Module 3

Creating Optimum Conditions for Sleep

When addressing sleep difficulties, it is important to start by getting the basics right. In many cases, this means starting by addressing ‘sleep hygiene’. Sleep hygiene is a term commonly used to refer to the day and night-time habits that may affect your child’s sleep. This can include the bedroom environment, bedtime routine, and even daytime activities.

This module covers:
  • Features of good sleep hygiene
  • The importance of a consistent bedtime routine and environment
  • The importance of a relaxing bedtime routine and environment
  • Sensory considerations
  • Features of Good Sleep Hygiene

    When exploring potential support options, it is important to consider various features of sleep hygiene. Below is a checklist developed as part of the Good Nights Programme to help identify features of children’s sleep hygiene that may need to be modified to promote healthy sleep.

    Exposure to daylight

    It is important to ensure that your child is exposed to sufficient daylight when they wake in the morning and throughout the day. If natural daylight is limited (e.g., in winter months) exposure to light inside (i.e., turning all house lights on) is sufficient. Doing so helps to maintain a regular circadian rhythm. In other words, being exposed to light, signals to your child’s body that it is time to be awake and as it gets darker, this signals to your child’s body that it is time to sleep. These natural environmental cues are extremely important!

    Diet

    It is important to ensure that your child is well hydrated and fed before bedtime, as hunger and thirst can keep people awake during the night and make it harder to stay asleep. However, it is also important to ensure your child is not uncomfortably full (i.e., eaten a large meal right before bed or drunk a whole bottle of water right before bed). If they are hungry or thirsty within 90 minutes prior to bedtime, a light snack (e.g., piece of fruit) or small drink (e.g., one cup) is recommended. You may want to leave a drink bottle by your child’s bed for if they become thirsty in the night. If your child repeatedly requests food or drink post-bedtime, refer to Module 6 for further suggestions.

    It is also important to limit caffeine (e.g., coke, energy drinks, tea, coffee) consumption, as caffeine is a stimulant which increases activity in the brain making it more difficult to fall asleep. Ideally, children and teens should consume minimal to no caffeinated drinks and should not consume caffeine after 3.00pm. 

    Daytime activity

    It is important for young people to keep active during the day, so they expend enough energy to help them feel tired at bedtime. An average child should typically engage in at least 60 minutes of exercise per day. If your child is not getting sufficient exercise, this is something that you may wish to schedule. On the other hand, vigorous exercise close to bedtime (e.g., post-dinner) can have the opposite affect – it may stimulate your child making it hard for their body to calm enough to fall asleep.

    Screens

    Using electronic media (e.g., watching videos, playing video games, texting etc) close to bedtime can make it harder to fall asleep and stay asleep. This is because the blue light emitted from these devices can inhibit melatonin production (the hormone which makes us feel sleepy). In addition, using electronic media can be stimulating for our brains and body, making it harder to fall asleep.

    When a child becomes immersed in their device, especially if it is related to their special interests, it can be difficult to transition to another task such as bedtime. To facilitate this transition, consider engaging with your child about what they are doing on their device to encourage a sense of presence. You might also provide verbal and visual reminders at set intervals leading to the transition (see Module 4). If you continue to struggle with this transition, refer to Module 6 for further suggestions.

    Ideally, try to avoid screens 30-60 minutes prior to bedtime. If that is not possible, try to minimise the impact on sleep by turning down the brightness and blue light (this can be done by downloading programmes such as f.lux™) and opting for less stimulating content (e.g., reading an easy book versus playing a video game). If your child or teen have their device in their room at night, it may also be helpful to set their device to ‘night-mode’ to prevent notifications from disrupting their sleep.

    The bedroom environment

    Optimal environmental conditions for sleep include:

    • Comfortable temperature (warm, but not too warm; between 18-20 ֠C depending on the type and amount of bedding)
    • Dim/dark lighting
    • Consistent low noise level (e.g., no noise, or a white noise machine)
    • Comfortable and warm bedding
    • Safe and secure (e.g., no access to unsafe items, appropriate bedding for age)
    • Free from distractions (e.g., toys, devices)

    As well as ensuring these conditions are optimal for sleep, it is also important that they are consistent and calming. For further information, see below.


    Sensory Considerations

    Understanding sensory processing in Autistic children

    Everyone processes sensory aspects of the world around them in different ways. Our brains and bodies like and dislike different levels of sensory input including sounds, sights, smells, touch, taste, pressure and what is going on within our bodies (i.e., interoception; hunger, thirst, temperature).

    Differences in sensory processing is common among Autistic children. They might seek out sensory input or they might avoid it. This means a child may need lots of one sensory input in order to feel happy and calm. Or they might want to reduce the sensory input in order to feel relaxed. For example, an Autistic child might seek out visual input, constantly looking up at the bright sky or at bright lights, while another might avoid lights, shielding their eyes from windows, the sun or other bright lights. It is also possible a child might not have any sensory seeking or avoiding characteristics when it comes to visual processing. This applies across the senses. Let’s think about sound, a child may like loud noises and might listen to loud music or repetitive sounds in order to feel calm. On the other hand, a child might avoid loud noises (i.e., they may cover their ears and want to escape to a quiet space).  It is likely children will have a range of sensory seeking and avoiding preferences. It may also be that the child wants different things at different times of the day. As caregivers, it is important to think about your child’s sensory preferences and how these affect their ability to feel sleepy, fall asleep and stay asleep during the night.

    Supporting sensory needs and preferences

    When setting up the sleep environment you will need to think about and plan for your child’s unique sensory needs and preferences. This can be challenging, especially if your child’s sensory preferences are not compatible with sleep. If this is the case, a sensory activity to meet their needs, could be planned as part of your child’s daytime routine. Having time for the sensory activity during the day means your child has had the benefits of the activity before the night time routine begins. This is an example of a sensory diet. Making sure your child has had enough of the activities they like and need and making sure they haven’t been exposed to sensory input they don’t like, so they are in a happy and calm space to begin the bedtime routine.

    “The Spiky Fish” – anecdote from a caregiver of an Autistic child

    One day my son aged 4 years old, found a large wooden fish at the second-hand shop. The fish was heavy, about the size of a rugby ball and was oddly shaped for a small 4-year-old to carry.  He became attached to the fish and liked to stroke the wooden fins along the spine. After buying the fish, my son decided he wanted to take it to bed with him at night. At first, I worried the fish would wake him up if he rolled on to it. I also worried it might seem kind of weird to other family members to see him sleeping with a wooden fish. However, I decided to have a positive attitude toward him sleeping with the fish, and it became an essential part of his bedtime routine. Having the fish in bed helped my son to stay in bed. He would rub the hard and heavy edges of the fish which helped him to relax and eventually fall asleep.


    Keeping Things Consistent

    Consistent bedtime routine

    When a consistent sequence of events (e.g., bath, pyjamas, brush teeth, story) occur in the lead up to bedtime these provide children with cues that it is time to go to sleep. Sleep difficulties can occur when there is an absence of sleep cues or the cues are inconsistent (e.g., no instruction for bed, no bedtime routine, inconsistent bedtimes). This is particularly important for Autistic children who may thrive with routine. To help maintain a consistent bedtime routine every night it can be helpful to use visual supports that represent these steps (refer to Module 4). You could also add incentives and rewards for bedtime routine completion (refer to Module 4).

    Consistent environmental conditions

    To support children to independently (i.e., without help) fall asleep and maintain sleep throughout the night it is important that the conditions under which they fall asleep are also present when they wake during the night. This is because the conditions that are consistently present when children fall asleep can cue feelings of sleepiness necessary for your child to fall asleep. By contrast, if the conditions under which children fall asleep at the beginning of the night are different to the conditions present when they wake in the night, your child may have difficulty returning to sleep, unless those conditions are restored.

    There are a number of conditions that can contribute to difficulties re-initiating sleep in the night including:

    • Conditions that your child is unable to produce themselves (e.g., cuddling a caregiver during sleep onset).
    • Engaging with activities, until they fall asleep (e.g., reading a book, listening to music, device use, watching television). Engaging in these prior to bedtime/lights out is OK.
    • Falling asleep in a location other than their bedroom (e.g., a living room or caregivers’ bed), and then being shifted to their bed when asleep.
    • Changes to the physical environment (e.g., light on or door open while falling asleep).

    If the conditions under which your child falls asleep vary over the course of the night, you may consider making modifications to these. We recognise that these modifications are not always easy or practical to achieve. You may wish to refer to different content on this website, as follows:

    • Making modifications to the sleep environment – further described in this Module.
    • Fading parental presence –Module 6.
    • Managing access to activities/items –Module 6.

    Keeping Things Relaxed

    As well as keeping the bedtime routine and environmental conditions consistent, it is important to make sure they are relaxing and non-stimulating. This is because in order to fall asleep, children need to achieve a state of behavioural, emotional, and cognitive calm. If children engage in stimulating activities right before bed or while in bed, this can make it harder to achieve this calm state and ultimately fall asleep. Therefore, it is important children only engage in stimulating activities outside of the bedroom and prior to bedtime. While what is relaxing or stimulating can vary from child to child, some general examples are provided below.

    Stimulating activities to avoid immediately before bed include:

    • Work/homework.
    • Playing video games.
    • Intense exercise.
    • Loud games or movies.
    • Social activities (for some Autistic children)

    Relaxing activities could include:

    • Reading or listening to a story
    • Calm play or stimming with preferred items
    • Bath/shower
    • Hot drink
    • Cuddles
    • Deep breathing
    • Progressive muscle relaxation (refer to Module 5)
    • Imagery (refer to Module 5)