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)