Sleep Interventions for Children with Autism Spectrum Disorder​

Introduction 

About 2.3% of children are diagnosed with autism spectrum disorder (American Psychiatric Association, 2022). The effects and co-occurring disorders that come with autism spectrum disorder (ASD) not only affect the children diagnosed but also their families (Stores & Wviggs, 1998). Finding solutions to sleep disorders in children with ASD can help relieve stress that the child and the family face (Stores & Wviggs, 1998). Education in this area of research would positively impact families who are affected by sleep disorders and autism spectrum disorder and have not yet been guided to possible solutions.  

In the first section of the paper, I will describe the early research on autism spectrum disorder. I will review the changes in institutions and help surrounding ASD, the early study of sleep disorders, and the start of research experiments on children with ASD. In the second section of this paper, I will examine the effects of physical and behavioral interventions and how they impact sleep disorders in children with ASD. In the third section of this paper, I will examine melatonin medication interventions and how they impact sleep disorders in children with ASD. In the fourth section of this paper, I will review combination treatment interventions and how they compare and impact sleep disorders in children with ASD.  

Origins of Research on Autism Spectrum Disorder and Sleep Disturbances 

The earliest studies of Autism date back to the 1930s (Evans, 2014). Research surrounding autism spectrum disorder (ASD) grew in the United States after institutions for the “mentally retarded” began closing down in the 1950s and 1960s (Evans, 2014). The mass closure of institutions that housed people with mental disorders, psychosis and autism affected public policy surrounding the care that people with ASD are provided (Evans, 2014). 

In 1994, autism was officially recognized as a spectrum disorder (Caruso, 2010). In 2000 the IACC, the Interagency Autism Coordinating Committee was established and in 2006 the Combat Autism Act was passed (Caruso, 2010). This act allowed for the expansion of federally funded research on ASD.  

Children with autism spectrum disorder face many challenges such as challenges with social interaction and communication. Children with ASD face sleep problems including, sleep onset latency, the total time it takes to transition from weakness to sleep, more nighttime wakings, and shorter duration of sleep (Cann et al., 2023). The symptoms of sleep disorders can exacerbate ASD and vice versa (Cann et al., 2023). Sleep disturbances and their related symptoms are likely to be present before the age of 8 in children with ASD (Richdale & Prior, 1995) and are associated with higher stress and irritability in parents, leading to poorer quality of life for parents and children (Cann et al., 2023; Stores & Wviggs, 1998).  

Sleep disorders can be linked to biological reasoning, due to children with ASD having reportedly abnormal melatonin and serotonin (5-HT) levels, and it is theorized that these abnormal levels are what cause the biological differences that affect sleep and categorize sleep disorders by the physical inability to achieve successful sleep habits in children with ASD (Cann et al., 2023; Stores & Wviggs, 1998). Another biological standpoint includes the recognition of the sleep/wake cycle being linked to circadian rhythm, and issues with circadian rhythm being a biological indicator for sleep disturbances (Richdale & Prior, 1995; Stores & Wviggs, 1998). With these biological considerations in mind, early research focused on the underlying specific sleep related differences in children with autism.  

Knowing that sleep disorders can exacerbate the symptoms of ASD and vice versa, (Cann et al., 2023) studies have researched if differing levels of intelligence quotient (IQ) affect sleep disorders in children with ASD (Richdale & Prior, 1995; Stores & Wviggs, 1998). Children with ASD were placed into IQ groups split into < 55 and > 55 and studied during sleep (Richdale & Prior, 1995). Findings displayed both IQ groups had sleep disorder symptoms of longer sleep onset latency, longer periods awake at night and had overall less sleep per night compared to their control group, but no difference between IQ groups (Richdale & Prior, 1995).  

Ornitz et al. (1968) studied the auditory evoked responses of children with ASD during REM sleep. This study measured Auditory Evoked Response (AER) and eye movement bursts, and ocular quiescence through a Wave N2 system (Ornitz et al., 1968). Children with ASD were selected through the diagnostic criteria of severe disturbances under the nature of speech, perception, motility and developmental rate (Ornitz et al., 1968). Children with autism have increased auditory responsiveness during REM bursts and reduced sensory inhibition during sleep which means they are more sensitive to sounds and more prone to distractions to wake them up during sleep (Ornitz 1968). It is correct to say that while children with ASD suffer from sleep disorders on a more biological scale than children without ASD, the difference in IQ between these two groups is less of a factor than the biology.  

Physical and Behavioral Interventions 

Children with ASD have evidence of higher levels of cytokines in their brains, a protein involved in brain function, and cognitive and emotional processing. This is evidently linked to the sleep problems in children with autism (Ansari et al. 2021). Physical activity (PA) interventions aim to support the physical and biological side of sleep disorders in children with ASD by displaying a focus on these cytokines (IL-1b and TNF-a) and circadian rhythm(Ansari et al., 2021). To decrease the cytokines and positively impact sleep, children with ASD were assigned aquatic therapy for 60 minutes twice weekly (Ansari et al., 2021). Post-intervention blood samples showed a decrease in the cytokines as well as an improvement in sleep habits based on parent reports from the Child Sleep Habit Questionnaire (CSHQ). The Child Sleep Habit Questionnaire (CSHQ) is provided to caregivers of the children in the study to record results and observations during the study (Ansari et al., 2021; Ip et al., 2024; Papadopoulos et al., 2022). The CSHQ is helpful in understanding the differences in sleep disorders on an individual child basis. Unfortunately, the study from Ansari et al., should be viewed cautiously because the sample does not include both boys and girls.   

Aquatic interventions (Ansari et al. 2021; Liang et al. 2024) are one of many different PA interventions used for sleep disorders in children with ASD. PA interventions also include karate, running, and basketball (Liang et al. 2024). PA interventions aim to regulate circadian rhythm in ASD, and they showed significant improvement in sleep continuity (Liang et al., 2024). Aquatic therapy interventions showed improvement in bedtime resistance, sleep duration, and night wakings (Ansari et al., 2021; Liang et al., 2024). Other PA interventions such as running, karate, and basketball address the regulation of circadian rhythm in children with ASD (Ansari et al., 2021; Liang et al., 2024). Any study involving children will be difficult to manage. Researchers must understand the importance of parental consent and child awareness during the study. While CSHQs are helpful, they do include a bias in the results of any study that uses them because they are parent-reported.  

Behavioral interventions aim to address sleep disorders from the inside out. This intervention focuses more on behavior and emotional issues compared to physical activity. Though structured differently, all behavioral interventions aim for behavioral change and clinician advice to aid in sleep disorders in children with ASD (Ip et al., 2024; Papadopoulos et al., 2022). The “Sleeping Sound intervention” is a specialized style of behavioral intervention for sleep disorders in children with ASD. These sessions operate with two fifty-minute in person sessions and a follow-up phone call two weeks after the second session (Papadopoulos et al., 2022). In the sessions, clinicians focus on assessing the specific type and the suspected cause of the child’s sleep difficulties, as well as work with the parent and child to create a tailored sleep management plan (Papadopoulos et al., 2022). In-person sessions occurred over a two-week period, while other interventions operate for seven or more weeks (Ip et al., 2024; Papadopoulos et al., 2022). Tele-health intervention sessions operated over a seven-weeks and involved group sessions (Ip et al., 2024). These sessions were ninety-minutes and conducted by a clinician to groups of caregivers with children with ASD and sleep disorders (Ip et al., 2024). Following these tele-health sessions, bi-weekly fifteen-minute individual phone calls were conducted to touch base and offer any additional assistance (Ip et al., 2024). The focus is for the clinician to educate the parent about ASD and common sleep problems children may be facing as well as offer advice for behavioral changes (Ip et al., 2024). CSHQ scores showed improvements in sleep onset delay and bedtime resistance and improvements in behavioral and emotional problems (Ip et al., 2024; Papadopoulos et al., 2022) and effects from this study remained significant at 6 months post study (Papadopoulos et al., 2022).  

Melatonin Interventions 

Melatonin interventions are used to gain information on sleep and medication-related processes that can positively affect sleep habits in children with ASD (Hayashi et al., 2021; Malow et al., 2011).  The focus of melatonin studies is to improve sleep onset latency in children with ASD (Hayashi et al., 2021; Malow et al., 2011). Melatonin interventions aim to improve bedtime resistance, night wakings, and sleep duration (Cortesi et al., 2012; Tse et al., 2024). Melatonin, when administered to children with ASD is distributed in doses of 1mg, 2mg, 3mg, 4mg, 6mg, or 9mg (Cortesi et al. 2012; Hayashi et al. 2021; Malow et al. 2011). None of the studies included had melatonin doses over 9mg. Within studies melatonin doses were sometimes increased from 1mg to 2 or 4mg after a minimum 7-day period, or doses were increased by 3mg over a 3-week period (Hayashi et al., 2024; Malow et al. 2011). Melatonin was given to the children at approximately 9pm or ranging from 45 to 30 minutes before bedtime (Cortesi et al., 2012; Malow et al., 2011; Hayashi et al., 2021; Tse et al., 2024). Melatonin was effective in improving symptoms such as sleep onset latency (Cortesi et al. 2012; Hayashi et al. 2021; Malow et al. 2011; Tse 2024), and bedtime resistance, sleep duration, and night wakings (Cortesi et al. 2012). Results show that the sleep onset latency in children with ASD decreased with melatonin doses, and that children responded best to 1mg or 3mg of melatonin compared to the higher doses (Malow et al., 2011; Hayashi et al., 2021).   

Melatonin Combination Interventions 

Melatonin interventions, when combined with other intervention styles operated as single-blind, randomized control trial studies (Cortesi et al. 2012; Tse et al. 2024). When melatonin interventions were combined with other interventions, the goal was to compare each and determine the effectiveness between them. Children were split into groups of melatonin only, cognitive behavioral therapy (CBT) only and CBT and melatonin combined. CBT sessions combined with melatonin treatment sessions were conducted with children receiving a dose of 3mg of melatonin and 50-minute weekly CBT sessions. The CBT sessions focused on sleep cognition and aimed to change any dysfunctional thoughts and attitudes about sleep (Cortesi et al., 2012). While both melatonin and CBT were effective in their own way, when combined they were the most effective (Cortesi et al., 2021). 

Melatonin and physical therapy when combined showed a significant improvement in children’s sleep habits. Physical activity specifically cycling was compared to melatonin doses and a combination of cycling and melatonin doses (Tse et al., 2024). Improvements were shown in sleep onset latency and sleep efficiency (Tse et al., 2024). To obtain these results, children were monitored with an actigraph. An actigraph is a physical watch device used to measure movements to evaluate sleep patterns, sleep disorders. Melatonin studies displayed important results and appropriate p values that shows melatonin has a strong effect on the improvement of sleep disorder symptoms in children with ASD.  

Conclusion 

Research provides complete results and information regarding how sleep interventions affect children with ASD. These studies target different ages of children, and most include both male and female participants. They focus on the parents/caregivers to ensure that a full scope of biology and behavioral/emotional needs are met. Melatonin medication interventions appear to be the most beneficial for children with sleep disorders however, there are physical and behavioral options available for those who chose not to use medication. This information is ready to be given away to the public, but that does not mean that research stops here. The furthering of research on sleep interventions in children with ASD will make this area of research much stronger. Information and research about interventions for sleep disorders in children with ASD can be given away to the public in many different forms. The most successful ways would likely be in community and school presentations. Presentations would display information educating about ASD and sleep disorders and include the different interventions available. Presentations, as well as workshops in schools for parents would be helpful in providing education about sleep interventions in children with ASD. Presenting research and giving away psychology information to the public likely will always come with some risk, but the reward for educating and helping people to solve their problems, assist their childs needs, and better their family will always be greater.

Professional Application

"This project has prepared me for my career because I wish to become a School Psychologist. I enjoyed researching about sleep disorders and children with autism spectrum disorder. This has given me a lense for the kinds of struggles children with ASD may be having that I would not be aware of in a school setting. It has inspired me to continue to grow in myself and grow in my interest in research." - Madison Suk '26

For Further Discussion

This serves as an overview of the project and does not include the complete work. To further discuss this project, please email Madison Suk. 

Course Overview

PS 401: Integrative Capstone for Psychology and Behavioral Neuroscience Majors is the capstone course for Psychology and Behavioral Neuroscience seniors only. It consists of extensive readings of original research, theory and history on a topic selected by the student under the guidance of the professor. A senior thesis, written according to departmental standards, is a central part of the requirement..

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