Sleep disturbance in children with Autism Spectrum Disorder (ASD) Luci Wiggs Oxford Brookes University Department of Psychology
Outline • Nature of sleep problems • Associations • Management
Sleep abnormalities and ASD • Physiological sleep abnormalities eg. melatonin profile (Tordjman 2005;2012; Kulman et al 2000; Melke 1998; Nir et al 1995)
Kulman et al, (2000)
Sleep abnormalities and ASD • Physiological sleep abnormalities eg. melatonin profile (Tordjman 2005;2012; Kulman et al 2000; Melke 1998; Nir et al 1995) • Sleep disorders eg. sleep/wake cycle disorders (Inanuma 1984; Glickman 2010) • ‘Sleeplessness problems’ (Souders et al 2009; Malow et al 2006; Wiggs & Stores 2004; see Richdale 2001)
‘ sleeplessness’ – bedtime difficulties difficulty getting to sleep waking in night early waking irregular sleep short duration sleep
Sleeplessness and ASD • Sleeplessness rate in ASD about 66% (range 49-89%) ( Richdale 2001; Wiggs & Stores 2004; Krakowiak et al 2008, Souders et al 2009) • Compared to typically developing children, more of a decrease in night sleep (later bedtime, night wakes, early waking) from 30 months – 11 years (Humphreys et al 2013) • High rates in children intellectual disabilities (Patzold et al 1998; Krakowiak et al 2008) • IQ positively predictive of sleep anxiety (n=1583) (Hollway et al 2013)
Sleep disturbance and ASD: associations • Behaviour: Increased challenging behaviour and externalizing problems (e.g. Sikora 2012; Mayes & Calhoun, 2009; DeVincent et al, 2007, Allik et al, 2006, Patzold et al, 1998; Hoshino et al 1984) • Mental health: Increased anxiety and affective problems (Hollway et al 2013; Sikora 2012, Malow et al, 2006;Tani et al, 2004; Wiggs & Stores, 2004; Tani et al, 2003) • Cognition: Impaired perception/visual response, and cognitive procedural memory (Limoges et al 2013; Taylor, Schreck & Mulick 2012; Elia et al, 2000) • Motor function: Low sensory-motor memory, hand-eye co- ordination and adaptive skills (Limoges et al 2013; Taylor, Schreck & Mulick 2012; Elia et al, 2000) • Features of ASD: Severity of autistic symptoms, communication abnormalities, social skills, routines and rituals ( May et al 2014; Hollway et al 2013; Taylor et al 2012; Alik et al 2006; Liu et al 2006; Malow et al 2006; Hoffman et al 2005; Schreck et al 2004; Elia et al 2000)# • Parental sleep disturbance: (Lopez-Wagner et al 2008; Meltzer 2008; Hodge et al 2013)
Significance of successful resolution of sleep disturbance • Improved sleep associated with improvements in child behaviour, mental health, parents mental health and family functioning (in typically developing children and those with developmental disorders) • ASD – limited studies; range of sleep disorders/interventions • Some studies suggesting successful intervention associated with increased ease of management. e.g. – improved aspects of child , behaviour (e.g. hyperactivity, self injurious behaviour, rigid/repetitive behaviour) – mood, internalising problems – communication, social interaction – child quality of life – parenting sense of competence (Malow et al 2014; 2012 Wright et al, 2010; Reed et al, 2009; Malow et al 2006; Paavonen et al 2003; De Leon et al, 2004)
Sleep disturbance is common in a range of conditions associated with intellectual disabilities and autism Down syndrome Smith-Magenis syndrome Prader-Willi syndrome Angelman syndrome Williams syndrome Fragile X syndrome Cornelia de Lange syndrome Cri du Chat syndrome Rett syndrome Mucopolysaccharidoses
Sleep disturbance - comorbidity common Comorbidity with: • Neurodevelopmental disorders • Medical/neurological problems • Emotional/behavioural disorders Direct effects (e.g. discomfort, physical features of Down syndrome) Indirect effects (e.g. treatment) (See Wiggs (2012) for discussion)
Management approaches • Psychological • Reassurance/explanation * Behavioural • Safety measures * Cognitive • Sleep hygiene • Chronotherapy • Medication (see Hollway & Aman 2011) * Hypnotics * Stimulants * Melatonin * Others • Physical measures • Surgery (See Wiggs. L. (2012). Sleep Disturbances and Learning Disability (Mental Retardation) In C. M. Morin and C. Espie (Eds.), The Oxford Handbook of Sleep and Sleep Disorders. New York: Oxford University Press)
Sleeplessness Management in ASD • Sleep hygiene • Behaviour therapy • Melatonin • Other interventions • Weighted blankets
Sleep Hygiene “A set of sleep -related behaviours that exposes the individual to activities and cues that prepare them for and promote appropriately timed and effective sleep” (Meltzer & Mindell 2004) • Environment - familiar, comfortable, dark, quiet • Scheduling – consistency in timing, daytime activities • Sleep practices – calming routine • Physiologic – naps, caffeine, TV/PC use
Sleep Hygiene and ASD • Poor evidence base for special considerations in children with developmental disorders (Jan 2008) and ASD (Vriend et al 2011) • Unusual/inconsistent bedtime routines in children with ASD - maladaptive for promoting good sleep hygiene? (Henderson et al 2011) • TV/computer in room and time spent playing video games in boys with autism more strongly associated with reduced sleep than for boys with ADHD and controls (Englehardt et al 2013)
Elements of sleep are learnt behaviours including… • How we prepare for bed • How we settle to sleep • Where we settle to sleep • What we do when we wake up Behaviour therapy likely to play a role where elements of sleep behaviour have been learnt ‘incorrectly’ or ‘not learnt’ at all
Behaviour Therapy • Number of ‘well established’ techniques for TD infants (see Mindell 2006; American Academy of Sleep Medicine 2006) • Helpful for children with developmental disorders inc. ASD Vriend et al (2011) Richdale & Wiggs (2005)
Interventions for sleeplessness likely to include • Appropriately timed bedtime routine (cueing) • Appropriate bed time (linked with sleep onset) (conditioning) • Extinction/stimulus fading/checking (removing positive reinforcement for undesired behaviour) • Positive reinforcement (shaping)
Behaviour therapy: general considerations • intervention based on functional assessment • use diary • pick good time to start • support
Behaviour therapy: special considerations • Making the room/house safe/secure • Changes as gradual as required (for parent and child) • Communication difficulties with child – social stories – visual schedules – use of all senses • Use of school/drivers • Creative use of reinforcement
Reports of behaviour therapy for sleeplessness in ASD • 4 RCTs – 36 children 2-10 years (Adkins et al, 2012) – 39 children, 4-16 years (Wiggs & Stores, in preparation) – 33 children 2-6 years (Johnson et al, 2013) – 144 children (33 CBT), 4-10 years (Cortesi et al 2012) • 2 uncontrolled trials, 20 children 3-10 years (Reed et al 2009); 80 children, 2-10 years (Malow et al, 2014) • 1 multiple baseline study, 6 children 3-7 years (Weiskop et al 2005) • 9 case reports, 18 children, 3-12 years
• 36 children 2-10 years • Information pamphlet : no effect on sleep latency • Parents needed to know ‘how’ not just ‘what’ to do (Adkins et al, 2012) • 80 children, 2-10 years • Group (4x1 hr) vs individual (1hr) parent education (+2 follow up calls): both statistically reduced sleep latency (Malow et al, 2014) http://www.autismspeaks.org/science/resources-programs/autism-treatment- network/tools-you-can-use/sleep-tool-kit
Randomised control trial (RCT) of behaviour therapy (BT) in children with ASD Children with ASD and sleep disturbance (2-6 years). RCT of manualised BT (n=15) vs non-sleep parent education (PE) (n=18) over 8 weeks PE BT The BT group improved significantly more PE than the comparison group based on composite sleep index (CSI) parent report. No change in objective sleep (actigraphy) (Johnson, Kylan, Foldes, Kronk, & Wiggs 2013) Same pattern of findings in older children with ASD (5-16 years) (Wiggs & Stores, in preparation)
Some parents’ comments… “our child sleeps the best now that he’s ever done in his life” “massive improvement – thank you!” “has made our lives a lot easier as it’s so much calmer in the house” “we have our evenings back! Thank you” “for the first time I am able to say ‘good night’ to my child and it’s a pleasant experience” (Wiggs & Stores, in preparation)
Cortesi et al (2012) 134 children (4-10y)-ASD (no ID) and sleeplessness 3mg controlled release Multifactorial BT – Combined (n=35) – Melatonin (n=34) – BT (n=33) – Placebo (n=32) Sleep latency Mean % change from baseline Combined Melatonin BT Placebo Sleep onset latency 60.75 44.33 22.54 -0.02 Total sleep time 22.01 17.31 9.31 0.07
Recommend
More recommend
