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What’s so special about sleep in children with ASD? Daslne May 2012

What’s so special about sleep in children with ASD? Daslne May 2012. Professor Paul Gringras Paediatric Neurodisability and Sleep Paediatric Neurosciences and Sleep Group Evelina Children’s Hospital Guys and St Thomas’s NHS Foundation Trust Kings College London. Plan. Why bother to sleep

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What’s so special about sleep in children with ASD? Daslne May 2012

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  1. What’s so special about sleep in children with ASD?Daslne May 2012 Professor Paul Gringras Paediatric Neurodisability and Sleep Paediatric Neurosciences and Sleep Group Evelina Children’s Hospital Guys and St Thomas’s NHS Foundation Trust Kings College London

  2. Plan Why bother to sleep Overview of sleep patterns in ASD Sensory and Behavioural aspects of sleep in ASD Physiology of sleep in ASD Sleep Disorders in ASD Drugs that affect sleep

  3. Not just little adults… By the age of 2 years the average child has spent 13 months sleeping Memory, behaviour and learning Growth, metabolism, immune function, injuries Obesity and cardiovascular

  4. Blair PS, Humphreys JS, Gringras P, Taheri S, Scott N, Emond A, Henderson J, Fleming PJ. Childhood sleep duration and associated demographic characteristics in an english cohort. Sleep. 2012 Mar 1;35(3):353-60.

  5. Correlation of sleep duration over time 6 vs 30 months (ρ=0.30) 6 vs 42 months (ρ=0.26) 6 vs 69 months (ρ=0.16) 6 vs 81 months (ρ=0.15) 6 vs 115 months (ρ=0.11) 6 vs 140 months (ρ=0.04)

  6. Sleep and Autism • 44-83% Sleep Disturbance • Subjective and Objective Difficulties: • Falling Asleep • Staying Asleep • Biochemical and Genetic Assocations: • Low plasma/saliva melatonin levels • Low SM rates • ASMT enzyme deficiencies Richdale 1999 Wiggs 2004 Malow et al. 2006 Yasuhara 2010 Leu 2010 Menke 2008

  7. Evidence for behavioural interventions • >420 children in >4 studies that showed extinction or graduated extinction works • Evidence in children with learning difficulties that an information booklet can be as effective as therapy • In most studies, across most conditions, behavioural input achieves an effect size of >0.6 • Mindell JA. J Pediatr Psychol. 1999 • Kuhn BR, Elliott AJ. J Psychosomatic Res. 2003 • Weiss 2005 ACAP conference proceedings • Montgomery 2004 Child neurology and disability

  8. Which symptoms respond to behavioural interventions? Usually Pre-sleep disruptions Falling asleep alone Disturbing night wakings Co-sleeping Rarely Sleep latency Sleep duration Early morning wakening Night rocking S Weiskop, A Richdale, J Matthews - Developmental Medicine and Child Neurology, 2005

  9. Deep Pressure Edelson, Edelson, Kerr, Grandin T (1999). Behavioral and physiological effects of deep pressure on children with autism: A pilot study evaluating the efficacy of Grandin’s hug machine. The American Journal of Occupational Therapy. 1999, 53, 2 145-152.

  10. Weighted Blankets in Autism Champagne et al (2007). AOTA: http://www.ot-innovations.com/content/view/33/63 Olson LJ, Moulton HJ (2004). Use of weighted vests in pediatric occupational therapy practice. Physical and Occupational Therapy in Pediatrics, 24, Issue 2/3

  11. Atypical Sleep Architecture Long latency More wakings Decreased stage 2 sleep spindles Lower number of rapid eye movements during REM sleep Less REM sleep

  12. Treatments • No Naps! • Anchor morning wake-up time • Chronotherapy • Light therapy • Melatonin (phase advance, not as a soperific)

  13. 12 UK Centres and the Pasteur Institute • 350 Children (200 Autism) • 170 RCT melatonin 0.5mg-12mg • Actigraphy and sleep diaries • Daytime measures behaviour and cognition • Salivary melatonin and DNA analysis

  14. www.researchautism.net/mends

  15. Sleep Booklet Intervention • 50% improved from baseline to start of RCT Role of self-monitoring/being involved in trial/booklet? Available on Research Autism website for free download. www.researchautism.net/mends

  16. Outcomes • Children fall asleep ~37 minutes faster • Effect size 0.534 • Children stay asleep ~22 minutes longer • Effect size 0.39 • No significant change to daytime behaviours or parental quality of life • Genes, melatonin levels and dose finding all to come...

  17. Intelligent Melatonin Prescribing • Will improve sleep latency by 30-40 minutes • Will probably not improve night-wakening • Will only make small (possibly temporary improvement to total night sleep) • Side-effects minimal • Dose-start low, even 0.5mg can help • There are slow metabolisers of melatonin-take breaks • Late DLMO predicts increased success • No evidence that slow release is superior to fast release

  18. Obstructive Sleep Apnoea Syndrome • GASP • During the night does your child ever: • G gasp or choke? • A stop breathing? • S snore loudly or • P sweat

  19. Medications that can worsen sleep SSRI antidepressants High dose tricyclic antidepressants Beta-blockers Steroids Most anticonvulsants Mophine and NSAIDS

  20. Medications that may help • Short-term analgesics • Sleep facilitators • Benzodiazepines and Z drugs • Gabapentin and Pregabalin • Trazodone • Amitryptiline • Sleep promoters and muscle relaxants • Clonidine and Tizanidine

  21. Pharmacological Treatments

  22. What’s the point of coming to the workshop now? Your chance to teach me about your children’s sleep and what we should be looking at next!

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