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Sleep Disorders in Children with Autism

Sleep problems occur frequently in children with autism spectrum disorder (ASD) and may have a significant impact upon both child and family functioning. Factors inherent to ASD, such as differences in neurotransmission, co-occurring medical conditions, and behavioral issues that include poor sleep habits, can contribute to sleep onset insomnia (difficulty falling asleep), shorter sleep duration, daytime sleepiness, frequent awakenings, and other sleep issues. Children with ASD who sleep well show fewer behavioral problems and better social interactions than those who are poor sleepers.

Screening

The American Academy of Pediatrics recommends that all children with ASD should be screened yearly for sleep issues. [Malow: 2012]. A detailed sleep history includes asking about:
  • Bedtime routine and sleep hygiene
  • Sleep onset and duration
  • Pattern of nighttime awakenings
  • Frequency of snoring
  • Presence of restlessness
Available screens may include tools such as the free BEARS Sleep Screening Tool (PDF Document 197 KB), which is divided into 5 sleep domains (B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) and helps clinicians evaluate potential sleep problems in children 2 to 18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview.

Underlying Medical Conditions

Common medical problems in children with ASD that may contribute to sleep difficulties include: [Johnson: 2008]
  • Nutritional issues: Many children with ASD have restricted eating habits that could stem from a preference for foods with similar flavors or other challenges eating new foods. This can limit intakes of fresh fruits, vegetables, and other healthy foods that supply fiber, vitamins, and minerals. Resulting nutritional deficiencies may cause chronic health issues such as constipation and restless leg syndrome.
  • Constipation: In a meta-analysis of 2,215 children across 15 studies, children with ASD had an increased risk of constipation as compared to peers with an odds ratio of 3.86. [Jones: 2016] Constipation and abdominal pain related to constipation can affect sleep. Detailed assessment and management information for constipation can be found at Constipation.
  • Restless leg syndrome: Low-iron stores have been associated with periodic limb movement disorder/restless leg syndrome.
  • Gastroesophageal reflux: Burning and pain associated with acid reflux can affect sleep. Clinical signs, evaluation, and treatment information for this condition can be found at Gastroesophageal Reflux Disease .
  • Asthma: Asthma symptoms can make sleeping difficult. Assessment and management information can be found at Asthma.
  • Epilepsy: Rates of epilepsy can be as high as 1/3 among patients with ASD and may disturb sleep cycles. [Francis: 2013] Assessment and management information can be found at Seizures/Epilepsy.
  • Pain/anxiety: Altered sensory perception is one of the hallmarks of an ASD diagnosis, and children with ASD may have a higher level of anxiety or sensitivity with respect to their immediate environment. Screening and management information for anxiety can be found at Anxiety Disorders. Children with ASD may also have altered pain perception, but struggle to communicate this to caregivers.
The following questionnaire from [Malow: 2012] has a list of 29 yes/no questions that clinicians can give to parents to help evaluate medical contributors to sleep issues in children with autism:
Consider referral to a pediatric sleep medicine specialist if questions remain regarding the nature of the sleep disorder. A sleep study may help identify disorders such as obstructive sleep apnea:

Behavioral Approaches

Problems in children with ASD are often related to poor sleep hygiene. After excluding medical contributors, educational and behavioral interventions are first-line treatment. [Malow: 2012]
Sleeping Child
Behavioral supports include parent education about sleep hygiene, extinction, and positive reinforcement. [Reed: 2009] [Weiskop: 2005] Good sleep hygiene includes a comfortable, quiet sleep environment with a routine. Some parents have had success using a visual schedule to help shuttle through the bedtime routine (see Bedtime Routines Shown with Photos and Checklists (Autism Speaks) (PDF Document 2.1 MB)). Teaching self-soothing techniques may help the child to fall back asleep on their own.

Photo, left: Hebe Aguilera/Flickr (CC)
If parents are in the habit of falling asleep with their child, an extinction technique may be helpful, whereby a caregiver slowly decreases their support of bedtime soothing over a few days or weeks. For example, parents can shift from sleeping with a child, to sitting in a chair, and then moving the chair further away from the bed until it is out of the child's visual field.
Positive reinforcement techniques could include using rewards for staying in bed all night or a pass system where a child gets 1 “pass” to use in the night, and if it is not used, the child can exchange it for a reward in the morning.
The Sleep Toolkit (Autism Speaks) (free to download, but login is required) can help parents who are able and willing to modify sleep routines and behaviors. Families can also consider consultation with a sleep specialist for additional family education and support. 

Medications

If sleep problems do not resolve with behavioral management and treatment of underlying conditions, consider sleep medication and/or consultation with a sleep specialist.
Melatonin
Individuals with ASD have been shown to have abnormalities in the regulation of melatonin. Multiple review articles have found melatonin supplementation to have a consistent effect on sleep onset and sleep latency; sleep duration may also be improved, though this does not appear to be consistently true across all studies. [Rossignol: 2011]. Melatonin, particularly at the higher end of the dosage range, has an immediate hypnotic effect allowing parents to gauge effectiveness after the first few doses. Adverse effects are rare and include vivid dreams and nightmares. Although not established, melatonin may have a proconvulsant effect. General recommendations are:
  • 2-6 years: 0.5-1 mg and adjust upward to 3 mg as needed
  • >6 years: doses as low as 1 mg may be effective; adjust upward to 5 mg as needed
Families should be informed that melatonin is considered a supplement and is therefore not regulated by the U.S. Food and Drug Administration. [Andersen: 2008]

Melatonin and Sleep Problems in Autism: A Guide for Parents (Autism Speaks) discusses types of melatonin and the pros and cons of their use to help with sleep disorders in children with autism.
Clonidine
The alpha-2 agonist clonidine has shown effectiveness in improving sleep latency and nighttime awakenings. The half-life of this medication is variable, and it may cause daytime sedation, irritability, hypotension, bradycardia, and EKG changes. Obtaining an EKG should be considered if an alpha-2 agonist is to be added to a stimulant medication. General recommendations are:
  • 3-5 years: 025-.05 mg (1/4 to 1/2 of a 0.1 mg tablet) 30 to 60 minutes before bedtime and adjust upward to 0.2 mg as needed
  • >6 years: 0.1 mg and adjust upward to 0.2 mg as needed
When ready to discontinue the medication, taper over 1 week to avoid rebound hypertension. [Ming: 2008]
Iron
In children with restless sleep, consider obtaining a CBC and serum ferritin. Supplementation to replenish iron stores has had positive effect in individuals with restless sleep and low or low-normal serum ferritin levels. General recommendations for supplementation are: [Dosman: 2007]
  • 1-3 mg/kg elemental iron per day in 1 to 3 divided doses; iron may be discontinued after 2-3 months if serum ferritin has normalized
Other medications
Other classes of medications, such as antidepressants, antipsychotics, and anticonvulsants (including mirtazapine, nirtazapine, and trazodone) have been used successfully in the management of sleep disorders. These medications have not, however, been well studied in the pediatric population and should be prescribed by, or in consultation with, a physician experienced in their use.
A high-level overview of the key steps in managing sleep disorders in children with ASD can be found at Algorithm for Management of Sleep Problems in Children and Adolescents Who Have ASD (AAP) (PDF Document 277 KB). [Malow: 2012]

Resources

Practice Guidelines

Malow BA, Byars K, Johnson K, Weiss S, Bernal P, Goldman SE, Panzer R, Coury DL, Glaze DG.
A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S106-24. PubMed abstract / Full Text

Patient Education

Bedtime Routines Shown with Photos and Checklists (Autism Speaks) (PDF Document 2.1 MB)
Tips, sample visual bedtime routines, and a sample bedtime pass.

Melatonin and Sleep Problems in Autism: A Guide for Parents (Autism Speaks)
Discusses types of melatonin and the pros and cons for using them to help with sleep disorders in children with autism.

Sleep Toolkit (Autism Speaks)
Strategies, visual schedules, and tips for parents to help improve sleep in children and teens with autism; free to download, log-in is required.

Tools

Algorithm for Management of Sleep Problems in Children and Adolescents Who Have ASD (AAP) (PDF Document 277 KB)
A Practice Pathway from A Practice Pathway for the Identification, Evaluation, and Management of Insomnia in Children and Adolescents with Autism Spectrum Disorders by Malow BA, Byars K, Johnson K, et al., published in Pediatrics (2012).

BEARS Sleep Screening Tool (PDF Document 197 KB)
BEARS is divided into 5 major sleep domains (B=Bedtime Issues, E=Excessive Daytime Sleepiness, A=Night Awakenings, R=Regularity and Duration of Sleep, S=Snoring) and helps clinicians evaluate potential sleep problems in children 2 to 18 years old. Each sleep domain has a set of age-appropriate “trigger questions” for use in the clinical interview. The screen is free to use.

Questionnaire to Help Identify Underlying Medical Conditions in Children with Autism (AAP) (PDF Document 281 KB)
A list of 29 yes/no questions given to parents by clinicians to help evaluate potential medical contributors to sleep issues in children with autism; American Academy of Pediatrics.

Services

Pediatric Sleep Medicine

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Sleep Studies/Polysomnography

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For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Malow BA, Byars K, Johnson K, Weiss S, Bernal P, Goldman SE, Panzer R, Coury DL, Glaze DG.
A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S106-24. PubMed abstract / Full Text

Authors

Authors: Tara Buck, MD - 8/2012
Catherine Jolma, MD - 8/2009
Reviewing Author: Quang-Tuyen Nguyen, MD - 10/2017
Content Last Updated: 10/2017

Page Bibliography

Andersen IM, Kaczmarska J, McGrew SG, Malow BA.
Melatonin for insomnia in children with autism spectrum disorders.
J Child Neurol. 2008;23(5):482-5. PubMed abstract

Dosman CF, Brian JA, Drmic IE, Senthilselvan A, Harford MM, Smith RW, Sharieff W, Zlotkin SH, Moldofsky H, Roberts SW.
Children with autism: effect of iron supplementation on sleep and ferritin.
Pediatr Neurol. 2007;36(3):152-8. PubMed abstract

Francis A, Msall M, Obringer E, Kelley K.
Children with autism spectrum disorder and epilepsy.
Pediatr Ann. 2013;42(12):255-60. PubMed abstract

Johnson KP, Malow BA.
Sleep in children with autism spectrum disorders.
Curr Treat Options Neurol. 2008;10(5):350-9. PubMed abstract

Jones KB, Cottle K, Bakian A, Farley M, Bilder D, Coon H, McMahon WM.
A description of medical conditions in adults with autism spectrum disorder: A follow-up of the 1980s Utah/UCLA Autism Epidemiologic Study.
Autism. 2016;20(5):551-61. PubMed abstract

Malow BA, Byars K, Johnson K, Weiss S, Bernal P, Goldman SE, Panzer R, Coury DL, Glaze DG.
A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders.
Pediatrics. 2012;130 Suppl 2:S106-24. PubMed abstract / Full Text

Ming X, Gordon E, Kang N, Wagner GC.
Use of clonidine in children with autism spectrum disorders.
Brain Dev. 2008;30(7):454-60. PubMed abstract

Reed HE, McGrew SG, Artibee K, Surdkya K, Goldman SE, Frank K, Wang L, Malow BA.
Parent-based sleep education workshops in autism.
J Child Neurol. 2009;24(8):936-45. PubMed abstract / Full Text

Rossignol DA, Frye RE.
Melatonin in autism spectrum disorders: a systematic review and meta-analysis.
Dev Med Child Neurol. 2011;53(9):783-92. PubMed abstract / Full Text
Melatonin administration in ASD is associated with improved sleep parameters, better daytime behavior, and minimal side effects.

Weiskop S, Richdale A, Matthews J.
Behavioural treatment to reduce sleep problems in children with autism or fragile X syndrome.
Dev Med Child Neurol. 2005;47(2):94-104. PubMed abstract