Epidemiology and Management of Insomnia in Children with Autistic Spectrum Disorders

Abstract

Insomnia is the predominant sleep concern in children with autistic spectrum disorder (ASD), and its nature is most likely multifactorial, with neurochemical (abnormalities in serotonergic transmission or melatonin levels), psychiatric (anxiety), and behavioral (poor sleep habits) etiological factors involved. Children with ASD experience sleep problems similar to those of typically developing children, although the prevalence is markedly higher, occurring in 44-83% of school-aged children with ASD. Caregivers usually report that insomnia is the most frequent sleep disorder, described as disorders of initiating and maintaining sleep, restless sleep, bedtime resistance, co-sleeping, alterations of sleep hygiene, and early awakenings in the morning. Many actigraphic studies have added information on sleep disorders, confirming the questionnaire findings in the majority of cases. There are relatively few polysomnographic data for ASD, compared with questionnaire studies, and most of these studies reported a reduction in total sleep time and more undifferentiated sleep in the youngest patients. These findings were associated with several sleep microstructure alterations during rapid eye movement (REM) sleep, and with non-REM (NREM) sleep microstructure changes that appeared to be related to cognitive impairment rather than to the autistic core. Moreover, few data about other less frequent sleep disorders, such as periodic limb movements disorder and obstructive sleep apnea syndrome, bruxism, and the influence of epilepsy and EEG abnormalities, are available. Both pharmacologic and behavioral interventions have been suggested for the treatment of sleep problems in autistic children. The most common types of behavioral interventions are complete extinction (removing reinforcement to reduce a behavior) and various forms of graduated extinction. Melatonin has shown promising results in the treatment of insomnia in children with ASD. Although controlled studies are limited, there are more data demonstrating the safety and effectiveness of melatonin in ASD than for other sedative/hypnotic drugs. Finally, a dual treatment for insomnia in ASDs with melatonin and behavioral techniques has been suggested. A recent study using a combination of genetic and functional experimental techniques reported evidence that low melatonin concentration caused by a primary deficit in acetylserotonin methyltransferase activity is a risk factor for ASD. Sleep problems usually start at the same age as developmental regression, suggesting a higher vulnerability at this period of life. Further studies, beginning at younger ages, are necessary to better investigate these aspects and the role of melatonin in insomnia in children with ASD.

Influence of sleep disorders on the behavior of individuals with autism spectrum disorder

“…Another fact that needs to be considered is the use of medication by the ASD group (77%). Drug treatments for behavioral seizures and anxiety, among other disorders, may cause side effects such as sedation, drowsiness or insomnia (Rotta, 2002; Dorris et al, 2008), which can obscure the diagnosis of sleep disorders (Miano and Ferri, 2010). There is a trend for typically developing children to overcome sleep problems over the course of aging.…”

“…Regarding the sleep characteristics, subjective data about sleep patterns, such as questionnaires completed by the parents and sleep diaries, as well as objective data (polysomnography and actigraphy) indicate that the most striking feature of sleep in individuals with ASD is the inability to maintain the required latency time; common complaints include difficulty initiating and/or maintaining sleep, reduced total sleep, waking during the night and in the early morning and being unable to stay awake during the day (Elia et al, 2000; Schreck and Mulick, 2000; Miano and Ferri, 2010). …”

“…Thus, sleep disturbances, whether transient or permanent, could become more severe clinical conditions in individuals with ASD and interfere with the behavioral aspects of attention and learning (Johnson et al, 2009). Furthermore, there is a direct relationship between a reduction in the hours of night sleep and the severity of behavioral stereotypes, difficulties in social interactions, communication disorders and family stress (Richdale, 1999; Elia et al, 2000; Gregory and O’Connor, 2002; Thunström, 2002; O’Brien and Gozal, 2004; Hoffman et al, 2008; Miano and Ferri, 2010; Minkel et al, 2012). …”

Care of the patient with an autism spectrum disorder by the general physician

“…Patients with an ASD may present with worsening of their underlying behavioural symptoms, insomnia or parasomnias (sleepwalking, bruxism or nightmares) 56 57. New or worsening violent behaviour should prompt an urgent sleep assessment referral.…”

“…Given that epilepsy is common among patients with ASD, thrashing movements, confusion or agitation during sleep times should be carefully differentiated from seizure activity based on history from care givers or the patient if possible. Insomnia can be treated with improved sleep hygiene (bedtime routines and avoiding parental/care giver reinforcement of bad sleep practices) and possibly melatonin 26 56. It is appropriate for the general physician to refer a patient with an ASD with evidence of a sleep disturbance to a sleep specialist for long-term management.…”