Solve Your Child’s Sleep Problems
Autism Cymru 3rd International Conference Caerdydd; April 2008
Dr David Bramble MD
Consultant Child & Adolescent Learning Disability Psychiatrist
Telford & Wrekin Primary Care Trust
Disclaimer
“The advice provided by Dr Bramble today is
underpinned by research findings and
peer-evaluated practices; however, he
cannot take responsibility for parents or
carers who wish to implement any of his
advice or suggestions provided in this talk.
Should parents wish to use this
information they do so at their own risk.”
What about your sleep?
1. What time do you usually get to sleep?
2. Do you wake during the night?
(a) How many times?
(b) For how long each time usually?
3. What time do you normally get up?
4. Usually, how many hours undisturbed sleep do you
get?
5. Do you feel refreshed in the mornings?
6. Do you regularly feel sleepy in the day?
7. Have you fallen asleep during the day?
8. Do you feel tense most of the day?
9. Do you often feel depressed?
10. Rate your overall sleep quality (0 = “very bad” to
10=”very good”): ____/10
Children’s Sleep Disorders:
BACKGROUND (1)
● Children’s sleep problems common but poorly
recognised
(Stores, 1990)
 Most health workers receive no specific
training in sleep medicine
(British Sleep Society,’97)
 Over-reliance on old fashioned sedatives
(“Vallergan”, etc.)
 No evidence of efficacy in long term
(Ramchandani et al., 2000)
Children’s Sleep Disorders:
BACKGROUND (2)
 Strongly associated with daytime
behavioural problems for children and high
levels of stress for parents
 Most common forms preventable: most
children physiologically capable of sleeping
through night from 3-6 months of age
 Minority of sleep-disordered children
become chronically insomniac adults
Sleep Problems in Autism: the Myths
1. Are not serious
2. Are inevitable
3. Are short-lived
4. Cannot be treated
What are we talking about?
• Difficulty settling (falling asleep)
• Staying asleep (& waking at wrong
times)
• Strange behaviours in & around primary
sleep period (eg. sleepwalking)
• Sleepy by day
• Effects upon family and caregivers
What are we talking about (really)?
"...what happens when a child doesn't sleep? When
night after night, year after year, a child wakes, cries
and demands attention? That's when exhaustion
takes over and life becomes a grey limbo, all thoughts
of the future forgotten, our only concern to survive
another day. It erodes the fabric of life, causing
depression and resentment both of which are closely
followed by overwhelming guilt, especially when the
child is so disabled.
Most parents who suffer this
type of long- term sleep deprivation must do so in
silence, their optimism replaced by resignation".
--- mother of a 12 year-old autistic boy (1990)
Why Treat a Sleep Problem?
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Everyone benefits from a good night’s sleep
Promotes independence and fear resilience
Improves daytime thinking, feeling and behaviour
Prevents a chronic problem developing
Prevents other problems
Helps people to make the most of their potential
Keeps families happy
Prevents accidents
Children’s Sleep Disorders:
Prevalence Rates

20% of pre-school children (Richman, 1977)
 10% of school age children
 40-50% of children with severe learning disabilities
(Pahl & Quine, 1984)
 Up to 2/3 of ASD children and adolescents (Hoshino,1984)
 75% of children with profound learning disabilities
(Hogg & Lambe, 1988)
 25% of adults (ASDA, 1990)
 Most parents of ASD/SLD children have sleep problems
Children’s Sleep Disorders:
(1) COMMONEST TYPES
Pre-School:
- “colic”, night settling, night waking and early waking;
rhythmic movement disorders; bruxism.
Early School Years:
-nocturnal enuresis, fear of dark; night-terrors;
sleepwalking; nightmares; night-settling problems
Teenage Years:
-adult-type insomnias, delayed sleep phase disorder,
poor sleep hygiene.
Children’s Sleep Disorders:
(2) SOME RARER TYPES
Obstructive Sleep Apnoea (large tonsils, Down
Syndrome, storage diseases, pathological obesity).
Narcolepsy: catalepsy, cataplexy, hypogogic
hallucinations (genetically determined)
Nocturnal forms of epilepsies: frontal seizures
Why do Autistic People Have High Rates
of Sleep Problems?
1. Part of challenging/difficult behaviours in majority of children,
ie. extrinsic factors
2. Due to factor(s) linked to the disorder, ie. intrinsic factors
3. A combination of last 2 factors (intrinsic & extrinsic factors )
The Vicious Cycle of Sleep Problems
Children who do not get
adequate sleep
Day time behavioural
problems
Improved sleep
better behaviour by day
However:
Better daytime behaviour
improved sleep (normally)
1.Intrinsic Factors (1)
(i) High Anxiety/Arousal
 opposite to what promotes sleep
(ii) Bedtime Routines & Rituals (and Repetitive
Movements)
 severe or inappropriate ones can affect sleep
onset and maintenance
(iii) Sensory Abnormalities
 oversensitivity to sound or touch:
uncomfortable bedroom and bedclothes
1.Intrinsic Factors (2)
(iv) Social & Communication Difficulties
 social cues for sleep onset ignored
(v) Melatonin
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abnormalities of tryptophan metabolism?
 abnormalities of melatonin secretion?
(vi) “Sleep Architecture”
 no consistent differences compared to controls
 effects of epilepsy and its treatment
Extrinsic Factors: Medication
Sedatives (“Vallergan”, “Phenergan”)
-daytime sedation
-paradoxical excitement
Anticonvulsants (“Tegretol”, “Epilim”, lamotrigine)
-all may produce daytime sedation and affect
sleep architecture
Others:
thyroxine - stimulates in higher doses
b-blockers - nightmares
diuretics - bedwetting
salbutmol inhaler - stimulates
Children’s Sleep Disorders:
Assessment
1. General assessment inc. physical exam
2. Mental State (anxious, depressed, etc?)
3. Sleep history + diary data
4. Sleep habits of family (sleep hygiene)
5. Sleep environment (inc. type of bed)
6. Special investigations
Eg:
Polysomnography for OSA and nocturnal
epilepsies, genetic tests for narcolepsy, overnight
videotaping for parasomnias
“There never was a child more deeply loved than when he was asleep”
(R.W.Emerson)
TREATMENT:
1. Behavioural Modification
•Many research studies support this general approach
(Richman et al. 1985)
• Works for LD children (Quine & Wade, 1991)
•Few studies directly involving ASD children
•Involves: use of “sleep diaries”, extinction, cueing,
sleep hygiene, rewards
• Efficacy: 75% plus!
•Parents/carers: implement therapy
•Treatment of choice for most childhood sleep problems
(especially night settling and night waking problems)
Sleep Diary : A Practical Record for Parents
Name/Age:
Week commencing:
Monday
Time woke in morning
Mood on waking
Time of nap(s) in day
Time went to bed in evening
Time went to sleep in evening
Time(s) woke in night
What you did?
Time(s) went to sleep again
Time you went to bed
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
TREATMENT (contd.)
2. Medication
 Stimulants and anti-depressants for
narcolepsy
 Sedative hypnotics for short-term
insomnias of adolescents
(NB: sedatives are contra-indicated in infants)
 Melatonin in severe, refactory cases
3. Surgery
 Adeno-tonsilectomy for OSA
Dr Bramble’s
“Ten Steps to a Quiet Night”
1. Make bedroom safe, secure and unstimulating.
2. Set regular bedtime and waking time and stick to it.
3. Avoid stimulating activities (rough play, loud music, TV) in the
hour before bedtime.
4. Pre-bedtime settling routine (use symbols and other aids).
5. Rapid settling in bedroom (less than four minutes); use your
“magic phrase”; leave bedroom; lights off; door closed.
6. Ignore thereafter (unless physically unwell). Put back without
fuss if he/she gets up during the night.
7. Don’t give in - you will only train your child to get worse if you
do!
8. Praise and cuddles (if tolerated) once awake in the morning
following a good night
9. Initial worsening of the problem means it is working
10. Stick to this and your child (children) will learn not to disturb
you during the night.
“Ten Steps to a Quiet Night”
CAVEATS:
1. Chose a good time (ie. no holidays or special events
pending)
2. Child and parents must be in optimal health
3. Move bedroom furniture around or change bedrooms
4. Support and encourage other children
5. Discuss progress with a friend, Health visitor &/or teacher
6. Warn the neighbours of risk temporary disruption
7. If possible, brief child thoroughly before and throughout
treatment
8. Wavering parents need to back one another up
9. If illness suspected pause until physically well again
10. Persist and it stands a good chance of working in:
3 to 4 nights!
Graded Withdrawal
(For children who insist on parent’s presence at night)
1. Place mattress on floor next to bed and switch bedroom
light off
2.
3.
4.
5.
Lie next to child on bed for 3 nights
Lie on mattress next to bed for 3 nights
Move mattress by two feet closer to door every 3 nights
When at the door sit on a chair in the bedroom with door
open for 3 nights
6. Sit on a chair outside the bedroom but visible to child with
door open for 3 nights
7. Sit on a chair outside the bedroom not visible to child with
door open for 3 nights
8. Sit on a chair outside the bedroom with door closed for 3
nights
NB: If child tries to join you, return to bed with no fuss, no
eye contact
Controlled Crying
(For children who wake and cry but parent cannot ignore)
1. Discover whether there is anything worrying him/her
2. Establish how much crying and distress you can
tolerate (eg. 10 mins).
3. When child awakes and cries, wait 10 mins and go in.
4. Instruct to return to bed (if necessary) in emphatic
manner
5. No cuddles, food eye contact, etc.)
6. Reassure simply and leave after 15 secs
7. Wait for 10 mins and repeat (if necessary)
8. Extend by a set number of minutes on subsequent
nights.
Scheduled Awakening
(Another way of addressing night waking problems)
1. Discover from sleep diary data when exactly your
child habitually first wakes up during the night
2. Set your alarm clock (or stay up!) for 30 mins
before this time
3. Wake your child up by gently touching him; when he
opens his eyes let him fall back to sleep
4. If your child does not fall back to sleep, try 45 mins
the following night and, by trial and error, you will
find the best time to wake and fall back to sleep
quickly.
Restricting Sleep
(Another way of ensuring that a child is sleepy at
bedtime*)
1. Discover from sleep diary data how much sleep
he/she is having each night (av. per night in hours)
2. Calculate 90% of this and make this the new
sleeping time (delay bedtime &/or waking time)
3. If lying awake quietly occupy in another room until
sleepy and return to bed
4. Avoid naps during the day and oversleeping at
weekends
5. Never restrict below 5 hours
6. After a week move settling/waking time by 15 mins
7. Continue until desired pattern is acquired
*as long as he/she isn’t sleepy by day
Melatonin (1)
• Growing use in UK practice
• Most generic C&A specialists now prescribe
• Increasing evidence base for use with
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learning disabled, ASD and visually impaired
Established treatment of “jet lag”
Safe agent? (Probably)
Overall efficacy c. 75% (Smits et al. ‘01; Ross et al. ‘02)
Problems with prescription and supplies
GPs unfamiliar with or wary of agent
Natural Sources
Melatonin (2)
1. Exposure to sunlight in mornings
2. Foods that contain melatonin: oats, sweetcorn, rice,
ginger, tomatoes, barley.
3. Foods containing tryptophan: cottage cheese, instant
breakfast cereals, poultry, milk, nuts (esp. almonds &
peanuts)
4. Vitamins (B6, nicotinamide) and minerals (calcium &
magnesium): these promote melatonin production
Avoid Melatonin Depleting Agents
1. Caffeine (coffee, tea, cola drinks, chocolate)
2. Drugs: aspirin, steroids
3. Strong electromagnetic fields: TVs, clocks, baby
monitors, electric blankets within 1.5 metres (~4 feet) of
bed
Melatonin (3)
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Use only for refractory cases or for crises
Discussion of its unlicensed status and safety profile
Start at 2 to 5mg nocte (immediate-release formulation), and may
be increased up to 12 to 15mg nocte
Regular monitoring of response (by phone)
Slow- or controlled-release preparations and alternate-night, PRN
or tapering doses can be used
Trial withdrawal for a night or so in order to test ongoing need.
Some patients may require long-term treatment (growth and other
developmental parameters should be measured)
Patient information leaflets, treatment advice summaries and blank
sleep diary sheets should be provided.
Melatonin therapy should be under specialist review but care may
also be shared with GPs
Miscellaneous Other Techniques
• “Social stories”, “PECS” or other symbolic
communication system
• Bedroom door “modifications”
• Spy holes or CCTV
• Lock up other rooms, cupboards and ‘fridges
• Sleep suits
• Sleep systems (“Safe Space”)
If all else fails:
1. Stop, have a break, and try again
2. Reflect upon how and, possible, why the treatment
didn’t work
3. Respite care (for LD children)
4. Major tranquiliser drugs (short-term only)
5. Request a second opinion
6. Refer to Sleep Disorder Centre
Prevaricating Penny
Penny is five years-old and attends mainstream school. At
her home, every evening she has to watch her favourite
“Thomas” video three times (~4 hours) before falling asleep on
the settee in front of the TV. Her father carries her
upstairs at 11pm, gently dresses her in her “Thomas” pyjamas
(specially warmed up by her mother), puts her favourite
“Thomas” tape, reads her favourite “Thomas” book to her on
and then lies with her until she is asleep again (< 60 mins).
Usually, she sleeps through (usually) until 6 am when she gets
up and watches her video again (once). Should anything
interrupt this routine she will become extremely upset, scream
and lash out at her family. She manages to settle to sleep at
her grandparents’ house by herself and without “Thomas’s”
help! His teachers have commented upon her particularly
difficult behaviour in the afternoons.
Q1. What’s the sleep problem?
Q2. Who’s affected?
Q3. How would you help Penny?
References
Specific advice for parents:
1. Confederation of Service Providers for People
with Autism. (2002) Learning to sleep. In: “Living
with autism – learning to manage”. CoSPPA
(tel/fax: 01569 763309)
2. Dr. John Pearce (2000) “The new baby and
toddler sleep programme”. Vermillon
Children’s Sleep Disorders
AWAKE
SLEEP