Why Won’t They Go to Bed? A BCBA’s Guide to Effective Bedtime Routines

Why Sleep Problems Belong on a BCBA's Caseload

Sleep is not a side issue in autism services. Lindsay Anderson pointed to recent studies where as many as 80% of children with ASD have clinical sleep problems. That is about two to three times the rate seen in children with typical development. If you carry a full caseload, several of those kids are sleeping badly right now.

Poor sleep spills into everything you measure. Anderson said sleep issues carry long-term costs for health, behavior, mood, and thinking. In practice you see more sickness and more cancellations. Behaviors get bigger and louder. Kids also hold on to less of what you taught last session.

So is sleep in our lane? Research shows behavioral sleep treatment works for children with ASD. It can improve total sleep, cut night wakings, and reduce bedtime resistance (fighting or stalling at bedtime). These treatments also carry fewer side effects and last longer than medication does.

The behavioral roots go back decades. One researcher suggested in 1977 that lying quietly and falling asleep are operant behaviors (actions shaped by what follows them). Sleep itself is the reinforcer (the reward that follows the behavior) for falling asleep. Michael built on this in 1982. He said that recent sleep, plus hours spent awake, acts as an establishing operation (a shift in what you want right now). That shift changes how likely a child is to fall asleep. The same 1977 work made another point: the bedtime chain needs real SDs (cues that signal a reward is ready), both inside and outside the body.

So we can make changes to how long the child has been awake or asleep to make sleep more reinforcing and make the child more likely to lay quietly in bed.

From the talk — Lindsay Anderson

Rule Out Medical Issues, Then Name the Behavior

Anderson starts every case with medical red flags. Sleep disordered breathing (trouble breathing during sleep) tops her list. The most common type is obstructive sleep apnea. The throat muscles relax too much and block the airway. The brain then wakes the child up all night just to breathe. She noted that apnea in preschoolers has more than doubled in ten years, from 9% to 20%. Loud snoring or odd breathing at night should go to a doctor.

Other causes are easy to miss. Reflux, constipation, and pain all cause wake-ups. Restless leg syndrome (an urge to move the legs at night) is common in kids with ASD. It often traces back to low iron. Anderson cited a study called Rethinking Bedtime Resistance. Of 103 children with ASD and chronic insomnia, 41 also had restless legs. Most were treated with iron alone. Dental pain and eczema belong on the list too.

She framed this step as both ethics and parsimony (start with the simplest cause). Jumping to a behavior plan while a child is in pain wastes months. Get the red flags checked first.

The talk's topic has a name in the literature: bedtime resistance. It usually shows up after age two. It covers stalling, verbal protests, crying, clinging, refusing bed, and getting out of bed. It also covers curtain calls, where the child keeps coming out for a drink or one more thing. Childhood insomnia has two subtypes. Bedtime resistance sits in the limit-setting subtype (trouble holding a steady bedtime line). That label points to what parents need support with, not to fault.

Now, of course, we're not blaming parents here.

From the talk — Lindsay Anderson

Work Backward From a Fixed Wake-Up Time

Timing comes before the routine. Anderson walked through research on sleep variability, which is how much sleep times shift from night to night. Bates and colleagues found this in 2002. Swings in sleep amount and bedtime tracked with preschool trouble, as rated by teachers. Biggs and colleagues in 2011 studied over 1,600 children ages 5 through 10. Schedules that moved by more than an hour came with more behavior problems. Iwata in 2012 found that shaky schedules meant longer time to fall asleep and less sleep on weeknights.

The easiest lever is the wake-up time. Find the earliest the child must be up on a weekday, then make that the daily goal. Ask parents to wake the child at that time even on weekends. If that is not realistic, keeping weekends within an hour still helps a lot. Hold the line after a late night or a rough night too. Sleeping in feels kind, but it keeps the problem running. Sickness is the obvious exception.

Next, count backward using sleep needs for the child's age. Toddlers ages 1 to 2 need about 11 to 14 hours. Preschoolers ages 3 to 5 need about 10 to 13. School-age kids, 6 to 13, need about 9 to 11. Anderson stressed that these numbers are based on chronological age, not developmental level, because sleep is a biological process. Take a 4-year-old who needs 11 to 12 hours and wakes at 7 a.m. Their bedtime lands between 7 p.m. and 8 p.m.

Naps count inside that total, so they push bedtime later. That same 4-year-old who naps from 1 to 2 p.m. probably belongs in bed between 8 and 9 p.m. The driver here is homeostatic sleep pressure (the need for sleep that builds while awake). A 2-year-old may be tired again after about four hours. A 5-year-old may need six or seven hours to build that same pressure. A 2019 study looked at when kids drop naps. By age 3, 33% had stopped. By age 5, 80% had stopped, and 94% had stopped after that. Even a short doze on the bus or in the car can reset that pressure.

And in younger kids, sleep pressure accumulates very quickly.

From the talk — Lindsay Anderson

Long Sleep Latency and the Faded Bedtime

Normal sleep latency (the time from lights out to sleep) runs about 10 to 20 minutes. Much longer than that creates a second problem. Lying in bed awake builds an association between the bed and being awake. That is the opposite of what we want. It can feed insomnia symptoms and make it harder to fall back asleep after a night waking.

A long wait also opens the door to behavior. A child asked to lie still when they are not tired has time to protest, stall, and leave the room. Anderson also cited a 2024 study on this. It linked long sleep latency in childhood with a higher chance of depression, ADHD, or conduct disorder in the teen years. So this is worth treating early, not waiting it out.

The fix is a faded bedtime (start bedtime near the real sleep time). If a child is put down at 8 p.m. but never sleeps before 9:30, start at 9:30 or a bit later. Tell parents plainly that this later time is temporary. Once the child falls asleep within about 15 minutes, move bedtime 15 minutes earlier the next night. If sleep takes too long, push it 15 minutes later to rebuild pressure. Keep going until you hit the target bedtime.

An attendee asked how many good nights you need before fading. Anderson said the studies vary. She mentioned the Piazza work as using a single night, and said she would confirm the details. Her practical answer was to individualize it. Treating it like shaping toleration (building tolerance through small steps) works well. Go slowly at the start, then speed up as you get close to the goal.

So based on this information, the main takeaway that we want to guide parents on is really putting kids to bed at a time that they're actually tired.

From the talk — Lindsay Anderson

What Belongs in the Bedtime Routine

Before the routine, check the child's relationship with the bedroom. Have they ever slept there? Are they neutral, or a little scared of it? If sessions happen in the home, spend a few minutes playing in the bedroom with strong reinforcers. Parents can do the same with snuggling, tickles, or favorite toys. Start with a few minutes and build up. Anything that makes the sleep space feel safe and fun is time well spent.

The routine itself has strong support. In a 2009 study by Mindell, three weeks of a nightly routine alone helped children fall asleep faster and cut night wakings. A 2015 study by Mindell and colleagues covered more than 10,000 children ages zero through five. Routines on three or more nights a week came with earlier bedtimes and shorter sleep onset latency. They also brought fewer night wakings and more sleep overall. The effect was dose dependent (more nights gave better results).

A 2018 review by Mindell and Williamson asked what makes a routine work. They defined it as the predictable activities in the hour or so before lights out. Same activities, same order, same closing signal every night. That might be a certain tuck-in, an I love you, then the light going off. One study used a 30-minute, three-step routine of bath, lotion, and quiet time. Another simply asked parents to do 4 to 7 quiet activities for 20 minutes, with the activities left up to them. Both worked.

A few add-ons make a routine stronger. A 2011 study of over 4,000 children looked at language-based routines: reading, storytelling, or singing. A routine like this at age 3 predicted longer nighttime sleep at age 5. Another study gave 23 infants and toddlers a nightly routine ending in one of two ways: a 15-minute massage from a parent, or a bedtime story. After a month, the massage group showed less bedtime resistance and shorter latencies. A nap study found that soft classical guitar music helped children fall asleep faster. Stories, massage, and quiet music all earn a spot.

So the key word they used here is predictable.

From the talk — Lindsay Anderson

Adjust for the Learner, and Cut What Backfires

For autistic learners, Anderson suggested a few changes. An hour-long routine is too long for some kids and leads to overstimulation or rigid rituals. Other kids need longer to settle. If a child has few leisure skills, it is fine to fold in dinner or a longer bath. Use that time while you teach new activities. A visual schedule helps the child know what comes next and helps parents stay consistent. Choices boost cooperation. Keep the order fixed, but let the child pick which book.

Some activities work against sleep. Rocking or feeding a child right as they fall asleep creates sleep associations. These are things the child needs in order to fall asleep. The child then wakes at night looking for them again. Move those activities earlier in the routine, before lights out. Also cut anything that revs the child up in the last hour.

Screens are the classic example. The older story blamed blue light for blocking melatonin (the hormone that makes you sleepy). Newer work points more at behavior. Screens delay winding down and push bedtime later, and screens left on overnight break up sleep. Engaging use like gaming or scrolling delays sleep much more than watching television, and autoplay features make it worse. A calm show with a clear start and end can still work if it helps a child settle. Skip the close-up, active screen time near bed.

Movement is the other trap. Parents often try to burn off energy at bedtime. One newer study found that hard exercise within two hours of bed pushed sleep onset 36 minutes later. Exercise raises core body temperature, and that temperature needs to drop for sleep. It also sharpens focus at the exact moment we want focus to fade. Running, jumping, and rough housing count here.

Set Up Transitions, Reinforcers, and the Room

A bedtime routine is a chain of transitions, and transitions are where things fall apart. Put the most preferred activities early in the routine and work down toward the least preferred. That way you never jump straight from tablet time to toothbrushing. Use natural endings too. Most kids know the tablet cannot come in the bath. Let bath time be the point where the tablet goes away for the night.

Plan for the things the child calls out for after lights out. If they ask for a snack, build a small snack into the routine. If they call parents back to ask questions, put five minutes of talking about favorite topics into the routine. Deliver those reinforcers up front and the child has less reason to chase them later.

The room matters as much as the steps. Keep the temperature steady all night, between 65 and 70 degrees. The body needs to cool down for sleep. Dress the child in light, loose clothing with nothing bulky. Keep lights dim through the whole routine, because light tells the circadian rhythm (the body's daily clock) to stay awake. If a child fears the dark, use a night light instead of an overhead light. It should stay on all night and not shine in their eyes.

Sound is the last piece. Keep the house quiet during the routine so the child can wind down. If noise is out of your control, like a busy street or a full house, a white noise machine can help. Run it all night to mask the sound. Anderson had one firm caution here. Measure the decibel level. The American Academy of Pediatrics warns that anything over 50 decibels for long stretches can harm hearing.

Teach Bedtime Skills During the Day, Then Take Data

Much of bedtime is a skill set you can teach in session. Start with sitting. A child who never sits still during the day will struggle to settle at night. Give lots of practice sitting in different spots with preferred activities. Add following directions. Bedtime often sounds like go upstairs, put on pajamas, brush your teeth. Break that down and build fluency with one-step directions first. Practicing a visual schedule during the day pays off at night.

Three more targets matter. First, giving up a preferred item, since the routine starts by asking a child to stop what they love. Bring strong reinforcers like electronics into session just to practice handing them over. Second, calm leisure skills. Many kids only have active play. Teach seated options like matching folders, puzzles, or coloring. Watch closely, because an activity you assumed was calming may rev a child up. Third, self-care skills like toothbrushing and changing clothes, where even small choices help.

Flexibility deserves its own goal. A routine should be steady without becoming brittle. Some nights mom runs it, some nights dad. Some nights the favorite pajamas are dirty. Practice with neutral items first, like being out of blue crayons, then work up to stronger preferences. The same goes for controlling adult bodies. If a child directs a caregiver to sit in one spot, teach them to tolerate that adult moving away.

When antecedent work is not enough, the bedtime pass is an option. Use it only once the schedule is right and the child can fall asleep alone. The child gets a card to trade for one trip out of the room for a specific purpose. They hand it over for the night. In the 1999 study, two brothers ages three and ten took part. Crying and coming out dropped to zero and held at a three-week follow-up. A 2006 replication with four three-year-olds worked with no extinction bursts (a spike in behavior before it drops). You can start with several passes and fade to one, or let kids trade an unused pass in the morning. Then measure something real: trips out of the room, time to fall asleep, prompts needed, or passes used.

It is important to note that the evidence for the bedtime pass is based on participants that can communicate in sentences and respond to directions from parents so it might not be the best intervention for kids with lower language levels that might not understand the contingency.

From the talk — Lindsay Anderson