Sleep problems in
Annotation
autism: prevalence,
cause, and
intervention
Amanda L Richdale* PhD, Lecturer in Psychology,
Department of Psychology and Intellectual Disability
Studies, RMIT, Bundoora, Victoria, Australia, 3083.
*Correspondence to author at above address.
Autism, Asperger’s disorder (AD), and pervasive develop-
mental disorder not otherwise specified (PDDNOS) are com-
monly referred to as ‘autistic spectrum disorders’ (ASD)1 and
are classified as pervasive developmental disorders (PDD) in
the fourth edition of the Diagnostic and Statistical Manual on
Mental Disorders (DSM-IV)2. Deviant and delayed develop-
ment in social and communication skills and the presence of
restricted routines and interests, and stereotypic behaviours
are variously present in ASD2,3. The majority of children with
autism have an intellectual disability (ID) while those with
AD do not2.
Sleep problems are among a number of secondary behav-
ioural difficulties which may occur in children with autism2,
but little is known about their occurrence in AD or
PDDNOS. Seigel4 comments that ‘autism is not uncommon-
ly related to disturbances of sleep’ (p 292). Sleep problems
are reported to differentiate young children with autism
from those with other disabilities, particularly retrospective-
ly5,6. Nevertheless, Rapin and Katzman7 comment that the
‘Study of the prevalent and troublesome sleep disorders of
autism has barely started’ (p 8). Additionally, studies of sleep
difficulties in children with an ID indicate that such prob-
lems can be a source of stress for families8, particularly when
children have autism9.
This paper reviews sleep problems in children with
autism and addresses the issues of aetiology and interven-
tion. Reference to AD and PDDNOS is also made. To set the
nature of these sleep difficulties in context, brief reviews of
sleep problems in typically developing children and children
with an ID are provided.
Sleep problems in typically developing children
The establishment of a mature sleep–wake rhythm is a devel-
opmental phenomenon. The infant moves from the polypha-
sic pattern of the newborn infant to a longer night sleep with
two daytime naps around 3 months of age, gradually reduc-
ing to one nap per day during the latter part of the first year.
By 3 to 4 years the daytime nap is abandoned. Factors which
entrain the sleep–wake rhythm include the light–dark cycle,
and regular events in the child’s environment related to feed-
ing and social activity. Sleep ‘problems’ are common in child-
hood and may be defined as a sleep behaviour that is
60 Developmental Medicine & Child Neurology 1999, 41: 60–66
disturbing in some way to the child, the child’s family, or
both; and is distinct from a sleep ‘disorder’ which implies an
underlying abnormal physiological function10.
There are a range of sleep problems which occur in chil-
dren: settling difficulties and night waking are common in
infancy and the preschool years, with around 30% or more of
children in this age group reported to have problems11,12.
During this period, nightmares, confusional arousals, and
night terrors also begin13. During middle childhood, sleep
improves considerably, with only a small percentage of chil-
dren still experiencing or developing sleeping difficulties14,15.
Studies suggest that difficult temperament, fearfulness, and
anxiety may also be associated with sleep problems14,16,17.
Usually, behavioural interventions13,18, or progressive
rescheduling of the sleep–wake cycle19 can be successfully
used to treat sleep problems in typically developing children
such as settling difficulties and night waking. However, there
is little research on treatment of the parasomnias13. There
are a number of recent reviews10,20,21 of sleep problems in
children and their treatment.
Sleep problems in children with an ID
There is still little research concerning sleep difficulties in
children with developmental disabilities. However, while
the available literature is considerably less than for typically
developing children, there are a number of recent studies
which document the frequency and type of problems
found8,23–26. In her review, Johnson22 reported that 34% to
80% of children with an ID have a sleep problem, suggesting
that such children are likely to have ‘unique factors’ (p 674)
which contribute to their sleep problems. As for typically
developing children, problems are more common at
younger ages8,23,24.
The majority of sleep studies in children with an ID con-
sider mixed-disorder groups and the cause of the disability is
known for some children, but not others. Typically, studies
investigate children with more severe levels of ID. The fre-
quency with which sleep-onset and sleep-maintenance prob-
lems occur is considerably higher in children with an ID than
in typically developing children, and sleep problems appear
to be associated with more difficult and problematic behav-
iours8,23,24,26 and communication difficulties8,24. The latter is
likely to be important for the comprehension of social cues
and daily routines which influence the establishment of an
appropriate sleep–wake rhythm. Little is known about the
parasomnias in these children, but rates appear to be low9,26.
Stores27 suggests that sleep problems in children with an
ID may vary with aetiology. Studies of sleep problems in spe-
cific disorder groups support this notion. For example, those
with Prader–Willi syndrome suffer from excessive daytime
sleepiness, excessive night sleep, and REM-sleep abnormali-
ties28; girls with Rett syndrome have problems with night
waking, early waking, short night sleep, and increased day-
time napping with problems worsening with age29, and chil-
dren with Down syndrome suffer from sleep apnea30, with
about two-thirds of children exhibiting settling difficulties,
and around a fifth, more severe night-waking problems31.
Other groups with severe sleep difficulties associated with
sleep onset and maintenance include those with tuberous
sclerosis32 and Sanfilippo syndrome33. There are recent
reviews of the literature in relation to sleep difficulties associ-
ated with specific disorders27,34.
The causes of sleep difficulties in children with an ID are
likely to be related to specific aetiological factors which
result in impairment in either or both the control and main-
tenance of sleep processes. Additionally, behavioural diffi-
culties, particularly severe communication problems, are
likely to affect the development and maintenance of appro-
priate sleep–wake routines. Thus, as previously defined,
sleep ‘disorders’ and/or sleep ‘problems’10 may be present in
this group.
Sleep problems in children with autism
Studies of children with an ID have suggested that sleep
problems are associated with autistic behaviours8,23 and that
children with autism may suffer from sleep problems more
frequently than other groups of children with an ID26,35.
Rates of 56%23, 65%36, and 68%26 for sleep difficulties in chil-
dren with autism have been reported, with more variable
sleep patterns when compared with typically developing
children36. Reported rates of occurrence for sleep problems
in other specific disability groups have ranged from 40 to
58%26 to 44 to 71%8. In two separate studies, groups contain-
ing children with mixed diagnoses exhibited sleep problems
at rates of 31%26 and 83%8. However, while there were no
children with autism in the former group, it is not known
whether any children with autism were in the latter. Patzold
et al.37and Richdale and Prior38 found that between 44% and
83% of children with autism had a sleep problem. Rates dif-
fered according to whether the problem was reported to be
current or past. Altogether, 89% of a group of higher-func-
tioning children had a current sleep problem and/or had one
in the past38. Comparing rates of sleep problems within dis-
ability groups, sleep problems occur in autism as much as or
more than those reported for other groups, particularly chil-
dren with Down syndrome.
The high rate of reported sleep problems in children with
autism appears to occur at all IQ levels, including those who
do not have an ID36–38 and those with AD who appear to have
sleep problems which are qualitatively similar to those in
children with autism37. Also, given that AD has only recently
been recognized in the DSM-IV2 it is likely that some of the
higher-functioning children with autism included in earlier
studies would now be given a diagnosis of AD. Studies which
include children with PDDNOS have not been reported,
although it was found that sleep problems in a group of chil-
dren with PDD, but no diagnosis of autism, did not differ
from those of children with autism35.
In other disability groups, children with sleep problems
are typically those with more severe levels of ID, although the
preliminary results of Richdale et al.9 suggested that, in gener-
al, sleep problems in children with an ID were not significant-
ly associated with level of ID. The question as to whether the
lack of a relation between sleep problems and intellectual
ability in autism is due to factor(s) specific to the disorder can-
not be answered at present as there appears to be little report-
ed concerning sleep problems in those children with mild to
moderate levels of ID and other disabilities. Patzold et al.37
reported no substantial relations between sleep and IQ in
either their autism or control groups, but analysis of their
data by IQ group alone showed that children with a low IQ
were more likely to exhibit night waking.
Studies of sleep in children with autism have generally
reported severe problems associated with sleep onset and
maintenance. Irregular sleep–wake patterns, problems with
sleep onset, poor sleep, early waking, and poor sleep rou-
tines have been found at all developmental levels, with
increasing severity at lower developmental levels36.
Additionally, shortened night sleep, alterations in sleep
onset and wake times, night waking39,40, and irregular sleep
patterns (with the presence of a free-running rhythm in one
case40 ) have been reported.
In a recent sleep diary study, children with autism particu-
larly under 8 years of age were likely to exhibit severe sleep
problems, including long sleep latencies, night waking,
early-morning waking, and shortened night sleep. These dif-
ficulties improved with age, but older children still slept less
at night and tended to have long sleep latencies. Those with
higher IQ had more severe current sleep problems38. In a fol-
low-up study37 similar difficulties were found, with the
exception of early-morning waking, though the children
with autism were more likely to wake spontaneously in the
morning. Sleep difficulties were not related to IQ, and while
there were some improvements with age, older children still
exhibited sleep problems. Similarly, using a sleep question-
naire, Schreck35 found a greater frequency of dyssomnias in
children with autism, as compared with children with an ID,
children with specific developmental problems, and typical
children. However, reduced sleep length was not found. This
conflict in findings may be due to differences in methodolo-
gy between the latter and two diary studies.
Unusual sleep routines may also be disruptive in that
sleep problems are likely to occur when the conditions for
the routine are not met. Unusual routines for settling to
sleep have been noted in children with autism41. A more spe-
cific investigation showed that the children with autism had
unusual and problematic sleep routines compared with a
control group of children, though the frequency of sleep
routines was similar for both groups37.
There is little data concerning the parasomnias in autism.
Inclusion of questions relating to sleepwalking, sleeptalking,
and nightmares in two diary studies indicated that the inci-
dence of these problems was low, and did not differ from
those of children in comparison groups37,41. Conversely,
Schreck35 included questions specific to the parasomnias
and found that children with autism were more likely to
Annotation 61
exhibit parasomnias than were other children in her study. In
particular nightmare behaviours, sleepwalking, and bruxism
were reported to be increased.
As for children with an ID, more difficult daytime behav-
iours have been reported to be associated with sleep prob-
lems in children with autism36. Richdale and Prior38 reported
that while there were no correlations between difficult
behaviour and sleep problems, a current sleep difficulty was
associated with more energetic and excited behaviour dur-
ing the day. However, Patzold et al.3 found significant associa-
tions between more problematic daytime behaviour as
measured on the Developmental Behaviour Checklist
(DBC)42 and sleep problems, while in their comparison
group, a higher score on the autistic relating scale of the DBC
was associated with a shorter night-sleep length. Schreck35
reported that both abnormalities of communication and
social interaction were related to the presence of parasom-
nias while, more specifically, apnea and bruxism were relat-
ed to communication problems.
It appears that children with autism have a specific con-
stellation of sleep problems, particularly in relation to onset
and maintenance. Problems occur at a high frequency and
are more severe than those found in typically developing
children and many children with other developmental dis-
abilities. There are also associations between problematic
behaviours and sleep problems, and more energetic daytime
behaviour and sleep problems. Sleep difficulties occur at all
levels of intellectual functioning. These findings suggest that
sleep difficulties are related to some particular deficits found
in children with autism, rather than to an impairment in
intellectual functioning per se.
Aetiology of sleep problems in autism
The cause(s) of these sleep problems is not known.
Associations between sleep disturbances and: (1) difficult
daytime behaviour; and (2) communication difficulties, sug-
gest that these may be fruitful areas of inquiry. However,
these two factors are probably interrelated. Sleep studies
also refer to overactive behaviour, waking spontaneously in
the morning, and being energetic, together with evidence of
less night sleep in children with autism. These behaviour
descriptions do not appear to be consistent with the usual
effects of sleep loss, which may be expected to result in low-
ered energy levels and irritable behaviours. However, there
may be some relation between poor routines, including
sleep, and difficult behaviours.
A relation between social and communication difficulties
and sleep problems is possible35,38,41. The sleep–wake cycle
is a circadian rhythm and there is evidence to suggest that, as
well as the light–dark cycle, humans use social cues to
entrain circadian rhythms43,44. Routine and social cues are
thought to help young infants develop stable sleep–wake
patterns with the longest sleep occurring during the night
hours. Children with a primary social-communication deficit
may therefore find it difficult to use such cues to entrain their
rhythms, resulting in problems with their sleep–wake sched-
ule. A similar argument is also put forward by Johnson22.
For a subgroup of children with autism, the underlying
cause of the sleep difficulties may be related to production of
melatonin. Melatonin’s major physiological role relates to
the synchronization of bodily rhythms to photoperiodic
information45. It is thought to assist in phase-setting the cir-
62 Developmental Medicine & Child Neurology 1999, 41: 60–66
cadian pacemaker46, and is also important in the regulation
of sleep45,47. The association between the sleep and mela-
tonin rhythms, and the relation between alterations in the
synchronization of the melatonin rhythm and the presence
of sleep problems have been noted47. There are recent
reviews regarding melatonin and its relation to sleep and
psychiatric disorders45,47.
Synthesis of melatonin begins with the essential amino
acid tryptophan, reported by some to be either elevated48 or
reduced49 in children with autism. The neurotransmitter
serotonin is generally reported to be elevated in about a
quarter7 to a third or more50 of children with autism and is
further along this synthetic pathway. However, the relation
between altered blood levels of these compounds and brain
synthesis of serotonin or melatonin respectively has yet to be
clearly established. While Chamberlain and Herman52 first
suggested that melatonin regulation may be abnormal in
autism, there have been few studies of melatonin levels.
Daytime elevation53, decreased amplitude54, and lack of
night-time elevation55 have been reported. Children in the
latter study were also reported to have sleep difficulties.
Alterations in the melatonin rhythm may be responsible
for sleep-onset and maintenance difficulties in autism, with
the speculation that those with sleep-onset problems may
have a melatonin rhythm which peaks later in the night,
while reduced rhythm amplitude may be related to night
waking and early-morning waking41. Others have also sug-
gested that abnormalities in the melatonin rhythm may be
related to the sleep problems found in children with
autism7,37. The issue of melatonin regulation and its possible
relation to sleep disturbance in children with autism certain-
ly warrants further investigation.
While melatonin is also postulated to assist in synchroniz-
ing other rhythms to the light–dark cycle, there is no evidence
to support a general problem with the synchronization of cir-
cadian rhythms in children with autism41,51. However, sleep
problems in autism may be related to a greater sensitivity to
changing photoperiod, with sleep problems and sleep length
changing in relation to the seasons. Thus it would be hypoth-
esized that sleep length would be longer in the winter
months37,41. Such an hypothesis may also explain anecdotally
reported periodicity in behaviours, including sleep difficul-
ties, in children with autism. This has yet to be tested.
Given that many children with autism wake spontaneous-
ly and sleep less compared with other children, and given
the associations between daytime activity and problematic
sleep, a further hypothesis regarding sleep difficulties may
be a relation with arousal factors. Early literature on chil-
dren with autism suggested that they may be either hyper- or
hypoaroused56–58 and stereotypical behaviours are hypothe-
sized to serve an arousal function. Problems with sleep
onset and maintenance may therefore relate to arousal fac-
tors38, with a need for less sleep related to heightened
arousal41. A relation between disturbed night sleep and the
need to alter stimulation through stereotypical behaviour
has also been suggested22.
Anxiety is a prominent feature for many children with
autism and autobiographical reports include feelings of fear
and anxiety59,60. Anxiety may cause insomnia in both chil-
dren and adults10 and adversely affect sleep61. Children with
autism have been found to have significantly higher DBC
anxiety scores than comparison children37 and a relation
between psychosocial factors and sleep problems in children
with an ID has been suggested27. Therefore, fears and anxi-
ety may also significantly contribute to sleep problems in
children with autism, particularly in more-able children who
may be more likely to think deeply about any fears.
A further area of interest with regard to sleep difficulties in
children with autism is the sleep EEG, but studies are limit-
ed. Ornitz et al.62 reported that there were no EEG abnormal-
ities, but later studies suggested an immaturity in the EEG
pattern of REM-sleep episodes and eye movements63,64, with
immaturity in sleep spindles in non-REM sleep63. More
recently Elia et al.65 reported a higher REM density with
fewer REM clusters in a group of adolescents with autism.
These findings suggest that there may be developmental dif-
ferences in sleep EEG in children with autism. Considered
together with the known sleep problems, further EEG stud-
ies appear warranted. Sleep EEG measurements in conjunc-
tion with melatonin administration would be of particular
interest. Melatonin has been reported to increase stage-2
sleep, decrease stage-3 and -4 sleep, and to alter REM-sleep
latency in adults without autism66.
A final area of interest is the relation between brain
pathology and sleep problems in children with autism. The
site of any brain pathology in autism has not been definitively
identified. Reviews regarding brain pathology can be found
in Bauman and Kemper67. Some recent studies have suggest-
ed that abnormalities may occur in the cerebellar vermis68,
the limbic system69,70, and in the Purkinje cells of the cerebel-
lum69,70. Any relation between these putative sites and sleep
problems appears to be unexplored, and speculation is
beyond the scope of this review.
Intervention for sleep problems
While we may still only speculate about the cause, there is
now sufficient evidence to show that children with autism
are highly likely to suffer from severe sleep disturbances.
Sleep disturbances are also stressful for families8 and should
not be viewed as an inevitable consequence of autism.
Effective intervention strategies are required. Thus the pres-
ence of sleep problems must be perceived by both clinicians
and researchers as an important and potentially stressful
behaviour which requires intervention. Wiggs and Stores71
reported that less than half of parents of children with a dis-
ability and a sleep disorder received help. Medication was
the most prevalent form of help, though parents viewed
behavioural interventions as more helpful. Just over half of
the parents wanted help; the remainder had declined for rea-
sons unspecified. Interventions may be based upon tech-
niques which are known to be effective in other groups of
children, but should also be informed by an analysis of the
sleep behaviour and the postulated cause(s) of the problem.
Interventions which should be explored include: (1) behav-
ioural interventions; and (2) interventions related to the circa-
dian regulation of the sleep–wake cycle, including melatonin,
light therapy, and chronotherapy.
No sleep intervention should begin without appropriate
and thorough history-taking. One requires both parental
description of the problem and baseline data in the form of a
diary kept for a minimum of 1 week. As parents typically
remember the worst aspect of the child’s sleep, a history
alone is unlikely to determine sufficiently the nature and
extent of the problem10. Our data have shown that while chil-
dren with autism have, both by description and diary report,
severe sleep problems, there is considerable inter- and intra-
individual variation37,38. Some parents also anecdotally
describe what appear to be cyclical changes in sleep. Thus,
before appropriate interventions can be formulated one may
need to collect data both at the time of presentation, and at a
later period, to determine what factors may precipitate
cycles of poor sleep.
Behavioural interventions have been shown to be effec-
tive in treating daytime behavioural difficulties in children
with autism72,73 but reports of the effectiveness of such inter-
ventions for sleep problems are rare and large-scale studies
do not appear to exist. Some authors have suggested that
behavioural interventions are effective for children with a
disability and sleep problems10,19, including those with
autism22. Families of children with an ID and sleep problems
find behavioural interventions preferable to medication71,
and effective and acceptable74. Strict and appropriate bed-
time routines also appear to be important in the establish-
ment of less problematic sleep patterns in children with
autism37,38. In some cases, medication may be required in
conjunction with behavioural intervention18. Behavioural
programmes for sleep problems in children are typically
based upon parents developing appropriate bedtime rou-
tines for their children and ignoring their child’s cries for
attention in a systematic way. The choice and effectiveness of
the various approaches will be subject to individual child and
family variables18. There are two single case-study reports of
successful behavioural interventions for sleep problems in
autism75,76.
More recently, a comparison of two behavioural interven-
tions for sleep problems in a group of 14 children, most of
whom had severe or profound levels of ID and other behav-
ioural problems, included three children with autism77. One
group of seven children, including two with autism, was
treated using a faded bedtime (gradually changing bedtime)
with response cost (removal from bed to prevent sleeping)
and significant improvements were found in five children.
One child with autism showed the most improvement in
sleep, while the other child showed little improvement. The
second group of seven children included one child with
autism. They were treated using bedtime scheduling, but
improvement in sleep was generally small to minimal. The
child with autism was described as improving ‘slightly after
treatment’ (p 417). Thus faded bedtime with response cost
was more successful in reducing sleep problems in children
with an ID than was a bedtime-scheduling procedure. The
authors hypothesized that the former method was superior
because it used both classical and operant conditioning, as
well as gradual adjustment of the sleep–wake rhythm to
appropriate hours of the day.
A parent-training programme for parents of young chil-
dren with autism and sleep problems has been investigat-
ed78. Four families began the programme, with one family
remaining at follow-up. Over a 6-week period, the pro-
gramme taught parents how to monitor behaviour and eval-
uate their child’s progress, give effective instructions to their
child, reinforce appropriate sleep behaviours, decrease
inappropriate behaviours; and provide partner support.
Progress was monitored throughout. Improvements in chil-
dren’s sleep were reported during the programme. For the
family and their 3-year-old child completing the programme
Annotation 63
and evaluation, reduction in parent stress, significant
improvements in bedtime routine, a reduction of night-time
disturbances, and an increase of about 1 hour in night sleep
was found. Signs of increases in night-sleep length were also
noted in two other children (aged 3 and 4 years). However,
the children still slept less than the average 3- to 4-year-old.
Daytime compliance was also investigated for three of the
four children in the programme and significant increases
were found79. It was hypothesized that this may be related to
improvements in night-time sleep. Two of three mothers also
transferred their behaviour management skills to other situa-
tions at home and this may also have accounted for improve-
ments in compliance. These results illustrate the potential
usefulness of a behavioural programme which may alleviate
not only sleep problems but may also transfer across set-
tings, resulting in general improvements in both behaviour
and parental management skills.
Although restricted, the data suggest that behavioural
interventions can be successful in treating sleep problems in
children with autism. No single behavioural approach is like-
ly to be the most appropriate for these children, rather the
intervention needs to be tailored to the individual child.
Other factors which need to be taken into account are the
age and developmental level of the child. No child with
autism referred to in these behavioural studies was older
than 8 years and the lowest functioning child had a profound
level of disability. Age and intellectual ability may impact on
the efficacy of particular behavioural interventions but this
possibility has not been investigated. Additionally, the sug-
gested improvements in parenting skills and daytime com-
pliance79 also require investigation.
Melatonin administration prior to bedtime has been
shown to be helpful in specific circadian-rhythm distur-
bances, and has been widely used to alleviate sleep problems
due to shift work and jet lag, and for adult sleep disor-
ders45,47. It has been shown to induce sleep and alter sleep
architecture in adults without autism66 and to entrain the
sleep–wake rhythm of blind subjects with free-running
sleep–wake cycles80. Additionally, administration of mela-
tonin to children with severe sleep disorders, along with
other severe disabilities (including autism), has been report-
ed to help resolve sleep problems81,82. Typically melatonin is
given orally just prior to desired sleep onset. Further studies
regarding the efficacy and safety of melatonin for sleep prob-
lems in children with autism or other disabilities are required.
Two additional treatments for sleep disorders which
involve adjustment of the circadian sleep–wake cycle, are
light therapy and chronotherapy. Light therapy may be used
to treat a variety of rhythm problems, including sleep prob-
lems21,83: bright light suppresses the secretion of melatonin..
Additionally, it has been shown that periods of bright light
treatment in the morning will advance the melatonin and
sleep–wake rhythms, while bright light treatment in the
evening has a delaying effect45,47,84. Thus its mechanism of
action in relation to sleep problems is most likely via alter-
ations to the melatonin rhythm and sleep onset. Morning
and midday phototherapy, together with strict daytime and
bedtime routines, was successfully used to treat five of 14
young children with severe brain damage and intractable
sleep problems, and at long-term follow-up, several years
later, sleep had not deteriorated85. It was concluded that this
treatment was a useful option when others had failed.
64 Developmental Medicine & Child Neurology 1999, 41: 60–66
Chronotherapy is a procedure where the sleep–wake
cycle is successively phase delayed until the desired bedtime
is reached. Typically it is used to treat individuals, including
children and adolescents, with delayed sleep-phase syn-
drome21. Recently chronotherapy was reported to be suc-
cessful in the treatment of severe sleep problems in an
8-year-old girl with severe ID and autism86. Average night
sleep increased and the girl was still sleeping appropriately
at a 4-month follow-up. Both light therapy and chronothera-
py are non-invasive and are promising interventions in the
treatment of severe and intractable sleep problems in chil-
dren with autism. They deserve further consideration, partic-
ularly in severe cases where more traditional interventions
have failed.
Conclusion
Children with autism frequently suffer from severe sleep dif-
ficulties of unknown origin which should not be dismissed as
an inevitable consequence of the disorder. Sleep problems
may be related to deviant and delayed social and communi-
cation skills, adherence to routines, fear and anxiety, or to an
abnormality in the secretion of melatonin. The issue of brain
pathology and sleep disturbances remains unexplored and
EEG studies are few. Nevertheless, careful history-taking and
baseline measures of sleep should enable the clinician to for-
mulate appropriate interventions. Behavioural interven-
tions can be very helpful and should be the first choice. In
intractable cases, medication may be necessary as an addi-
tional treatment, or administration of melatonin, or light
therapy, or chronotherapy in conjunction with behavioural
measures may be required. Clearly more research regarding
both cause and intervention is required concerning sleep
problems in autism. The issue of sleep problems in the other
autism spectrum disorders, AD, and PDDNOS has yet to be
addressed. However, indications are that children with AD
have sleep problems which do not differ qualitatively from
those of children with autism37.
Accepted for publication 28th May 1998.
Acknowledgement
An earlier version of this paper was presented as a keynote paper at
Encuentro Mundial de Educación Especial, Cancún, Mexico, May,
1997.
References
1. Wing L. (1996) Autism spectrum disorders. No evidence for or
against an increase in prevalence. British Medical Journal
312: 327–8.
2. American Psychiatric Association. (1994) Diagnostic and
Statistical Manual of Mental Disorders. 4th Edn. Washington
DC: American Psychiatric Association.
3. Gillberg C. (1993) Autism and related behaviours. Journal of
Intellectual Disability Research 37: 343–72.
4. Seigel B. (1996) The World of the Autistic Child. Understanding
and Treating Autism Spectrum Disorders. New York: Oxford
University Press.
5. Trevarthen C, Aitken K, Papoudi D, Robarts J. (1996) Children
with Autism. Diagnosis and Intervention to Meet Their Needs.
London: Jessica Kingsley.
6. Gillberg C. (1989) Early symptoms in autism. In: Gillberg C,
editor. Diagnosis and Treatment of Autism. New York: Plenum
Press. p 23–32.
7. Rapin I, Katzman R. (1998) Neurobiology of autism. Annals of
Neurology 43: 7–14.
8. Quine L. (1991) Sleep problems in children with a mental
handicap. Journal of Mental Deficiency Research 35: 269–90.
9. Richdale A, Gavidia-Payne S, Francis A, Cotton S. (May 1997)
Sleep characteristics of children with an intellectual disability.
Poster presented at the 121st Annual Meeting of the American
Association on Mental Retardation, New York.
10. Ferber R. (1996) Childhood sleep disorders. Neurologic Clinics
14: 493–511.
11. Armstrong KL, Quinn RA, Dadds MR. (1994) The sleep patterns
of normal children. Medical Journal of Australia 161: 202–5.
12. Johnson CM. (1991) Infant and toddler sleep: a telephone
survey of parents in one community. Developmental and
Behavioral Pediatrics 12: 108–14.
13. Mindell JA. (1993) Sleep disorders in children. Health
Psychology 12: 151–62.
14. Clarkson S, Williams S, Silva PA. (1986) Sleep problems in
middle childhood – a longitudinal study of sleep problems in a
large sample of Dunedin children aged 5–9 years. Australian
Paediatric Journal 22: 31–5.
15. Fisher BE, Pauley C, McGuire K. (1989) Children’s sleep
behavior scale: normative data on 870 children in grades 1 to 6.
Perceptual and Motor Skills 68: 227–36.
16. Pollock JI. (1994) Night waking at five years of age: predictors
and prognosis. Journal of Child Psychology and Psychiatry
35: 699–708.
17. Weissbluth M. (1984) Sleep duration, temperament, and
Conner’s rating of three-year-old children. Developmental and
Behavioral Pediatrics 5: 120–3.
18. France KG, Henderson JMT, Hudson SM. (1996) Fact, act, and
tact. A three stage approach to treating the sleep problems of
infants and young children. Child and Adolescent Psychiatric
Clinics of North America 5: 581–99.
19. Ferber R. (1985) Solve Your Child’s Sleep Problems. Melbourne,
Australia: Penguin.
20. Anders TF, Eiben LA. (1997) Pediatric sleep disorders: a review
of the past 10 years. Journal of the American Academy of Child
and Adolescent Psychiatry 36: 9–20.
21. Stores G. (1996) Practitioner review: assessment and treatment
of sleep disorders in children and adolescents. Journal of Child
Psychology and Psychiatry 37: 907–25.
22. Johnson CR. (1996) Sleep problems in children with mental
retardation and autism. Child and Adolescent Psychiatric
Clinics of North America 5: 673–83.
23. Clements J, Wing L, Dunn G. (1986) Sleep problems in
handicapped children: a preliminary study. Journal of Child
Psychology and Psychiatry 27: 399–407.
24. Piazza CC, Fisher WW, Kahng SW. (1996) Sleep patterns in
children and young adults with mental retardation and severe
behavior disorders. Developmental Medicine and Child
Neurology 38: 335–44.
25. Stores R, Stores G, Buckley S. (1996) The pattern of sleep
problems in children with Down’s syndrome and other
intellectual disabilities. Journal of Applied Research in
Intellectual Disabilities 9: 145–58.
26. Wiggs L, Stores G. (1996) Severe sleep disturbances and daytime
challenging behaviour in children with severe learning
disabilities. Journal of Intellectual Disability Research
40: 518–28.
27. Stores G. (1992) Sleep studies in children with a mental
handicap. Journal of Child Psychology and Psychiatry
33: 1303–17. (Annotation.)
28. Cassidy SB, McKillop JA, Morgan WJ. (1990) Sleep disorders in
Prader–Willi syndrome. Dysmorphology and Clinical Genetics
4: 13–7.
29. Piazza CC, Fisher WW, Kiesewetter K, Bowman L, Moser H.
(1990) Aberrant sleep patterns in children with the Rett
syndrome. Brain and Development 12: 488–93.
30. Marcus CL, Keens TG, Bautista DB, von Pechman WS, Davidson
Ward SL. (1991) Obstructive sleep apnea in children with Down
syndrome. Pediatrics 88: 132–9.
31. Epstein R, Pillar D, Tzichinsky O, Herer P, Lavie P. (1992) Sleep
disturbances in children with Down’s syndrome. Journal of
Sleep Research 1: (Suppl.) 68.
32. Hunt A, Stores G. (1994) Sleep disorder and epilepsy in children
with tuberous sclerosis: a questionnaire based study.
Developmental Medicine and Child Neurology 36: 108–15.
33. Colville GA, Watters JP, Yule W, Bax M. (1996) Sleep problems in
children with Sanfilippo syndrome. Developmental Medicine
and Child Neurology 38: 538–44.
34. Okawa M, Sasaki H. (1987) Sleep disorders in mentally retarded
and brain-impaired children. In: Guilleminault C, editor. Sleep
and its Disorders in Children. New York: Raven Press. p 269–90.
35. Schreck KA. (1997) Preliminary Analysis of Sleep Disorders in
Children with Developmental Disabilities. Doctoral
dissertation, Ohio State University, Ohio, USA.
36. Hoshino Y, Watanabe H, Yashima Y, Kaneko, M, Kumashiro H.
(1984) An investigation on the sleep disturbance of autistic
children. Folia Psychiatrica et Neurologica Japonica 38: 45–51.
37. Patzold LM, Richdale AL, Tonge BJ. (1998) An investigation into
the sleep characteristics of children with autism and Asperger’s
disorder. Journal of Paediatrics and Child Health.
(Forthcoming.)
38. Richdale AL, Prior MR. (1995) The sleep–wake rhythm in
children with autism. European Child and Adolescent
Psychiatry 4: 175–86.
39. Inamura K. (1984) Sleep–wake patterns in autistic children.
Japan Journal of Child and Adolescent Psychiatry 25: 205–17.
(In Japanese.)
40. Segawa M. (1985) Circadian rhythm in early infantile autism.
Shinkei Kenkyu No Shinpo 29: 140–53. (In Japanese.)
41. Richdale AL. (1992) An Investigation of Circadian Rhythms in
Childhood Autism. Doctoral dissertation, La Trobe University,
Melbourne, Australia.
42. Einfeld SL, Tonge BJ. (1994) Manual for the Developmental
Behaviour Checklist Parent-Carer Version. Sydney, Australia:
University of New South Wales.
43. Aschoff J, Fatranska M, Giedke H, Doerr P, Stamm D, Wisser H.
(1971) Human circadian rhythms in continuous darkness:
entrainment by social cues. Science 171: 213–5.
44. Wever RA. (1988) Order and disorder in human circadian
rhythmicity: possible relation to mental disorders. In: DJ Kupfer,
TH Monk, JD Barchas, editors. Biological Rhythms and Mental
Disorders. New York: The Guilford Press. p 253–346.
45. Brown GM. (1995) Melatonin in psychiatric and sleep disorders.
Therapeutic implications. CNS Drugs 3: 209–26.
46. Armstrong SM. (1989) Melatonin: the internal zeitgeber of
mammals? Pineal Research Reviews 7: 157–202.
47. Brzezinski A. (1997) Melatonin in humans. New England
Journal of Medicine 336: 186–95.
48. Hoshino Y, Yamamoto T, Kaneko M, Tachibana R, Watanabe M,
Ono Y, Kumashiro H. (1984) Blood serotonin and free
tryptophan concentration in autistic children.
Neuropsychobiology 11: 22–7.
49. Naruse H, Hayashi T, Takesada M, Nakane A, Yamazaki K. (1989)
Metabolic changes of aromatic amino acids and monoamines in
infantile autism and development of a new treatment related to
the finding. No To Hattatsu 21: 181–9. (In Japanese.)
50. Anderson GM. (1987) Monoamines in autism – an update of
neurochemical research. Medical Biology 65: 67–74.
51. Richdale AL, Prior MR. (1992) Urinary cortisol circadian rhythm
in a group of high-functioning children with autism. Journal of
Autism and Developmental Disorders 22: 433–47.
52. Chamberlain RS, Herman BH. (1990) A novel biochemical
model linking dysfunctions in brain melatonin,
propiomelanocortin peptides, and serotonin in autism.
Biological Psychiatry 28: 773–93.
53. Ritvo ER, Ritvo R, Yuwiler A, Brothers A, Freeman BJ, Plotkin S.
(1993) Elevated daytime melatonin concentrations in autism: a
pilot study. European Child and Adolescent Psychiatry 2: 75–8.
54. Nir I, Meir D, Zilber N, Knobler H, Hadjez J, Lerner Y. (1995)
Brief report: circadian melatonin, thyroid-stimulating hormone,
prolactin and cortisol levels in serum of young adults with
autism. Journal of Autism and Developmental Disorders
25: 641–54.
55. Kulman G, Neri F, Rovelli F, Roselli MG, Lissoni P, Bertolini M.
(1995) Lack of light/dark rhythm of the pineal hormone
melatonin (MLT) in autistic children. Divisione di
Neuropsichiatria Infantale, Ospedale S. Gerado, Monza, Italy.
(Abstract.)
56. Cohen DJ, Johnson WT. (1977) Cardiovascular correlates of
attention in normal and psychiatrically disturbed children.
Archives of General Psychiatry 34: 561–7.
Annotation 65
57. Graveling RA, Brooke JD. (1978) Hormonal and cardiac 81. Jan JE, Espezel H, Appleton RE. (1994) The treatment of sleep
responses of autistic children in response to changes in disorders with melatonin. Developmental Medicine and Child
environmental stimulation. Journal of Autism and Childhood Neurology 36: 97–107.
Schizophrenia 8: 441–55. 82. Jan JE, O’Donnell ME. (1996) Use of melatonin in the treatment of
58. Hutt C, Hutt SJ, Lee D, Ounsted C. (1964) Arousal and paediatric sleep disorders. Journal of Pineal Research 21: 193–9.
childhood autism. Nature 204: 908–9. 83. Wetterberg L. (1994) Light and biological rhythms. Journal of
59. Volkmar ER, Cohen DJ. (1985) The experience of infantile Internal Medicine 235: 5–19.
autism: a first person account by Tony W. Journal of Autism and 84. Arendt J, Broadway J. (1987) Light and melatonin as zeitgebers
Developmental Disorders 15: 47–54. in man. Chronobiology International 4: 273–82.
60. White BB, White MS. (1987) Autism from the inside. Medical 85. Guilleminault C, Crowe McCann C, Quera-Salva M, Cetel M.
Hypotheses 24: 223–30 (1993) Light therapy as treatment of dyschronosis in brain
61. Wagner DR. (1991) Sleep and arousal disorders. In: N impaired children. European Journal of Pediatrics 152: 754–9.
Rosenburg, editor. Comprehensive Neurology. New York: Raven 86. Piazza CC, Hagopian LP, Hughes CR, Fisher WW. (1998) Using
Press. p 731–77. chronotherapy to treat severe sleep problems: a case study.
62. Ornitz EM, Ritvo ER, Walter RD. (1965) Dreaming sleep in American Journal on Mental Retardation 102: 358–66.
autistic and schizophrenic children. American Journal of
Psychiatry 122: 419–24.
63. Ornitz EM. (1972) Development of sleep patterns in autistic
children. In: CD Clemente, DP Pupura, EF Mayer, editors. Sleep
and The Maturing Nervous System. New York: Academic Press.
p 363–81.
64. Tanguay PE, Ornitz EM, Forsythe AB, Ritvo ER. (1976) Rapid eye
movement sleep (REM) activity in normal and autistic children
during REM sleep. Journal of Autism and Childhood
Schizophrenia 6: 275–88.
65. Elia M, Ferri R, Musumeci SA, Bergonzi P. (1991) Rapid eye
movement modulation during night sleep in autistic subjects.
Brain Dysfunction 4: 348–54.
66. Hughes RJ, Badia P. (1997) Sleep-promoting and hypothermic
effects of daytime melatonin administration in humans. Sleep
20: 124–31.
67. Bauman ML, Kemper TL, editors. (1994) The Neurobiology of
Autism. Baltimore, MD: Johns Hopkins University Press.
68. Courchesne E, Yeung-Courchesne R, Press GA, Hesselink JR,
Jernigan TL. (1988) Hypoplasia of cerebellar vermal lobules VI and
VII in autism. New England Journal of Medicine 318: 1349–54.
69. Bauman M. (May 1997) The neuropathology of autism. Paper
presented at the 121st Annual Meeting of The American
Association on Mental Retardation, New York.
70. Bauman ML, Kemper TL. (1994) Neuroanatomic observations of
the brain in autism. In: ML Bauman, TL Kemper, editors. The
Neurobiology of Autism. Baltimore, MD: Johns Hopkins
University Press. p 119–45.
71. Wiggs L, Stores G. (1996) Sleep problems in children with
severe intellectual disabilities: what help is being provided?
Journal of Applied Research in Intellectual Disabilities
9: 160–5.
72. Howlin P, Rutter M. (1987) Treatment of Autistic Children. New
York: John Wiley Press.
73. Koegel RL, Koegel LK. (1995) Teaching Children with Autism.
Baltimore, MD: Paul H Brookes.
74. Bramble D. (1996) Consumer opinion concerning the treatment
of a common sleep problem. Child: Care, Health and
Development 22: 355–66.
75. Howlin P. (1984) A brief report on the elimination of long term
sleeping problems in a 6-year-old autistic boy. Behavioural
Psychotherapy 12: 257–60.
76. Wolf M, Risley T, Mees H. (1964) Application of operant
conditioning procedures to the behaviour problems of an
autistic child. Behaviour Research and Therapy 1: 305–12.
77. Piazza CC, Fisher WW, Sherer M. (1997) Treatment of multiple
sleep problems in children with developmental disabilities:
faded bedtime with response cost versus bedtime scheduling.
Developmental Medicine and Child Neurology 39: 414–8.
78. McDonald J, Patzold L. (1995) Better Bedtime Behaviour
Program. Unpublished MA Thesis. Available from RMIT, Victoria,
Australia.
79. Letch NM. (1995) An Evaluation of a Behavioural Parent-
Training Program for Sleep Problems and its Generalised
Effects on the Diurnal Compliance Rate of Autistic Children
and Their Parent’s Use of Alpha Commands and Appropriate
Responses. Unpublished Grad Dip App Child Psych Thesis.
Available from RMIT, Victoria, Australia.
80. Sack RL, Lewy AJ, Blood ML, Stevenson J, Keith DL. (1991)
Melatonin administration to blind people: phase advances and
entrainment. Journal of Biological Rhythms 6: 249–61.

66 Developmental Medicine & Child Neurology 1999, 41: 60–66