Q1: How common is insomnia in children with ASD?

Paediatric insomnia is a widespread problem, affecting 1% to 6% in the general paediatric population and around 50% to 80% of children with autism.^1,2

Sleep problems in ASD include difficulty falling asleep, frequent and prolonged wakenings, shorter consolidated (uninterrupted) sleep, shorter sleep duration or extremely early rising. Sleep issues go hand in hand with daytime behaviours and can affect quality of life for the entire family.²

Evidence suggests that there is an association between sleep problems in one year old infants and the development of early autistic symptoms by two years. It is, therefore, important to assess sleep in all autistic children.³

Q2: What are the causes of insomnia in children with ASD?

There are multiple factors that are thought to contribute to the development of sleep disorders in individuals with autism. A decrease in the secretion of melatonin (a hormone produced by the brain) and a desynchronisation of the internal clock (when the internal clock is no longer in harmony with the environment) in children with ASD are also believed to be partly responsible. See detailed article on melatonin.⁴

Q3: How do I know if my autistic child has insomnia?

In general, children with ASD frequently present with:

• Difficulty falling asleep: for example, taking longer than 30 minutes to fall asleep
• Reduced total sleep time: for example, less than 8 hours for a child aged 3 to 5
• Frequent night awakenings of more than an hour which lead to fragmented and therefore less restorative sleep (e.g., less than 6 hours of continuous sleep per night)
• Early awakenings (more than an hour before the desired time to get up)⁵

Disordered sleep may also worsen the core, and related, symptoms of autism including social interactions and repetitive behaviours. Therefore, interventions that target sleep may not only improve your child’s health, and reduce whole family distress, but may also improve the core, and related, symptoms of autism.⁶.

If you have concerns about your child’s sleep it is recommended to consult a healthcare professional. However, before seeking help, a sleep diary, such as the SNappD^®, sleep and nap diary app, can be very helpful to identify your child’s sleep pattern and any underlying problems. Record your child’s sleep and wakefulness throughout the day and night over the period of two weeks. This will enable a healthcare professional to develop a sleep plan to establish a regular night-time sleep pattern for your child.

If your child is young and still takes naps, maintain a regular schedule of the naps. If possible, the nap should take place in the child’s bedroom. Wake your child from their afternoon nap before 4p.m. or it will be difficult for them to fall asleep at night. If your child is older and no longer needs to nap, don’t let them nap unless they are unwell. Older children who sleep during the day will have more difficulty sleeping at night.

If you would like to capture sleep statistics for your child, the free Sleep Nap Diary App is available to download.

More information on seeking help from a healthcare professional for sleep disorders in children with ASD →

Q4: What is a good night’s sleep?

The duration (length) of sleep, its quality (which influences how a person performs the next day) and its architecture (the basic structure of sleep patterns) vary throughout life, and particularly during the first 5 years.

A newborn spends 80% of the day asleep, and pre-schoolers about 50%. Studies have shown the importance of good quality sleep for child growth and development and for family wellbeing.

Here are the main measures of good quality sleep:

• The time taken to fall asleep after lights out (sleep latency) should be less than 30 minutes
• The maximum uninterrupted sleep time (longest time your child stays asleep at night without waking up) should be more than 6 hours
• The total sleep time should be within the recommended range for the child’s age –
  see table below.^5,7

If you would like to capture sleep statistics for your child a free to download Sleep Nap Diary App is available to download.

National Sleep Foundation Recommended Sleep Duration by Age⁷

In 2015, the National Sleep Foundation evaluated the optimal sleep durations by age group.⁷ These recommendations are summarised in the table. We can see from the table that sleep needs change as children get older.

It helps to have an idea of how much sleep your child needs as this will be different depending on their age. However, all children are unique, and some will need more or less sleep than others which is why the recommendations are for sleep ranges.

Q5: Why is it important to treat insomnia in children with autism?

In typically developing children, sleeping too little is associated with attention, behaviour, and learning problems.

In autistic people it is particularly important to address sleep problems since the severity of sleep problems and the severity of autism spectrum disorder may be linked.

In autistic individuals sleep disorders may:

• Increase communication disorders and behavioural disorders
• Increase anxiety and mood swings, irritability, motor stereotypies (repetitive behaviours, moves or sounds), aggressive and hostile behaviours
• Reduce the ability to pay attention and understand which may lead to a deterioration in school performance^8,9

In particular, it is the duration of consolidated (continuous) sleep that influences the child’s daytime functioning. In the case of fragmented sleep (less than 6 hours of continuous sleep per night), an increase in behavioural difficulties has been observed in autistic children.¹⁰

Additionally, sleep disorders can disrupt family balance by increasing parental stress and decreasing family cohesion.¹¹

Q6: How can I improve my autistic child’s sleep?

There are many useful strategies you can use to help your child sleep better although you may need to adapt them to suit your child’s needs and their level of understanding.

Tips for parents include:

1. 1. Explaining to your child why sleep is important. A fictional story written by Dr Susan Ozer (consultant neurodevelopmental paediatrician) explains the importance of sleep and is aimed at children with autism and/ or ADHD aged 7-11 years.
   2. Keeping a sleep diary to record your child’s sleep pattern and any underlying problems can be helpful. Should you need to seek help from a healthcare professional the diary will enable them to develop a sleep plan to establish a regular night-time sleep pattern for your child.
   3. Creating a reassuring bedtime routine will help your child learn how to relax and prepare for sleep. It should include calming activities and the predictability of the routine will calm your child each night.
   4. Encouraging and establishing good sleep habits by having daily routines that promote uninterrupted sleep can help.
   5. Creating a comfortable, calm and consistent sleeping environment will ensure your child feels safe.
   6. Teaching your child to fall asleep alone will ensure that they fall back to sleep when they wake up naturally at night.

You can learn more about this by reading: Tips for improving sleep for children with autism →

In addition to establishing good sleep habits, behavioural and/or drug treatment (medicine) may be offered to your child. Do not hesitate to talk about sleep disorders with your child’s doctor.

Q7: How do I know if the management of my child’s sleep disorder is effective enough?

A successful sleep intervention needs to define successful outcomes that can be measured. A free Sleep Nap Diary App can help you to capture and monitor sleep statistics for your child.

In assessing your child’s response to a treatment for their insomnia it is important to understand the main measures of good quality sleep which are:

• The time taken to fall asleep after lights out (sleep latency) should be less than 30 minutes
• The maximum uninterrupted sleep time (longest time your child stays asleep at night without waking up) should be more than 6 hours
• The total sleep time should be within the recommended range for the child’s age – see table

Additionally, since there is evidence that sleep problems in autistic children can worsen behavioural issues and difficulties with social interactions, a successful sleep intervention would be expected to demonstrate improvements in these areas. Other outcomes that should be captured when determining if an intervention has been successful are parental satisfaction and well being because we know that these too are negatively associated with insomnia in children with ASD.

To help you check if the intervention to treatment of your child’s sleep problems is effective you can download an evaluation checklist →

Q8: What is melatonin and how is it linked to sleep disorders in autistic children?

Humans are programmed to be awake during the day and sleep at night. This is made possible by our “internal clock” which regulates our sleep-wake rhythm. This “clock”, which is located in our brain in an area called the suprachiasmatic nucleus (SCN), also controls the secretion of melatonin.

The Endogenous Circadian Clock System

Melatonin is a hormone naturally produced by the brain in the pineal gland. Melatonin is known as the ‘hormone of darkness’ because it is secreted during the night – levels of melatonin in your blood peak in the middle of the night and are low during the day. In humans melatonin regulates our sleep-wake rhythm in response to light and dark. Production of melatonin is controlled by the “internal clock”.

Natural Secretion Profile of Melatonin

To try to understand the association between melatonin secretion and autism a team of French researchers measured the average levels of melatonin excreted in the urine (melatonin is eliminated from the body in our urine) of 49 children or adolescents with autism and compared them to those of 88 children or adolescents of the same age without autism (the control group).

The results showed that 63% of children with ASD had night-time melatonin levels less than half the average levels found in the group without ASD. Lower melatonin production was also linked to the severity of autistic symptoms.¹¹

Another study examined the average levels of melatonin over a 24-hour cycle in teenagers and young adults found that both daytime and night-time melatonin levels were lower in people with ASD compared to people without ASD.³