Sleep Issues in Autism
David Ermer MD
June 8, 2012
Children with Autism have High
Rates of Sleep Problems




44-89% rates of sleep disturbance in
autism spectrum disorders (ASDs)
Compared to 20-50% of typically
functioning children with sleep
disturbances
Sleep problems tended to be chronic with
low remission rate compared to children
without ASD
Insomnia is one the most common
concurrent problems in children with ASDs
Characteristics of Children with
ASD and Autism




No correlation between
developmental level and sleep
problem
One study found sleep problems
more common in boys than girls
More sleep problems with higher
level of communication impairment
More sleep problems with severity of
daytime behavior and diagnosis of
comorbid ADHD
Common Sleep Problems in ASD
(Jody Mindell PhD)





Highly irregular sleep-wake cycles
Unusual, problematic sleep routines
(often accompanied by repetitive
behaviors)
Difficulty settling, delayed sleep
onset
Frequent and prolonged night
wakings
Short sleep duration
Causes of Insomnia
Neurobiological



Abnormalities in GABA, Serotonin,
and melatonin production in ASDs
Neuron transmitter system disruption
Circadian disturbances affecting
sleep wake cycle
Causes of Insomnia
Behavioral/Emotional






Inadequate sleep hygiene, poor sleep
habits
Hypersensitivity to environmental stimuli
Hyperarousal/difficulty with self regulation
Repetitive thoughts or behaviors that
interfere with settling
Inability to benefit from
communiction/social cues regarding sleep
Co-occurring psychiatric condition
(anxiety, ADHD)
Causes of Insomnia
Medical/physical





Coexisting neurologic disorder: (eg,
epilepsy)
Coexisting medical disorder: (eg,
gastrointestinal reflux disease, asthma,
allergies, constipation)
Medications: ( eg, corticosteroids,
bronchodilators, stimulants)
Chronic pain: (eg, tooth pain)
Other sleep disorders: (eg, obstructive
sleep apnea, restless leg syndrome etc.)
Effects of Sleep Problems in
Children with ASD





Stress in families and children;
families report more daily stress and
more intense hassles
Parental sleep difficulties
Increased daytime behavior problem
Higher rates of stereotyped behavior
along with higher overall autism
severity scores
Higher social skills deficits
Effects of Sleep Problems (cont)


Exacerbation of medical problems
such as seizure disorder or
gastrointestinal problems
In summary sleep problems affect
the health and quality of life of
children, parents, and others in the
family
Evaluation of Sleep Problems in
ASD



The Autism Treatment Network has
developed an algorithm for dealing with
sleep in ASDs and the algorithm is
currently being studied at several medical
centers
With the high prevalence of sleep
problems everyone with an ASD should be
screened for sleep problems
If sleep problems are reported a
comprehensive sleep history should be
done
Comprehensive Sleep History



Data collection should include bedtime,
waking time, napping time, and waking
during the night along with associated
behaviors
Daytime functioning should be assessed
Children’s Sleep Habits Questionnaire is a
useful tool to assess multiple domains of
sleep problems including breathing
disorders, anxiety, resistance and daytime
sleepiness
Comprehensive Sleep History
(cont)



Family Inventory of Sleep Habits
(FISH) is an instrument that
assesses bedtime routines and
parental interactions
Behavioral rating scales can be used
to assess for comorbid psychiatric
conditions
Assess for treatable causes of
insomnia such as medical condition
(obstructive sleep apnea),
Further Sleep Evaluations


Polysomnography (PSG) is the gold
standard for sleep evaluations but is
expensive and difficult to tolerate
Sleep diaries and sleep actigraphy in
addition to good history and physical
exam can many times identify
causes of sleep problems
Initial Treatment of Insomnia




Treatable medical and psychiatric
conditions should first be addressed
Basic sleep hygiene (sleep
environment, bedtime routine etc)
should be addressed
If no improvements more structured
behavioral interventions should be
considered
Children with ASDs have a less
robust response to behavior
interventions
Sleep Hygiene Strategies
(From presentation by Jodi Mindell, PhD)


Daytime habits including exercise,
exposure to light, limited caffeine
Evening habits including decreased
stimulation, decreased light,
decreased exposure to electronics
Sleep Hygiene
Sleep Environment



Cool with minimal light and sound:
Children with ASD may be
hypersensitive to stimuli such as
light and sound
Sound machine
Sensory issues: Textures (pajamas,
sheets, blankets), Deep pressure
(weighted blanket), body pillow
Behavioral Interventions




Best to work with behavior expert
with experience in pediatric ASDs
Interventions include use of visual
cues and extinction techniques
Autism Treatment Network is
currently evaluating efficacy of a
manualized protocol
Sleep hygiene is “necessary but not
sufficient”
Pharmacologic Treatment of Sleep
Disorders in Children with ASDs



There are no FDA approved
medications for pediatric insomnia
Must be used in conjunction with
behavioral strategies and sleep
hygiene
Medications all have side effects and
are much less tolerated in individuals
with ASDs compared to typically
developing children
Melatonin



Most used and most research
currently supporting melatonin
Melatonin is a neurohormone
naturally produced from the pineal
gland in the brain to promote sleep
Non FDA regulated as it is considered
a nutritional supplement
Melatonin




Low cost, easily available without a
prescription
Not extensively studied but so far no
significant side effects
85% sleep improvement in one study
of children with ASDs
Improved sleep latency and duration
Melatonin




Should be given 30 minutes before
desired bedtime
1 mg usual starting dose with 1 mg
increases every week up to 6 mg or
higher
Once a sleep cycle has been
established for 6 weeks or more
attempts should be made to
discontinue
Long term use appears safe,
however, and may be necessary
Other Sleep Medications
Clonidine




One of the most widely use
medications for pediatric insomnia
Not adequately studied
Side effects include hypotension,
bradycardia, irritability, and rebound
hypertension after discontinuation
Dosing is usually 0.05mg to 0.1mg
30 minutes before desired bedtime
Other Sleep Medications
Trazadone



Sedating antidepressant with limited
pediatric studies
Use caution in males as can cause
priapism and children with ASDs may
have limited ability to communicate
side effects
Dosing is starting at 25 mg, usually
not higher than 100 mg at bedtime
Other Sleep Medications
Mirtazapine




Sedating antidepressant
Can cause morning sedation
Does not change sleep architecture
Dosing 15 mg at bedtime, higher
doses are less sedating
Other Sleep Medications
Benzodiazepines



Typically avoid due to sedation and
cognitive effects,
Tolerance and dependence can
develop
Clonazepam has been used for
nonREM arousal disorders such as
sleep walking if the events pose a
risk to the child; eg. walking outside
in sleep
Other Sleep Medications
Diphenhydramine (Benadryl)




Most commonly used over the
counter sleep medication
Tolerance can develop
Can cause morning sedation, dry
eyes, dry mouth
Dosing 10 to 50 mg at bedtime
Sleep Medications



Consider treatments for other
disorders that may help sleep
Use the sedating side effects of other
medications
For instance give sedating allergy
treatments at night or sedating
seizure medications at night
Discussion of Risperidone




Risperidone can improve sleep quality but
should not be used solely for the
treatment of insomnia
There are reports of risperidone being
overprescribed and for inappropriate
reasons
Risperidone has the potential for
significant side effects
Risperidone should only be used for
serious and extreme behavior problems
Summary





Sleep problems are common in children with
ASDs
Sleep problems have a significant impact on
children parents and other family members
Cornerstone of treatment is understanding the
cause
Targeting effective treatment strategies is
dependent on understanding the underlying
cause or causes
Medication should always be used in conjunction
with sleep hygiene and behavioral treatments