Autism, ADHD, and Sleep
Sleep problems are common among children and adults with autism or attention-deficit/hyperactivity disorder (ADHD). While those with autism spectrum disorder or ADHD may be more commonly affected by sleep disorders and other sleep challenges, a lack of sleep can exacerbate symptoms of autism or ADHD. However, with healthy sleep habits and treatment, sleep problems and the daytime challenges they present may be alleviated or eliminated.
What is Autism?
Autism, also known as autism spectrum disorder, is a developmental disability. It affects how children and adults engage socially. Those affected by autism may struggle to communicate with others, have poor nonverbal communication, and face struggles with social skills. People with autism may have difficlty with reasoning and planning and have intense, narrow interests. Sensory sensitivities and motor skills may also be affected.
Who it affects
Autism is primarily diagnosed in children. One out of every 68 children is affected by autism or a related disorder. However, in the past, autism was estimated to have a prevalence of one out of every 2,000 children. Today, autism is more prevalent than childhood diabetes or breast cancer. Families that include a child with autism are 15 to 20 percent more likely to have another child with autism.
Although autism is often considered with regard to children, the disorder also affects adults. Adults with autism may have grown up aware of how the disorder affects them. Children do not outgrow autism, but can have improved outcomes with early diagnosis and intervention. Adults may be diagnosed later in life as they recognize symptoms, particularly those with high-functioning autism.
How it is diagnosed
There is no medical test, such as a blood test, for autism spectrum disorder. Autism is diagnosed with a combination of developmental screening and diagnostic evaluation. Developmental screening tests children to identify potential delays. For example, a pediatrician will ask parents questions and interact with a child during an exam to observe the child. These screenings typically occur at 18 months and 24 months, but may include nine months, 30 months, and additional screenings, especially if a child is at a high risk for autism spectrum disorder.
A comprehensive diagnostic evaluation is called for if a doctor sees signs of autism spectrum disorder during a developmental screening. This assessment is typically performed by developmental pediatricians, child neurologists, child psychologists, or child psychiatrists. They will review the child’s behavior and development and interview the parents. This evaluation may include hearing and vision screening, genetic testing, neurological testing, and other medical testing.
Symptoms of autism spectrum disorder include:
- Language delay or loss of language skills
- Little to no interest in playing games, such as peekaboo
- Little to no eye contact
- Difficulty or lack of interest in establishing peer friendships
- Preferring to play alone
- Difficulty regulating emotions
- Lack of empathy
- Difficulty understanding body language and tone of voice
- Difficulty starting or continuing a conversation
- Repetitive use of language, such as repeating a phrase over and over
- Difficulty interpreting humor
- Intense focus on detail, such as parts of toys rather than the whole toy
- Sensory sensitivities
- Repetitive behaviors including hand flapping, jumping, twirling, arranging objects, or body rocking
- Above average intelligence
- Ability to remember detail and information for long periods of time
- Visual and auditory learning strengths
The autism spectrum
Autism spectrum disorder is referred to as a spectrum because there is a wide range of symptoms, skills, and disability levels. Some people on the autism spectrum are severely disabled by their symptoms, while others have minor impairment. In 2013, the American Psychiatric Association merged four previously separate diagnoses under autism spectrum disorder: autistic disorder, childhood disintegrative disorder, pervasive developmental disorder-not otherwise specified, and Asperger syndrome.
How autism is treated
As each child or adult with autism is uniquely affected by the disorder, treatments for the disorder are tailored to specific needs. Treatments typically include behavioral therapy and may include medicine. Early intervention is particularly beneficial and focuses on social skills, language, communication, play, motor skills, daily living, and play skills.
How autism impacts sleep
Children, adolescents, and adults with autism are more frequently affected by sleep problems than people without the disorder. Sleep disturbances are one of several medical and mental health issues that may accompany autism, including gastrointestinal disorders, seizures, ADHD, anxiety, and phobias.
What is ADHD?
ADHD is a disorder that affects an individual’s ability to focus, control impulses, and maintain appropriate movement. It is a brain disorder that interferes with functioning or development. Executive functioning skills are impacted, including concentration, attention, memory, impulsivity, organization, and social skills. ADHD is mostly a result of genetics and is caused by chemical, structural, and connectivity differences in the brain.
Who it affects
ADHD is one of the most common mental disorders affecting children. An estimated 5 percent of children have ADHD and it affects boys more commonly than girls. Risk factors for ADHD include genetics, exposure to environmental toxins, cigarette smoking, alcohol, or drug use during pregnancy, exposure to environmental toxins at a young age, low birth weight, and brain injuries.
ADHD also affects many adults. An estimated 2.5 percent of adults have ADHD. Symptoms of the disorder can continue through adolescence and adulthood. Adults with ADHD may not realize they have the disorder.
How it is diagnosed
ADHD is usually identified in school aged children when they have trouble with schoolwork or behavior in the classroom. Symptoms can appear as early as three to six years of age. In preschoolers, hyperactivity is the most common ADHD symptom. Teachers or school staff may identify behavior and learning problems in school aged children with ADHD. Most children affected by ADHD will receive a diagnosis while they are in elementary school. However, there can be delays in diagnosis with children who are quiet and well behaved, as symptoms can be mistaken for emotional or disciplinary struggles.
ADHD is diagnosed with a comprehensive evaluation by a pediatrician, psychologist, or psychiatrist. Diagnosis includes behavior and symptom rating, interview, observations, and a comprehensive history review. Diagnosis may include comprehensive neuropsychological and psychoeducational testing. This testing is not necessary to receive a diagnosis, but it can be helpful in understanding the unique brain profile of each person with ADHD and may be useful for receiving accommodations in school and the workplace.
Symptoms of ADHD include:
- Inability to give close attention to details, tasks, or play activities
- Careless mistakes in schoolwork or other activities
- Losing focus and failing to finish schoolwork, chores, or duties
- Being forgetful or easily distracted
- Often losing things such as keys, glasses, phone, pencils, or books
- Avoiding or disliking tasks that require extended mental effort, such as homework
- Not listening when spoken to
- Excessive talking and activity
- Trouble taking turns
- Interrupting conversations or blurting out answers preemptively
- Feeling restless, leaving seats or climbing in inappropriate situations
- Frequent fidgeting of the hands or feet, squirming
- Inability to stay quiet when appropriate
- Low self control
- Rash decision making without concern for long term effects
ADHD vs. ADD
The terms ADHD and ADD (attention deficit disorder) are often used interchangeably. ADD was the diagnostic term used in the Diagnostic and Statistical Manual (DSM) released in 1980, but in later revisions, the diagnosis name was changed to ADHD. The term ADD now typically refers to cases where inattention is the primary presentation. Typically, an individual who has inattentive and impulsive behaviors, but isn’t hyperactive, will be diagnosed with ADD. Individuals with inattentive, impulsive, and hyperactive behaviors will be diagnosed with ADHD.
How ADHD impacts sleep
Evidence has shown that individuals with ADHD are affected by sleep disorders more commonly than others. In fact, children with ADHD are two to three times more likely to have sleep problems. These problems can include restless legs syndrome (RLS), periodic limb movement disorder (PLMD), sleep disordered breathing (SDB), and circadian rhythm sleep disorders such as delayed sleep phase disorder. With inadequate sleep, ADHD symptoms including hyperactivity, impulsivity, and behavioral problems can be amplified. People with ADHD may suffer sleep problems due to difficulty settling down in the evening, stimulants (including stimulant medication used to treat ADHD), and co-existing conditions such as anxiety and depression.
How ADHD is treated
ADHD treatment options include behavioral therapy, medications, and accommodations and interventions. Behavioral therapy is typically the first option for treatment, especially for children under the age of six. Behavior therapy helps individuals with ADHD learn new behaviors to replace behaviors that cause problems or don’t work. For children with ADHD, parents will receive behavior training as well, learning how to teach, guide, and manage behavior.
Medications for ADHD include stimulants and nonstimulants. Stimulants are more fast acting and are effective for 70 to 80 percent of children. However, they can interfere with healthy sleep. Nonstimulants have been approved for treating ADHD since 2003. They can last up to 24 hours, but do not work as quickly as stimulants. Finding the right medication and dose can require some trial and error, as medications can affect children and adults with ADHD differently.
The Difference Between Autism and ADHD
Autism and ADHD can look very similar. With both conditions, children can have trouble focusing and interacting with other people and be active and impulsive. In fact, many children receive an ADHD diagnosis first and are later diagnosed with autism. In some cases, children have both conditions, but in others, the diagnosis of ADHD is incorrect, and the child actually has autism. It’s believed that up to half of children with autism also have ADHD.
Although autism and ADHD share similar symptoms, they are separate disorders and have their differences. The most marked difference is in social interaction. While children with ADHD may struggle to maintain relationships due to impulsive and abrupt behavior, those with autism struggle with empathy, humor, communication, and social engagement.
Is it Autism, ADHD, or a Lack of Sleep?
The symptoms of sleep deprivation can be similar to the symptoms of ADHD and autism. These are some of the symptoms of sleep deprivation, autism, and ADHD that could be mistaken for one or another condition. Children with sleep problems are more likely to be impulsive, hyperactive, inattentive, and display oppositional behaviors.
|Impaired concentration||Difficulty regulating emotions||Difficulty concentrating|
|Impaired attention||Sensory sensitivities||Difficulty focusing on finishing work|
|Hyperactivity||Careless mistakes or missed details|
|Impulsive behavior||Forgetfulness, easily distracted|
|Low self control||Losing things|
|Careless mistakes or missed details||Feeling restless|
|Stubbornness||Low self control|
Rash decision making
Common Sleep Disorders for Children and Adults with Autism or ADHD
Children and adults with autism spectrum disorder or ADHD are more frequently affected by some sleep disorders. These include insomnia, sleep disordered breathing, sleep related movement disorders, and circadian rhythm disorders.
|Sleep disordered breathing||Sleep disordered breathing|
|Sleep related movement disorders (RLS and PLMD)||Sleep related movement disorders (RLS and PLMD)|
|Circadian rhythm disorders||Circadian rhythm disorders|
|Daytime sleepiness||Daytime sleepiness|
|Lower percentage of REM sleep||Anxiety about bedtime|
|Waking during the night|
|Delayed sleep phase disorder|
Insomnia is difficulty falling asleep, staying asleep, and getting restful sleep. People with insomnia may take an hour or more to fall asleep. Insomnia can also make it difficult to stay asleep for a full restful night. Instead, people with insomnia toss and turn and may be easily woken up throughout the night. Without a good night of rest, it can be difficult to wake up in the morning and lead to daytime drowsiness.
More than half (56 percent) of children with autism spectrum disorder suffer from insomnia. Children with autism often fall asleep later, wake up more during the night, and wake up either very early or very late.
Up to 15 percent of children with ADHD suffer from some form of insomnia, and 50 percent of adolescents with ADHD have insomnia. It can be difficult for people with ADHD to get their mind to stop racing at night, or they can get a sudden burst of energy before bed.
Sleep related movement disorders
Sleep related movement disorders include restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). With RLS, sufferers have an irresistible urge to move their legs to relieve the tingling sensation associated with RLS. This often happens while sleeping or resting. PLMD is sudden limb movement experienced during sleep. This movement occurs periodically and can wake sufferers from sleeping.
Sleep disordered breathing
Sleep disordered breathing is a spectrum of breathing abnormalities in sleep. These include snoring and sleep apnea. Snoring, with or without sleep apnea, is noisy breathing during sleep that can cause difficulty sleeping for bed or room partners. Sufferers may feel tired upon waking and experience symptoms associated with a lack of restful sleep. Those who suffer from sleep apnea experience recurrent airway obstruction during sleep and frequently awaken or arouse to breathe. Sleep apnea increases mortality risk.
Sleep disordered breathing affects a quarter of people with autism. One third of people with ADHD are affected by sleep disordered breathing. About 40 percent of people with ADHD are obese, which is a risk factor for sleep apnea.
Circadian rhythm disorders
Circadian rhythm disorders, particularly delayed sleep-phase disorder may affect people with autism or ADHD. Delayed sleep-phase disorder occurs when a person’s circadian clock is not aligned with normal patterns of sleeping and waking. With this disorder, children and adults go to sleep later and wake up later than most other people. This typically results in daytime sleepiness.
Children with autism may not fit the traditional diagnostic criteria for circadian rhythm disorders. For example, a child with autism may go to sleep later or have bedtime resistance, and then wake up multiple times in the night. Children with autism may be more affected by circadian rhythm disorders because circadian timing relies on social cues that they typically have a decreased awareness of. In children with autism, 54 percent experience bedtime resistance problems, 45 percent morning arising problems, and 31 percent daytime sleepiness.
Improving Sleep to Improve Symptoms
A lack of sleep can make symptoms of autism and ADHD more difficult, especially those that overlap with sleep deprivation. These can include difficulty regulating emotions, sensory sensitivities, difficulty concentrating, difficulty with attention, forgetfulness, careless mistakes, feeling restless, and low self control. If your child is struggling with sleep and experiencing these symptoms, getting a better night’s sleep may improve their symptoms. In fact, studies suggest that some children with ADHD can eliminate attention and hyperactivity issues by treating sleep problems.
Sleep Improvement Tips for People with Autism or ADHD
Cognitive behavioral therapy (CBT) is typically the first approach to managing difficult sleep symptoms in children and adults with autism or ADHD. These include sleep restriction with a strict bedtime and wake schedule and light therapy with artificial light that can re-synchronize an individual’s circadian cycle.
Experts recommend an assessment of underlying medical problems for people with autism or ADHD that suffer from sleep disturbances. Medical issues that affect sleep can include tonsillitis, adenoids, gastrointestinal disturbances, and seizures. Individuals should also be screened and treated for sleep disorders including sleep apnea, restless legs syndrome, and periodic limb movement disorder.
In addition to CBT and investigation of medical problems and serious sleep disorders, improving sleep habits can treat and improve the symptoms of difficult sleep in children and individuals with autism and ADHD.
|Establish a routine||Sensory cues and needs||Communication cues||Behavioral||Ignoring||Scheduled awakening|
|Aromatherapy||Visual prompts||Bedtime change||Gradual|
|Eye pillow||Visual sequence||Sleep restriction||With parental presence|
|Massage||Reward charts||Gradual parent distance|
|Weighted quilts and pillows||Visual cue cards|
- Evaluate food and drink: A key component of good sleep occurs well before bedtime: food and drink. What people with autism and ADHD consume during the day can affect sleep at night. Avoid high levels of sugar or caffeine, especially close to bed time. Reduce or eliminate consumption of foods with serotonin close to bedtime, which can reduce anxiety and support feelings of happiness and calm, but may interfere with healthy sleep. Foods with serotonin include nuts, cheese, and red meat.
- Create a healthy sleep environment: A calm and comfortable sleep environment is essential for good sleep, especially people with autism or ADHD. Keep the room cool, dark, and quiet, and eliminate visual stimuli in the room that may be distracting. Encourage family members to stay quiet while others are sleeping. Electronics should be kept out of the bedroom and the bedroom should be used only for sleep. Bedrooms should have little light exposure, and some people will need blackout blinds and covers for the bottom of doors to block out light effectively. White noise machines should be considered. Certain textures may relax or disturb individuals with autism or ADHD. Sheets and pajamas with scratchy material or distracting elements such as sequins or ruffles should be avoided.
- Consider light stimulation: Light stimulation before bed can interfere with healthy sleep, signaling to the brain that it’s still daytime although it’s night and time to go to bed. Be especially cautious about light stimulation in the hour before bed, particularly from bright lights, video games, or television. Consider using a lower strength bulb in rooms where the bedtime routine is followed, such as in the bathroom, hallway, and bedroom. Conversely, it can be helpful to expose individuals with autism and ADHD to light in the morning upon waking. This signals the brain that it’s morning and time to wake up.
- Exercise regularly: An active day can lead to a more peaceful night for people affected by autism or ADHD. Both children and adults should have physical exercise or playtime most days of the week to use energy and fall asleep more quickly. Brain stimulation with work or school, and social interaction can also use energy and make sleep come more easily.
- Develop a bedtime routine: Individuals with autism or ADHD typically do well with established routines and consistency, and this extends to bedtime as well. Establish a bedtime routine with a regular sleep and wake schedule. Spend time every evening before bed preparing for sleep in the same way, including pre-bedtime activities such as brushing teeth, taking a bath, massage, reading a book, and putting on pajamas. Repeating this routine nightly helps to signal the brain that it’s time for bed and, with time, can induce sleepiness and rest. In children, following a bedtime routine can reduce bedtime resistance and teach them to relax and prepare for sleep.
- Wake gently: If you’re responsible for waking a child with autism or ADHD, take care to wake them up calmly. Traditional alarms may be too harsh and spark irritability in individual affected by autism or ADHD. Start the day off with calm by taking a gentler approach, this can include opening curtains or blinds to let light in, soft touches, low voices, or a gradual alarm that slowly gets louder.
- Be consistent: Healthy sleep habits thrive on consistency, especially for those affected by autism or ADHD. Each day and night, you should stick to your sleep routine. Although it’s tempting to loosen sleep schedules and other habits on the weekend, doing so can be disruptive and interfere with sleep patterns. Stay consistent seven days a week to maintain a healthy sleep pattern.
- Consider non-drug therapies: Aromatherapy with calming essential oils including lavender, vanilla, chamomile, and sandalwood can aid in better sleep. They can be diffused or dabbed on a cotton ball and placed inside a pillowcase. A heavy weighted blanket can provide comfort and calm an overactive nervous system.
Sleep Treatment Options for People with Autism or ADHD
When behavioral therapy and healthy sleep routines do not alleviate difficult sleep symptoms in individuals with autism or ADHD, doctors will typically consider other treatments. These include pharmacotherapy and even surgery.
Melatonin may be used to help induce sleep. It is a naturally produced hormone that helps to regulate the sleep-wake cycle. With melatonin supplements or agonists, some people are able to manage sleep issues. It can be administered in toothpaste form for children who have difficulty swallowing pills.
In children with autism, 85 percent of children who received melatonin to improve sleep had improved sleep or eliminated sleep concerns. However, 13 percent continued to have sleep problems, and 1 percent had worse sleep.
Sleeping pills may be used to treat insomnia in individuals with autism or ADHD. However, research has yet to confirm whether sleep medication is helpful or safe as a long term treatment option for insomnia for people affected by autism or ADHD.
For those with sleep apnea, surgical treatment may be considered. In children, removing the tonsils or adenoids can relieve apnea. In adults, a similar procedure, uvulopalatopharyngoplasty, can be used to remove and/or remodel tissue in the throat, including removing tonsils and adenoids.
What is Autism?
- Centers for Disease Control and Prevention: Autism Spectrum Disorder
- National Institute of Mental Health: Autism Spectrum Disorder
- Autism Speaks: What is Autism?
- Autism Speaks: How is Autism Treated?
- Autism Center of Excellence: What is Autism Spectrum Disorder?
What is ADHD?
- Centers for Disease Control and Prevention: Is it ADHD?
- Centers for Disease Control and Prevention: Attention-Deficit/Hyperactivity Disorder
Is it Autism or ADHD?
- Harvard Health Blog: Is it ADHD — or Autism?
- Riley Children’s Health: ADHD and Autism: Understanding the Differences
- ADDitude Magazine: Is it ADHD or Autism? Or Both?
Autism and Sleep
- Journal of Neurodevelopmental Disorders: The Relationship Between Sleep and Behavior in Autism Spectrum Disorder
- Sleep and Autism Spectrum Disorder
- Journal of Pediatric Neurosciences: Autism and Sleep Disorders
- Sleep Research Society: Sleep Behaviors and Sleep Quality in Children with Autism Spectrum Disorders
- Current Sleep Medicine: Sleep in Autism Spectrum Disorders
ADHD and Sleep
- National Sleep Foundation: ADHD and Sleep
- CHADD: ADHD, Sleep, and Sleep Disorders
- Sleep: Sleep Disorders and Daytime Sleepiness in Children with Attention-deficit/Hyperactive Disorder
- Touch Neurology: The Relationship Between Attention-deficit Hyperactivity Disorder and Restless Legs Syndrome