Module 4

Teaching Children Healthy Sleep Habits

An important consideration for any sleep programme, is how we can help children to learn the skills they need to fall asleep independently and remain asleep throughout night. There are a number of strategies and tools you can use to facilitate this. These should be adapted to your child’s needs, interests, strengths and preferences.

This module covers:
  • The use of visual supports
  • The use of other teaching aides such as sleep stories and rewards
  • Visual Supports

    Visual supports are pictures, charts or other visuals that can be used to support children’s learning. Visual supports are commonly used throughout everyday life with Autistic children and can be a helpful tool to facilitate healthy sleep, when used alongside other strategies. In particular, they can help children to understand their bedtime routine, sleep schedule and other sleep strategies. There are many different types of visual supports that can be embedded within sleep programmes, some of which are outlined below.

    Involving your child in decisions about the support they receive and how they receive it is key to promoting their autonomy. Your child should have input on the timing, content and images associated with these supports. Regularly check in with your child about their comfort in using these supports and adjust them if they show any signs of distress (e.g., meltdowns, discomfort, withdrawal) or resistance.

    Day/night visual cues

    It can be helpful for children to have visual cues to signal to them when it is time to sleep and when it is time to get up for the day. This is particularly helpful for children who have difficulties related to settling at bedtime or early morning waking. Sleep trainer clocks such as a Gro-clock™ or Yoga sleep light can provide a useful visual cue for your child. As an alternative to a sleep trainer clock, there are also low-tech options. For example, you can create cards with one side displaying a picture reflecting nighttime (e.g., moon, stars, or other things that your child may associate with night-time) and on the other side a picture reflecting day time (e.g., the sun). You can turn the card to the picture resembling the night at your child’s bedtime and to the picture resembling the daytime at your child’s wake time. An example of a day/night-time card is provided below.

    Finished symbols

    Finished symbols or pictures can be used to help children to understand when something is finished. For example, a child may have an allocated time to play with their toys before bed. Once the time is up, a finished symbol may be placed on the toy box to indicate to your child that their playtime has come to an end and that its time to put their toys or activities away. This can help with the transition to bed.  Examples of finished symbols may include an image of a checkered flag, or a word indicating the activity is finished. A sand or ooze timer system may also be beneficial, particularly because it also provides the child with a visual in the lead up to the transition. An example of a finished symbol image is provided below.

    Visual schedules

    Visual schedules can be used to help your child learn their bedtime routine. They are often created in the form of a visual checklist (e.g., on a whiteboard or paper template), where children can “tick off” what they have done as they go, in turn enhancing their autonomy. Other forms may include a grid where the child adds or removes an object (e.g., magnet or Velcro dot) each time they complete a task as part of their routine. The presentation of this schedule will depend on your child’s understanding and preferences.

    Creating a visual schedule can be a fun task to do with your child. You can select pictures to use in the schedule together, or you can take the pictures with your child, getting them to act out each step. For example, the first item on the schedule may be to brush their teeth. An image of a toothbrush may be used for this step. The second item may be to put their pyjamas on. An image of pyjamas may be used for this step. Sometimes, visual schedules end on a preferred activity to make the process more rewarding (e.g., reading a special book with a caregiver). Another example is a visual list of options of readily accessible supports (e.g., coping cards, safety symbols, relaxation strategies) they can use in the night if needed (see Module 5).

    Examples of visual schedules are provided below.

    A programme calendar

    Programme changes (e.g., implementation of new strategies) can often be difficult for Autistic children and it can take time for them to feel comfortable with new routines or expectations. A programme calendar can be used to help them to understand and prepare for the programme. In turn, this might make their experience of change easier. For example, notes or images can be placed on set dates (negotiated with your child) on a calendar to signal when a change might occur.  In addition to a programme calendar, other suggestions for supporting your child before and during change are provided below.

    • Discuss ideas and options with your child in relation to the planned change.
    • Make changes at times where they have the emotional and physical capacity to process the change.
    • Allow more time for your child to adjust to the change, e.g., more time to complete their new bedtime routine.
    • Implement changes gradually, i.e., in small steps/parts, one step at a time.
    • Ensure their sensory needs are met (e.g. provide a preferred sensory item).
    • Pair changes with positive experiences.

    Sleep Stories

    Sleep stories are a type of Social Story™ (developed by Gray & Garand, 1993) designed to help children to understand what they can expect around bedtime and sleep to reduce uncertainty. They typically combine pictures and text to describe to the child what bedtime, and night-time sleep look like. In turn, they can help to make implicit rules and exceptions to rules clear and explicit for both you and your child. For example, your child may not understand why they need to brush their teeth before bed (i.e., Before bed, I brush my teeth. Brushing my teeth keeps them healthy. And keeping my teeth healthy keeps them from hurting).

    Creating a sleep story can be a fun task to do with your child. You can select pictures to use in the story together, or you can take the pictures with your child, getting them to act out each step. For example, one page might say: “Before bed, I brush my teeth”. A picture of your child brushing their teeth can then be taken and used on that page. Doing this, also helps you and your child learn, as you work your way through the steps together.

    Your child’s sleep story should be available for them to read or look at when they want to. In addition, you could read and show them the story each night before commencing the bedtime routine, and at other times if they request it.

    Tips for creating a sleep story:

    • The content should be descriptivemeaningful and physically, socially and emotionally safe for your child. For example, it should state what actions to do (i.e., the steps in the bedtime routine), where they might take place (e.g., I go to the bathroom and brush my teeth), when things need to be done (e.g., when I get into bed, I close my eyes) and why they need to be done (e.g., to help me fall asleep). In doing so, consider the environmental details in the story and images and how important replicating these exact conditions might be to your child. For some children, adhering closely to these will be very important. In such cases, ensure the story closely replicates what will happen to minimise any risk of potential distress. For example, ensure the object (e.g., toothbrush) depicted is readily available, reduce background distractions etc.
    • It should have a patient and supportive “voice” (i.e. no judgemental statements and using statements such as “I will try to…” rather than “I must…”).
    • It should describe more than direct (e.g., “when I wake at night, I cuddle my teddy” as opposed to “when you wake at night you should cuddle your teddy”). In other words, first-person language should be used from the perspective of your child.
    • It should have a title and introduction that clearly identifies the topic (e.g., “I am learning to sleep in my own bed all night”), a body that adds the detail, and a conclusion that summarises the information.
    • It should include other’s role(s) within the steps (e.g., once I am in bed, mum/dad will turn off the light).
    • It should be tailored to the child’s abilities, learning and communication style, and where possible, their interests.

    Please find examples of sleep stories, below.


    Rewards

    Rewards can be used to encourage helpful sleep-related behaviour such as engaging in the bedtime routine, sleeping independently in their bed or bedroom, and going to bed at an appropriate bedtime. The suitability of rewards will depend on your child’s preferences, but examples include toys, activities, descriptive praise, additional screen time (e.g., extra 10 minutes on I Pad) and certificates for effort and achievement. Rewards should reflect your child’s preferences, including sensory preferences. Praise and encouragement should also be a natural part of the bedtime and night-time routine.

    While rewards can be useful, it is important to use them alongside other supportive strategies like sleep hygiene, sleep/wake scheduling, visual cues (e.g., schedules, cards) and sensory supports. Below are some tips for using rewards in the context of promoting healthy sleep habits for your child:

    Tips for use of rewards:

    Incorporate rewards as a natural part of your child’s routine

    It is recommended rewards are provided in a natural way, as part of your child’s routine, to make the process overall more ‘rewarding’. Many Autistic children have a strong preference for sameness, so it’s important these steps can be consistently recreated.

    Incorporate rewards within visual supports

    If you choose to incorporate rewards as part of your child’s routine, these should be included in their visual schedule or accompanied by appropriate visual cues (when needed) to communicate the process.

    Embed flexibility, choice, and autonomy when using rewards

    An individuals (including your child’s) capacity fluctuates depending on many different factors (psychological, medical, family stressors etc), so it is important that your child is set-up for success with flexible and realistic night-time expectations. While this approach may take longer for your child’s sleep to improve, it fosters a sense of autonomy for your child.

    Tailor rewards to your child’s preferences

    Rewards should be exciting, interesting and suit your child’s sensory needs to effectively encourage helpful sleep behaviour. Think about things that your child likes to do or have. Children’s preferences change over time so a variety of rewards may be needed.

    Select rewards that are appropriate at night-time

    Consider rewards that are both rewarding and calming for your child (e.g., backrub, calming sensory activity, extra bedtime story). Providing your child with a reward that is stimulating (e.g., lollies, active games) may be counterproductive, i.e., contribute towards difficulties falling asleep.

    Provide attention and descriptive praise as encouragement

    Descriptive praise describes praise that is behaviour specific (e.g., “you did a good job putting your pyjamas on”). This type of praise has been found to be more effective compared to general praise (e.g., “good job”). Attention and praise can be provided spontaneously and naturally and should also recognise your child’s effort.


    All resources for this module are available on the Treatment & Assessment Resources page