FALLING ASLEEP
Parent reports and clinical studies indicate individuals with ASDs often have sleep problems. In one study parents reported 64% had sleeping problems, and in another clinical study 80-85
SLEEP STAGES: When your child curls up under his or her favorite blanket with their head on their pillow, that they've scrunched just so it conforms to the shape of their head, falling asleep is a gradual process divided into two broad phases. The first phase is called Non-REM (rapid eye movement) sleep lasting about 80 minutes, and the second is REM sleep, lasting about 10 minutes. When a child first closes their eyes they are drowsy and start dozing off, but are easily aroused if their name is called quietly or they hear a sound outside their room. During the next stage, they breathe very regularly, make few movements and are more difficult to arouse. The next two stages involve the deepest sleep. A loud sound may be required to awaken them, and some children even need to be physically shaken to awaken during Stage 4 sleep. During the 10 minutes of Rapid Eye Movement Sleep (REM) sleep, eye muscles are moving rapidly and the child is often dreaming. REM and Non-Rapid Eye Movement Sleep (Non-REM) alternate in roughly 90 minute cycles throughout the night.
Parents report that most children with ASDs who have sleeping difficulties either have difficulty falling asleep (Non-REM Sleep) or they wake up during the night and can't fall asleep again. Problems with initially falling asleep can be due to medications being taken during the day, or foods or beverages consumed, usually from around dinner to bedtime. Coke, Mountain Dew, and Sunkist Orange Drink all contain large amounts of caffeine and should be avoided beginning mid-afternoon. Similarly coffee or cappuccino ice cream or yogurt contain substantial amounts of caffeine, as do many chocolate candy products. Hot Cocoa or Hot Chocolate contains smaller amounts of caffeine.
Over the counter medicines can cause difficulty falling asleep, such as Anacin and Excedrin that contain caffeine, and nasal spray decongestants and should be avoided. Prescription medications such as Ritalin or Adderall and other stimulants, Prozac and related SSRIs, Beta blockers (e.g. Tenormin, Inderal) and some steroids can prevent children from falling asleep.
NAPS: Difficulty falling asleep can also be due to the child's daily schedule or behavioral factors. An average 2 year old naps about 90 minutes during the day. A child who is 4-5 years old or older usually doesnt require a nap. Allowing an older child to regularly nap during the day will decrease their ability to fall asleep and remain asleep at night.
DAILY ROUTINES: Children with ASDs respond favorably to regular routines and have difficulty when daily routines are unpredictable. All children need regular, specific bedtimes, but children with ASD even more so. One hour before bedtime the child should be bathed and gotten ready to begin settling for sleep. Large snacks should be avoided within 1-2 hrs of bedtime, and those that are permitted should not include high fat or spicy ingredients (e.g. such as pizza) which cause night time indigestion. After the child's bath and their pajamas are on they can be given a light snack consisting of a small beverage (4 oz) or food that is high in tryptophan content, such as cottage cheese, cheese, soy milk (e.g. Silk), tofu, chicken breast, oatmeal cookie with milk, half slice of whole wheat bread with peanut butter and a 4 ounce glass of passion fruit juice. These foods will not cause the child to fall asleep, but they will prepare them for falling asleep by making them relaxed and slightly sleepy.
BEHAVIORAL FACTORS: During the last 20 minutes or so before putting the child down for the night, read her/him an age appropriate book or picture book, and if they enjoy music, put on a CD with calming instrumental music (avoid prominent rhythms or loud music with lyrics). Encourage the child to sit quietly and look at the pictures in the book and relax. Its a great time for expressing warmth and affection. Once its time for bed, turn down the volume on the TV in the family room, avoid loud conversations anywhere near the child's room, and turn off the Heavy Metal music coming from his older brother's bedroom. In other words, keep things quiet for the first half hour or so the child has been put down for the night. When the child is placed in their bed, make certain they have their favorite blanket and stuffed animal, turn on a CD of quiet, calming music for no more than 15 minutes that shuts itself off automatically (see Sleep Problems: Remaining Asleep for suggestions). This can be accomplished by plugging the CD power cord into an inexpensive timer purchased in an electronics or home supply store that automatically shuts off a power source after a specified time. Turn on their night-light, cover them with their blanket, kiss them good night, turn out the room light and leave the room. The music will provide a transition cue beginning a minute or two before the bedroom light is turned off until 10-12 minutes after the light has been extinguished.
ARE THEY AFRAID? Many parents are convinced the reason their child is crying at bedtime is because they are terrified of being alone in the darkened bedroom, so they coax and cajole them and sit alongside their bed talking with them, attempting to reassure them. In most instances the child isn't afraid, they prefer to stay up rather than go to bed. They employ whatever behavioral measures have been effective for them in past, from melt downs, screaming and threats of self injury (e.g. they may slap their face or bump their head against the headboard) to convince their parents to allow them to stay up rather than going to bed. Parental coaxing and cajoling will nearly always make matters worse. If the child fusses, cries, calls for Mommy, it is best to ignore them. It is common for children with ASDs who strongly resist going to bed to cry for 30-45 minutes the first night. It is important that parents agree BEFORE beginning this procedure that they will not allow their child to get up no matter how much they carry on. If one parent begins to feel they have to "give in" to their child, they should go for a walk or take the car out for a drive and allow the other parent to handle the situation. Parents need to support one another through this difficult and trying experience, and taking turns sitting through the child's crying is a good way to do that. In most instances, by the second night the childs crying is about half to two-thirds the duration of the first night. By the fourth or fifth night most children fuss a little and then fall asleep. Within a week to 10 days mos children faill asleep wihin a few minutes of turning off the light in their room. If parents go into the child's room "to make certain the child is really all right" in the midst of a crying outburst, even once, the whole cycle will resume and then the procedure will have to start over again, beginning with 45 minutes of crying or possibly longer.
MEDICATIONS: Some children continue to have intermittent problems falling asleep even after parents have regularized their schedules and established a sound night-time sleep routine. Parents should consult their child's pediatrician about sleep medication options. A recent study by Dr. Gianatti and colleagues in Rome examined effectiveness of controlled-release melatonin for autistic children with chronic sleep disorders and found it effective with minimum side effects. Atarax (hydroxyzine) an antihistamine, is often prescribed to promote sleep (0.5-2mg) for children with ASD though it is not specifically recommended by the FDA for this purpose. Finally, Catapres (clonidine), a blood pressure medicine has mild sedation as a side effect and is also used to assist with sleep. Occasionally children may have other emotional or health problem that interfere with sleep, and an overall sleep hygiene strategy may require targeted treatments for those conditions as well.
REFERENCES
Couturier, JL et. al. (2005) Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorders: Prevalence, severity and pattern J. Am Acad Child Adolesc Psychiatry 44: 815-22
Gianotti, F. et. al. (2006) An open-label study of controlled-release melatonin in treatment of sleep disorders in children with autism. J. Autism Dev Disord 36: 741-52
Polimeni, MA et. al. (2005) A survey of sleep problems in autism, Asperger's disorder and typically developing children. J Intellect Disabil Res 49: 260-8
Schreck Ka and Mulick JA (2000) Parental report of sleep problems in children with autism: J Autism Deve Disord 30: 127-135
Zhdanova IV, et al. (1995) Sleep-inducing effects of low doses of melatonin ingested in the evening. Clin Pharm Ther. 57:552-558.
See: Sleep Problems: Remaining Asleep