Autism spectrum disorder (ASD) affects an ever-increasing number of children and adults each year. Among its many impacts are sleep disturbances, which studies estimate to affect between 40% to 80% of children with ASD.¹
Sleep disturbances — including insomnia, sleep-related anxiety, and sleep fragmentation — are common among adults with ASD and can further exacerbate social communication deficits, lack of concentration, aggression, and hyperactivity.
This guide provides information and resources about the impacts of autism spectrum disorder on sleeping behaviors and effective methods for improving sleep.
What is autism spectrum disorder?
What causes ASD?
Diagnosis of ASD
How does autism spectrum disorder affect sleep?
Treatment for ASD sleep disorders
Sleep management tips for ASD individuals
Autism spectrum disorder (ASD) is a neurobehavioral disorder affecting approximately one in 44 children, according to the latest CDC statistics from 2018.² ASD impacts:
- Social communication
- Learning development
Unlike many genetic disorders, there are no outstanding physical traits or features that indicate a person has ASD.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines four primary criteria for diagnosis:³
Persistent deficits in social communication and interaction within different contexts. Within this criteria, examples include deficits in reciprocity and communication regarding shared interests and emotions, failure of normal back-and-forth communication, lack of initiation of social interactions, and failure to engage in social exchanges. Other impairments include those related to eye contact, body posturing, physical gestures, speech patterns, and facial expressions.
Restricted, repetitive behavioral patterns, as manifested by at least two of four symptoms. Examples of behaviors within this criteria include repetition of words or phrases, unusually formal speech patterns, pronoun reversal, repetitive noises or vocalizations, repetitive movements, abnormality of posture, unusual face grimacing or teeth-clenching, and repetitive use of objects, among others.
Symptoms must be present in early childhood (age eight and younger). But they may not fully manifest until the child’s limited capacity is exposed to social demands.
The symptoms limit and impair everyday functioning. Levels of impairment vary across the spectrum, from minimal social impairments to high severity.
The DSM-5 further details the levels of severity on the autism spectrum. The following chart outlines these levels.³
|Severity level||Social communication||Repetitive behaviors and restricted interests|
|Level 1: Requires support||“Without supports in place, deficits in social communication cause noticeable impairments. Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.”||“Rituals and repetitive behaviors (RRBs) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRBs or to be redirected from fixated interest.”|
|Level 2: Requires substantial support||“Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.”||“RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRBs are interrupted; difficult to redirect from fixated interest.”|
|Level 3: Requires very substantial support||“Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.”||“Preoccupations, fixated rituals, and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.”|
Previous definitions of autism
Earlier versions of the DSM characterized autism spectrum disorder in four different subtypes. When the DSM-5 was released in 2013, these subtypes were absorbed into ASD. Some of these subtypes still appear in authoritative lists other than the DSM. They include:
Considered to be a mild and high-functioning form of autism, Asperger syndrome was previously diagnosed in children and adults that displayed symptoms like hypersensitivity to sensory stimuli, hyperfocused areas of interest, and inability to pick up on social cues.
Considered to be in the mid-spectrum, autistic disorder was defined as exhibiting more severe symptoms than Asperger syndrome but less debilitating than other forms.
Childhood disintegrative disorder
Before the release of the DSM-5, childhood disintegrative disorder was considered the most severe form of autism. It was commonly diagnosed between the ages of two and four and was characterized by severely impacted cognitive, social, and speech capabilities.
Pervasive development disorder (not otherwise specified)
Researchers and medical practitioners used the term PDD-NOS to describe individuals believed to be on the autism spectrum but who did not meet the criteria for other categories.
In the 2013 revision, the authors of the DSM-5 also removed other disorders once considered to be on the autism spectrum. Among these are Rett syndrome and social communication disorder.
Despite extensive research, scientists know little regarding the causes of autism. However, they have identified several risk factors, including genetic, biological, and environmental factors, which include:²
- Complications during childbirth
- Having older parents
- Having siblings with ASD
- Having certain genetic conditions, including tuberous sclerosis or fragile X syndrome
The CDC has been conducting a multi-year study to identify risk factors for ASD called SEED (the Study to Explore Early Development). This project produces highlights from published research studies on ASD and now covers follow-up reports on adolescents to determine outcomes of ASD as individuals mature.
The World Health Organization (WHO), Centers for Disease Control (CDC), and other research-based institutions have stated that epidemiological data has concluded no causal association between traditional vaccines (rubella, measles, and mumps) with the onset of autism. According to the WHO, no evidence suggests other childhood vaccines increase autism rates either.⁴
ASD is not a genetic disease like Down syndrome, so there is no simple medical test to determine whether a child falls on the spectrum. ASD diagnosis must come from a physician or specialist’s direct observation of the child’s behavioral development. ASD traits can appear as young as 18 months, and diagnosis may be considered reliable when given by experienced professionals when the child is as young as two years old.²
Treatment for ASD, including many different forms of intervention in behavioral, developmental, and social-relational therapies, serve to improve the quality of life and reduce symptoms of the disorder. Treatments must begin early after diagnosis to ensure children with ASD achieve optimal development.
If a child falls into one or more risk factors (described above), they may undergo screening at the age of nine months, again at 18 months, and again at two years of age. Screening for ASD involves interactions between the screening professional and the child, with a focus on determining if the child displays the following ASD traits:
- Self-injury or self-harm
- Limited attention span
- Abnormal sleeping or eating patterns
Professionals conduct age-specific questionnaires focusing on motor skills, communication, and intellectual development. Examples of these assessments include:
Communication and Symbolic Behavior Scales (CSBS)
This checklist for infant and toddler evaluations looks at communication, gestures, eye contact, emotion, object use, sounds, words, and understanding.
Modified Checklist for Autism in Toddlers (M-CHAT)
This simple yes-or-no questionnaire consists of 23 questions assessing motor skills, speech, behavior, and interests. Results range on a scale from 0-20, with 20 considered to indicate high risk.
Parents’ Evaluation of Developmental Status (PEDS)
This evidence-based screening looks at children’s early academic skills, self-help abilities, social-emotional and mental health, and language and motor skills.
Screening Tool for Autism in Toddlers and Young Children (STAT)
This 20-minute screening evaluates children between 24-36 months in 12 segments.
If your pediatrician or specialist determines positive results associated with ASD, they recommend a comprehensive diagnostic evaluation, which involves family participation and discussion of symptoms and behaviors.
According to the CDC, a definitive diagnosis of ASD requires a comprehensive evaluation involving at least two diagnostic tools.² These tools include:
Autism Diagnosis Interview — Revised (ADI-R)
This diagnostic tool for children over 18 months looks at questions relating to restricted interests, repetitive behaviors, and social communication styles.
Autism Diagnostic Observation Schedule — Generic (ADOS-G)
The ADOS-G is a 120-minute evaluation of social and communication deficits. It consists of four 30-minute sessions focusing on a patient’s expressive language abilities.
Childhood Autism Rating Scale, Second Edition (CARS2)
In this scale, children two and older undergo different tests to evaluate the subject’s functionality and distinguish where they fall on the autism spectrum. Assessors gauge the child’s autistic tendencies based on the intensity, frequency, and duration of performing each criterion. This scale also works to distinguish ASD from other disabilities.
Gilliam Autism Rating Scale, Second Edition (GARS-2)
This diagnostic tool is designed for teachers and clinicians when evaluating children and adults between the ages of three and 22. It looks at communication skills, social interaction, and stereotyped behavioral traits.
Considerations for diagnosing ASD in adults
Autism is most commonly diagnosed in children, but according to the latest study by the CDC, an estimated 2.21% of the adult population in the US has ASD — that’s almost 5.5 million people.⁵
You may not have been diagnosed as being on the autism spectrum in childhood and now suspect you have the disorder. If so, consider the following criteria that present in adults with ASD:⁶
- Difficulty with communication
- Social difficulties
- Self-stimulating behaviors
- Hyper-sensory awareness of the world around you
Diagnosing adults with ASD is tricky because most diagnostic tools are designed for children up to 22 years of age. However, the Adult Repetitive Behaviours Questionnaire – 2 (RBQ-2A), introduced in 2015, shows promise in evaluating tendencies toward autistic behaviors. It is not, however, a definitive evaluation tool.
Researchers have conducted multiple studies and clinical reports on the comorbidity of sleep disturbance and autism spectrum disorders. Results show that as many as 83% of ASD subjects suffered daily sleep problems. Among the sleep problems reported were:¹
- Bedtime resistance (54%)
- Insomnia (56%)
- Parasomnias (53%)
- Sleep-disordered breathing (25%)
- Morning arising problems (45%)
- Daytime sleepiness (31%)
Associated sleep problems related to ASD
Understanding sleep disorders in autistic individuals requires looking at some of the comorbidities accompanying ASD. These comorbidities contribute to sleep dysregulation, often exacerbating symptoms like irritability, communication issues, and aggression.
Mental health disorders
Clinical studies have indicated high comorbidity of psychiatric disorders with autism — anxiety disorders and ADHD as the most prevalent. Researchers found that 72% of autistic children had at least one additional psychiatric diagnosis in one study.⁷ Anxiety, depression, and ADHD present issues of sleep dysfunction, which may contribute to insomnia in comorbid ASD individuals.
Irregular circadian rhythms
Circadian rhythms are natural internal processes regulating the sleep-wake cycle based on sunlight, temperature, and environmental factors. The natural hormone melatonin essentially synchronizes the circadian clock in humans. Several studies have shown that children with ASD produce irregular melatonin secretion, disrupting their circadian rhythm.⁸ ⁹
Researchers estimate that 11% to 39% of individuals with autism develop epilepsy.¹⁰ If an ASD individual has comorbid epilepsy, sleep dysfunction is likely. Further, sleep deprivation can lead to more seizures, creating a cycle of insomnia and illness. Other medical issues that may lead to sleep loss in those with ASD are acid reflux, constipation, and diarrhea.
Side effects from medications
Many of the medications prescribed for ASD individuals have side effects that may impair sleep. SSRIs, for instance, can cause bedtime anxiety and hyperactivity.
The chart below highlights some common medications prescribed to ASD subjects and their impacts on sleep regulation.
|Medication||Trade name||What it treats||Can it impact sleep?||Other side effects|
|Risperidone||Risperdal||Aggression, irritability, and aberrant social behavior||
|Nausea, constipation, diarrhea, and weight gain|
|Aripiprazole||Abilify||Aggression and irritability||
|Nausea, weight gain, and upper respiratory infections|
|Clozapine||Clozaril||Aggression and irritability||
|Tachycardia, enuresis, constipation, weight gain, and frequent nightmares|
|Haloperidol||Haldol||Aggression, irritability, and aberrant social behavior||Rarely||Dry mouth, constipation, muscle rigidity, and hypotension|
|Sertraline||Zoloft||Aggression and irritability||No||Poor concentration, elevated energy, and diarrhea|
|Oxytocin||Ritalin||Hyperactivity and inattention||
|Dry mouth, anxiety, nausea, appetite suppression, and weight loss|
|Venlafaxine||Effexor||Hyperactivity and inattention||
|Nausea, headache, dry mouth, and dizziness|
|Dry mouth and headaches|
|Dry skin, diarrhea, excitability, and elevated energy levels|
The impacts of sleep dysregulation on ASD individuals can worsen the disorder’s symptoms, leading to more significant struggles in school, work, and social environments. Insomnia — defined as difficulty falling and staying asleep throughout the night — is the most common sleep disorder in adults and children with ASD, affecting between 40% and 80% of subjects.¹
Parasomnias, including nightmares and night terrors, also affect many ASD individuals, especially those diagnosed with Asperger syndrome. Bedwetting, which is also common, disrupts sleep and may lead to chronic sleep dysregulation.
Other less common causes of sleep dysfunction in ASD individuals include:
- Obstructive sleep apnea due to intracranial hypertension
- REM behavioral disorder
Treatment for ASD-related sleeping disorders depends on the circumstances of the sleeping disorder, comorbidities, and environmental factors. Individuals with autism or their caregivers should discuss options with their doctor or pediatrician. Often, the doctor requests that the client records the individual and environmental factors that may impact sleep dysfunction in a sleep diary.
Your doctor may also perform one or more tests to assess sleeping behavior and the underlying causes of disruption to diagnose and prescribe treatment. Some diagnostic tools include:
- Actigraphy: Involves the subject wearing a sleep monitor to record sleep-wake cycles
- Polysomnography (PSG): A comprehensive sleep study performed in hospitals or sleep centers to diagnose sleeping disorders
Once your physician has made a diagnosis, you may face several options for treatment. We’ll look at some of the benefits and drawbacks of these below.
Sleep therapy options
Sleep therapy is often the first choice for treatment in ASD patients because it has no adverse side effects. There are many options for sleep therapy, including cognitive-behavioral therapy (CBT), which has proven effective in both in-office and teletherapy models.¹¹
CBT helps ASD individuals establish bedtime routines and sleep hygiene, which often improves sleep and helps to diminish insomnia symptoms. Dedicating 15-30 minutes before bedtime to the following activities can help reduce bedtime anxiety and benefit those with ASD:
- Dressing for bed
- Brushing teeth
- Using the restroom
- Washing hands
- Getting in bed
- Reading a book (or being read to)
- Shutting off the light
Additionally, some of the following behavioral interventions may prove helpful in diminishing bedtime anxiety and establishing healthy bedtime routines:
- Create a checklist for the ASD individual to complete bedtime tasks like those above.
- Limit the bedtime routine to 10-30 minutes.
- End television, computer, or phone time at least 30 minutes before bedtime.
- Provide positive reinforcement for maintaining the bedtime routine.
- If the bedtime routine changes, give advance notice for mental preparation.
Light therapy is an option for helping ASD individuals with boosting melatonin production. This type of therapy involves using a light box near the bed that increases light in the room during morning hours, making for an easier transition to waking.
Pharmacological treatments are second in line as therapeutics for ASD individuals. They include melatonin and other dietary supplements.
As noted above, researchers have discovered inconsistencies and abnormalities in melatonin production in ASD subjects. Melatonin supplementation has demonstrated a 60% success rate in improving sleep disruption for those with ASD in studies and may be an affordable option for many individuals.¹ Melatonin has few side effects, although dizziness, stomach discomfort, and nausea may occur.
Natural dietary supplements for promoting sleep often include valerian, kava, iron, and 5-Hydroxytryptophan. These products may help promote sleep in ASD individuals. However, you should talk to your physician or pediatrician before administering any dietary supplements, especially if the ASD individual takes any other medications.
Over-the-counter sleep medications are not advisable for most children with ASD. We recommend consulting your physician before administering any over-the-counter sleeping aids, such as diphenhydramine or doxylamine succinate.
Prescription medications are generally the last option for improving sleep in ASD individuals due to their potential side effects. However, prescription options are available for children and adults resistant to other therapies. The following prescription drugs may be effective for children:
Clonidine is a sedative and antihypertensive drug for treating ADHD, high blood pressure, and other conditions. In a 2008 study, clonidine proved its effectiveness in reducing insomnia in ASD subjects, and a 2020 study demonstrated its efficacy in reducing agitation and aggression in those with ASD.¹² ¹³
Mirtazapine is an antidepressant that also treats ASD-related anxiety and may aid sleep behavior. Clinical trials have demonstrated efficacy in alleviating insomnia in depressed subjects, improving sleep efficiency, quality, and total sleep time.¹⁴
Prescription medications for ASD adults offer more options, but they should still be considered a last resort and thoroughly discussed with one’s doctor.
Nonbenzodiazepines, or z-drugs, are the most effective option for treating insomnia in adults. However, it’s important to note that these medications carry high dependency risks and may cause side effects. It is essential to discuss a patient’s full medication schedule with their physician before considering administering z-drugs to children or adults with ASD.
The three most common drugs in this category include:
- Zolpidem (Ambien)
- Zopiclone (Lunesta)
- Zaleplon (Sonata)
Sleep therapy and medications used independently or in conjunction should improve sleeping patterns for children and adults with ASD. Some of the following additional tips will help make bedtime a less stressful experience.
- Eat a healthy, balanced diet, and avoid late-night snacks. Getting the proper nutrients helps your body and mind prepare for peaceful rest. Avoid substances like caffeine, alcohol, nicotine, and processed sugars. Foods containing tryptophan help induce sleepiness, including turkey, bananas, beans, and chicken.
- Create a relaxing bedroom environment. Establish an atmosphere conducive to relaxation in your bedroom and eliminate electronic devices from the room.
- Shut off electronic devices an hour before bedtime.
- Avoid daytime napping for any period over 30 minutes.
- Adjust your lighting. Introduce dimmable lights in the bedroom and avoid LED and fluorescent lighting, which emits blue light and can diminish melatonin production.
- Adjust the temperature. Ensure that your bedroom environment is comfortable and conducive to sleep.
- Adjust mattresses and bedding as needed. Sleeping position is a significant factor in the comfort level of bedding. Those who sleep on their sides and backs tend to find more comfort in latex or memory foam mattresses, while innerspring mattresses offer less spinal support.
- Keep a sleep diary. This can help keep track of your nightly patterns so you can discuss any issues with your doctor.
- Exercise daily. Physical activity during the daytime hours helps many individuals achieve better rest at night. However, you should limit exercise to hours during the day and avoid such activity in the hours before bedtime.
- Use relaxation techniques. These can help adults and children prepare for bedtime. They include breathing techniques, meditation, and guided visualizations.
- Check on children in the early stages of sleep. If your ASD child is struggling with sleep anxiety, reassuring them with physical touch and emotional support may help ease them into bedtime.
For more information about the day-to-day management of autism and handling sleeping disorders, explore the following links:
- Autism Speaks helps adults with ASD access national and local resources for advocacy groups, community support, employment, post-secondary education information, and advice on diagnosis and treatment.
- National Autism Resources provides information for teachers, caregivers, and parents of ASD children.
- The Autism Society is a national organization offering timely and relevant information, resources, and support for the autism community.
- The American Academy of Child & Adolescent Psychiatry offers an Autism Resource Center for adults and children with autism and their caregivers.
- Exceptional Lives provides information for diagnosing, treating, and coping with the impacts of ADS in children and adults.
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