SLEEP PROBLEMS IN CHILDREN WITH AUTISM

Sowmya Nath | Interactive Autism Network at Kennedy Krieger Institute | August 14, 2013 | IANCommunity.org

Most parents struggle at one time or other to get their children to sleep. Tantrums before bedtime, waking up at night, refusing to fall back asleep are common behaviors in children. If your child is experiencing any of these problems, you are definitely not alone.

Though the numbers vary from study to study, researchers estimate that 26 percent to 32 percent of typically-developing children experience sleep problems. An even larger portion of children (estimates range from 53 to 78 percent) with autism spectrum disorder (ASD) experience the same issues1.

Researchers believe that the biological systems that lead to autism symptoms could also be the reason that people with autism experience sleep problems2,3. While researchers are still trying to understand the causes of sleep problems in ASD, they have found that treating them can also help improve daytime behavior.

SLEEP AND DAYTIME BEHAVIOR

Sleep is essential. It helps regulate mood and movement. It even enables learning4 and helps us turn our experiences into long-term memories. When we don’t get enough sleep, a whole range of problems can result.

“Look at how we feel when we do not get a good night’s sleep,” Dr. Beth Malow, director of the Vanderbilt Sleep Division and the Vanderbilt Sleep Research Core, says. “Children with ASD are going to have a harder time with attention, ability to focus, ability to stay calm in emotional situations– all of these things could be affected.”

Studies show that certain types of sleep problems are associated with deficits in specific skills in children with autism. For example, one study found that children who woke up during the night experienced more speech problems than children who did not. In addition, children who did not get enough sleep had motor deficits that hindered daily activities like eating and grooming5. Those who experienced sleep problems also showed more hyperactivity6,7, aggression5, and repetitive behaviors6.

WHAT CAUSES SLEEP DISTURBANCES IN CHILDREN WITH ASD?

Often, typically-developing children experience sleep problems because they do not follow a bedtime routine8. The reasons in children with autism, however, are much more complicated.

Researchers in Italy found that one-quarter of the children with ASD who participated in their study had experienced sleep and feeding problems since birth. On that basis, they suggested that sleep problems may have biological causes2. This study and several others point to a problem related to the production of melatonin– a hormone that that is related to our daily biological or ‘circadian’ rhythms9,10.

The rise and drop in body temperature, the release of hormones, bowel movements, sleep– all of them happen at about the same time in a day for most healthy people. One of the functions of circadian rhythms is to control the release of melatonin according to changes in daylight. Our bodies produce less melatonin during the day and more at night. When more melatonin is produced, our body temperature dips and we feel drowsy– conditions necessary for a good night’s sleep.

Researchers believe that the pathways involving circadian rhythms and melatonin production could be negatively affected in individuals with autism, leading not just to sleep problems but also to sensitivity to light and temperature9.

EVALUATING THE CAUSES OF INSOMNIA TO IMPROVE SLEEP IN CHILDREN WITH ASD

Whatever the physiological reasons, many children with ASD experience insomnia?a type of sleep disorder that causes the individual to have difficulty with falling and staying asleep8,11.

Dr. Malow’s sleep study recommends screening all children with ASD for insomnia. She also suggests evaluating the child for any underlying medical conditions that may contribute to it, such as seizures, disordered breathing, or gastrointestinal problems. If these conditions exist, the healthcare provider may refer the child to a sub-specialist for treatment1.

Sleep problems could also be a side effect of the medications the child is taking to treat their autism symptoms1. If this is the case, the healthcare provider could work with a sleep specialist to decide if the medications need to be changed or the dosage altered. Dr. Malow adds that stimulating medications could also be taken earlier in the day so that their effects wear off by bedtime.

MEDICINES AND SUPPLEMENTS AS TREATMENTS FOR INSOMNIA

Though a number of supplements have been evaluated2, melatonin is the most promising. It has been shown to improve the quantity and quality of sleep in children with ASD. It has also been shown to decrease challenging daytime behaviors such as hyperactivity, and repetitive and compulsive behaviors12. However, studies proving melatonin’s effectiveness have involved only a small number of children. Researchers need to conduct studies with more individuals before children with autism start using melatonin as a viable treatment for their sleep disorders. Dr. Malow advises that families use behavioral interventions to treat sleep problems before treating children with melatonin or other supplements.

BEHAVIORAL INTERVENTIONS FOR SLEEP PROBLEMS IN CHILDREN WITH ASD

Behavioral interventions can be effective in reducing sleep problems. They can include lessening stressful situations during the day2,13 and encouraging good bedtime routines13,14.

“The child might have some issues like drinking caffeine, watching stimulating videos or playing with their computers too close to bedtime,” Dr. Malow explains. “We really try to pinpoint what the problem is.”

The American Academy of Pediatrics strongly encourages parents to reduce the time that their children spend watching television or using digital devices before bed15.

Researchers in Australia found that children with ASD and sleep problems were falling asleep in ways that did not help them get back to sleep by themselves when they awoke during the night13,14. Some children in their study fell asleep in a family member’s bed, on a couch, or with a bottle. The researchers tested methods for implementing appropriate changes in bedtime routines that supported independent and restful sleep and found that they were able to improve the children?s sleep by applying the behavioral methods13,14. Parents can make changes to disruptive bedtime behaviors by phasing them gradually out or eliminating them all at once. Children should engage in quiet and less stimulating activities outside of the bedroom before bedtime. That way, the child is calm before bed, and learns to associate the bedroom with sleep and other rooms with other activities13,14 Parents need to set an appropriate bedtime for a child, and let the child know when she is expected to wake up14.

Some children with autism understand step-by-step visual instructions better than spoken instructions. Putting up a series of pictures depicting a good bedtime routine on the bedroom wall would be a helpful technique. Rewarding the child for maintaining consistency in those activities is also important13.

Dr. Malow suggests regularly monitoring a child for sleep problems in order to treat them effectively. If none of these interventions work, she says families can then consider using medication to improve sleep.

ALTERNATIVE THERAPIES TO IMPROVE SLEEP

Parents use a host of methods hoping to improve their children’s sleep problems including massage therapy, acupuncture, and homeopathy. Research on the effectiveness of these methods is either inconclusive or nonexistent16,17,18.

WHAT NEXT?

If you think your child is not getting adequate sleep, talk to your healthcare team about interventions that could help your child reap the benefits of restful sleep.

1. References:
   Malow, B.A., Byars, K., Johnson, K., Weiss, Shelly, Bernal, P., Goldman, S.E., Panzer, R., Coury, D.L., Glaze, D.G. (2012). A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics, 130(2), 106-124.
2. Miano, S., Ferri, R. (2010). Epidemiology and management of insomnia in children with autistic spectrum disorders. Pediatric Drugs, 12(2), 75-84
3. Richdale, A.L. (1999). Sleep problems in autism: Prevalence, cause and intervention. Developmental Medicine & Child Neurology, 41(1), 60-66.
4. Kotagal, S., Broomall, E. (2012). Sleep in children with autism spectrum disorder. Pediatric Neurology, 47(4), 242-251
5. Taylor, M.A., Schreck, K.A., Mulick, J.A. (2012). Sleep disruption as a correlate to cognitive and adaptive behavior problems in autism spectrum disorders. Research in Developmental Disabilities, 33(5), 1408-1417.
6. Mayes, S.D., Calhoun, S.L. (2009). Variables related to sleep problems in children with autism. Research in Autism Spectrum Disorders, 3(4), 931-941
7. Goldman, S.E., Surdyka, K., Cuevas, R., Adkins, K., Wang, L. Malow, B. (2009). Defining the sleep phenotype in children with autism. Developmental Neuropsychology, 34(5), 560-573.
8. Bonuck, K., Grant, R. (2012). Sleep problems and early developmental delay: Implications for early intervention programs. Intellectual and Developmental Disabilities, 50(1), 41-52.
9. Nir, I., Meir, D., Zilber, N., Knobler, H., Hadjez, J., Lerner, Y. (1995). Brief report: Circadian melatonin, thyroid-stimulating hormone, prolactin, and cortisol levels in serum of young adults with autism. Journal of Autism and Developmental Disorders, 25(6), 641-654.
10. Tordjman, S., Anderson, G.M., Pichard, N.P., Charbuy, H., Touitou, Y. (2005). Nocturnal excretion of 6-sulphatoxymelatonin in children and adolescents with autistic disorder. Biological Psychiatry, 57(2), 134-138.
11. Krakowiak, P., Goodlin-Jones, B., Hertz-Picciotto, Croen, L.A., Hansen, R.L. (2008). Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: A population-based study. Journal of Sleep Research, 17(2), 197-206.
12. Malow, B., Adkins, K.W., McGrew, S.G., Wang, L., Goldman, S.E., Fawkes, D., Burnette, C. (2012). Melatonin for sleep in children with autism: A controlled trial examining dose, tolerability and outcomes. Journal of Autism and Developmental Disorders, 42(8), 1729-1737.
13. Weiskop, S., Richdale, A., Matthews, J. (2005). Behavioural treatment to reduce sleep problems in children with autism or fragile X syndrome. Developmental Medicine & Child Neurology, 47(2), 97-104.
14. Weiskop, S., Matthews, J., Richdale, A. (2001). Treatment of sleep problems in a 5-year-old boy with autism using behavioural principles. Autism, 5(2), 209-221.
15. American Academy of Pediatrics.(2013, January 14). More TV before Bedtime Linked to later Sleep Onset in Children. Retrieved from http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/More-TV-before-Bedtime-Linked-to-later-Sleep-Onset-in-Children.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
16. Piravej, K., Tangtrongchitr, P. Chandarasiri, P., Paothing, L., Sukprasong, S. (2009). Effects of Thai traditional massage on autistic children?s behavior. The Journal of Alternative and Complementary Medicine, 15(12), 1355-1361.
17. Williams, T.I. (2006). Evaluating effects of aromatherapy massage on sleep in children with autism: A pilot study. Evidence Based Complementary and Alternative Medicine, 3(3), 373-377.
18. Escalona, A., Field, T., Singer-Strunk, R., Cullen, C., Hartshorn, K. (2001). Brief report: Improvements in the behavior of children with autism following massage therapy. Journal of Autism and Developmental Disorders, 31(5), 513-516.

Photo Credits

Top Right Image: By Rachel CALAMUSA (It’s time to sleep. Uploaded by xiaphias) [CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)] via Wikimedia Commons
Bottom Left Image: Pirata Larios / Foter / CC BY-NC-ND