ATN Sleep Strategies Document for Teens

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1 ATN Sleep Strategies Document for Teens Sleep problems-- either trouble falling asleep, staying asleep, or early morning waking, are common problems in teens with Autism Spectrum Disorders (ASD). There are some sleep problems that may be more likely to arise during the teenage years. There are some causes of sleep problems which need further evaluation and treatment from a sleep specialist. However, in many cases, there are steps that can be used by parents and teens to develop better sleep habits. This handout was designed for teens with autism and their caregivers. A key strategy that is helpful for all teens with sleep difficulties is to improve sleep hygiene (sleep habits). This can mean changes to the teens sleep setting (where they fall asleep at night). Other changes may include how much a parent gets involved with helping their teen fall asleep or return to sleep after waking during the night. The steps below were developed with teens in mind. The following ideas are based on both research and clinical knowledge of sleep experts. These ideas may help your teen get a better night s sleep. The areas to consider include the following: 1. Where does your teen fall asleep at night? Ensuring a comfortable sleep setting 2. Keeping regular bedtime habits 3. Keeping a regular schedule 4. Focus on age-appropriate sleep practices 1. A comfortable sleep setting Choose a bedroom for sleeping and minimize other activity in this room. Keep the bedroom at a comfortable temperature (less than 75 degrees). Keep the bedroom quiet after bedtime. Some people find it easier to fall asleep with white noise or background low, quiet sound like a ceiling fan. Fall asleep in a quiet bedroom. Don t have your teen fall asleep with music, the television or a computer on. Keep the bedroom dark at bedtime. (a nightlight in the room is o.k.) Use heavy curtains on the windows to block any outside light this room receives at night. Only use the bed for sleeping. Avoid studying, reading, playing video games, and watching television in bed. 1

2 If you find an activity is distracting (such as books, games, computers, telephones, television) for your teen at bedtime or at times of night waking, remove them from the room. Teens with ASD may be more aware of noises at night that do not bother other children. Things such as water running or other household noises can affect sleep. Teens with ASD may be more sensitive to things like textures of bedding and pajamas. Try to find out if this affects your child (for example, does your teen prefer loose pajamas over tight pajamas, or light over heavy covers?) 2. Keeping regular bedtime habits Bedtime habits that are short and expected are the basis for a good sleep routine. A good routine improves relaxation at bedtime and makes getting ready for sleep go more smoothly. The routine should include activities that are calming and relaxing such as soothing music, reading or listening to someone else read. A consistent relaxing routine can be calming. The routine should be started 30 to 60 minutes before bedtime but should not be more than 60 minutes. The minutes before bed should be considered a wind down time. It is vital that the routine be followed each night. The more regular the routine from one night to the next, the easier it will be for your teen to fall asleep. The following are some helpful Dos and DON Ts to guide the routine prior to bed: Avoid eating or drinking things that contain caffeine 3 4 hours before bedtime. (This would include things like coca cola, coffee, tea, chocolate.) Avoid exercise, rough play, computer games and television viewing during the hour before bedtime. Don t go to bed hungry. A light snack before bed is good (carbohydrates such as cheese and crackers, or fruit) Avoid heavy meals within an hour or two of bedtime. Keep the lighting in the room dim in the hour before bed End the bedtime routine in the bedroom. These are some simple tips about the bedtime routine: a. The routine can include: bathing/showering, getting dressed for bed, brushing teeth, soft calming music, reading, or listening to someone else read. b. For some teens the use of a visual schedule or to-do list (for example, pictures, words, or both of the routine in order) may help remind them of each step. The visual schedule helps to reinforce the consistency and timing/order of events that make up the bedtime routine. A visual schedule can also assist others who provide care for your teen at bedtime. c. When making the schedule, find out which evening events are calming and which events are stimulating. Calming activities should be part of the bedtime routine. 2

3 Events that are stimulating should be moved to an earlier time in the evening. For example, if bathing/showering is stimulating rather than relaxing, move this event to an earlier time in the evening. 3. Keeping a regular schedule As much as possible (given the changes that go along with daily life), keep a consistent bedtime and wake time for your teen that is the same for every day of the week (including weekends). As your teen goes through puberty, there are changes in the biologic clock which is an internal clock that helps us go to sleep at a certain time at night, and wake up at a certain time in the morning. This internal clock becomes delayed during puberty. This change in the internal clock results in later bedtimes because teens do not feel sleepy until later in the evening compared to younger children. The delay in the internal clock also makes teens feel more tired and less likely to wake up early in the morning compared to when they were younger. The bedtime should be one that works well with your family s evening schedule to help with a routine that is the same each night. Remember that it is common to get a second wind in the hour before bedtime. This may lead to problems falling asleep if bedtime is too early. If your teen takes more than an hour to fall asleep, think about putting off bedtime by 30 minutes to 1 hour to try to help with sleep. Bedtime should always be set to allow enough sleep each day. Teens are more likely to stay up later and sleep in later. This later time shift may be even more marked on weekends. Work with your teen to set a schedule that will allow them to get enough sleep each night. The average teen needs about 9 ½ hours of sleep each night. Here are some ideas for keeping a regular sleep-wake schedule: Wake up at a consistent time on weekdays and weekends (no more than 1 hour difference between week and weekend). Open curtains upon waking to get morning sunlight Spend time outside each day during daylight hours. Morning light exposure is very important because it helps to keep your body s internal clock on track. Exercise regularly; it can help your teen sleep more soundly. Avoid napping. If your teen is very sleepy and napping is necessary, he or she should nap for no longer than 30 to 45 minutes in the early afternoon (no later than 4:00 p.m.). Eat meals at regular, consistent times Avoid bright light exposure in the evening hours after sundown. 3

4 4. Focus on age-appropriate sleep practices In many cases teens with autism have learned to fall asleep independently and sleep in their own bedrooms. However, developmental, behavioral, and or medical challenges may have prevented your teen from learning to fall asleep on his or her own. It is important to learn the skill of self-soothing and falling asleep without help. It is normal to wake up several times each night. For individuals that are able to fall asleep on their own, each time they wake up, they briefly check out their sleep environment and then quickly go back to sleep. These wakings are so brief, that they are not aware in the morning that they woke at all. However, if you can t fall asleep alone, then each time you wake up, it is hard to fall back asleep without help. It is never too late to try and teach these skills to your teen. If your teen learns to fall asleep alone, then he/she will also be able to learn to fall back asleep at times of natural night waking, and wake more rested in the morning. If your teen is not able to fall asleep alone, you need to slowly teach him/her to do this. You may find techniques in parenting books about sleep. The idea of these techniques is that over time (usually 1-3 weeks) you give your teen the message that you are still present but reducing your contact at bedtime. If you usually stay with your teen when he/she falls asleep at bedtime, you could change your pattern by following this example: Sit on the bed for a few nights Then sit in a chair beside the bed. Continue sitting in the chair, but move it farther from the bed each night until you are out of the room and out of visual contact with your teen and out of the bedroom While you are making these changes, reduce the amount of attention you pay to your teen such as talking, facial expressions, or eye contact Once you are out of your teen s bedroom, if he/she is upset and not sleeping, you can wait a few minutes, and then go back into the room to check. When you go into the room, make it a brief visit (less than a minute) and only give limited physical or verbal contact (for example,. a quick hug). Gently but firmly say something like It is time for bed. You are OK. Good night. and then leave the room. If you need to go back into the room, wait longer each time and keep the visit brief Once your teen is able to fall asleep alone, you can use these same techniques to teach how to fall asleep if he/she wakes in the night, or before wake time in the morning. If your teen with autism is able to understand about bedtime passes (as described below), you can try this method to teach him/her to self-sooth at night. This method is for teens who wake up many times at night. This can be a card that your teen gives you if he/she wakes at night. It can be traded for something brief, such as a quick hug or a drink of water. Your teen should be taught that they may only use the pass one time, and that once the pass is used, it will be given to you. You will return the pass to the teen the following night to use again for one time during the night. Your teen should also be taught that if the pass isn t used all night, it can be used for a morning present. You can also give the teen who is functioning at a younger age level, similar to a younger aged child, a sticker 4

5 that can be used for a present once a certain number of stickers (e.g. five) have been earned. The presents can be dollar-store items or a special outing with you. Conclusion Sleep problems are common in children and teens with ASD. Many teens with ASD, similar to typically developing teens, will respond to changes in sleep hygiene as described above. In fact, children and teens with ASD may respond to some of these methods easier than typically developing children and teens, because of their need for routines and rituals. If you cannot stick to these steps or his/her sleep remains disturbed, you should talk to your teen s doctor to find out if a meeting with a sleep specialist is needed. Acknowledgement: This document was developed by Kelly Byers, Psy.D, CBSM, Associate Professor of Pediatrics at Cincinnati Children s Hospital with the input of Shelly K. Weiss, MD, FRCPC, Child Neurologist at the Hospital for Sick Children (SickKids), University of Toronto, Toronto, Ontario, Canada and Beth Ann Malow, MD, MS, Neurologist and Director of the Sleep Disorders Program of Vanderbilt University, Nashville Tennessee, as a product of the Autism Treatment Network (ATN), a program of Autism Speaks. The valuable assistance of the members of the ATN Sleep Disorders Subcommittee in reviewing this document is gratefully acknowledged. (February 2010) The bedtime pass concept was developed by Dr. Patrick Friman. 5

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