Pediatric Sleep Pediatric Sleep Problems and Problems and ASD: Types, ASD: Types,
Assessment, & Assessment, & InterventionIntervention
Presented by:Presented by:Kathleen Armstrong, Ph.D., NCSPKathleen Armstrong, Ph.D., NCSP
Department of PediatricsDepartment of PediatricsNovember 2, 2012November 2, 2012
ObjectivesObjectives
Review prevalence of pediatric sleep Review prevalence of pediatric sleep problems problems
Describe relationship between sleep Describe relationship between sleep problems, age, and ASDproblems, age, and ASD
Differentiate types of sleep-wake Differentiate types of sleep-wake disordersdisorders
Compare interventions for pediatric Compare interventions for pediatric sleep problems in ASD populationsleep problems in ASD population
Function of Normal Function of Normal SleepSleep
Sleep TheoriesSleep Theories Restorative TheoryRestorative Theory Conservation of Energy TheoryConservation of Energy Theory Adaptive TheoryAdaptive Theory Memory Consolidation TheoryMemory Consolidation Theory
What makes us sleepWhat makes us sleep
Adenosine and other Adenosine and other neurotransmittersneurotransmitters
Environmental cues alter biological Environmental cues alter biological clockclock
Stages of SleepStages of Sleep
• 4 stages of sleep4 stages of sleep• Cyclic (go through them in same Cyclic (go through them in same
order)order)• First 3 are non-rapid eye movement First 3 are non-rapid eye movement
(Non-Rem)(Non-Rem)• Fifth is rapid eye movement (REM)Fifth is rapid eye movement (REM)• Amount of REM changes with Amount of REM changes with
developmentdevelopment
Sleep and LifespanSleep and Lifespan
Optimum Sleep and Optimum Sleep and DevelopmentDevelopment
Sleep optimizes cognition, memory, Sleep optimizes cognition, memory, behavior regulation, and learningbehavior regulation, and learning
Slow wave (stage N3 sleep) plays Slow wave (stage N3 sleep) plays role in memory consolidationrole in memory consolidation
REM sleep essential for processing REM sleep essential for processing memories within emotional memories within emotional componentcomponent
Prevalence of Prevalence of Pediatric Sleep ProblemsPediatric Sleep Problems
Common complaint, exact prevalence is Common complaint, exact prevalence is unknownunknown 53-78% of children with ASD53-78% of children with ASD 20-50% of children with ADHD20-50% of children with ADHD 46% of children with developmental delay46% of children with developmental delay 32% of typical children32% of typical children 27% of children presenting to community 27% of children presenting to community
screening for developmental concernsscreening for developmental concerns 18% of children in the bottom 10% of their 18% of children in the bottom 10% of their
class have a sleep disorder class have a sleep disorder Only 2% of children with sleep disorders Only 2% of children with sleep disorders
diagnosed and treated diagnosed and treated
Consequences related to Consequences related to Pediatric Sleep DisordersPediatric Sleep Disorders Health ProblemsHealth Problems
Car crashesCar crashes ObesityObesity Growth hormone deficiencyGrowth hormone deficiency Immune system compromisedImmune system compromised
School Performance School Performance Poor AttentionPoor Attention Lower GradesLower Grades Impaired Social SkillsImpaired Social Skills
Emotional & Behavioral ProblemsEmotional & Behavioral Problems Disruptive Behavior, Mood, Inattention, Disruptive Behavior, Mood, Inattention,
Aggression, AnxietyAggression, Anxiety
Sleep problems and ASDSleep problems and ASD
Sleep problems major health concern for Sleep problems major health concern for ASDASD
Sleep problems probably not related to Sleep problems probably not related to subtype of ASD, or IQsubtype of ASD, or IQ
Sleep problems change as children grow Sleep problems change as children grow olderolder
Sleep problems in ASD may increase Sleep problems in ASD may increase aggressive behavior, developmental aggressive behavior, developmental regression, mood, stereotypies, and anxietyregression, mood, stereotypies, and anxiety
Sleep problems related to medical problemsSleep problems related to medical problems
Sleep Problems and Sleep Problems and DevelopmentDevelopment
Children Children Under 5-sleep Under 5-sleep
anxiety, bedtime anxiety, bedtime resistance, resistance, parasomnias, night parasomnias, night wakeningswakenings
AdolescentsAdolescents Long-standing poor Long-standing poor
sleep hygienesleep hygiene Anxiety related to Anxiety related to
sleep difficultiessleep difficulties Circadian rhythm Circadian rhythm
difficultiesdifficulties Daytime sleepinessDaytime sleepiness
Medical Risks and Sleep Medical Risks and Sleep ProblemsProblems
Allergies, ear infections, & asthmaAllergies, ear infections, & asthma Cranial-facial SyndromesCranial-facial Syndromes DiabetesDiabetes GI problemsGI problems Large tonsils or mouth malformationsLarge tonsils or mouth malformations Neuromuscular disordersNeuromuscular disorders ObesityObesity SeizuresSeizures Vision problemsVision problems
ASD and Sleep ASD and Sleep DysregulationDysregulation
TheoriesTheories Genetic mutations in the neuroligin-3 an Genetic mutations in the neuroligin-3 an
neuroligin-4 genes resulting in epilepsy or neuroligin-4 genes resulting in epilepsy or sleep-wake disturbance in ASDsleep-wake disturbance in ASD
Decrease in GABADecrease in GABAB B receptors in occipital receptors in occipital and cingulate corticesand cingulate cortices
Abnormally low levels of MelatoninAbnormally low levels of Melatonin Decreased interhemispheric Decreased interhemispheric
synchronization between right and left synchronization between right and left temporal gyrus during sleeptemporal gyrus during sleep
Sleep-Wake Disorders in Sleep-Wake Disorders in ASDASD
Circadian rhythm sleep disturbancesCircadian rhythm sleep disturbances Behavioral insomniaBehavioral insomnia Rapid eye movement sleep disorderRapid eye movement sleep disorder Daytime sleepinessDaytime sleepiness Restless leg syndromeRestless leg syndrome Periodic limb movement disorderPeriodic limb movement disorder Obstructive sleep apneaObstructive sleep apnea NarcolepsyNarcolepsy
Assessment of Sleep Assessment of Sleep ProblemsProblems
Clinical historyClinical history Sleep initiation, maintenance, duration; Sleep initiation, maintenance, duration;
refreshed and alert in AM; bedtime routine; refreshed and alert in AM; bedtime routine; anxiety/depression; unusual nighttime anxiety/depression; unusual nighttime behaviors behaviors
Sleep logSleep log 2-3 weeks to document sleep-wake patterns2-3 weeks to document sleep-wake patterns
Wrist actigraphyWrist actigraphy Can combine with sleep logCan combine with sleep log
PolysomnographyPolysomnography Needed for OSAS, RLS, or nocturnal seizuresNeeded for OSAS, RLS, or nocturnal seizures
Child’s Sleep DiaryChild’s Sleep DiaryMonMon TuesTues WedWed TheThe FriFri SatSat SunSun
BedtimeBedtime
Time fell Time fell asleepasleep
Times awake Times awake during nightduring night
Time awake Time awake in morningin morning
Child Child refreshed?refreshed?
YesYes
NoNoYesYes
NoNoYesYes
NoNoYesYes
NoNoYesYes
NoNoYesYes
NoNoYesYes
NoNo
ActigraphyActigraphy
Promising technique to measure Promising technique to measure sleep patterns and response to sleep patterns and response to intervention, especially for those intervention, especially for those with neurodevelopmental disorderswith neurodevelopmental disorders
Parent still needs to maintain Parent still needs to maintain accurate sleep diary, so actigraph accurate sleep diary, so actigraph can be interpreted in context of can be interpreted in context of when child went to bed.when child went to bed.
Documents sleep onset delay.Documents sleep onset delay.
Medical Intervention Medical Intervention for OSASfor OSAS
Tonsillectomy & ATonsillectomy & Adenoidectomy denoidectomy (T&A)(T&A)
Continuous Positive Airway Continuous Positive Airway Pressure (CPAP)Pressure (CPAP)
Weight LossWeight Loss Dental AppliancesDental Appliances
Evidence-Based Evidence-Based Behavioral InterventionsBehavioral Interventions
Problems with initiating and Problems with initiating and maintaining sleepmaintaining sleep Sleep hygiene*Sleep hygiene* Standard extinctionStandard extinction
Problems with night terrorsProblems with night terrors Scheduled awakeningsScheduled awakenings
Problems with co-sleepingProblems with co-sleeping Standard extinctionStandard extinction
Sleep Hygiene*Sleep Hygiene*
Consistent bedtime routine*Consistent bedtime routine* Avoid stimulating bedtime activitiesAvoid stimulating bedtime activities Turn off mediaTurn off media Provide relaxing activitiesProvide relaxing activities Keep bedroom dark and coolKeep bedroom dark and cool Restrict caffeine before bedtimeRestrict caffeine before bedtime Offer protein snackOffer protein snack Encourage sun exposure and exercise Encourage sun exposure and exercise
during dayduring day
Standard ExtinctionStandard Extinction
1. Parents ignore all bedtime 1. Parents ignore all bedtime disruptionsdisruptions Ferber Method (1985)-ignore all disruptive Ferber Method (1985)-ignore all disruptive
behaviors for a preset timebehaviors for a preset time At the end of time, parent settles child At the end of time, parent settles child
back in bed, with minimal interactionback in bed, with minimal interaction 2. Often results in extinction burst2. Often results in extinction burst
Parents need support to stay the courseParents need support to stay the course May not be suitable for children with self May not be suitable for children with self
injurious behavior or physical disabilitiesinjurious behavior or physical disabilities
Sleep Disorders and Sleep Disorders and MedicationsMedications
Circadian rhythm disorder-Melatonin 5-Circadian rhythm disorder-Melatonin 5-6 hours prior to bedtime6 hours prior to bedtime
Parasomnias of NREM or REM sleep-Parasomnias of NREM or REM sleep-Clonazepam at bedtime, or melatonin at Clonazepam at bedtime, or melatonin at bedtimebedtime
Epilepsy-Antiepileptic agents depending Epilepsy-Antiepileptic agents depending upon seizure typeupon seizure type
RLS-Oral iron; gabapentin(Neurontin) RLS-Oral iron; gabapentin(Neurontin) PLMD-Oral ironPLMD-Oral iron
MelatoninMelatonin
Pineal hormone that regulates sleep-Pineal hormone that regulates sleep-wake cycle and promotes sleepwake cycle and promotes sleep
Prolonged sleep latency and decreased Prolonged sleep latency and decreased sleep time in ASD consistent with sleep time in ASD consistent with circadian rhythm disorder, potentially circadian rhythm disorder, potentially related to melatoninrelated to melatonin
Deficiencies in melatonin in blood and Deficiencies in melatonin in blood and urine samples documented in ASDurine samples documented in ASD
Melatonin and Cognitive Melatonin and Cognitive Behavioral TherapyBehavioral Therapy
160 children with ASD, with sleep 160 children with ASD, with sleep onset insomnia and sleep onset insomnia and sleep maintenancemaintenance
Randomly assigned to (1) Randomly assigned to (1) Combination of melatonin and CBT, Combination of melatonin and CBT, (2) Melatonin, (3) CBT, (4) Placebo(2) Melatonin, (3) CBT, (4) Placebo
Combination group showed fewer Combination group showed fewer dropouts, achieved normal sleep dropouts, achieved normal sleep efficiency, and sleep onset latency.efficiency, and sleep onset latency.
Off-Label MedicationsOff-Label Medications
MedicationMedication IndicationsIndications Clonidine Clonidine RLS, ADHDRLS, ADHD Non-benzodiazepinesNon-benzodiazepines Sleep onset/mainten.Sleep onset/mainten. AntidepressantsAntidepressants InsomniaInsomnia BenzodiazepinesBenzodiazepines Sleep onset/mainten.Sleep onset/mainten.* Not FDA approved for use with children. Limit * Not FDA approved for use with children. Limit
usage at lowest possible dose. Use in caution in usage at lowest possible dose. Use in caution in patients with respiratory, renal, hepatic patients with respiratory, renal, hepatic impairment. No Alcohol.impairment. No Alcohol.
Other Agents-with caution*Other Agents-with caution* Non-prescription agentsNon-prescription agents
ValerianValerianKavaKavaAntihistamines*Antihistamines*
Autism Speaks/Autism Speaks/Sleep Sleep Tool KitTool Kit
ATN/AIR-P Sleep Tool Kit-Parent ATN/AIR-P Sleep Tool Kit-Parent Booklet and Quick TipsBooklet and Quick Tips Using visual schedule to teach bedtime Using visual schedule to teach bedtime
routinesroutines Using a bedtime passUsing a bedtime pass Sleep tips for children with autism who Sleep tips for children with autism who
have limited verbal skillshave limited verbal skills
Case Study: SavannaCase Study: Savanna Girl, age 36 months diagnosed with ASDGirl, age 36 months diagnosed with ASD Presenting problems: Inconsistent sleep Presenting problems: Inconsistent sleep
schedule, difficulties falling asleep at schedule, difficulties falling asleep at night, night-time awakenings/unable to night, night-time awakenings/unable to console self, restless sleeper, snores console self, restless sleeper, snores loudly, and usually ends up in parent’s loudly, and usually ends up in parent’s bedbed
Medical: Allergies, ear infections, poor Medical: Allergies, ear infections, poor eater, height/weight < 5eater, height/weight < 5thth percentile percentile
Delayed social communication skills Delayed social communication skills Difficulty with transitionsDifficulty with transitions
Savanna’s InterventionSavanna’s Intervention
Referred to pediatric sleep specialist Referred to pediatric sleep specialist by her pediatricianby her pediatrician Polysomnogram confirms OSAPolysomnogram confirms OSA Tonsils and adenoids removedTonsils and adenoids removed
Parent educationParent education Establish healthy sleep routineEstablish healthy sleep routine Implement standard extinctionImplement standard extinction Use social story to reinforce sleep Use social story to reinforce sleep
routineroutine
6-month Follow-up6-month Follow-up
Sleep problems resolvedSleep problems resolved Improved ability to follow directionsImproved ability to follow directions Seems happy in morning Seems happy in morning Less emotionally reactiveLess emotionally reactive Improved social skillsImproved social skills
Case Study: SamCase Study: Sam Boy, age 15, diagnosed with ASDBoy, age 15, diagnosed with ASD Presenting problems: Difficulties falling Presenting problems: Difficulties falling
and staying asleep, difficult to wake in AM and staying asleep, difficult to wake in AM and late for bus, sleeps during AM classesand late for bus, sleeps during AM classes
Medical: Long history for sleep problems, Medical: Long history for sleep problems, anxious mood, picky eater, constipation, anxious mood, picky eater, constipation, average height and weightaverage height and weight
Limited interest in social activities with Limited interest in social activities with peers, but has on-line “friends” peers, but has on-line “friends”
Propensity for routines and motivation for Propensity for routines and motivation for samenesssameness
Sam’s InterventionSam’s Intervention Referred to pediatric sleep specialist & Referred to pediatric sleep specialist &
psychologist:psychologist: Maintain sleep diary for 3 weeksMaintain sleep diary for 3 weeks Prescribed extended release Melatonin 3-6 Prescribed extended release Melatonin 3-6
mgmg Parent education regarding sleep hygieneParent education regarding sleep hygiene
Maintain consistent sleep scheduleMaintain consistent sleep schedule Increase outdoor daily activityIncrease outdoor daily activity Shut off electronic media by 8 PMShut off electronic media by 8 PM
Sam-CBTSam-CBT Practice CBT prior to bedtimePractice CBT prior to bedtime Chart and graph progressChart and graph progress
6-month Follow-up6-month Follow-up
Sleep problems are resolving with Sleep problems are resolving with new routinenew routine
Continues to graph progressContinues to graph progress Less difficulty getting up and ready Less difficulty getting up and ready
for schoolfor school Less anxiety reported by SamLess anxiety reported by Sam Improved performance at schoolImproved performance at school
Take-home messageTake-home message Increased prevalence of sleep problems Increased prevalence of sleep problems
for children and adolescents with ASDfor children and adolescents with ASD Consequences of poor sleep include Consequences of poor sleep include
problems with behavior, learning and problems with behavior, learning and memory, growth, and higher parental memory, growth, and higher parental stressstress
More research needed to establish More research needed to establish efficacy of sleep interventions for those efficacy of sleep interventions for those with ASDwith ASD
Improving sleep habits always first line Improving sleep habits always first line of treatment*of treatment*
ReferencesReferences Armstrong, K., Kohler, W., & Lilly. (2009). The young
and the restless: A pediatrician’s guide to managing sleep problems. Contemporary Pediatrics, 26(3), 28-39.
Cortesi, G., Giannotti,F., Sebastiani, T., Panuzi,S., Cortesi, G., Giannotti,F., Sebastiani, T., Panuzi,S., Valente, D. (2012). Controlled-release melatonin, singly Valente, D. (2012). Controlled-release melatonin, singly and combined with CBT for persistent insomnia in and combined with CBT for persistent insomnia in children with ASD: A randomized placebo-controlled children with ASD: A randomized placebo-controlled trial. trial. Journal Sleep Research, 21(6),Journal Sleep Research, 21(6), 700-709. 700-709.
Goldman, S., Richdale, A., Clemons, T., & Malow, B. Goldman, S., Richdale, A., Clemons, T., & Malow, B. (2012). Parental sleep concerns in ASD: Variations from (2012). Parental sleep concerns in ASD: Variations from childhood to adolescence. childhood to adolescence. Journal Autism Developmental Journal Autism Developmental Disorders, 42, Disorders, 42, 531-538.531-538.
Kotagal, S., & Broomall, E. (2012). Sleep in children Kotagal, S., & Broomall, E. (2012). Sleep in children with ASD. with ASD. Pediatric Neurology, 47Pediatric Neurology, 47, 242-251., 242-251.
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