Sleep disorders in ADHD and autism

Sleep disorders are among the most common co-occurring health problems in children with attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). These problems affect not only the child's well-being and functioning, but also the entire family.

It is estimated that 50 to 80% of children with autism spectrum disorder (ASD) have sleep problems. In comparison, sleep problems affect 11 to 37% of typically developing children. Therefore, we briefly present the most important information available in the scientific literature on sleep in children with autism.

What are the most common sleep disorders?

The most common difficulties are related to insomnia – children have difficulty falling asleep or wake up frequently during the night. Difficulty falling asleep at night may be related to delayed sleep phase syndrome, the most common circadian rhythm disorder. It involves a shift in sleep onset to later in the night, while maintaining normal sleep duration and a typical sleep pattern.

Restless legs syndrome and periodic limb movements during sleep are also common in children with autism. Parasomnias, or abnormal symptoms or behaviors during sleep, are also more common than in typically developing children. These include sleepwalking (commonly known as walking during sleep), night terrors (waking up screaming, crying, or with symptoms of intense anxiety), nightmares, sleep apnea (temporary disorientation upon waking), and nocturnal bruxism (teeth grinding).

What are the causes of sleep disorders in children with autism?

Biological

The causes of sleep problems can be attributed to the same factors believed to be involved in the development of autism spectrum disorders: genetic abnormalities and abnormalities related to neurotransmission and hormones, especially melatonin.

Medical

Autism spectrum disorder (ASD) can be accompanied by other medical conditions, such as epilepsy and digestive disorders, which are known to negatively affect sleep. Similarly, anxiety disorders and ADHD are common in autism and may also be associated with poor sleep quality. In addition, many medications prescribed for these comorbidities have stimulating effects and can disrupt sleep.

Behaviors and Habits

Before establishing a daily routine with the child, which involves ending daytime activities and transitioning to nighttime ones, interrupting engaging or stimulating activities can be difficult. If this transition is accompanied by protests, tantrums, and crying, agitation occurs, which prevents sleep. Difficulties in emotional regulation in autistic children do not contribute to the calming process, and communication difficulties hinder the understanding of parental needs. It is also worth noting that the bright screens of televisions, cell phones, and tablets, with which children often play before bed, inhibit the release of sleep-related hormones and can contribute to sleep difficulties.

How to deal with sleep problems?

Behavior change

The first step is to develop good sleep habits, sometimes called "sleep hygiene." This involves activities that help the child fall asleep and prevent them from waking up. Common practices include ensuring the child's room is adequately cool, dark, and quiet. It is worth paying special attention to aspects of the child's environment that may stimulate or hinder sleep, especially in the context of sensory disorders (e.g., tactile hypersensitivity—the texture of bedding and pajamas).

It is helpful to introduce rituals that calm and prepare the child for sleep. There are no universal solutions: what may be calming for one child may be extremely stimulating for another. A good example is bath time, which relaxes some children while stimulating others to play energetically. It is important that rituals are easy to learn and repeat every night. They can be reinforced with techniques derived from therapeutic interventions, such as an activity plan, visual cues, reinforcement of desired behaviors, or sleep-related stories.

Electronic devices that emit light, mentioned earlier, should preferably be turned off during nighttime activities; it is recommended to avoid using them shortly before bedtime. If a game or a story is a good way for your child to calm down and relax, it is important to ensure that the screen brightness is kept to a minimum.

Medication

If lifestyle changes are ineffective or difficult to implement without medication, drug interventions remain an option. It is important to emphasize that before a child begins taking medication to treat sleep disorders, it is crucial to ensure that the underlying cause is not more serious. Remember, sleep disorders can result from comorbidities or the medications used to treat them.

What about sleep duration?

When discussing sleep in children with autism, it's worth mentioning a topic that has been debated for years: what are the recommendations for sleep duration? It is not yet determined whether these guidelines are similar to those for typically developing children. It is possible that children with autism need fewer or more hours of sleep. Research generally agrees that children with autism (from age 3 to adolescence) sleep less, on average, than their typically developing peers. However, it is unclear whether this is beneficial for them. Some question the feasibility of establishing general guidelines on the appropriate duration of sleep for children with autism, believing it to be a highly individual matter.