SleepProblemsinChildrenwithAutism.txt

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Sleep Problems in Children with Autism Spectrum Disorders
P. Gail Williams, M.D. 

Professor of Pediatrics 

University of Louisville 


Overview
.Prevalence 
.Neurobiology 
.Impact 
.Types of sleep disorders 
.Diagnosis 
.Treatment 



Prevalence
.50% to 80% of children with autism have 
sleep problems 
.Sleep problems similar across cognitive 
abilities and subtypes of autism 
.Correlation of sleep problems with 
aggression, anxiety and developmental 
regression 
. Higher than rate of sleep problems for 
general population of children or those with 
developmental delay 



Neurobiology
.ASD characterized by neurobiologic changes 
in sleep-wake cycle 
.Neurotransmitters that are likely involved 
include: Gamma-aminobutyric acid (GABA), 
serotonin and melatonin 
.Genes implicated in ASD (neurologins and 
neurexins) influence GABA synaptic function 
.Serotonin is a precursor to melatonin and 
platelet serotonin levels have been abnormal 
in some studies of ASD 



Neurobiology
.Children with ASD have reduction in in GABA 
receptors in anterior and posterior cingulate 
cortex and fusiform gyrus 
.Difficulties with sleep onset and maintenance 
may be influenced by social emotional and 
face processing deficits regulated by the 
cingulate gyrus in children with ASD 
. Melatonin secretion may be reduced or 
undergo altered time release in ASD 


 


Role of sleep in learning
.Sleep plays important role in optimizing 
cognition, memory, behavioral regulation 
and learning 
.Slow wave component of sleep plays critical 
role in memory consolidation 
.Rapid eye movement (REM) sleep critical in 
processing memories with emotional overlay 
.Sleep is essential for behavioral regulation 
and affective impulses 



Impact of sleep problems in ASD
.Sleep disturbances contribute to stress and 
parental sleep disruption 
.Sleep problems associated with behavioral 
issues, inattention and hyperactivity 
.In ASD, sleep problems seem to be correlated 
with increased repetitive behaviors and 
insistence on sameness 
.Short sleep duration associated with higher 
autism severity scores, social skills deficits 



Types of Sleep Disorders: Insomnia
.Most common of sleep problems in ASD 
.Includes difficulty falling asleep, increased 
nighttime wakenings, decreased efficiency of 
sleep 
.Medical conditions such as epilepsy and 
GERD may contribute to insomnia 
.Medications (antiepileptics, psychotropics) 
may also play a role 


 



Insomnia
.Comorbid conditions such as ADHD and 
anxiety may also contribute 
.Behavioral concerns can create problems in 
setting bedtime routine 
.Limited communication skills may also play a 
role 



Types of Sleep Disorders: OSA
.Obstructive sleep apnea is caused by airway 
obstruction and results in disordered 
breathing during sleep 
.Often characterized by loud snoring 
.Can be the result of enlarged 
tonsils/adenoids, obesity; hypotonia can 
contribute 



Types of Sleep Disorders: Parasomnias
.Non-rapid eye movement arousal disorders 
.Include night terrors, sleep walking and 
confusional arousals 
.Usually occur during first half of night during 
deep, slow wave sleep 
.Some studies report increased parasomnias 
in ASD 



Types of Sleep Disorders: movement disorders
.Restless Legs Syndrome is characterized by 
urge to move legs; occurs at bedtime and 
relieved by movement 
.Periodic Limb Movements in Sleep are 
defined by repetitive stereotypic movements 
of the limbs during sleep 
.RLS often responds to iron supplements if 
iron levels low 



Sleep history
.Bedtime, time of sleep onset 
.Mood and energy level upon waking 
.Daytime napping, attention, mood 
.Activities in hours preceding bedtime 
.Technology available in child�s room 
.Medications 
.Anxiety or depression 



Questionnaires
.Children�s Sleep Habits Questionnaire (35 
items, ages 4 to 10, parents complete) 
.Family Inventory of Sleep Habits 
.Pediatric Daytime Sleepiness Scale 
.Child Behavior Checklist 



Sleep diary
.Sleep latency 
.Total sleep time 
.Night waking 
.Response to treatment 



Actigraphy
.Involves use of a portable device (usually 
wrist band) that records movement over 
extended periods of time 
.Measures sleep patterns and total sleep time 
.Can be helpful in characterizing circadian 
rhythm patterns 
.May also be useful in determining response 
to treatment 



Polysomnography
.Overnight study that records brain waves 
(EEG), measures oxygen level, heart rate and 
breathing, as well as eye and leg movements. 
.Noninvasive and painless, but may be difficult 
for children with ASD to tolerate 
.Gold standard for detecting OSA, PLMD, 
parasomnias, etc. 



Treatment
.Medical treatment of sleep disrupting 
conditions 
.OSA, RLS 
.Epilepsy 
.GI problems (GERD, constipation, abdominal 
pain, etc.) 
.Anxiety, depression 
.Medication changes if disruptive of sleep 


 


Treatment
.Implementation of appropriate sleep 
practices 
.Daytime habits: attention to quantity and 
timing of exercise; light exposure; dietary 
choices; naps; bedroom use 
.Evening habits: �wind-down� activities; 
minimizing light exposure; bedtime routine 
and consistency of bed time 



Treatment
.Behavioral interventions 
.Use of visual schedule for each step of 
bedtime routine 
.Social stories about bedtime 
.Fading 
.Use of Bedtime Pass 



.Melatonin 
.Meta-analysis of studies of children with ID 
found melatonin safe and effective in short 
term 
.Retrospective study of 107 children with ASD 
found improvement in sleep onset and 
minimal side effects 
.Start with 1 mg 30 minutes before bedtime; 
can go up fairly rapidly; usually no more than 
6 mg studied 



Other medications
.Clonidine: retrospective study showed 
improved sleep onset 
.Others: trazodone, mirtazepine, atypical 
antipsychotics 



Resources
.Autism Speaks Toolkit: Strategies to Improve 
Sleep in Children with Autism Spectrum 
Disorders, A Parent�s Guide 
.Sleep and Autism: Helping Your Child 
(National Autistic Society � UK) 
.Establishing Positive Sleep Patterns for 
Children on the Autism Spectrum (Autism 
Society) 



Conclusion
.Sleep problems are very common in children 
with Autism Spectrum Disorders 
.Insomnia is the most common sleep disorder 
in ASD 
.Other sleep problems include sleep 
disordered breathing, sleep movement 
disorders and parasomnias 
.Sleep diaries and questionnaires are helpful in 
diagnosis 



Conclusions
.Objective measures include actigraphy and 
polysomnography 
.Treatment includes: 1) medical treatment of 
sleep disrupting conditions 2) establishing 
appropriate sleep practices 3) behavioral 
interventions and 4) melatonin/ 
pharmacology 



References
.Malow B et al. (2012) A Practice Pathway for the Identification, 
Evaluation and Management of Insomnia in Children and Adolescents 
with Autism Spectrum Disorders, Pediatrics 130: S106-S124. 
.Reynolds A, Malow M. (2011) Sleep and Autism Spectrum Disorders, 
Pediatric Clin N Am 58: 685-689, 
.Kotaga S, Broomall E. (2012) Sleep in Children with Autism Spectrum 
Disorder, Pediatric Neurology 47: 242-251. 
.Guenole F et al. (2011) Melatonin for disordered sleep in individuals with 
Autism Spectrum Disorders: Systematic Review and Discussion, Sleep 
Medicine Reviews 14:379-387. 
.Richdale A, Schreck K. (2009) Sleep problems in autism spectrum 
disorders: Prevalence, nature and possible biopsychosocial etiologies, 
Sleep Medicine Reviews 13: 403-411.