Sleep challenges and autism

35-50% of young children struggle with sleep however this increases to 63-73% for autistic children¹. Sleep is such an important part of a child’s life and crucial to ensuring that they have the energy levels to participate actively and concentrate in school. However, around two thirds of autistic children have issues related to sleep. In this blog we will be exploring helpful strategies to manage those issues. 

What are the most common challenges around sleep? 

Sleep difficulties for autistic children can impact their overall health, behaviour and quality of life. These difficulties can manifest in various forms including trouble falling asleep, frequent night awakenings, and early morning arousals often resulting in insufficient and poor-quality sleep. Understanding these difficulties are crucial as they are often also linked with sensory sensitivities, co-occurring conditions and environmental factors. Addressing these challenges requires a holistic approach that encompasses behavioural strategies, medical interventions if required and advised by your local GP, and support for both the child and their family.²

Common areas of need include:  

• Challenges with bedtime routine e.g., refusing to brush teeth, put pyjamas on 
• Sleep interfering behaviour e.g., wanting lots of cuddles, self-stimulatory behaviours 
• Delayed sleep onset – taking a while to fall asleep 
• Night awakenings 
• Early awakenings

How can we best support sleep for autistic children? 

Hanley outlined a 5-step checklist to support with sleep, ranging from developing a positive bedtime routine to optimising sleep conditions. The steps are as follows: 

• Step 1: Develop ideal sleep schedule 
• Step 2: Get a bedtime routine 
• Step 3: Optimise bedroom conditions 
• Step 4: Regularise sleep dependencies 
• Step 5: Address sleep interfering behaviour  

Step 1: Develop a sleep schedule 

The number of hours of sleep a child should be getting will depend on their age. This should be taken into account when creating a sleep schedule. 

When developing a sleep schedule, initially schedule bedtime slightly later than when your child fell to sleep the previous night. This will make it more likely they fall asleep quicker. Then gradually move the sleep phase earlier – if they fall asleep within 15 minutes, move the bedtime 15 minutes earlier until the desired bedtime is achieved. You may want to do it in smaller steps depending on your situation. 

Step 2: Establish a bedtime routine 

Creating a bedtime routine is such an important step in addressing challenges with sleep. Routines can help children feel more comfortable with the situation when they know what is expected of them and when. 

Pre-bedtime routines should be individualised based on how easy/hard a child finds an activity, whether it is stimulating or relaxing, and their preference.  

Ranking these to work out an ideal bedtime routine can be done using the following ‘worksheet’:  

You want to schedule hard and stimulating activities earlier in the schedule, and easy and relaxing activities later in the schedule to ensure that the child is as relaxed as they can be by the end of the routine. 

You may want to eliminate some activities from the schedule (or place them earlier in the day).  

Using a visual schedule can help children to follow a pre-bedtime routine. This is a good opportunity to let the child take ownership of their schedule, which can also help increase predictability. Make sure that where possible you are praising  them for following the schedule or offering small rewards e.g., you can do a longer story time before bed. Adding photos or pictures, helps the child to understand and follow what is happening with their routine. It is important to think about if a symbol or picture will be more beneficial for the child. 

Step 3: Optimise bedroom conditions 

Sensory needs can often be a big factor in sleep challenges for children. Perhaps the smell of the washing detergent is too powerful, or the room itself is too hot or cold. It could be that white noise would be helpful. Optimising bedroom conditions will look different for every child, based on their sensory preferences – here are some suggestions you can think about. 

• Make the bedroom a sleep haven. Where possible, try to avoid playing in the bedroom as the child will see it as somewhere to play rather than somewhere for sleep 
• Temperature – it is often suggested that a cooler temperature is easier to fall asleep in 
• Dim, indirect lighting – dim the lighting gradually if possible 
• Removing any stimulants from the bedroom e.g. favourite toys not visible  
• Non-undulating noise (i.e. not increasing in pitch or volume. If the child is affected by changes in noises, having a consistent noise such as white noise, a fan or air purifier may help.) 
• It is important to take into account other sensory needs such as sensitivity around bedding or pyjamas. Trialling different materials to find the best fit, i.e. choices between loose or tight pyjamas, light or heavy covers etc.  

Step 4: Regularise sleep dependencies 

Your child may want you to be in the room whilst they sleep. This isn’t unusual, but it can lead to the child becoming dependant on this so it’s best to try and avoid this if possible. Fading your presence is a useful strategy to avoid this. 

For example, if the child wants the parent lying in the bed next to them, the parent could move to sitting up on the bed, then lying half on the bed, to sitting on a chair by the bed, and moving the chair further away etc. Another mattress could also be used, and gradually moved further and further away. 

It may also be appropriate to introduce a full-size pillow or an alternative item to help with the fading process. 

In general, if your child needs something with them to sleep, try and ensure are things that: 

• Don’t require you to be present to deliver them  
• Can be available at bedtime and during the middle of the night 
• Can be transported (i.e. for family holidays such a blanket or cuddly toy) 

Step 5: Address sleep interfering behaviour 

Sleep interfering behaviour can include a range of things, including: 

• Leaving bed
• Crying/calling out
• Talking to oneself
• Playing in bed or bedroom

Try and work out what it is about these interfering behaviours that maintains them, i.e. does your child want attention/interaction, do they want food/drink, do they want access to TV/toys, escape/avoidance of the dark/bedroom or is it automatically reinforcing (e.g. self-stimulatory behaviour). Once you’ve discovered why the behaviours are happening, it’s possible to prepare strategies to support with those. This could include:

• Relocating relevant materials:  Here you can think about want to think about what environmental factors are contributing to sleep interfering behaviours. For example, removing unnecessary items from the bedroom, can help to create a calming environment and reduce overstimulation. Additionally, ensuring sensory items such as comfort toys and blankets are within easy reach.
• Time based visiting:  this strategy is used where an adult regularly checks in on a child at premeditated intervals, after the child has been put to bed i.e., checking in after every 15 minutes. This approach provides the child with a sense of reassurance and security, while gradually encouraging them to fall asleep independently. 

Nightmares 

Addressing nightmares in autistic children requires a holistic approach that considers their sensory, emotional, and communication needs, aiming to improve both their sleep quality and overall quality of life. If nightmares occur: 

1. Help your child to develop good sleeping habits (see above) 
2. Avoid developmentally inappropriate TV, movies, magazines and video games 
3. Soothe your child’s fears by listening to them, but show them that you are in control and that they are safe 
4. Do not feel obligated to grant all requests (e.g., keep the lights on, check for monsters etc.) 
5. Help them with their anxieties during the day hours (e.g., breathing exercises) 
6. Address night time fears by teaching child relaxation techniques and reward “bravery” in the morning  

Sleep toolkit resources 

• Create a sleep diary to spot trends and patterns. This can be as simple or as complex as you like. Note down important things like time of last meal, toilet trip, their mood during the day and lead up to bed time. Anything you think might be useful in understanding more about their sleep. 
• ACT Videos
• NHS Website
• Goodnight iPad book

Top tips for supporting with sleep 

• Start the bedtime routine earlier 
• Exercise at least every other day, at least 4 hours before bed 
• Avoid all caffeinated drinks (especially after 4pm or 6 hours before bed) 
• If aged 4 and over, avoid all napping (especially after 3pm) 
• Only use bed for sleeping, not for playing/social if possible 
• Work on following instructions during the day

If you want a deeper look at some of the topics raised above, take a look at our Lunch and Learn webinar on sleep below. It is important to remember that if your child is having issues with sleep, you’re not alone. The most crucial thing is to try and establish a routine to give your child the best chance of being successful with sleep. Utilising the steps above you can set boundaries for the bedroom and create expectations with your child that will help you both stick to those routines. You can also take a look at our autism in the early years online training course, which looks in depth at sleep as well as other topics.

If you have any concerns around medical reasons for the challenges, it’s essential you seek the help of a medical professional. 

1. Hanley (2015) – Understanding and treating sleep problems of children – https://babat.org/wp-content/uploads/2015/06/Sleep-GH_BABAT-10_15-2.pptx
2. Ferber, R. (2006). Solve your child’s sleep problems: revised edition: new, revised. Simon and Schuster.