When my grandson was born it seemed like he never slept. He would be fidgety all night, crying at the top of his lungs as if something was bothering him. Multiple visits to the pediatrician only prompted snide comments about the anxiety of first time parents. Several years later it is now evident that he does have problems with sleep. I have never been able to talk to him about this. He is autistic, nonverbal and low functioning. Whether he is restless, anxious or even whether he dreams or not, it is all hidden from me.
Sleep is an important problem in ASD, affecting 40 to 80% of diagnosed individuals. The quoted figures are higher than for any other neurodevelopmental condition. Prevalence rates are highest among higher functioning individuals. Some people believe that this may be due to the higher capacity to express their concerns as compared to lower functioning individuals (note: this may also account for the higher prevalence of mood disorders among higher functioning ASD individuals). Sleep disturbances in ASD may be multiple and include: finding it hard to fall asleep, waking up early and never falling back to sleep or being restless/anxious. The end result is feeling grumpy during the day and a a predisposition to maladaptive behaviors. More so, I have found that this symptom goes on to affect the sleep pattern of the parents who are often awakened and have their own sleep disturbed.
Infants spend most of their sleep in the REM stage but this gradually decreases with time, reaching only about 20% in adulthood. Autistic individuals also seem to spend less time in REM sleep. Some researchers believe that the reported REM deficiency reflects an abnormality of neuronal organization during brain development.
Adults need about 8 to 9 hours of sleep daily but children need a lot more (age 1-3 need 12-14 hours, and age 3-6 need 10 to 12 hours). If we do not get enough sleep (sleep deprivation) our threshold for stress is lowered, we become inattentive and forgetful, creativity is impaired, our sociability suffers and our optimism in regards to life diminishes. Problems with sleep lead to raised blood pressure and an increase in food consumption, thus procreating a risk for cardiac mortality. Sleep problems may be associated with behavioral issues including inattention and hyperactivity. In ASD sleep problems seem to correlate with increased repetitive behaviors, instance on sameness, higher autism severity scores, and more social skill deficits.
The cause for sleep difficulties in ASD is not known. Some people suspect it is related to the hormone melatonin as timing of release of this hormone may be abnormal in some ASD individuals. Another possible contributor is serotonin (a precursor to melatonin) as platelet levels of this neurochemical are abnormal in some ASD studies.
When taking a history of sleep in ASD it is necessary to clarify whether the problems are due to night terrors, sleep walking and/or confusional arousals. These conditions usually occur during the first half of the night during deep. In some cases sleep abnormalities are due to restless leg syndrome. This condition has been associated to low blood iron levels. For those interested a previous blog in corticalchauvinism dealt with the role of iron in autism (http://bit.ly/1NMXkAT). Other important points during history taking include medication usage (e.g., antiepileptic, psychotropic), and the presence of concomitant medical conditions such as epilepsy, gastroesophageal reflux (GERD), dental problems, eczema, asthma exacerbations, and mood disorders -all of which may contribute to poor sleep.
When considering treatment options start by establishing healthy sleeping practices. Establish how much caffeine and other dietary stimulants the child may be taking. Avoid taking prolonged naps during the day, especially those after 4 PM. Provide adequate exposure to light and perform a good amount of exercise to release your energy. Use the bedroom primarily for sleep and sleep only. Do winding down activities that calm you down, no rough housing before going to bed. When necessary or if found to your liking use massage and/or other relaxation techniques. White noise in the room helps some individuals. Eliminate TV and computers in the bedroom (as they can entice the patient to go to them during the night). Do not take a heavy meal before bedtime. Some individuals may benefit from sleeping with a weighted blanket (see http://bit.ly/1L9OM4j). Establish a bed time routine with a visual schedule- write a social story to illustrate how to go to bed.
Melatonin has proven of some benefit in treating sleep problems in ASD. A pediatrician will prescribe .5 mg 30 to 45 minutes before bedtime and titrate up fairly rapidly but usually to no more than 10 mgs. There is an extended release form for those who have problems staying asleep. Common side effects include daytime drowsiness, a morning “hangover” effect, nausea, headaches and dizziness. Clonidine used primarily to treat high blood pressure, has also been used for insomnia as it has a strong sedative effect, similarly some antidepressants (trazodone, mirtazapine, atypical antipsychotics) may be of some benefit.