Children with autism and other neurological disorders often struggle when it comes to sleep. RDI® Certified Consultant Dr. Sarah Wayland shares some tips on how to make bedtime smoother and help your child get they rest they need to keep growing!
This guest blog post was written by RDI® certified consultant Dr. Sarah Wayland. You can read the original here.
We all know that getting a good night’s sleep is fundamental to being able to function. Chronic sleep deprivation can cause a host of problems, from seemingly minor things like difficulty getting things done efficiently to much more serious issues like being able to keep your emotions in check. Indeed there is evidence that disabilities like ADHD may be caused, in part, by difficulty sleeping. I know one mom who was hospitalized with sleep-deprivation induced psychosis several months after her child, later diagnosed with autism, was born.
If you are the parent of a child who has trouble sleeping, you know how important sleep is. There is a reason sleep is the foundation at the base of Maslow’s hierarchy of needs – it is fundamental. When you are deprived of sleep, your need for it dominates every aspect of your day until you are able to finally get what you so desperately need.
Unfortunately, parents of kids who have trouble sleeping struggle to get useful and nonjudgmental help for their kids, and thus themselves. While it’s almost never your fault that your kids aren’t sleeping, fellow parents and professionals often assume that you haven’t tried very basic things like Ferberizing or other sleep training methods.
I wrote this post because of all the things my families struggle with, this is one of the most devastating and difficult to address. The article is long, but I’m hoping that there are ideas in here that will help. As with everything I recommend, please view these suggestions as a toolbox of options, and not a one-size-fits-all solution.
The first step to helping children sleep is to figure out how much sleep they need. Over-tired children have a hard time falling asleep. These guidelines from the National Sleep Foundation can serve as a starting point:
- Toddlers (ages 1-2) need between 11-14 hours of sleep in a 24-hour period. When they reach about 18 months of age their naptimes will decrease to once a day lasting about one to three hours. Difficulty falling asleep and nighttime waking are common.
- Preschoolers (ages 3-5) typically sleep 11-13 hours each night and most do not nap after five years of age.
- Children ages 6-13 need 9-11 hours of sleep.
- Teenagers need 8-10 hours of sleep, and their biological clocks are set to fall asleep around 11pm.
These numbers are just averages. Your child may need more or less sleep than the times listed above. One way to figure out how much sleep your child needs is to track how long it takes them to wake up on their own when you are on vacation. In a perfect world, your child should wake up without external cues.
It’s also important to note that it is perfectly normal for kids to have trouble settling at night and to wake up in the middle of the night! Learning to settle your body and mind are skills that your child will need to learn.
That said, there are steps you can take that will make it easier for your child to calm down enough that his or her body can drift off to sleep.
The Basics of A Good Night’s Sleep
Most recommendations start with developing good sleep hygiene. I’ll start there too, but if you have a child with neurodevelopmental differences, I’m betting you’ve already tried most of these strategies. Read them over in case there’s something helpful, but you may want to skip to the section after this (Other Issues) where I talk about ways to help kids with neurological differences.
Typical Recommendations for Good Sleep Hygiene
Follow a consistent bedtime routine that is relaxing and that ends in the room where the child sleeps. Some kids will be able to do the routine independently if you post the steps – either written or using a picture schedule. For example:
- Put on pajamas.
- Brush your teeth.
- Wash your hands and face.
- Listen to a story.
- Get a goodnight hug.
- Say goodnight to a favorite toy.
- Turn off the lights.
Other kids will need close supervision, perhaps because of difficulties with time awareness and understanding that things need to be done in order.
Additional steps that may help:
- Turn off all screens (TV, computer, electronic device) 1½ hours before bed.
- Eat a small healthy snack.
- Take a warm bath or shower.
- Stick to a regular sleep schedule – go to bed at the same time every night and wake up at the same time each morning.Create a schedule based on the amount of sleep your child needs – not what you think it should be.
- For younger children: Encourage use of a security object such as a blanket or stuffed animal.
- If reading a story: Make sure the story is simple with short sentences, familiar words and repetition. Exciting stories sometimes make it difficult to fall asleep.
- For older children: Don’t go to bed until sleepy.
- Getting regular exercise can help make it easier to sleep. If your child is not getting enough movement during the day, it can make it hard to settle down at night.
- Children may need to use their beds only for sleeping, and avoid using them for other activities like watching television, using electronics, reading, etc. NOTE: Some people need to do something to wind down once they get into bed. For them, this advice may not be appropriate.
- Take melatonin 1½ hours before bed. To determine dosage, start low and go slow. It is available in a variety of forms, including regular tablets, quick dissolve tablets, gummies, and liquid. This makes it possible to tailor the dose and administration in a way that makes sense for your kid. To determine the correct dose, start low and go slow. Start with 0.5 mg or less (you can split a 1 mg pill or you can buy low dose capsules) and try it for 3 nights. If it’s not helping, increase to 1 mg; try for 3 nights. Keep increasing in 1/2 mg increments until your child falls asleep within an hour after dosage. Most kids do not need more than 3 mg, but some do. If the dose is too high, an unfortunate side effect is nightmares, so be careful. You can back the dosage off to a lower level if your child experiences side effects.
It’s important to remember that disrupted sleep can be a symptom of an underlying medical condition. If your child has trouble falling asleep, or is exhausted during daylight hours, you will want to evaluate whether there’s a biological reason for that difficulty.
- Allergies (dust, pollen, mold, etc.) can make it tough for a kid to fall asleep and stay asleep. Constant sneezing, coughing, and difficulty breathing contribute, as do inflammation and itching. Effectively managing allergies can make a big difference in a kid’s ability to sleep.
- Many medications interfere with child’s ability to sleep. The most notorious of these are the stimulants used to treat ADHD. Stimulants stay in some kids’ systems for longer than normal and this can make it hard to sleep. (Counterintuitively, some kids actually need to take a stimulant so they can calm down enough to get to sleep! One size does not fit all.)
- Evaluate your child for sleep disorders including sleep apnea, sleep-related movement disorders like restless legs syndrome or teeth grinding, circadian rhythm sleep disorders like delayed sleep phase syndrome, or narcolepsy.
- If your child is exhausted during the day, consult a doctor. It may be a health condition that you can treat.
Sometimes your kid is just not comfortable in his or her bedroom. If you have a kid with sensory differences, these suggestions inspired by this wonderful article on sleep may help you create a sleeping environment that allows your child to relax.
- Make sure it is dark in the bedroom. Use light blocking shades on the windows and turn out any lights that may make it too bright in your child’s room.
- If your child needs a nightlight, make sure it is not blue. Lights that are red or yellow are less likely to keep your child awake. A dim light is much better than a bright light.
- Some children suffer from visual crowding and their environment will need to be very simple – no pictures on the wall, minimal furniture, and bedding of a uniform calming color.
- If necessary remove all clocks from bedroom so your child can’t watch the clock (though see the section on Different Sleep Schedules, below, for kids who are early risers).
- Some children like it to be very quiet and may be bothered by sounds that others don’t even notice. (One that surprises many of my families is humming electronics or lights.) If they will tolerate wearing them, earplugs can be helpful for these children. A white noise machine may also help mask those sounds.
- Others need soothing background sounds (e.g., the sounds of a waterfall or the ocean, or soft music) to calm down.
- Some children are very sensitive to irregularities – tags, seams in their pajamas, fabrics or fillers that make their skin itch or trigger allergies (wool, fleece, down, etc.), wrinkled sheets, or textures that irritate their skin. Work with your child to find pajamas, sheets, blankets, and pillow cases that are cozy and comfortable. Many kids have trouble with polar fleece or other synthetic fabrics. 100% cotton pajamas and nighties seem comfortable for most kids.
- Some children need the feeling of a heavy (weighted) blanket to help soothe them to sleep.
- Others cannot sleep under any covers.
- It can be difficult for some kids to find a comfortable position in which to sleep. A body pillow, a soft mattress topper, or a firm mattress (depending on their specific issues) can help. Lumps and sags in the mattress can cause additional challenges. Again, follow your kid’s lead in figuring out what will work for them.
- Some kids prefer pillows that are flat, others like big fluffy pillows.
- For some, a massage before bedtime can be very relaxing. Some kids like deep pressure, others like light touch. Again, whether this will be helpful differs from person to person.
Other environmental concerns
- Temperature – too warm or too cold. Most people like to sleep in a cool room. For those who need it cool, a fan can help when the nights are too warm. Some fans have the additional benefit of being a source of white noise (see Acoustic Environment, above).
- Low humidity – most people are more comfortable when sweat actually works to cool you off. High humidity environments make that difficult, and that can make it hard to get a good night’s sleep. Lowering the humidity with an air conditioner, or even just using a fan can make a big difference.
- Smells – some children are very sensitive to the smell of foods, perfumes, or smoke. These smells can keep them awake. For other children, smells can soothe them to sleep. Many families find that lavender or other essential oils help their kids calm down. Be careful – what is calming to one may trigger allergies or sensitivities in another.
- Motion – rocking is soothing for some children and can help them fall asleep.
- Some children need a bright morning light to help them wake up. There are alarms that operate by gradually increasing the light level in the room so that it is at full brightness at the time you want your child to get up. This can be especially helpful in the winter when sunrise is after the time you need your child to get up.
Once you’ve created an environment that works for your child, think about whether that environment changes during the course of the night. For example, some families open windows and turn off the air conditioning at night during the summer. This may wake your child.
While they are learning how to sleep, you may need to keep the environment constant throughout the night so they can stay asleep.
In addition, it will also be important to resist the urge to constantly change your child’s bedroom once you’ve created a sleeping environment that works. Keeping their world constant every night and throughout the night will help your children learn how to fall asleep and stay asleep.
Of all the issues pertaining to sleep, this is probably the most difficult to address. Children who have anxiety disorders have tremendous difficulty going to sleep and staying asleep. Even children who don’t have anxiety disorders will be troubled by experiences that wake them in the night, including nightmares and night terrors.
- Take your child’s fears seriously. Insisting that there isn’t a monster under your child’s bed won’t help. Instead, talk to him about how he can vanquish the monster. Many families have Monster Spray they use before bed to keep the monsters away. Other fears, like worrying about a friend who is being mean or a teacher who yells, are very real for your child. Validate their fears and brainstorm with them about what might help them cope.
- Help your child feel safe. Reassure them that they are safe and that you will protect them.
- Teach your child that being in the dark can be fun. Play games with a flashlight at night. Sit outside with your children at night and howl at the moon or watch the fireflies. Help them develop memories of having fun in the dark.
- Avoid scary stories, movies, and television shows. Some children are much more sensitive to scary story lines than others. Many children’s movies start with the death of a parent or another traumatic event. Others feature battles and scary villains who actively seek to harm others. While many children find these plot devices enjoyable, a significant number find them so terrifying that the memories haunt their thoughts for weeks and months afterwards. If you have a child like this, make sure to screen books, movies, and shows before your child watches them. This phase doesn’t last forever – many teens love a good scare despite being very sensitive as children. Other kids will always be sensitive. Respect their profile. Real life is tough enough; you don’t need to make it tougher for them.
- Teach your child to take control of their fears. When I was a child, I had a recurring nightmare that I was falling off a cliff. My mother taught me to take control of my dream so that when I realized I was falling, I changed the script so that I softly landed on a ledge and had a picnic while enjoying the view. As I got older, I changed the dream from being about falling to flying. Now I love those dreams!
- Teach coping skills. Relaxation training and meditation can help an anxious child learn how to soothe their nerves.
- Let your child come to you for comfort. Many caregivers with anxious children have learned that the only way they can get sleep is to allow their children to sleep with them in their bed. That is OK! Don’t feel guilty if you do this. Even the most anxious child will likely want to sleep in their own bed by the time they are in late elementary school. There are many professionals who tell parents of young children to avoid doing this, but I’m here to tell you that getting sleep is more important than forcing a child to sleep in their own bed. As they get older, you can teach your child how to self-soothe. But don’t feel guilty about allowing your child to sleep with you when they are anxious. Desperate times call for desperate measures.
- For older kids, make a palette next to your bed. As your child gets older, they won’t fit in your bed anymore. You can make a palette for them to sleep on. When my youngest was six or so, we put some soft blankets on the ground next to our bed with a pillow and a sleeping bag on top. When he got scared, he would come sleep on his palette while I held his hand. It wasn’t terribly comfortable for him, so eventually he would return to his own bed. This was a way that we could help him feel safe while also gradually encouraging him to stay in his own room. (The strategies described in the section on Different Sleep Schedules, below, can be used as well to help teach your child to stay in his room, once he’s able to do that.)
Older children whose anxiety continues to make sleep difficult will benefit from treatment for an anxiety disorder. The most effective treatment for anxiety disorders is cognitive-behavior therapy (CBT). For children who are not able to use the CBT strategies they have learned, medication may be required.
Nightmares are dreams with imagery that occur during REM sleep. They evoke fear, anxiety, or sadness. While children who are having nightmares will sometimes wake up to avoid the perceived danger, some are unable to do so. Kids will often remember their nightmares when they wake up, and this may make it difficult for them to go back to sleep. Some children have trouble distinguishing their dreams from their real life. For these kids, nightmares can make it difficult to get through the day. While isolated nightmares are normal, when they recur they can cause profound difficulties with getting enough sleep. The strategies described above, and elsewhere in this article can help.
Night (or sleep) terrors
Sleep terrors are often more frightening for the parent than the child. They most often occur early in the night. A child experiencing night terrors will seem to be awake despite the fact that they are in a deep (non-REM) sleep-state. They experience profound inconsolability and panic; they will sometimes scream and appear terrified, with their eyes open but unseeing, pupils dilated. They will be in this state for several minutes until they eventually relax and return to sleep. During a night terror, your child is generally unresponsive to your attempts to wake them or to console them. The only good news about night terrors is that your child will typically not remember the experience! All you can do during a night terror is to be near your child, speaking in soothing tones, and letting them know that they are safe and you are there to protect them.
You already know how important it is that you get enough sleep, or you wouldn’t be reading this article! Sometimes you will try everything, and your child will continue to wake before you are ready to get up, or stay awake after you are ready to go to sleep. Once your children have the ability to entertain themselves independently, you can tell them that while it is fine to wake up early, they cannot wake others before a specified time: perhaps 6:30am on weekdays and 9am on weekends.
For the kids who struggle to fall asleep, you may need to explain that you will need to have different bedtimes. One of my parents had a conversation with her child in which she explained, “Your bedtime is my bedtime. And I need to go to bed earlier than you do, or I can’t be the parent I want to be to you.”
Helping your child stay in their room while you sleep may require putting a clock in their bedroom. You can decide whether it is worse to be awakened before your alarm goes off in the morning, or to have a kid who watches the clock and stresses out about not falling asleep quickly enough at night.
Sometimes you try everything, and are faced with the realization that your child just does not need to sleep very much. I have a friend who needs nine hours of sleep a night whose son needed only four hours of sleep. When he was really young, she could put him in a play pen while she tried to get some rest. But once he was able to climb, that option was no longer viable and she had to figure out how to keep him safe. The toddler years were absolutely brutal.
Once he attained The Age of Reason, my friend was able to implement the “don’t wake me up until I can function” solution, but between the Age of Mobility and the Age of Reason, she just had to accept that he was going to be awake for 20 hours a day. After they determined there were no biological reasons for his reduced need for sleep, his parents had to accept it for what it was and plan for it. His dad would watch him some nights, and his mom would watch him other nights. One heavenly weekend, grandparents watched the kids, and my friend and her husband got a hotel and both of them Slept Through The Night for two nights running!
You do what you can….
While these ideas have been helpful for many of my families, I’m always looking for more solutions. If I didn’t mention something in this article that you found helpful, please share in the comments below. If we can help each other, maybe fewer children and their parents will have to suffer with chronic sleep deprivation.
Sarah Wayland, Ph.D., is an RDI Certified Program Consultant and special needs care coordinator. She helps parents of children with ADHD, autism spectrum disorders, learning disabilities, and other diagnosed and un diagnosed challenges. You can learn more about her at www.guidingexceptionalparents.com.