Supporting Positive Sleep Habits in Autistic Children & Adults

Introduction:

Have you ever struggled to get eight hours of sleep every night? Sleep deprivation is something all of us have likely encountered at some point in our lives, but for individuals on the autism spectrum, these sleeping struggles are more likely to be an everyday experience.

Research has shown that among  typically developing children, between 25% to 45% are likely to encounter sleep problems, while autistic children experience them at a much higher rate of 40% to 80% (Cohen et al., 2014). Similarly, among a pool of 288 autistic adults from the United Kingdom, 90% were determined to have poor sleep quality (Halstead et al., 2021). Given the myriad barriers that many autistic individuals face (such as communication with non-autistic peers), sleep deprivation can compound these difficulties, leading to more intense burnout and heightened irritability (Henderson et al., 2023).

Support:

So the question becomes: how can we better support autistic individuals experiencing lower quality sleep? For many adults on the spectrum, this often looks like being prescribed medication and managing sleep on their own without receiving greater supports, such as talk therapies or coaches  (Halstead et al., 2021). Melatonin, a commonly prescribed medication for sleeping difficulties, may only be effective for autistic individuals who have trouble falling asleep rather than staying asleep, as its effects don’t last the entire night no matter how much one takes (Cohen et al., 2014). If the sleep difficulties are also related to nightmares, melatonin holds the risk of increasing the vividness and duration of such experiences. Due to its varying effectiveness, it is recommended that clinicians explore sleep hygiene interventions and support before resorting to medication to manage sleep difficulties.

Sleep Hygiene Strategies:

Consistent sleep schedule

Avoiding caffeine before bedtime

Avoiding large meals before bedtime

Comfortable sleeping environment

Putting aside electronic devices before getting into bed

Set Bedtime routine

Light exercise earlier in the day

While there is no specific evidence-based behavioral intervention for children that demonstrates high efficacy beyond a month after treatment, there are a variety of strategies that parents and clinicians can use for support.

The following strategies are pulled from the “Sleeping Sound” intervention, a parent support program for sleeping issues in autistic children (Pattison et al., 2024). 

• Sleep Onset

• • Checking Method

• • • Checking in at regular intervals throughout the night to support and reassure them

• • • Consistency is key

• • • Can be draining for parent

• • Camping Out Method

• • • Sitting next to child throughout the night, gradually moving further away from them each day until they are able to sleep alone

• • • Can be preferred for the exhausted parent

• Delayed Sleep Phase (Falls asleep late, wakes up late)

• • Bedtime Fading

• • • Set bedtime to the time they are currently getting sleepy at

• • • Once sleeping within thirty minutes of set bedtime, gradually move bedtime earlier in the night until desired bedtime

• • • Create preset time to wake up them in the morning

• • • Increase light exposure in the room if possible

• • Healthy Sleep Habits

• • • Consistent bedtime and wake up time set every day

• • • Avoiding caffeine and other stimulants in evenings 

• • • • If taking medication for ADHD, incorporating dosage wear off time into the sleep routine

• • • Remove electronic devices from the room

• Bedtime Resistance

• • Bedtime Pass

• • • Child receives a pass to leave the bedroom once before falling asleep

• • Ignoring Protests, Guiding Back

• • • Ignore protests against bedtime

• • • Lightly tell them it’s time for bed just once

• • • Lead them back to bed

• • • Consistency is key

• Insomnia

• • Relaxation Training

• • • Parent helps to teach the child relaxation techniques in the bedroom

• • • • Ex. Controlled Breathing and Progressive Muscle Relaxation

• • Restricting Bedtime
    • Parent encourages child to leave bed when they cannot sleep and move out of the bedroom for a quiet activity (Ex. reading a book)

Conclusion

While there isn’t a specific high-efficacy behavioral program that clinicians can rely on yet, these tools and strategies are indispensable for supporting families and adults in managing their sleep. However, these tools are only effective if we tailor their selection to the environment and experiences of each family or individual we work with. For example, flatly recommending camping out or checking strategies for a family that already sleeps in close proximity to each other would be ill-advised. Instead, try to identify the most realistic options for your client by having a discussion about the strategies they feel most comfortable implementing, as well as  specific adaptations that would aid them starting out.

References

Cohen, S., Conduit, R., Lockley, S. W., Rajaratnam, S. M., & 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

Halstead, E., Sullivan, E., Zambelli, Z., Ellis, J. G., & Dimitriou, D. (2021). The treatment of sleep problems in autistic adults in the United Kingdom. Autism: The International Journal of Research and Practice, 25(8), 2412–2417. https://doi.org/10.1177/13623613211007226

Henderson, L. M., St Clair, M., Knowland, V., van Rijn, E., Walker, S., & Gaskell, M. G. (2023). Stronger Associations Between Sleep and Mental Health in Adults with Autism: A UK Biobank Study. Journal of Autism and Developmental Disorders, 53(4), 1543–1559. https://doi.org/10.1007/s10803-021-05382-1

Pattison, E., Papadopoulos, N., Fuller-Tyszkiewicz, M., Sciberras, E., Hiscock, H., Williams, K., McGillivray, J., Mihalopoulos, C., Bellows, S. T., Marks, D., Howlin, P., & Rinehart, N. (2024). Randomised Controlled Trial of a Behavioural Sleep Intervention, ‘Sleeping Sound’, for Autistic Children: 12-Month Outcomes and Moderators of Treatment. Journal of Autism and Developmental Disorders, 54(2), 442–457. https://doi.org/10.1007/s10803-022-05809-3