Wednesday, September 3, 2008

Even James Must Sleep

I recently promised a reader that I would write post about sleep strategies. There is a little irony in me writing this as I am a terrible sleeper myself, but one need not be good at something to teach about it, I guess. I have worked through this issue with many parents over the years so I will share what I can.

Overview

1. Sleep problems may require a medical solution rather than a communication solution (an alternative way of communicating with your child) or a behavioral solution (systematically training a new skill), so consult a doctor who is experienced with children who have autism if the following information is not enough. Don't jump straight to medication, though, without trying to teach your child how to sleep.


2. A communication solution often works because there is information about sleeping that your child does not have and can't learn in a typical way--that is by listening and watching. This information might include the following: that sleep is not dangerous, that parents are close by (including exactly where), that sleep is a routine that happens in a particular way every night, and that going to bed is not negotiable.

3. After this information has been successfully communicated, you need to make a commitment to teaching whatever bedtime routine you choose. Teaching the routine may take a few nights of dedicated and determined effort.

The Problem

Learning to sleep in a socially conventional manner requires a number of skills that are challenging for children on the autism spectrum. Sleep can be frightening or at least confusing for a child who can't ask and would not understand a verbal explanations for dreams, for the creaking sound that the furnace makes, the reason that baby brother cries and receives mom's attention at 2:00 pm, why grandpa gets up to use the bathroom every night but does not intend to stay up and so on. We typically tell and show a child how to sleep but your child may not understand what you say as these are complicated things to understand. Your child may not be persuaded by your logic. Compounding the social/communication challenge, there may be sensory or neurological differences that make sleeping even more scary or confusing. You may need to help your child find a way to cope with these differences.

Solutions

Rather common suggestions to counter some of the inherent scariness of sleep, include leaving a night light on, providing white noise to cover up other noises, putting a weighted blanket on your child so that he or she is able to feel his or her body more clearly and know where he or she is in space. For a child who sees toys and gets up to play, a goodnight blanket over the toys might help. For a child who stays up when he goes to the bathroom, a piece of blue painter's tape from the bed to the toilet can help clarify the route he or she is suppose to take in two directions. For a child who wants to visit with mom at night, a talking button that has a picture of mom's face on it and her voice recorded saying I love you. Go to sleep. For a child who loves Thomas the Train more than anything, a story that involves trains might do the trick--Even James the Train must sleep at night, and you must sleep like James!

The most common helpful strategy of all is to create a really good bedtime routine. Helping your child learn to calm and relax his or her own body and mind while getting ready for bed often requires a bedtime routine that has consistent sensory components. Create a bedtime routine that involves all the senses and occurs in the same order and time frame every night. Example:

1. Warm, fragrant herb tea with honey (stimulating the sensory systems of taste & smell. Also drinking something that is only consumed before bed is a clear beginning to a bedtime routine)
2. Brush Teeth (taste stimulation and also important after honey)
3. Kiss and hug family members and say goodnight (visual, auditory, proprioceptive stimulation)
4. Bedtime song, story, prayer or all three (auditory input and can be unique to bedtime if the song, story or prayer is only said at that time)
5. Back rub (tactile, proprioceptive stimulation and calming)
6. Goodnight to the parent or adult who tucks your child in (clear ending to the bedtime routine)

More Do's and Do Not's

Do Not: Lay beside your child after the last goodnight if you don't want to sleep with your child for the next several years. I must confess that I slept next to my kids for years. I didn't mind that much and looking back, it is a very sweet memory. But, I hear more frustrated moms tell me that they are upset because a child does not let me leave the bed and so I must mention that you can leave the bed if you want to and if you really want your child to learn to sleep without you beside him or her, you need to leave the bed at the same time in the routine each night. This seems to be more a mom trap than a dad trap as I have yet to meet a dad who is willing to stay after he decides the bedtime routine is over. If need be, let dad take over the bedtime routine for a while to get through this hurdle.

Do Not: Let bedtime routine grow longer or vary once the steps are set, even for illnesses, vacations, weekends. It can be helpful to vary the person who puts your child to bed though (if this is an option) because this variation might happen from time to time and you want your child able to sleep when this happens. Also, very lovely and loving parents have been known to get crabby and need a break.

Do: Use visuals supports (pictures). Make a visual schedule (hand drawn or with photographs or with pictures pulled from online) and show your child the bedtime routine each night for a while, crossing off the steps as you do each part of the routine. If your child seems fearful at night, write a story and draw pictures or take a photographs so that you can show your child where you will be and where other family members will be while he or she sleeps. Explain anything else that you suspect is frightening to your child with pictures. Use simple and calming language in this story. E.g. You are safe in this house. Daddy locks the doors. Not: Bad guys can't get in because I lock the doors at night and I would punch anybody in the face if he did come in anyway.

Do: Think about how you can help your child become progressively more relaxed and calm over the course of the evening. Provide meals and baths and quiet calming bedtime play early enough that these will not spill over into the time set aside for a bedtime routine. While horseplay with dad or siblings is wonderful and to be encouraged, don't do this right before bedtime if it seems to get your child too wound up. For some children, bath time is quite energizing and should happen two hours before bedtime or in the morning. Turn off the T.V. and computer at a set time each night. Call this Family Time, or Quiet Time or something neutral and don't relate turning off these machines to bedtime. Some children do fall asleep watching a video and this is fine if this is part of your routine and works to calm your child. But children can become very upset about having to stop a preferred activity in order to go to bed and it is better not to make bedtime seem like a punishment by making it right after the computer is shut off.

Do: Schedule 1/2 hour for bedtime routines and make the routine begin and end at the same time each night. Even if you have a shorter bedtime routine, schedule this much time so that you won't expect to be done faster. Someone once said, Disappointment is the fruit of unrealistic expectations. If you expect to pull bedtime off in ten minutes and your child is not able to calm and prepare for sleep that quickly, you will become stressed and compound the difficulty with your frustration.
It Can Be Rocket Science

You might need help to get a good bedtime established but good sleep habits are a lifetime gift and worth the effort both for your sanity and your child's well-being. The behavioral part to teaching bedtime routines include not inadvertently rewarding your child for tantrums or other undesirable behavior. If you have two adults involved in problem solving a habitually difficult bedtime, one should watch carefully while the other carries out the bedtime routine. The watcher's job is to see if the other is actually rewarding undesirable behavior. Even really capable parents get blinded by the emotional dynamics and don't realize that, for example, that last hug a child begged for and got was the wrong move when the last goodnight had already been said. Parents are tired at night, as well, and cave for short term relief even though they know it is not the best thing to do. A little support can help a parent overcome bedtime difficulties. Sometimes, a parent will tell me all about bedtime-hell one week and have the solution mostly accomplished before we meet again and before I have given any suggestions at all. I just needed to get a little more strength of will is the most common explanation for this. No parent is really accountable to me but if they want to use me for a little borrowed courage and determination, I am happy to provide this. Certainly there is someone out there ready to help you if you look around. Don't hesitate to consult a professional if you need help or borrow the wisdom and courage from another parent of a child with ASD who has mastered the Bedtime Routine.

Please read Dr. Kidd's comment below for more great sleep strategies and information.


Link to Blog on Sleep Program for children with ASD
Link to a night light that might really be helpful for a child with ASD



Note: Photo is from flickr

5 comments:

Dr. Larson Kidd said...

Tahirih is absolutely correct in sharing with you how important it is for your child (and you!) to sleep. People with ASD and other neurobehavioral disorders often experience much more stress in their daily lives. This impacts their brain's ability to process, and therefore, to learn and live happily. Sleep is the known way that we evolved in order to perform the higher thinking functions that we do. During sleep, we relive and integrate much stimulus we experienced during the day, and this is essential to learning and maturing. This doesn't happen without sleep. Additionally, sleep is necessary for your body's immune system to work well, which is a-whole-nother-blog!
What I have also found to be very helpful to children on the spectrum in sleeping besides what Tahirih offered you are these things: Play music that is 60 beats per minute or less for 15 minutes while your child is preparing for bed. If you need help locating music like this, you can get anything from the Baroque genre, George Winston's piano music, or Google it. Play the same music at the same time everynight for at least three weeks to "train" the brain and body to respond to it in a calming way. Pair this time with the calming activities Tahirih mentioned such as hugs and reading books. Soon, the music alone will serve as the cue to relax and be in the sleep ready state. Try this for yourself to experience how it works if you like! The other important strategy to help kids with ASD sleep involves sensory dysfunction. Once, a child described to me that when he lies down in the bed, he feels as if he is floating and then to close his eyes-well that is just too scary! That insight was very helpful and to counteract this, use heavy blankets, tuck the child in if they like, use lots of pillows to surround the child, and/or throw a lead blanket on top of their bedding. It also needs to be cool enough to do these things, so keep the temperature in the child's room around 68 degrees if possible. There are also physiological reasons why this low temperature helps trigger your brain for sleep. Melatonin supplements have helped some children too-for more information on that, go to Autism Research Institute. I would definitely endorsed trying all of these things before ever going to a medication due to the ease of dependency build up. But the bottom line is--if the child isn't sleeping more than 7 hours a night, the child must get the sleep somehow. Thanks for letting me add my two to three cents!!
Dr. Susan Larson Kidd

Serene said...

Saying to consistently leave after the last goodnight is something I wished I had known as a frustrated teenage babysitter!

Michelle said...

These tips are great! After 6 years of not getting sleep, we finally resorted to medication. It was by far the best thing that ever happened to our family! It is, of course, a last resort, but not one to feel badly about if it becomes necessary. Once my son started getting a full nights sleep (instead of 4-5 hours), he stopped having wild mood swings and was much, much less violent. The rest of the family was much happier, too!

Tahirih said...

This has been the experience of many families that I know. There are certainly biological challenges that make sleep for children with ASD and even this week one of the children that I see was like a different child after one week of sleeping--thanks to a medication. There is no shame in it and the other tips her and in Dr. Kidd's comment section are good to try even if medication is part of the solution.

Anonymous said...

Very well written and helpful. Kudos and thank you!