What’s so special about sleep in children What’s so special about sleep in children with ASD?with ASD?

Daslne May 2012Daslne May 2012

Professor Paul GringrasPaediatric Neurodisability and Sleep

Paediatric Neurosciences and Sleep GroupEvelina Children’s Hospital

Guys and St Thomas’s NHS Foundation TrustKings College London

Plan

• Why bother to sleep

• Overview of sleep patterns in ASD

• Sensory and Behavioural aspects of sleep in ASD

• Physiology of sleep in ASD

• Sleep Disorders in ASD

• Drugs that affect sleep

Not just little adults…

• By the age of 2 years the average child has spent 13 months sleeping

• Memory, behaviour and learning

• Growth, metabolism, immune function, injuries

• Obesity and cardiovascular

Blair PS, Humphreys JS, Gringras P, Taheri S, Scott N, Emond A, Henderson J,Fleming PJ. Childhood sleep duration and associated demographic characteristics in an

english cohort. Sleep. 2012 Mar 1;35(3):353-60.

Correlation of sleep duration over time

6 vs 30 months (ρ=0.30) 6 vs 42 months (ρ=0.26) 6 vs 69 months (ρ=0.16)

6 vs 81 months (ρ=0.15) 6 vs 115 months (ρ=0.11) 6 vs 140 months (ρ=0.04)

Sleep and Autism

• 44-83% Sleep Disturbance

• Subjective and Objective Difficulties:– Falling Asleep– Staying Asleep

• Biochemical and Genetic Assocations:– Low plasma/saliva melatonin levels– Low SM rates– ASMT enzyme deficiencies

Richdale 1999Wiggs 2004Malow et al. 2006Yasuhara 2010Leu 2010Menke 2008

Evidence for behavioural interventions

• >420 children in >4 studies that showed extinction or graduated extinction works

• Evidence in children with learning difficulties that an information booklet can be as effective as therapy

• In most studies, across most conditions, behavioural input achieves an effect size of >0.6

– Mindell JA. J Pediatr Psychol. 1999– Kuhn BR, Elliott AJ. J Psychosomatic Res. 2003– Weiss 2005 ACAP conference proceedings– Montgomery 2004 Child neurology and disability

Which symptoms respond to behavioural interventions?

• Usually• Pre-sleep

disruptions• Falling asleep alone• Disturbing night

wakings• Co-sleeping

• Rarely• Sleep latency• Sleep duration• Early morning

wakening• Night rocking

S Weiskop, A Richdale, J Matthews - Developmental Medicine and Child Neurology, 2005

Deep Pressure

Edelson, Edelson, Kerr, Grandin T (1999). Behavioral and physiological effects of deep pressure on children with autism: A pilot study evaluating the efficacy of Grandin’s hug machine. The American Journal of Occupational Therapy. 1999, 53, 2 145-152.

Weighted Blankets in Autism

Champagne et al (2007). AOTA: http://www.ot-innovations.com/content/view/33/63

Olson LJ, Moulton HJ (2004). Use of weighted vests in pediatric occupational therapy practice. Physical and Occupational Therapy in Pediatrics, 24, Issue 2/3

Atypical Sleep Architecture

• Long latency

• More wakings

• Decreased stage 2 sleep spindles

• Lower number of rapid eye movements during REM sleep

• Less REM sleep

Treatments

• No Naps!• Anchor morning

wake-up time• Chronotherapy• Light therapy• Melatonin (phase

advance, not as a soperific)

• 12 UK Centres and the Pasteur Institute

• 350 Children (200 Autism)

• 170 RCT melatonin 0.5mg-12mg

• Actigraphy and sleep diaries

• Daytime measures behaviour and cognition

• Salivary melatonin and DNA analysis

www.researchautism.net/mends

Sleep Booklet Intervention

• 50% improved from baseline to start of RCT

Role of self-monitoring/being involved in trial/booklet?

Available on Research Autism website for free download.

www.researchautism.net/mends

Outcomes

• Children fall asleep ~37 minutes faster – Effect size 0.534

• Children stay asleep ~22 minutes longer– Effect size 0.39

• No significant change to daytime behaviours or parental quality of life

• Genes, melatonin levels and dose finding all to come...

Intelligent Melatonin Prescribing• Will improve sleep latency by 30-40 minutes• Will probably not improve night-wakening• Will only make small (possibly temporary

improvement to total night sleep)• Side-effects minimal• Dose-start low, even 0.5mg can help• There are slow metabolisers of melatonin-take breaks• Late DLMO predicts increased success• No evidence that slow release is superior to fast

release

Obstructive Sleep Apnoea Syndrome• GASP

• During the night does your child ever:

• G gasp or choke?

• A stop breathing?

• S snore loudly or

• P sweat

Medications that can worsen sleep

• SSRI antidepressants

• High dose tricyclic antidepressants

• Beta-blockers

• Steroids

• Most anticonvulsants

• Mophine and NSAIDS

Medications that may help

• Short-term analgesics

• Sleep facilitators– Benzodiazepines and Z drugs– Gabapentin and Pregabalin– Trazodone– Amitryptiline

• Sleep promoters and muscle relaxants– Clonidine and Tizanidine

Pharmacological Treatments

What’s the point of coming to the workshop now?

Your chance to teach me about your children’s sleep and what we should be looking at next!