March 16, 2012

Sleeping Strategies for Individuals with ASD

  The following is written by Luke Walker, a Positive Behavior Support Trainer for the West Virginia Autism Training Center. In this article Luke discusses strategies to support individuals with ASD in improving their sleep experience.

Many parents and caregivers express concerns over the sleeping habits of individuals with ASD. In my experience those concerns often focus on: the number of hours asleep, the timeframe for falling asleep, sleeping too much throughout the day, not sleeping throughout the night, and assisting the individual in learning to sleep in his or her own bed.

Research suggests sleep problems exist for 44% to 83% of individuals on the autism spectrum, so families that express concern are far from alone. The most common reported sleep problem is Insomnia, which can result in prolonged time getting to sleep, a later bedtime, decreased amounts of sleep, an early wake time, and increased amount of awakenings during a normal sleep cycle.  Sleep disordered breathing, arousals from sleep with confusion or wandering, leg movements and daytime sleepiness are other commonly reported problems.

It is important to address sleep issues with individuals on the spectrum; difficulty with sleep can affect daytime behavior, contribute to difficulties with attention, and result in increased anxiety and stress. Following are strategies that may be helpful in supporting a better sleep experience for individuals living with ASD:

A Consistent Bedtime Routine
The best approach to reducing insomnia is to develop a consistent bedtime routine. This routine should be between 20 and 30 minutes in length and occur during the same time each night to help synchronize sleeping rhythms.

Some individuals may get a “second-wind” before bed time and have trouble getting to sleep if it is too early. If it takes more than an hour to get to sleep, try adjusting the bedtime by 30 minutes to an hour.

Keep a steady wake-up time, even if the person sleeps later than usual. Keeping a regular wake-up time will improve the quality of sleep and help maintain developed sleeping rhythms.
To assist sleeping in daylight hours, make sure the room is dark. Open curtains to allow natural light in during morning hours to help with wake-up.

To reduce the amount of stimulation and help calm the body and mind, avoid activities centered on the computer and television one hour before bedtime. Use that final hour to practice self-help skills, complete hygiene activities before bed, or read a story together.
Assess the environment for the sleeper. For example, is there need for a night light? Would a white noise machine be helpful in reducing the effect of other sounds during the night? Is too much light entering the room? Is the blanket too light to be felt or too heavy and warm? Would a weighted blanket help the individual fall sleep?

A visual support, especially one that uses text and pictures to display different steps in the bedtime process, can aid in building independence around the bedtime routine. This type of support will help reduce the need to constantly prompt for the next step in the routine and allow the individual to know exactly what is required and how many steps there are in the routine. An excellent example of a visual bedtime routine schedule can be found at this link, which takes you to the Autism Speaks document: "Strategies to Improve Sleep in Children with Autism Spectrum Disorders."

If night waking occurs, avoid actions that may look like play to the sleeper.  Enter the room and simply state: “back to bed”. Reinforce this desired behavior of sleeping through the night with a reward in the morning. Keep track of how many hours the individual is sleeping through the night so that both of you are able to observe progress. Changes may be slow and it can be easy to overlook small increases in sleep consistent and reliable data.

Teaching Individuals to Sleep Alone
Adults and children typically wake up for brief periods several times each night to assess the sleep environment and then quickly fall back to sleep. If the individual with ASD cannot fall asleep alone, he or she may visit you for assistance during the night when these awakenings occur. As a result, both of you may feel less rested in the morning.
It is, therefore, important to fade the supports you are using that involve your physical presence, such as sleeping in the bed next to a child or letting a child sleep in your bed. This can be accomplished gradually over a few weeks by fading your physical presence with the child. For example, if you usually lie down on the bed with your child, you would fade to sitting on the bed, then in a chair next to the bed, and slowly move the chair towards the door over the period of a week until you were out of the room.

Allowing a child to use a bedtime pass may also be useful. This is an object or card that can be exchanged (for a hug, a kiss, a drink of water, time with a parent etc.) one time during the night. You can supplement this with a reward strategy for not using the pass, such as gaining a sticker or smiley face for every unused pass and earning a trip for 5 smiley faces.

The Use of Medications for Sleep
Some consider using medication as a sleep aid when behavioral strategies have been unsuccessful. The decision to use medication is a highly pesonal one, so it is important to consult with a physician about the possibility before medication is used. If the decision is made to use medication, it is important to pair the use with behavioral strategies, and to discuss with phsyicians the idea of starting doses at the lowest therapeutic level, as individuals with ASD may be less able to communicate effectively any side effects they may be experiencing. A Melatonin supplement has been used successfully to treat insomnia in individuals with autism; a dietary supplement, Melatonin is easily available and has few side effects.
That being said, there are no medications approved by the Food and Drug Administration (FDA) for the treatment of pediatric sleep disorders, illustrating again the importance of a consult with a medical professional. 

A Personal Perspective
Embedded below is the video: Insights from an Autistic: Insomnia & Sleep Problems. The video narrator provides insight into why he experiences challenges with sleep, and offers tips on how to overcome those challenges. While these insights and specific tips may not apply to everyone, they reinforce that consistency and a method to reduce anxiety are integral to success.