as a sudden awakening from a deep sleep accompanied by signs of intense fear. With scheduled awakenings, a parent would gently arouse their child (just enough that the child opens his or her eyes) about 30 minutes prior to when a terror typically happens, then allow them to go back to sleep. After 7 successive days without terrors, parents can skip one night of awakening the next week and then skip one additional night each week the child goes without terrors.  If a child does experience a terror, the parents should then go back to the nightly awakenings (Durand, 2002).

These behavioral methods have all shown to be effective in clinical research samples.  For many families, implementing such methods greatly improved their child’s sleep patterns and decreased parental stress.  Most importantly, many parents with professional guidance were able to effectively implement and incorporate these interventions into their daily lives.

Sunfield Center psychologists are available to help address sleep and other challenges faced by families whose children have special needs. To schedule an appointment, please call us at (734) 222-9277. For more information about Sunfield Center for Autism, ADHD and Behavioral Health, and our Autism Spectrum Disorders Service, please visit our website at sunfieldcenter.com.

References:
– Christodulu, K.V. & Durand, M. (2004). Reducing Bedtime Disturbance and Night Waking Using Positive Bedtime Routines and Sleep Restriction. Focus on Autism and Other Developmental Disabilities, 19,  130-139.
-Durand, V.M. (2002). Treating sleep terrors in children with autism. Journal of Positive Behavior Interventions, 4, 66-72.
– Durand, V.M., Gernet-Dott, P. & Mapstone, E. (1996). Treatment of sleep disorders in children with developmental disabilities. Journal of the Association of Persons with Severe Handicaps, 21, 114-122.
– MRCPCH, S.D. & Wing, Y.K. (2006). Sleep problems of children with pervasive developmental disorders: correlation with parental stress. Developmental Medicine & Child Neurology, 48, 650-655.