Sleep Issues in Autism

1. Sleep Issues in Autism David Ermer MD June 8, 2012

2. Children with Autism have High Rates of Sleep Problems • 44-89% rates of sleep disturbance in autism spectrum disorders (ASDs) • Compared to 20-50% of typically functioning children with sleep disturbances • Sleep problems tended to be chronic with low remission rate compared to children without ASD • Insomnia is one the most common concurrent problems in children with ASDs

3. Characteristics of Children with ASD and Autism • No correlation between developmental level and sleep problem • One study found sleep problems more common in boys than girls • More sleep problems with higher level of communication impairment • More sleep problems with severity of daytime behavior and diagnosis of comorbid ADHD

4. Common Sleep Problems in ASD(Jody Mindell PhD) • Highly irregular sleep-wake cycles • Unusual, problematic sleep routines (often accompanied by repetitive behaviors) • Difficulty settling, delayed sleep onset • Frequent and prolonged night wakings • Short sleep duration • Early morning wake times

5. Causes of InsomniaNeurobiological • Abnormalities in GABA, Serotonin, and melatonin production in ASDs • Neuron transmitter system disruption • Circadian disturbances affecting sleep wake cycle

6. Causes of InsomniaBehavioral/Emotional • Inadequate sleep hygiene, poor sleep habits • Hypersensitivity to environmental stimuli • Hyperarousal/difficulty with self regulation • Repetitive thoughts or behaviors that interfere with settling • Inability to benefit from communiction/social cues regarding sleep • Co-occurring psychiatric condition (anxiety, ADHD)

7. Causes of InsomniaMedical/physical • Coexisting neurologic disorder: (eg, epilepsy) • Coexisting medical disorder: (eg, gastrointestinal reflux disease, asthma, allergies, constipation) • Medications: ( eg, corticosteroids, bronchodilators, stimulants) • Chronic pain: (eg, tooth pain) • Other sleep disorders: (eg, obstructive sleep apnea, restless leg syndrome etc.)

8. Effects of Sleep Problems in Children with ASD • Stress in families and children; families report more daily stress and more intense hassles • Parental sleep difficulties • Increased daytime behavior problem • Higher rates of stereotyped behavior along with higher overall autism severity scores • Higher social skills deficits

9. Effects of Sleep Problems (cont) • Exacerbation of medical problems such as seizure disorder or gastrointestinal problems • In summary sleep problems affect the health and quality of life of children, parents, and others in the family

10. Evaluation of Sleep Problems in ASD • The Autism Treatment Network has developed an algorithm for dealing with sleep in ASDs and the algorithm is currently being studied at several medical centers • With the high prevalence of sleep problems everyone with an ASD should be screened for sleep problems • If sleep problems are reported a comprehensive sleep history should be done

11. Comprehensive Sleep History • Data collection should include bedtime, waking time, napping time, and waking during the night along with associated behaviors • Daytime functioning should be assessed • Children’s Sleep Habits Questionnaire is a useful tool to assess multiple domains of sleep problems including breathing disorders, anxiety, resistance and daytime sleepiness

12. Comprehensive Sleep History (cont) • Family Inventory of Sleep Habits (FISH) is an instrument that assesses bedtime routines and parental interactions • Behavioral rating scales can be used to assess for comorbid psychiatric conditions • Assess for treatable causes of insomnia such as medical condition (obstructive sleep apnea), medications, seizures etc.

13. Further Sleep Evaluations • Polysomnography (PSG) is the gold standard for sleep evaluations but is expensive and difficult to tolerate • Sleep diaries and sleep actigraphy in addition to good history and physical exam can many times identify causes of sleep problems

14. Initial Treatment of Insomnia • Treatable medical and psychiatric conditions should first be addressed • Basic sleep hygiene (sleep environment, bedtime routine etc) should be addressed • If no improvements more structured behavioral interventions should be considered • Children with ASDs have a less robust response to behavior interventions

15. Sleep Hygiene Strategies(From presentation by Jodi Mindell, PhD) • Daytime habits including exercise, exposure to light, limited caffeine • Evening habits including decreased stimulation, decreased light, decreased exposure to electronics

16. Sleep HygieneSleep Environment • Cool with minimal light and sound: Children with ASD may be hypersensitive to stimuli such as light and sound • Sound machine • Sensory issues: Textures (pajamas, sheets, blankets), Deep pressure (weighted blanket), body pillow

17. Behavioral Interventions • Best to work with behavior expert with experience in pediatric ASDs • Interventions include use of visual cues and extinction techniques • Autism Treatment Network is currently evaluating efficacy of a manualized protocol • Sleep hygiene is “necessary but not sufficient”

18. Pharmacologic Treatment of Sleep Disorders in Children with ASDs • There are no FDA approved medications for pediatric insomnia • Must be used in conjunction with behavioral strategies and sleep hygiene • Medications all have side effects and are much less tolerated in individuals with ASDs compared to typically developing children

19. Melatonin • Most used and most research currently supporting melatonin • Melatonin is a neurohormone naturally produced from the pineal gland in the brain to promote sleep • Non FDA regulated as it is considered a nutritional supplement

20. Melatonin • Low cost, easily available without a prescription • Not extensively studied but so far no significant side effects • 85% sleep improvement in one study of children with ASDs • Improved sleep latency and duration

21. Melatonin • Should be given 30 minutes before desired bedtime • 1 mg usual starting dose with 1 mg increases every week up to 6 mg or higher • Once a sleep cycle has been established for 6 weeks or more attempts should be made to discontinue • Long term use appears safe, however, and may be necessary

22. Other Sleep MedicationsClonidine • One of the most widely use medications for pediatric insomnia • Not adequately studied • Side effects include hypotension, bradycardia, irritability, and rebound hypertension after discontinuation • Dosing is usually 0.05mg to 0.1mg 30 minutes before desired bedtime

23. Other Sleep MedicationsTrazadone • Sedating antidepressant with limited pediatric studies • Use caution in males as can cause priapism and children with ASDs may have limited ability to communicate side effects • Dosing is starting at 25 mg, usually not higher than 100 mg at bedtime

24. Other Sleep MedicationsMirtazapine • Sedating antidepressant • Can cause morning sedation • Does not change sleep architecture • Dosing 15 mg at bedtime, higher doses are less sedating

25. Other Sleep MedicationsBenzodiazepines • Typically avoid due to sedation and cognitive effects, • Tolerance and dependence can develop • Clonazepam has been used for nonREM arousal disorders such as sleep walking if the events pose a risk to the child; eg. walking outside in sleep

26. Other Sleep MedicationsDiphenhydramine (Benadryl) • Most commonly used over the counter sleep medication • Tolerance can develop • Can cause morning sedation, dry eyes, dry mouth • Dosing 10 to 50 mg at bedtime

27. Sleep Medications • Consider treatments for other disorders that may help sleep • Use the sedating side effects of other medications • For instance give sedating allergy treatments at night or sedating seizure medications at night

28. Discussion of Risperidone • Risperidone can improve sleep quality but should not be used solely for the treatment of insomnia • There are reports of risperidone being overprescribed and for inappropriate reasons • Risperidone has the potential for significant side effects • Risperidone should only be used for serious and extreme behavior problems

29. Summary • Sleep problems are common in children with ASDs • Sleep problems have a significant impact on children parents and other family members • Cornerstone of treatment is understanding the cause • Targeting effective treatment strategies is dependent on understanding the underlying cause or causes • Medication should always be used in conjunction with sleep hygiene and behavioral treatments