By Michael A. Goldberg, Ph.D. & Julia Berkman, Ph.D.
Child & Family Psychological Services, Inc., Braintree, Holliston, Norwood, MA
Studies find that approximately 73% of children with Asperger’s Syndrome (AS) experience sleep problems, and these problems tend to last longer in this group than they do for children without AS. For example, children with AS are more likely to be sluggish and disoriented after waking. Laboratory research has begun to describe the unique physiological presentation associated with sleep problems in children with AS, including disruptions in the sleep stage most associated with cognitive functioning (i.e. REM or Rapid Eye Movement sleep). In addition to physiological differences, some of the sleep difficulties in this population may be related to anxiety.
The impact of poor sleep is unequivocal. Poor sleep negatively impacts mood and exacerbates selective attention problems commonly found in children with AS, as well as impairing other aspects of cognitive function.
There is no one panacea to manage sleep problems in children with AS. However, there are many interventions that are likely to be helpful. In general, parents need to understand and be prepared for resistance to change that these children often show. Parents should also be prepared for problems to get worse before they get better as children often initially challenge but then gradually become accustomed to new routines.
A good place to start an intervention targeted at improving sleep is changing lifestyle behaviors and environmental conditions that can influence sleep/wake patterns. These include exercise, napping, diet, and aspects of the bedroom and sleep routine.
The goal is decreasing arousal as bedtime approaches. To achieve this it may be useful to have a scheduled period before bedtime (approximately 30-45 minutes) in which the aim is calmness and relaxation. During that period, media such as television, computers, electronic games, and music should be limited as they can stimulate the child through activity, sound, and light. The availability of VCR and DVR technology makes it easier to control when children can watch particular shows, thereby avoiding conflict over missing favorite programs that are shown in the late evening. The presence of televisions in children’s bedrooms has been consistently associated with sleep problems and should be avoided at all costs. Likewise, computer access in a child’s bedroom is discouraged for sleep as well as for safety reasons.
In general, exercise during the day is associated with better sleep. However, exercise within 2-4 hours of bedtime can lead to difficulties in falling asleep, as it can disrupt the natural cooling process of the body that leads to rest at night. Having the child soak their body, particularly their head, in a calm bath that is as warm as can be tolerated 90 minutes before bedtime may be useful too. When the child gets out of the bath, core body temperature will drop rapidly; this is believed to help them to fall asleep faster. Using a waterproof pillow and avoiding the pulsation associated with showers is recommended. The use of progressive muscle relaxation, deep breathing and imagery exercises is the most widely researched treatment for insomnia in children and may be useful for children with AS as well.
Controlled and limited (e.g. 20-30 minutes) napping is generally positive. However, longer daytime sleeping can be negative in that it makes it more difficult for the child to fall asleep at the ideal time in the evening. If the child’s sleep problems are associated with falling asleep, which is common for children with AS, it is advisable to avoid daytime napping.
It is recommended that children with sleep problems avoid all caffeine, alcohol, tobacco, high fat food, and monosodium glutamate (MSG). In contrast, food rich in protein may promote better sleep. Large meals within 2-3 hours of bedtime should also be avoided. A small carbohydrate/protein snack, such as whole wheat bread and low-fat cheese or milk before bedtime can be helpful to minimize nighttime hunger and stimulate the release of neurochemicals associated with falling asleep. For children who often wake during the night to use the bathroom, and then have trouble falling back asleep, limited fluid intake in the 2 hours prior to bedtime is also recommended.
Melatonin is a natural brain hormone associated with sleep onset. There is some evidence that natural production of melatonin may be reduced in AS children. While melatonin supplements may be useful, a common side effect may be increased sluggishness in the morning. As discussed above, this is already a common problem for children with AS. Use of melatonin and other alternative remedies should be discussed with a physician.
It is important that the bed and the bedroom are associated with sleep and are not associated with activity. When children have sleep problems, it is highly recommended that their bed and bedroom activity be limited to sleep only. It is important to make sure that extreme changes in temperature are avoided during the night. Increasing light is associated with decreases in the release of the neurochemical melatonin which triggers sleep onset. Thus, it is important to get the sunlight flowing in the child’s room as soon as possible in the morning. Conversely, darkening the room at night is critical. When a child’s fear of the dark is an issue, behavioral psychotherapy may be necessary. We also recommend moving the clock so that the child is not watching the time while lying in bed.
Setting and maintaining a regular time to sleep and wake may be critical. Parents often make the mistake of allowing their children to sleep much later on non-school days to “make up” for sleep. While this may be useful to a certain extent, allowing the child to sleep late in the day makes it difficult for them to fall asleep at an ideal time later in the evening. It is easier to wake a sleeping child then to force an alert child to go to sleep. Thus, we recommend that you keep your child on a regular schedule on non-school days and avoid drastic changes in the time that the child wakes. Likewise, having your children go to bed when they are not tired conditions them to be awake in bed. It is recommended that you let your children stay up until they are tired while maintaining their waking time in the morning. Then once they begin falling asleep within 10 minutes of going to bed, begin to move bed time earlier by 15 minutes at a time.
With carefully monitoring and patience, many parents can make changes in a child’s life that promote better sleep. Improved sleep supports better mood, sustained attention and general health. However, for many families professional consultation is often necessary to design or maintain the appropriate intervention. When you need help, speak with other parents of AS children about their experiences and ask your primary care doctor for referrals to a sleep expert.