Steven Felix, M.D. Pediatric Development and Therapy Center Our Lady of the Lake Regional Medical Center Understand normal sleep patterns Recognize abnormal sleep patterns Understand common sleep problems in children Know the relationship between Autism and sleep problems Be familiar with common treatments Sleep is not simply a state in which the brain is resting, but a dynamic, complicated condition during which the brain is quite active Multiple stages in sleep Reduced consciousness Follows a regular pattern Is associated with varied neurotransmitters (Melatonin, serotonin, etc.) Unknown Severe problems if impaired Impaired mood Memory problems Attention problems Learning problems Behavior problems Obesity Drowsiness First in the sequence 50% reduction in activity between wakefulness and stage 1 sleep. The eyes are closed during Stage 1 sleep, but if aroused from it, a person may feel as if he or she has not slept Light sleep Polysomnographic readings show intermittent peaks and valleys, or positive and negative waves. These waves indicate spontaneous periods of increased muscle tone mixed with periods of muscle relaxation The heart rate slows, and body temperature decreases. At this point, the body prepares to enter deep sleep. These are deep sleep stages, with Stage 4 being more intense than Stage 3
These stages are known as slow-wave, or delta, sleep
Pattern of deep sleep and rhythmic continuity
Period of most restful sleep The period of non-REM sleep (NREM) is comprised of Stages 1–4 and lasts from 90 to 120 minutes, each stage lasting anywhere from 5 to 15 minutes
During the deep stages of NREM sleep, the body repairs and regenerates tissues, builds bone and muscle, and appears to strengthen the immune system
As you get older, you sleep more lightly and get less deep sleep although studies show the amount of sleep needed doesn't appear to diminish with age. Heart rate and respiration speed up and become erratic, while the face, fingers, and legs may twitch. Intense dreaming occurs during REM sleep as a result of heightened cerebral activity, but paralysis occurs simultaneously in the major voluntary muscle groups REM sleep occurs 90 minutes after sleep onset. The percentage of REM sleep is highest during infancy and early childhood. During adolescence and young adulthood, the percentage of REM sleep declines. Infants can spend up to 50% of their sleep in the REM stage of sleep, whereas adults spend only about 20% in REM.
The five stages of sleep occur cyclically. The first cycle, which ends after the completion of the first REM stage, usually lasts for 100 minutes. Each subsequent cycle lasts longer, as its respective REM stage extends. So a person may complete five cycles in a typical night's sleep.
Newborn 15 - 16 hours per day Infant 14 - 15 hours per day Toddler 12 - 14 hours per day Preschool 10 - 12 hours per day School age 10 - 11 hours per day Teen 8 - 9 hours per day Polysomnogram. This test records several body functions during sleep, including brain activity, eye movement, oxygen and carbon dioxide blood levels, heart rate and rhythm, breathing rate and rhythm, the flow of air through your mouth and nose, snoring, body muscle movements, and chest and belly movement.
Children with Autism are children...with Autism Inadequate sleep hygiene Sleep-onset difficulties Sleep maintenance difficulties Early wakening Periodic limb movement disorder (PLMD) is repetitive cramping or jerking of the legs during sleep. Occurs only during sleep, and it is sometimes called periodic leg (or limb) movements during sleep. Movements are repetitive and rhythmic, occurring about every 20-40 seconds. Movements often disrupt sleep and lead to daytime sleepiness. PLMD typically diagnosed in adults, but frequently starts in childhood Association of PLMD and ADHD ◦ ADHD in 90% of children with PLMS ◦ PLMS in 64% in one study of newly diagnosed ADHD Relationship of PLMD and pediatric epilepsy has not been well studied ◦ PLMD in 10% in one study of intractable epilepsy Strange sensations in their legs (and sometimes arms) and an irresistible urge to move their legs to relieve the sensations. Sensations are difficult to describe: they are not painful, but an uncomfortable, "itchy," "pins and needles," or "creepy crawly" feeling deep in the legs. Sensations are usually worse at rest, especially when lying in bed. The sensations lead to walking discomfort, sleep deprivation, and stress. Nighttime snoring with occasional pauses Gasping or choking Sleep disruption Abnormal growth and development Bedwetting Behavioral and learning problems Daytime sleepiness Hyperactivity or ADHD Sleepwalking Night terrors Nightmares Rhythmic movement disorders such as head banging or rocking Arousal disorders – mostly arising out of stages 3 and 4 non-REM sleep (SWS)
Typically occur during first or second cycle of SWS (1-4 hours after falling asleep) Precipitants include sleep deprivation, febrile illness, emotional stress, sedating medications, ETOH Treatment approaches ◦ Avoid known precipitants ◦ Reassurance (treatment often unnecessary, tendency to diminish over time) ◦ Planned awakenings Asthma Allergies Anxiety/OCD Depression ADHD GER SSRI’s (i.e. Zoloft, Prozac) Steroids Thyroid medications ADHD medications (stimulants) Decongestants St John’s Wort Comorbid epilespy 5-38% Rossi PG et al. Brain Develop. 1995;17:169-74 Tuchman and Rapin. Lancet Neurol. 2002;1:352-58 Danielsson S et al. Epilepsia. 2005;46:918-23 Bimodal incidence of epilepsy ◦ Infancy to age 5 ◦ Adolescence (>10 years) Volkmar and Nelson. J Am Acad Child Adolesc Psychiatry. 1990;29:127-29 Clinical features ◦ Stereotyped presentation, timing of events, daytime abnormalities ◦ Neurological and psychiatric history, family history
Video EEG ◦ Ictal/interictal EEG with video confirmation ◦ Points to sleep disorders, sleep architecture ◦ May still require polysomnography (PSG) Nocturnal seizures occur in 60% of children with epilepsy, many of whom have seizures limited to sleep Most nocturnal seizures arise during non- REM sleep (primarily stage 2) Localization of seizure focus– frontal onset associated with sleep REM-onset seizures rare, but highly localizing Seizures can disrupt the regulation of the sleep-wake cycle ◦ Frequent seizures (and even frequent interictal discharges) produce sleep fragmentation, suppression of REM and increased spontaneous arousals Untreated epilepsy associated with feelings of non-restorative sleep Complex interaction between direct effects of drugs on sleep architecture and stabilization of neuronal excitability ◦ Sedating side effects with most older AEDs ◦ Insomnia associated with some drugs (ACTH, felbamate) ◦ Insomnia with AED withdrawal (PB, BZD) Incomplete data on newer AEDs Carbamazepine ◦ Decreases sleep latency, arousals ◦ REM unchanged Valproate ◦ Increases SWS ◦ Decreases REM Phenobarbital ◦ Decreases sleep latency, arousals ◦ Increases Stage 2, decreases REM ◦ Restlessness in latter part of night ◦ REM rebound with drug withdrawal Benzodiazepines ◦ Reduces sleep latency and awakenings ◦ Increases Stage 2, decreases SWS ◦ REM rebound with drug withdrawal Lamotrigine ◦ No effect on sleep architecture ◦ Mild increase in REM Topiramate ◦ No sleep studies Zonisamide ◦ Occasional reports of insomnia Levetiracetam ◦ Increases stage 2, decreases SWS Excessive daytime sleepiness not directly attributable to AEDs or frequent seizures Sleep-disordered breathing Nocturnal awakenings or unusual behavioral events in sleep not explained by video EEG Unexplained cognitive or behavioral deterioration ◦ Electrical Status Epilepticus of Sleep ◦ Frequent non-convulsive seizures Autistic spectrum disorders with language regression ◦ Landau-Kleffner syndrome
30% of typically developing children have sleep problems Settling Night wakening Night terrors Most typical children develop normal sleep patterns during middle childhood Temperament Fearfulness/anxiety 34 – 40% of children with developmental disabilities have sleep problems “Unique factors” Neurologic impairments Behavior problems Communication difficulties May vary depending on specific syndromes (i.e. Down’s, Prader-Willi, Retts) Prevalence rates of 41-86% for sleeping problems in children with ASD have been reported
Sleeping problems predicted more intense symptoms of autism
Sleep problems in children with ASD are a significant predictor of maternal stress (Hoffman et al., 2008). Parents of children with ASD report higher rates of sleep problems for themselves than parents of typically developing children (Lopez- Wagner, Hoffman, Sweeney, & Hodge, 2008).
More severe sleeping problems in children with ASD was related to higher rates of sleep problems in their parents (Lopez-Wagner et al., 2008).
Parents of children with ASD wake up earlier and sleep fewer hours per night than parents of typically developing children (Meltzer, 2008). Fewer hours of sleep predicted ◦ ↑ autism scores ◦ Social skills deficits
Stereotypic behavior predicted by ◦ Fewer hours of sleep ◦ Screaming during night
Schreck KA et al. Research Dev Dis. 2004;255:57-66 More variable sleep patterns Sleep onset Sleep maintenance – shorter sleep cycles Irregular sleep-wake patterns Hoshino Y et al. Folia Psychiatrica et Neurologica Japonica. 1984:38:45-51 Bedtime resistance Obstructive sleep apnea (OSA) Parasomnias (e.g. nightmares) Shorter sleep duration (Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006) Daytime sleepiness (Liu et al., 2006) Unwillingness to fall asleep in own bed (Williams, Sears, & Allard, 2004) Poor sleep hygiene (Malow et al., 2009) Medication use (Liu et al., 2006) Hypersensitivity (Liu et al., 2006) Comorbid epilepsy, ADHD, asthma, allergies, gastrointestinal problems (Liu et al., 2006) Melatonin regulation may be abnormal (Richdale, 1999). Anxiety/Fear (Richdale, 1999)
Establish a regular time for bed each night and do not vary from it. Similarly, the waking time should not differ from weekday to weekend by more than one to one and a half hours Create a relaxing bedtime routine, such as giving your child a warm bath or reading a story Do not give children any food or drinks with caffeine less than six hours before bedtime Make sure the temperature in the bedroom is comfortable and that the bedroom is dark Make sure the noise level in the house is low. Avoid giving children large meals close to bedtime Make after-dinner playtime a relaxing time as too much activity close to bedtime can keep children awake There should be no television, radio, games or music playing while the child is going to sleep Avoid excessive or late naps in younger children Melatonin is a hormone produced by the pineal gland that causes drowsiness.
Melatonin levels rapidly increase in the evening, peak in the middle of the night and decreases during the second half of the night.
Melatonin is not considered a drug, so it is not regulated by the FDA.
No side effects have been reported in children with ASD.
In a randomized, double-blind, placebo-controlled crossover trial of melatonin with 7 children with ASD and sleep problems, melatonin significantly reduced sleep latency, number of night wakings and increased total sleep time (Garstang & Wallis, 2006).
Two other studies obtained similar results (Giannotti et al., 2006; Wasdell et al., 2008) Melatonin (up to 6 mg) to treat insomnia ◦ Retrospective review of single pediatrician n=107 children 2-18 year-olds ◦ Parental report of change with treatment ◦ Melatonin dose range 0.75-6mg
Andersen IM et al. J Child Neurol. 2008;23(5):482-5 Results 25% no further sleep concerns 60% improved sleep, continued concerns 13% sleep problems, major concern 1% worse sleep with melatonin 1% undetermined response
Andersen IM et al. J Child Neurol. 2008;23(5):482-5 Chronotherapy involves systematically delaying bedtime on successive nights until the individual is falling asleep at an appropriate time.
Capitalizes on circadian drift (human circadian cycles last 25 hours; when time cues are absent we tend to fall asleep an hour later every day).
It is actually easier to change sleep onset from 2 a.m. to 10 p.m. by gradually increasing bedtime than by making bedtime earlier.
Irregular sleep onset times, night and early waking and short sleep times were successfully treated with chronotherapy in an 8-year old girl with autism and mental retardation (Piazza, Hagopian, Hughes, & Fisher, 1998). Bright light suppresses the secretion of melatonin, thereby decreasing drowsiness (individuals should be exposed to bright light in the morning and afternoon, not in the evening) (Richdale, 1999).
No studies have been conducted to assess the effectiveness of light therapy in reducing sleep problems in children with ASD. Almost all of the studies using behavioral interventions include establishing a bedtime routine.
A bedtime routine should consist of specific activities conducive to sleep.
For example, taking a bath, brushing teeth, changing into pajamas, read bedtime story, turn off the light and go to sleep.
There are no studies examining the effectiveness of this component by itself (Schreck, 2001) Non-graduated extinction (Schreck, 2001). ◦ Parents ignore all crying and screaming at bedtime and during the night. They keep the bedroom door closed and do not respond. Graduated extinction (Schreck, 2001). ◦ If the child engages in problem behavior at bedtime, the parents ignore it for a pre-set time period (e.g. 5 minutes). ◦ If the child continues to cry, the parents re-settle the child with as little attention as possible and leaves the room again. ◦ Continue this procedure until the child falls asleep. ◦ Used because parents feel uncomfortable letting their child tantrum for long periods of time.
Based on specific criteria for different classifications of evidence-based treatment effectiveness, extinction (graduated and non-graduated) was deemed a possibly efficacious ABA intervention for sleep problems by Schreck in 2001. Stimulus fading (Schreck, 2001). ◦ Used to eliminate co-sleeping. ◦ Involves gradually and systematically moving a co-sleeper (usually a parent) farther away from the child’s bed. ◦ On the first night, the parent sleeps on a bed or mattress beside the child’s bed. ◦ On subsequent nights, the parent is moved farther from the child’s bed until he or she is out of the child’s room. One study showed effectiveness of stimulus fading in eliminating co-sleeping and reducing night wakenings in a 5 year old boy with autism (Howlin, 1984, as cited in Schreck, 2001). Social Stories (Gray, 1995, as cited in Moore, 2004). ◦ Carol Gray developed social stories to help children with ASD understand social behaviors and teach them how to behave in specific situations. ◦ Social stories should be short (20-150 words) ◦ Explain subtle social cues and socially acceptable behavior ◦ Emphasis on perspective of child and perspective of others ◦ Children’s language comprehension should be taken into account. In my house everybody has a bed. I love my bed. I like it because it is cozy to be sleeping in. I have favorite things I can take in my bed too. I have stuffed animal pillows. I love to cuddle them.
Everybody in my house sleeps in their bed all night. Daddy sleeps in his bed all night. Mommy sleeps in her bed all night.
Sometimes it is hard for me to sleep all night. Sometimes I call my Mommy. Sometimes I cry for my Mommy. Guess what? One time Pooh Bear had a hard time sleeping all night too! He calls Christopher Robin all night. Pooh asks Christopher Robin to help him sleep all night.
Christopher Robin tells Pooh a secret. He said the secret to sleeping all night is to cuddle something and think about nice things. Pooh is going to try and cuddle his favorite blanket. If he wakes up, Christopher Robin will tell him to go back to sleep. Christopher Robin might put Pooh back into bed.
Pooh said he is going to try and sleep in his bed all night. If he wakes up he will cuddle his blanket. Pooh tried very hard to sleep all night in his bed. And he did it. He woke up at night and he started to call Christopher Robin. Christopher Robin told Pooh to go back to sleep. So Pooh cuddled his blanket and thought about honey! He went back to sleep by himself!! I think I am going to try and sleep in my bed all night too! If I wake up I can be like Pooh. I will cuddle something I like. I can cuddle Pooh!
If I wake up at night my Mommy can say, “Go back to sleep Johnny.” Then I will just stay in my bed and cuddle somebody. Weight loss Managing allergic rhinitis Nasal steroids Antibiotics Removal of the adenoids and tonsils - as a last resort PLMD - dopaminergic agonists (e.g. pergolide), l- dopa, clonazepam
Parasomnias - BZDs, low-dose tricyclics Clonidine Blood pressure medication 0.05 – 0.3 mg Side effects - low blood pressure, vivid dreams Trazodone Antidepressent 25 – 150 mg Side effects - dry mouth, constipation, increased heart rate Seroquel Atypical antipsychotic 25-200 mg Side effects - weight gain, atypical motor movements, increased blood sugar, increased heart rate Sleep an necessary factor in behavior and learning Multiple causes of sleep problems Increased sleep problems in Autism Varied strategies for treatment