Sleep Disturbances in Autism Spectrum Disorders

Sleep disturbances are prevalent among children and adolescents with Autism Spectrum Disorders (ASD), impacting their overall well-being and functioning (American Psychiatric Association, 2013; Richdale, 2022). Recent studies confirm that sleep difficulties in the autistic population are consistently high, with prevalence rates ranging from 60% to 86% (Malow et al., 2012; Richdale & Schreck, 2009). This blog explores the most common sleep difficulties in individuals with ASD, their underlying causes, and effective interventions to improve sleep quality.

Most Common Sleep Difficulties in ASD

Research indicates a consensus on the most common sleep difficulties in individuals with ASD (Malow et al., 2012; Richdale & Schreck, 2009), which include long sleep onset latency, night waking, reduced total sleep time, poor sleep efficiency, and, in some cases, extreme early morning waking. Additionally, autistic individuals may experience circadian sleep disturbances, sleep apnea, periodic limb movements, restless legs syndrome, and non–rapid eye movement parasomnias (Elrod & Hood, 2015; Richdale, 2022). Behavioral and arousal factors, as well as circadian rhythm disorders, contribute to these sleep challenges (Malow et al., 2012).

Environmental and Behavioral Factors

Several environmental and behavioral factors contribute to sleep difficulties in individuals with ASD (Malow et al., 2012). These include a lack of proper bedtime routines, excessive screen time, parental stress, and lower family income (Cohen et al., 2014; Malow et al., 2012). Parents who are stressed, anxious, or depressed may create a negative sleep environment for their children, exacerbating sleep quality issues (Cohen et al., 2014).

Arousal and Sensory Dysregulation

Arousal and sensory dysregulation play a significant role in insomnia among individuals with ASD (Cortesi et al., 2012; Malow et al., 2012). Increased cognitive activity (i.e. overthinking, rumination), high levels of sympathetic activity (nervous system activation in fight or flight mode), and difficulties in initiating sleep are associated with sensory processing challenges. Thus, calming strategies that help the mind and body slow down are essential to improve sleep, focusing on reducing physiological arousal and creating a sensory-friendly sleep environment (Elrod & Hood, 2015).

Circadian Relevant Gene Abnormality

The circadian rhythm refers to the physical, mental, and behavioral changes we go through in a 24 hour cycle.  Abnormalities in circadian-relevant genes can impact sleep patterns and social communication in individuals with ASD (Bourgeron, 2007). Understanding these genetic interactions is crucial in developing targeted interventions to address circadian rhythm disorders. Melatonin, closely related to circadian rhythm, plays a vital role in sleep regulation (Malow et al., 2012). Abnormal melatonin synthesis and secretion patterns are linked to circadian misalignment in individuals with ASD.

Comorbid Psychiatric Disorders

Comorbid psychiatric disorders, such as epilepsy, anxiety, depression, and ADHD, can negatively affect sleep in individuals with ASD (Cohen et al., 2014; Malow et al., 2012). The presence of intellectual disability, sensory integration deficits, and limited responsiveness to social cues further complicates sleep training and exacerbates sleep disturbances (Cohen et al., 2014).

Impact on Daily Functioning

Sleep disturbances in individuals with ASD have profound effects on daily functioning for both the individual and their family (Cortesi et al., 2012; Malow et al., 2012). Daytime sleepiness, lower cognitive abilities, irritability, emotional regulation challenges, and increased stress levels for parents are common consequences. Understanding these impacts is crucial for developing comprehensive interventions (Cohen et al., 2014).

The COVID-19 pandemic has introduced additional challenges for individuals with ASD, leading to disruptions in routines and increased sleep problems (Colizzi et al., 2020; Bruni et al., 2021). Home confinement, lack of obligations, reduced leisure activities, and increased screen time have contributed to changes in sleep habits.

Interventions

Behavioral and pharmacological interventions are essential in addressing sleep difficulties in individuals with ASD (Malow et al., 2012). Behavioral approaches, including sleep hygiene, extinction, bedtime fading, and reinforcement for sleep-conducive behaviors, have demonstrated effectiveness (Johnson & Malow, 2008). Melatonin supplementation is a common pharmacological intervention, with studies indicating improvements in sleep duration and onset latency (Gringras et al., 2012; Mammarella et al., 2023). Tryptophan and antipsychotics like risperidone and clonidine are also explored as potential interventions, though more research is needed to confirm efficacy and side effects (Malow et al., 2012).

Best Practices for Intervention

Best practices involve a combination of behavioral and pharmacological approaches tailored to individual needs. A comprehensive approach considers environmental factors, sensory regulation, circadian rhythm abnormalities, and comorbid psychiatric conditions (Mammarella et al., 2023). Here are some considerations and suggestions:

• Refrain from providing your child with stimulants like caffeine and sugar before bedtime.

• Establish a consistent nighttime routine for your child, involving activities such as a bath, storytime, and bedtime at the same hour every night.

• Facilitate your child’s relaxation before sleep through activities like reading, gentle back massages, or playing soft music.

• Power down electronic devices, including TVs, phones, and video games, and cease engaging in stimulating activities at least one hour before bedtime.

• Minimize sensory distractions during the night by using heavy curtains to block out light, installing thick carpeting, and ensuring the door doesn’t produce noise. Tailor the room’s temperature and bedding choices to meet your child’s sensory preferences.

• Consult your pediatrician regarding the potential use of melatonin just before bedtime. This dietary supplement is deemed safe and effective in normalizing sleep-wake cycles for autistic children with sleep-related challenges.

• Seek advice from a sleep psychologist if challenges persist and interfere with daily family functioning.

Addressing sleep disturbances in individuals with ASD requires a multifaceted approach that considers the unique challenges they face (Malow et al., 2012). By understanding the underlying causes and implementing effective interventions, we can significantly improve sleep quality and enhance the overall well-being of individuals with ASD and their families.

 

References

American Psychiatric Association. (2013). *Diagnostic and statistical manual of mental disorders* (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bruni, O., Melegari, M. G., Breda, M., Cedrone, A., Finotti, E., Malorgio, E., Doria, M., & Ferri, R. (2021). Impact of COVID-19 lockdown on sleep in children with autism spectrum disorders. Journal of Clinical Sleep Medicine. https://doi.org/10.5664/jcsm.9518

Bourgeron, T. (2007). The possible interplay of synaptic and clock genes in autism spectrum disorders. Cold Spring Harbor Symposia on Quantitative Biology, 72, 645–654. https://doi.org/10.1101/sqb.2007.72.060

Cohen, S., Conduit, R., Lockley, S. W., Rajaratnam, S. M. W., & Cornish, K. M. (2014). The relationship between sleep and behavior in autism spectrum disorder (ASD): A review. Journal of Neurodevelopmental Disorders, 6(1), 44. https://doi.org/10.1186/1866-1955-6-44

Colizzi, M., Sironi, E., Antonini, F., Ciceri, M. L., Bovo, C., Zoccante, L., & Fornasari, L. (2020). Psychosocial and behavioral impact of COVID-19 in autism spectrum disorder: An online parent survey. Brain Sciences, 10(6), 341. https://doi.org/10.3390/brainsci10060341

Cortesi, F., Giannotti, F., Ivanenko, A., & Johnson, K. (2012). Sleep in children with autistic spectrum disorder. Sleep Medicine, 13(6), 685–692. https://doi.org/10.1016/j.sleep.2011.11.008

Elrod, M. G., & Hood, B. S. (2015). Sleep differences among children with autism spectrum disorders and typically developing peers: A meta-analysis. Journal of Developmental & Behavioral Pediatrics, 36(3), 166–177. https://doi.org/10.1097/DBP.0000000000000135

Gringras, P., Gamble, C., Jones, A. P., Wiggs, L., Williamson, P. R., Sutcliffe, A., & Montgomery, P. (2012). Melatonin for sleep problems in children with neurodevelopmental disorders: Randomized double masked placebo controlled trial. BMJ, 345, e6664. https://doi.org/10.1136/bmj.e6664

Johnson, K. P., & Malow, B. A. (2008). Assessment and pharmacologic treatment of sleep disturbance in autism. Child and Adolescent Psychiatric Clinics, 17(4), 773–785, ix. https://doi.org/10.1016/j.chc.2008.07.007

Malow, B. A., Byars, K., Johnson, K., Weiss, S., Bernal, P., Goldman, S. E., & Panzer, R. (2012). Sleep committee of the Autism Treatment Network. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics, 130(2), S106–S124. https://doi.org/10.1542/peds.2012-0900L

Mammarella, V., Orecchio, S., Cameli, N., Occhipinti, S., Marcucci, L., Giuliano De Meo, Innocenti, A., Ferri, R., & Bruni, O. (2023). Using pharmacotherapy to address sleep disturbances in autism spectrum disorders. Expert Review of Neurotherapeutics, 1–16. https://doi.org/10.1080/14737175.2023.2267761

Richdale, A. L. (2022). An Overview of Autism Spectrum Disorder, Sleep Problems, and Their Associations. Springer EBooks, 3–17. https://doi.org/10.1007/978-3-030-99134-0_1

Seo, W. S. (2021). An update on the cause and treatment of sleep disturbance in children and adolescents with autism spectrum disorder. Yeungnam University Journal of Medicine, 38(4), 275–281. https://doi.org/10.12701/yujm.2021.01410