Autism and Sleep

As a psychologist, I primarily work with adults. When I see parents of children with autism either in the sleep center or in the clinic setting, they frequently report having problems with sleep. Most often they complain of insomnia or sleep deprivation. Many of their difficulties actually relate to the problems their children with autism have with regard to sleeping.

The publication of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders 5th edition in 2013 has been controversial and nowhere more so than in the changes associated with the categorization and diagnosis of the autism-related disorders. Several separate disorders including autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder have been subsumed under the category of autism spectrum disorder.

One of the better-known disorders was Asperger’s Disorder. It was defined as “severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interests, and activities… (that cause) clinically significant impairment in social, occupational, or other important areas of functioning” (APA, 1994, p 75) but without the more severe language and cognitive development characteristic of the other disorders now included in the autism spectrum.

People diagnosed with autism spectrum disorder have “persistent deficits in social communication and social interaction across multiple contexts … and restricted, repetitive patterns of behavior, interests, or activities …” (APA, 2013, p 50) that are present early in development and cause significant impairment in major life areas such as social relations and occupational functioning.

We are well aware that sleep is a complex process and can be easily disturbed by such factors as stress and disruption of the sleep schedule. Because of this, problems such as insomnia can be seen in very young children just as they can occur in adults and in the elderly. This is even more so the case for individuals who additionally have psychiatric or neurological problems.

Children who have been diagnosed with autism most often report problems related to difficulty falling asleep, fragmented sleep, and early-morning waking. The sleep patterns of children with autism tend to also be more irregular than those in non-autistic children. Obviously, a child’s disordered sleep has ramifications for the sleep of the parents. Information about the sleep of these children is being sought so that parents with children with autism can help both themselves and their children.

An early study conducted by Paavonen and her colleagues at the University of Helsinki Finland (Paavonen et al, 2008) addressed this issue by looking at the sleep of 52 children who had been diagnosed with Asperger’s disorder and compared their sleep with that of 61 healthy controls. The children were between 5 and 17 years of age.

They found that sleep onset difficulties, sleep maintenance problems, negative sleep attitudes, sleep-related fears, and daytime sleepiness were more common among children with Asperger’s disorder than among controls. Sleeping less than 9 hours occurred among 59% of the Asperger’s diagnosed children as compared to 32% among control children. Indeed, 5.9% of the children diagnosed with Asperger’s disorder slept less than 7 hours but none of the control children slept this little. Difficulty falling asleep occurred in 53% of the children with a diagnosis of Asperger’s but in only 10% of the controls. These differences were statistically significant.

A majority of children with Asperger’s disorder (58.3%) reported having sleep problems while only 7.0% of controls reported having these. Sleeping too little and daytime fatigue were more common among the children with Asperger’s disorder than among the control children. Children with Asperger's disorder had more negative views of sleep than control children. Most control children enjoyed going to sleep while only 64.6% of the children diagnosed with Asperger’s disorder felt this way. Fear of the dark and of sleeping alone were more common among the children diagnosed with Asperger’s disorder. Sleep problems were found to start earlier in the children with Asperger’s disorder than in the control children. Interestingly, sleep disordered breathing (sleep apnea) was no more likely to occur in one group than the other. The children diagnosed with Asperger’s disorder reported more often arguing with their parents about bedtime than did the control children.

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A more recent prospective study by Humphreys et al (2013) looked at sleep problems in children with autism spectrum disorders. The children studied were from a cohort in England and were born in 1991 and 1992. Information about sleep duration was gathered from parents at eight intervals when the children were between six months and 11 years of age. Children with an autism spectrum disorder were identified from health and education records. The sample included 73 children with an autism spectrum diagnosis and 10,704 control children at age 18 months. This decreased to 39 and 7,043 respectively at age 11 years due to attrition.

Before 30 months of age, no differences in sleep duration were found between children with an autism spectrum diagnosis and controls but after this age, they slept less on average. The difference between age 30 months to 11 years of age was 17–43 minutes. This difference appeared to be accounted for by later bedtimes and earlier rise times. Multiple awakenings were more frequent among children with an autism spectrum disorder. These differences in sleep continued through adolescence. The study was limited, however, in that results were obtained based on estimates of sleep duration by the parents rather than through the use of electronic monitoring such as that done with actigraphy.

Clearly, evaluations of children that are suspected of having an autism spectrum disorder should include an assessment of sleep patterns. The studies cited above give valuable insights into the sleep problems faced by these children and their parents. Such information can be helpful in formulating treatment approaches and this will be the topic of a future post.