FREQUENT ISSUES
REMAINING ASLEEP AND FALLING ASLEEP AGAIN
Many children with ASDs not only have problems falling asleep, but they often awaken during the night and have difficult falling asleep again. Sometimes they play quietly in their bed until they become drowsy and fall asleep. One mother reported peeking in her son's bedroom late at night, and seeing him rocking with his eyes closed for nearly 10 minutes, then slumping to one side and resuming sleep. At other times children begin crying and screaming in the middle of the night until a parent comes to their room to see what is wrong, and they usually promptly stop crying. The problem from the child's vantage point is that they don't understand how long it will be until morning and they dislike being alone in their room. Children with ASDs have little sense of time. They have no idea how long it will be until the next event happens, such as when her mother is going to come into her room and get her up for breakfast.
LIGHT SLEEP PERIODS: In "Sleep Problems: Falling Asleep", I noted that the typical 90 minute cycle of light and deep sleep that is followed by 10 minutes of REM sleep. During the first stage of each 90 minute cycle the childs sleep is light, and the slightest noise or discomfort is likely to awaken them. A dog barking next door, pain caused by sleeping in an awkward position, or indigestion may be sufficient to awaken them. If a child falls asleep at 9pm, the next sleep cycle is likely to begin around 10:30pm, when they are especially likely to awaken. This happens again around midnight, at 1:30am, 3:00am, 4:30am and 6am. So a typical child will have 5 or 6 light sleep periods per night when they are particularly likely to awaken.
MUSIC TRANSITION CUE TO SLEEP: The main problem is not so much whether a child arouses briefly, but how to help them to fall asleep again. Most typical children are able to fall asleep again on their own. In "Sleep Problems: Falling Asleep" we suggested using a CD that plays relaxing bedtime music to the child as a sleep cue. Older children who have problems awakening can be taught to turn on the CD player again, that will provide the falling asleep cue, that facilitates resuming sleep. Another aid is a Progression Wake Up Clock sold by Hammacher and Schlemmer, which can also be set to operate in reverse, gradually diminishing light, producing a distinctive scent, and sound to transition the child into a relaxed slumber. Several nature sounds can be selected that become softer and turn off after 15 minutes. Either of these approaches will work, but the child needs to be taught how to turn the music or the clock on so the sequence begins. Most 4-6 year old children can learn to do this with several repetitions.
BEHAVIORAL APPROACHES: Some therapists conduct falling asleep exercises with 3-6 year olds to teach self-quieting. It is often difficult for children with ASD to engage in pretend play, but some children enjoy playing with dolls or action figures that can be a vehicle for "putting the baby to bed" exercises. Sleep preparation may be more effective if used in conjunction with one of the commercially available heart beat musical CDs, such as that available from BabyGotoSleep.Com which superimposes calming childrens songs on top of the rhythm of the human heartbeat. Controlled studies have demonstrated the heart beat-music combination effectively calms infants and promotes restful sleep.
By practicing "putting the baby to bed" and then asking the child to lie down as well and listen to the CD, the music becomes a cue associated with falling asleep. Once the child has had 3-4 practice sessions preparing for nap time using the putting the baby to bed routine while listening to the CD, they can be asked to push the ON button on the CD player when they go to bed at night. After several repetitions demonstrating that they can turn on the CD player, they can then be encouraged to push the button if they wake up during the night.
Though the music is very quiet, if parents are concerned about awakening a sibling who shares the same bedroom, under the pillow speakers are available so only the child with ASD hears the music and heart beat. Older high functioning children can take advantage of relaxation therapy exercises similar to those used with typical children. Books and CDs are available from commercial distributors such as Barnes and Noble or Amazon. A child who successfully sleeps through the night or awakens but does not cry or scream should be rewarded in the morning with a favorite treat for breakfast.
MEDICATIONS: Most sleep medications are designed to encourage falling asleep but are not intended to maintain sleep throughout the night. Long acting melatonin appears to produce longer lasting sleep, but there have been insufficient studies to clearly demonstrate that. Atarax is an antihistamine with sedative properties with effects that typically last 4-6 hours, which may make it better choice for a child who awakens during the night, though no controlled studies are available. After several months, many pediatricians taper or discontinue sleep medications for young children assuming they have established more regular sleep patterns.
References
Gerkensmeyer J. & Keck J. F., (1999) Evaluations for Neonatal Procedural Pain. American Pain Society, 18th Annual Meeting Abstract: 157).
Weiskop, S. et. al. (2001) Treatment of sleep problems in a 5-year old boy with autism using behavioural principles Autism 5: 209-21
Weiskop, S, et.al. (2005) Behavioural treatment to reduce sleep problems in children with autism and fragile X syndrome. Dev Med