Sleep Difficulties in children with Autism and ADHD: How to address them effectively?

“Sleep is the golden chain that ties health and our bodies together”, said Thomas Dekker. This is true in both medical and literal sense, as good sleep is essential for attention, memory, decision making, behaviour, mood, and academic performance.

Sleep difficulties are prevalent. 20-30% of typically developing children could have sleep difficulties. Sadly, they are even more common in children with neurodevelopmental disorders, such as Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD). Up to 1 in 2 children with these disorders could have difficulties with sleep.

There are various types of sleep disorders in children. In this article, I have focused on sleep problems that are more common in children with neurodevelopmental disorders. I have briefly covered the causes and consequences of sleep difficulties, before listing the various strategies one could put in place to achieve adequate sleep for a child with ASD or ADHD.

 

Are there different types of sleep disorders?

Yes, there are. Sleep disorders can be categorised into:

• Primary sleep disorders such as bedtime resistance, delayed sleep onset, frequent awakenings, sleepwalking, night terrors, and nightmares.
• Secondary sleep disorders due to medical conditions such as cerebral palsy, epilepsy, asthma, eczema/dermatitis, and vision impairment.
• Sleep disorders due to neurodevelopmental/mental health conditions such as ASD, ADHD, phobias, anxiety, and depression.
• Substance-induced sleep disorders, due to caffeine, sedatives, alcohol and medications.

 

In this article, I have covered behavioural sleep disorders that constitute a significant proportion of cases, especially in children with neurodevelopmental disorders.

 

So, what are the causes of behavioural sleep disorders?

The causes of behavioural sleep disorders can be grouped into 3 categories:

• Parental factors such as emotional stress, long hours of work, too many responsibilities, depression, poor sleep hygiene, and poor limit setting.
• Environmental factors such as a shared bedroom, a noisy neighbourhood, a crowded household, temperature too hot or cold, and not adequate darkness.
• Child factors such as difficult temperament, developmental delay, anxiety, and neurodevelopmental disorders such as ASD and ADHD.

 

Are there consequences of inadequate sleep?

Yes. The consequences of sleep deprivation can be grouped into three categories:

• Consequences for the child in the short term could be, irritability, being inattentive, hyperactive, displaying oppositional behaviours, conduct problems, fussiness, daytime sleepiness, social withdrawal, and a predisposition to accidents and injuries.

The longer-term consequences could be, poor communication skills, impaired mood, diminished learning, negative impact on educational attainments, escalation of emotional and behavioural disorders, and overweight and obesity.

• Consequences for the family include an impact on the family’s functioning, diminished parental well-being, marital discord, escalation in the risk of child neglect/abuse, and reduced quality of life.
• Consequences for society can be increased risk of unemployment, family breakdowns, rise in anti-social behaviours, drug/alcohol abuse, and increased dependence on state benefits.

 

What is the recommended amount of sleep for my child?

The American Academy of Sleep Medicine (AASM) recommends that children need the following amount of sleep at different ages, including nap time:

• Child 1 to 2 years: 11 – 14 hours
• Child 3 to 5 years: 10 – 13 hours
• Child 6 to 12 years: 9 – 12 hours
• Teens 13 to 18: 8 – 10 hours

 

What is the role of a Neurodevelopmental Paediatrician in sleep problems?

If there are no concerns regarding your child’s development apart from sleep, then you should read the strategies outlined in the next section titled ‘How do I address sleep problems in my child?’

However, if you suspect that your child may have a neurodevelopmental disorder such as ASD or ADHD, then a neurodevelopmental paediatrician will be able to help you with the following:

1. Take a detailed history to find out the exact nature of the problem
2. Explore predisposing, precipitating and perpetuating factors for sleep difficulty
3. Elicit consequences of the sleep disorder
4. Check your child’s development, look for dysmorphic features or other neurocutaneous signs
5. Carry out a full physical examination looking for craniofacial abnormalities, size of tongue and tonsils
6. Review sleep diary and view any video recordings
7. Most importantly, carry out an assessment to look for a neurodevelopmental disorder such as ASD, ADHD or Learning Disability
8. Prescribe medications such as Melatonin, to be used in conjunction with behavioural interventions, in an individual child.
9. If required refer your child to a neurologist (narcolepsy, epilepsy), a respiratory physician (sleep apnoea), an ENT surgeon (obstructive sleep apnoea) or a psychiatrist (depression, substance abuse)

 

How do I address sleep problem in my child?

Behavioural interventions are effective and evidence-based in addressing behavioural sleep difficulties in children.

You should consider establishing good sleep hygiene by:

• Keeping a consistent sleep schedule
• Establishing a relaxing bedtime routine
  • Consider giving a warm bath 30-60 minutes before bedtime
  • Consider a warm glass of milk before brushing teeth
  • Read a bedtime story or a book in bed
  • Avoid computer games/stimulating activities 1-2 hours before
  • Avoid having a TV, a tablet or any kind of screen in the bedroom
  • Switch lights off. Invest in blackout curtains
  • Keep your voice to the minimum or speak softly before sleep
• Wake your child up at the same time every day, even on weekends
• A consistent sleep/wake time would help reinforce the circadian clock
• Keep a comfortable room temperature, e.g. between 16-19 degrees
• Limit exposure to bright lights in the evenings
• Avoid a large meal before bedtime
• Regular exercise and physical activity aids good sleep
• Maintain a healthy diet
• Avoid caffeine and caffeinated drinks
• Consider reducing fluid intake after 5-6 pm, if frequent visits to the toilet is an issue
• Putting the child to bed when drowsy but awake, would reduce parental dependence
• Establish a routine where a parent is not in the bedroom when your child falls asleep
• Avoid naps too long in duration, too late in the day or too close to the bedtime routine which may cause difficulties in sleeping at night

Various sleep programmes that would help, in addition to the above sleep hygiene measures are as follows:

• Graduated extinction involves ignoring your child’s bedtime crying for increasing length of time.
• Unmodified extinction involves putting your child to bed at a predetermined time, in conjunction with the above sleep measures, and to let your child develop self-soothing skills and falling asleep.
• Bedtime fading involves setting the bedtime to the current sleep onset time and then gradually advancing the time of lights switch-off by 15 mins or so each week.
• Positive reinforcement involves strategies such as sticker charts, with the child earning the sticker reward first thing in the morning. The rewards can be modified according to your child’s interests.
• Relaxation techniques and CBT (Cognitive Behaviour Therapy), could help both parent and child, especially where anxiety is an issue.

 

Are there any medications to treat my child’s sleep problems?

There are no medications licensed to treat insomnia in children specifically.  Medications such as Melatonin are not sleeping pills. Melatonin is used to manage the sleep-wake cycle disturbances.

Use of Melatonin is considered in children with neurodevelopmental disorders such as ASD, ADHD or Vision impairment, after having tried the above sleep hygiene measures and sleep programmes. Melatonin can also be used to help establish good sleep hygiene/routine for a short period, in conjunction with the above behavioural interventions. There is some evidence to suggest that Melatonin reduces the time for a child to fall asleep, and marginally increases the overall sleep duration.

As you can see from the above, various behavioural, environmental and occasionally medical measures can be put in place to effectively address sleep difficulties in a child with ASD, ADHD or LD. Adequate sleep would help optimise the child’s functioning, performance and attainments. Consequently, the profound and potentially harmful effects on the child, family and the society at large, can thus be prevented.

 

Sources for further information and support

1. The National Sleep Council of UK has several resources, nodcasts, blog, sleep tools and sleep diary on its website: https://sleepcouncil.org.uk/category/children-teen-sleep/
2. The NHS website: https://www.nhs.uk/live-well/sleep-and-tiredness/healthy-sleep-tips-for-children/
3. The National Sleep Foundation has reviewed this information leaflet https://www.sleepfoundation.org/articles/children-and-sleep
4. The American Academy of Sleep Medicine has excellent resources on sleep: http://sleepeducation.org/essentials-in-sleep/healthy-sleep-habits
5. National Sleep Foundation of USA- a website dedicated to positive benefits of sleep health: https://www.sleep.org/

 

References:

1. Gada S. Community Paediatrics. Sleep Disorders and Management. Oxford University Press. ISBN 978 0 19 969695 6. Published Sept 2012.
2. Owens JA, Chervin RD, Eichler AF. Cognitive and behavioural consequences of sleep disorders in children. UpToDate. Accessed on 7^th Aug 2020.
3. Owens JA, Chervin RD, Hoppin AG. Behavioural sleep problems in children. UpToDate. Accessed on 8^th Aug 2020.
4. British National Formulary for Children. Accessed on 8^th Aug 2020. https://bnfc.nice.org.uk/drug/melatonin.html
5. Sleep disorders in children and young people with attention deficit hyperactivity disorder: melatonin. Published Jan 2013. https://www.nice.org.uk/advice/esuom2/chapter/Key-points-from-the-evidence