My Child with Autism is Not Sleeping! What Should I Do?
Sleep problems are a common occurrence during childhood, affecting roughly 25-50% of children.1-3 Sleep problems are usually temporary and tend to resolve on their own. However, for individuals with autism spectrum disorder (ASD), sleep issues can be particularly persistent. Insomnia in children is defined as sleep onset delay of more than 30 min per night, on average, and/or frequent prolonged night waking with impaired daytime functioning.4
The prevalence of insomnia in people with autism spectrum disorder is difficult to estimate. A systematic review and meta-analysis conducted in 2019 found that about 13% of people with ASD had sleep-wake disorders, which is much higher than the 3.7% prevalence in the general population.5,6 However, other studies have shown that the prevalence of sleep disorders in people with ASD ranges from 40% to 80%. 1,7-12 This variation could be due to the heterogeneity of ASD or undiagnosed comorbid conditions that were not controlled for in these studies.
Studies using polysomnography (a sleep study) have shown differences in sleep between individuals with autism spectrum disorder (ASD) and neurotypical individuals. Children with ASD have difficulties with sleep continuity, which means they struggle to stay asleep. These disturbances suggest an imbalance in the arousal system, which is a common issue in ASD.13 People with ASD often have trouble regulating their arousal levels and may experience hyper- or hypo-arousal. It is worth noting that medication alone cannot be blamed for sleep difficulties, as insomnia has also been observed in medication-naïve children with ASD.14 These difficulties persist into adulthood, with impaired sleep reported in multiple aspects, including sleep onset latency, poorer sleep efficiency, more awakenings, decreased total sleep time, and poorer perceived sleep quality than individuals without ASD.12,15,16
The relationship between Autism Spectrum Disorder (ASD) and insomnia is not completely understood and is likely caused by a variety of factors, including comorbid mental health conditions, genes, arousal dysregulation, metabolism, and hormone regulation. Some genes that are linked to ASD also play a role in regulating sleep-wake cycles. Melatonin, a hormone that regulates circadian rhythms, is produced by the pineal gland in response to darkness. Abnormal melatonin secretion has been observed in individuals with ASD, with both high and low levels during the day.17-19 Studies have also suggested that ASD and insomnia have a bidirectional relationship, with poor sleep quality contributing to anxiety and sensory sensitivity, which in turn worsen sleep quality. This creates a vicious cycle.20,21 Addressing sleep disturbances in people with ASD may lead to improvements in core symptoms, behavioral outcomes, and cognitive functions related to attention and executive function.22,23
Due to the varied nature of Autism Spectrum Disorder (ASD), there is no single intervention that can be effective for all sleep problems that individuals with ASD may experience. However, research has shown that melatonin and behavioral interventions to improve sleep hygiene are the most effective.24 Behavioral interventions such as improving sleep hygiene should form the basis of any successful sleep intervention. These interventions include creating a comfortable sleep environment, avoiding co-sleeping with children, removing electronic devices, avoiding caffeine before bedtime, and keeping a consistent sleep schedule. Improving sleep hygiene has proven to significantly improve insomnia symptoms, including total sleep time, sleep efficiency, sleep latency, internalized and externalized behaviors, and the quality of life of parents and caregivers.25,26 Modest increases in physical activity can also help improve sleep. Various studies have reported improved sleep parameters in children with ASD by adding 30 to 60 minutes of aerobic activity 2-3 times per week. 27-29
Biochemical abnormalities that are associated with Autism Spectrum Disorder (ASD) may serve as treatment targets in the future. The chemical modifications of molecules, such as methylation and sulfation, and reduction in glutathione (GSH) redox capacity are areas of interest. These processes are necessary for neurotransmitters, hormones, nutrient metabolism, and DNA. A review and meta-analysis conducted by Rossignol et al. showed that B12 supplementation in oral and supplemental forms improved these processes. The dosages used in studies varied from 500-1600 micrograms for oral forms. This intervention was significantly associated with improvements in core symptoms of ASD and sleep and gastrointestinal symptoms.30 B12 is a water-soluble vitamin, and doses in excess of the body’s needs are excreted. However, adverse events may occur. Rossignol et al. noted that adverse events were mild and not significant from controls but included hyperactivity (11.9%), irritability (3.4%), trouble sleeping (7.6%), aggression (1.8%), and worsening behaviors (7.7%).30
As we previously discussed, studies have shown that individuals with Autism Spectrum Disorder (ASD) often have issues with melatonin regulation, which suggests that melatonin supplementation could be an effective intervention. Melatonin is frequently used in pediatrics to treat sleep disturbances; however, its efficacy and safety have only recently been investigated. Recent studies suggest that doses of 10mg taken for up to two years are safe and effective for treating sleep difficulties in individuals with ASD.31-33 Few adverse effects and no effects on growth or pubertal development have been observed.31,32,34 However, there are some possible adverse events with long-term use, including fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%).34
Researchers are still working hard to uncover the underlying causes of ASD, and at this time, we primarily understand ASD from a biopsychosocial perspective. Studies have shown that there are differences in sleep patterns between individuals with autism and those without, as well as differences in the levels of neurotransmitters, hormones, and nutrients that are essential for sleep. Given the complex nature of ASD, which involves a variety of factors in its development, phenotype, and outcomes, it is essential to adopt a multifaceted approach to addressing sleep issues for individuals with ASD.
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