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Insomnia and Autism Fuel a Vicious Cycle

Insomnia and Autism Fuel a Vicious Cycle

  • Autism and Insomnia: A Vicious Cycle? Autism spectrum disorder (ASD) affects 1 in 68 children in the US (1) Sleep disorders may affect 44-83% of children with ASD (2) Sleep disturbances in ASD can increase behavioral problems like hyperactivity, inattention, anxiety, social impairment, hypersensitivity, repetitive and disruptive behavior (2) The predominant sleep disorder in ASD is insomnia.
  • Mechanisms underlying insomnia in autism: Behavioral: Abnormal sleep hygiene, maladaptive bedtime routines related to emotional dysregulation. Biologic, medical disorders and comorbidities. Abnormalities in genes that control circadian clock; melatonin dysregulation, low melatonin levels (1)
  • Management of insomnia in autistic children. Behavioral interventions are effective for insomnia in typically developing children (3) Evidence base for efficacy in children with ASD is limited (3) Behavioral Therapies: Techniques most often used: positive reinforcement; parent training regarding sleep hygiene and extinction (reduced parental reinforcement for inappropriate bedtime behaviors) (3) Children with ASD may have difficulty with self-regulation around bedtime, but may adapt well to bedtime routines (3) Parental focus on behavioral symptoms can cause under-recognition of sleep disorder.
  • Melatonin Rx for insonmia in autism spectrum disorders. Treating sleep disturbances in ASD can improve behavioral problems. Limited evidence for efficacy of medications to treat sleep disorders in ASD. Majority of evidence points to role for melatonin (3). Largest RCT of melatonin in ASD randomized 22 children ages 3-16 to melatonin or placebo for 3 months. Data from questionnaires and sleep diaries found (4): Melatonin improved sleep latency and total sleep time, but not the number of nighttime awakenings. Children whose sleep improved also had fewer daytime behavioral problems.
  • The Sleep Committee of the Autism Treatment Network. Developed a practice pathway to capture best practices for an overarching approach to insomnia by a general pediatrician, primary care provider, or autism medical specialist, including identification, evaluation, and management. The final document is based on expert consensus and was published in 2012 in Pediatrics.
  • Practice Pathway of the Sleep Committee of the Autism Treatment Network: Screening (1). Practice Pathway indicates treatment of insomnia can be initiated by general pediatrician, primary care provider, or autism medical specialist. All care providers should screen all children with ASD for insomnia using these questions: “Does the child fall asleep within 20 minutes after going to bed?” “Does the child fall asleep in the parent’s or sibling’s bed?” “Does the child sleep too little?” “Does the child awaken once during the night?”
  • Practice Pathway: Contributing Factors. Screening should include potential contributing factors: Medical problems: GI disorders, epilepsy, pain, nutritional problems, sleep disordered breathing, asthma, sinusitis, restless legs syndrome. Psychiatric problems: Anxiety, depression, bipolar disorder. Medication review.
  • Practice Pathway: Intervention. Determine the need for intervention: Parent education, behavioral interventions are first line. Medication may be indicated in crises or when education is not feasible Follow up within 2-4 weeks to evaluate effectiveness and tolerance of therapy. Referral to sleep specialist if symptoms do not improve, cause significant impairment, or child is at risk of harm.
  • Take Home Points on Autism and Insomnia. The predominant sleep disorder in ASD is insomnia. Behavioral problems, medication side effects, neurobiologic, and genetic abnormalities affecting melatonin may underlie sleep disorders in ASD. Treating sleep disturbances in ASD can improve behavioral problems.
  • The Sleep Committee of the Autism Treatment Network has developed a practice pathway for sleep disorders in ASD, with an emphasis on screening. Education and behavioral interventions are first line with medication use under certain circumstances; most evidence supports a role for melatonin.

Insomnia is the most common sleep disorder seen in autism spectrum disorder (ASD). Because the behavioral aspects of ASD are so disruptive, focus on them may lead parents and professionals to overlook sleep disturbances, which may actually make the behaviors worse. 

Get an update on up-to-date thinking about causes, screening tools, and management in the short slide show above.

 

 

 

References: 

1. Veatch OJ, Goldman SE, Adkins KW, et al. Melatonin in children with autism spectrum disorders: how does the evidence fit together? J Nat Sci. 2015;1(7):e125.

2. Jeste SS. The neurology of autism spectrum disorders. Curr Opin Neurol. 2011;24:132-9. doi: 10.1097/WCO.0b013e3283446450.

3. Malow BA, Byars K, Johnson K, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130(Suppl 2):S106-24. doi: 10.1542/peds.2012-0900I.

4. Wright B, Sims D, Smart S, et al. Melatonin versus placebo in children with autism spectrum conditions and severe sleep problems not amenable to behaviour management strategies: a randomised controlled crossover trial. J Autism Dev Disord. 2011 Feb;41(2):175-84. doi: 10.1007/s10803-010-1036-5.

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