Vicki Kobliner, RDN, CD-N, describes nutritional and lifestyle strategies for improving sleep and overall health for autistic people. She discusses circadian rhythm and balancing cortisol and melatonin cycles throughout the day. The speaker considers screen time restrictions, environmental adjustments, and relaxation techniques that assist with sleep onset and quality. Kobliner emphasizes the connection between diet and sleep and highlights critical nutrients for balanced sleep cycles. She lists valuable herbs and supplements and summarizes the presentation before the Q&A. 

Handouts are online HERE (.pdf)

In this webinar: 

1:35 – Sleep
5:36 – Circadian Rhythm
7:36 – Lifestyle and sleep
11:30 – Journaling and relaxation
16:20 – Nutrition and sleep
18:10 – Carbs, melatonin, and vitamin D
21:30 – Magnesium and B vitamins
23:49 – Amino acids
26:45 – Herbs and supplements for sleep
33:46 – Adaptogens
36:18 – Summary
37:40 – Q&A

Sleep cycles and circadian rhythm

Kobliner outlines recommended sleep times (total length of sleep) for different age groups and notes that lack of sleep leads to impulsivity, attention deficits, forgetfulness, learning deficits, obesity, impaired immune function, anxiety, and depression in both children and adults (2:30). Circadian Rhythm, the speaker continues, is a cycle maintained by the body that influences the balances of cortisol and melatonin throughout the day. She highlights that healthy sleep patterns, or balanced cortisol and melatonin cycles, are associated with benefits to mental health, cognition, and development (5:36). 

How lifestyle affects sleep cycles

The speaker discusses several aspects of lifestyle and how they affect sleep patterns. For example, you must decrease your core temperature by two or three degrees to initiate and maintain sleep. Kobliner suggests taking a hot shower 60 – 90 minutes before bed or wearing socks to sleep to support radiation of heat through the extremities, thus cooling the body (7:36). Upon entering sleep, she continues, cortisol levels should be at their lowest, so winding down before bed is important (8:40). Some common techniques for winding down include avoiding electronics one to two hours before bed, stretching/relaxing body movements, and meditation (10:20). Kobliner discusses the correlation between gratitude journals and sleep quality, noting that research shows a 50% decrease in sleep onset in those who journal (11:30). 

To ensure sleep-supportive lighting, the presenter suggests avoiding LED, dimming the lights an hour or so before bed, using sleep masks, and eliminating blue wavelength light (from screens), which shuts off melatonin production (12:00). Kobliner recommends not eating within three hours of sleep to regulate body temperature and emphasizes the importance of consistent bedtimes (13:40). Exercise should be done earlier in the day and not less than 2 hours before bed because it can raise cortisol levels and increase core temperature (14:40). The presenter notes typical consequences of sleep obstruction including apnea, snoring, daytime fatigue, and attention deficit, among others (15:20). 

How nutrition affects sleep cycles 

Kobliner outlines research showing that a lack of crucial nutrients like calcium and magnesium, as well as vitamins A, C, D, E, and K, are associated with sleep problems. Nutrient consumption affects circadian hormonal pathways, making diet a critical aspect of balanced sleep cycles (16:20). Carbohydrates support melatonin production but can also increase time to sleep and drowsiness. Therefore, the speaker states, carbs should be consumed three to four hours before bed and should be whole grain, not processed (18:10). Calcium is necessary to convert tryptophan to melatonin and can be found in dairy, boned fish, almonds, broccoli, and sesame seeds. Deficiencies in vitamin D, which can be absorbed from sunlight, egg yolk, and fatty fish, are linked to insomnia (20:28). 

The presenter explains that magnesium supports neurotransmitter production, reduces restless leg syndrome, makes it easier to fall asleep, and improves sleep quality. Good sources of magnesium include leafy greens, nuts, seeds, whole grains, and soy (21:30). Vitamins B6 and B12 are necessary for melatonin production. Kobliner emphasizes balanced vitamin B levels, highlighting that deficiencies are linked to insomnia and depression while high doses are not safe. Sources for B6 include bananas, carrots, spinach, potatoes, eggs, fish, whole grains, milk and cheese. B12 can be absorbed from dairy, eggs, meat, fish, and shellfish (22:45). 

Amino acids are proteins’ building blocks, and some are critical to sleep. For example, tryptophan turns into serotonin, which ultimately turns into melatonin. Therefore, Kobliner asserts that we need to support this pathway with the food we eat. She lists some foods that support healthy sleep, including eggs, fish, peanuts, pumpkin seeds, tofu, and more (23:49). All of these foods are highlighted in the Mediterranean diet, which the speaker repeatedly notes as supportive of sleep. Other crucial amino acids include GABA and L-TEHTANINE, which work together to reduce anxiety, time to sleep, and overall sleep quality (25:49).

Herbs and supplements for sleep

Kobliner outlines potential melatonin doses and comments on its long-term use (26:45). She lists herbs and supplements that support sleep, noting specific qualities for each: valerian (28:40), lemon balm (29:09), Zyziphus (jujube) (30:08), passion flower (30:45), chamomile (31:15), skullcap (31:44), and lavender (32:20). 

Adaptogens are compounds that help our bodies deal with stress (33:46). Stress medications are often one way, meaning they reduce stress but then may keep the stress response from acting appropriately overall. However, adaptogenic herbs support and improve the body’s stress resilience and, because stress induces cortisol production, positively affect sleep cycles and quality (34:45). Kobliner highlights three adaptogenic herbs and their benefits to sleep: Rhodiola, ashwagandha, and holy basil (tulsi) (35:00). 

The speaker summarizes her presentation, reiterating the importance of circadian rhythm and balanced cortisol and melatonin cycles. She reminds viewers that poor sleep affects everything from energy to blood sugar to hormonal balance. Lifestyles, including diet, should aim at reducing stress and modulating cortisol to enhance sleep onset, duration, and quality. She notes that all of this can seem overwhelming and recommends starting with the “low-hanging” fruit or changes that are easier to implement (e.g., electronic schedules, bedtime snacks, adding protein to the diet) (36:18). During the Q&A the speaker discusses sources for essential nutrients, strategies for relaxing before sleep, and much more (37:40). 

Dr. Beth Malow provides research updates on drivers of sleep issues in autism and effective treatment strategies. She describes the complex relationship between genetic, medical, and behavioral factors and how these all impact sleep cycles across the lifetime. The speaker emphasizes behavioral strategies for sleep, underscoring their impact on daily function and social/family interactions. Malow also outlines recent studies on pharmacological sleep strategies and highlights the need for professional advice when considering medications. She summarizes the presentation and considers future directions before the Q&A. 

In this Webinar:  

1:35 – Presentation outline & disclosures
3:03 – Causes of insomnia in autism (or any child)
5:00 – Clock genes (circadian rhythm)
7:35 – Medical contributors to sleep issues
12:20 – Behavioral contributors to sleep issues
17:00 – Pharmacological treatments
18:45 – Prolonged-release melatonin
20:30 – Cholodine and Gabapentin
22:10 – Summary and future directions
24:45 – Q&A

Contributors to insomnia

Malow emphasizes the overlap of biological, behavioral, and medical contributors to insomnia (3:03). Although her presentation focuses on autism and neurodevelopmental disorders, she explains that the information provided pertains to all children and adults (4:30).

Genetic factors

Clock genes are the genes that contribute to circadian rhythm, or our biological clock. These genes regulate our sleep-wake cycles and how we function throughout the day (6:45). Malow outlines a 2017 review where two studies showed abnormalities in the circadian rhythm genes in autistic participants. These studies underscore the substantial role that genetics play in sleep issues, especially in autism (5:00). 

Medical factors

Medical conditions that contribute to sleep issues include sleep apnea, seizures, GI issues, and some medications (7:35). The speaker describes how researchers assess sleep issues using polysomnography. She emphasizes that because observations are recorded in a lab, they cannot evaluate regular sleep cycles. Therefore, researchers use polysomnography to assess whether physical sleep abnormalities like breathing problems or seizures are present (8:00). Malow explains sharp wave activity and how to read tracings for seizures and sleep apnea and highlights the importance of a family-centered approach to sleep assessments (10:00). 

Other forms of sleep and insomnia observations involve using a Fitbit-like watch to track standard sleep patterns across weeks or months (10:45). Malow explains how to read sleep-wake pattern results and notes that such technology is also available in a tight-fit t-shirt for those with sensory sensitivities (11:15). 

Behavioral factors

Common behavioral contributors to sleep issues include limited physical exercise, diet and nutrition, screen time routines, early bedtimes and wake times, and sometimes parental stress. The speaker emphasizes that parent and child sleep cycles impact one another (12:20). She asserts that treatments for insomnia should focus on behavioral approaches and outlines the Family Inventory of Sleep Habits (FISH), which observes daily diet, exercise, routines, and more (14:08). 

Behavioral treatment strategies

Malow suggests using calendars or picture displays of bedtime routines to create a supportive sleep environment and minimize sleep latency, or the time it takes to fall asleep. She provides links to free toolkits, resources, and other materials (14:53). A 2016 study employed a sleep education program for adolescents and teens who may receive different attention and care than younger children. Participants experienced improved sleep latency, efficiency, and duration after only two or three sessions (15:30). The speaker reiterates the importance of sleep cycle management across the lifespan. 

Pharmacological treatment strategies

Pharmacological treatments are best used only after behavioral therapies have been tried and were unsuccessful. It is also critical, Malow continues, to assess any co-occurring conditions, including medical conditions and mental health (17:00). She urges viewers to be careful about starting any medication for sleep (even over-the-counter). She insists that a general practitioner is involved in the process (18:00). 

Melatonin is one of the most commonly used medications for sleep. While standard pills only help with falling asleep, new prolonged-release melatonin shows great promise for reducing night wakings (18:45). The speaker outlines an extended-release melatonin study of 125 children (ages 2 – 17.5). Results were promising, with participants reporting that, on average, sleep latency decreased by 25 minutes and sleep time increased by 32 minutes (20:10). 

Malow discusses clonidine use, noting the long list of side effects and the need for more studies (20:30). Gabapentin is another common medication that has been found to be very effective, even in children for whom melatonin did not work (21:05). 

Summary and Q&A

Malow summarizes the presentation, reiterating that many causes and contributors are treatable. She emphasizes identifying sleep problems in autism and their impact on daily function and family dynamics (22:10). Future research directions include extensive treatment studies, randomized controlled trials, more adolescent and adult studies, long-term studies, and attention to co-occurring conditions. 

During the Q&A (24:45), Malow discusses the effect of metabolism on melatonin uptake, research on sleep routines (27:30), sleep hygiene and puberty (32:40), and cases of sudden onset sleep disruption (39:15). She outlines risks, concerns, and common questions around melatonin (43:45) and touches on GI health, depression, and the critical importance of communication (48:11). The speaker provides details on restless leg syndrome, the FISH assessment, and sleep dependency (55:10).

Beth Malow, M.D., discusses the prevalence, causes, and impact of sleep issues in autistic individuals. She explains the connection between core autism presentations, brain function, and sleep and emphasizes the importance of behavioral support strategies. The presenter considers the impact of poor sleep on daily social and emotional functioning for autistic individuals and their families. She touches on evidence-based medical, behavioral, and biological interventions and summarizes the presentation before the Q&A. 

In this webinar:

2:15 – Introduction and common case study
7:25 – Prevalence of sleep issues in autism
10:20 – Causes of sleep issues in autism
14:55 – Arousal dysregulation
17:00 – Melatonin
19:51 – Impact of sleep on social-emotional function
22:15 – Sleep-deprive brain function
24:55 – Insomnia interventions
29:15 – Components of successful sleep and resources
35:15 – Pharmacological interventions
36:25 – Melatonin
39:40 – Summary
40:45 – Q&A

Prevalence of sleep issues in autism

Malow describes typical bedtime routines for children and outlines presentation objectives (2:45). She explains that sleep disturbances can impact daytime functioning for the entire family unit (5:00). As of 2017, she continues, parent-report studies show between 53% and 66% of autistic children experience sleep problems (7:25). Studies also reveal a high prevalence of insomnia in autistic children across autism presentations. Insomnia symptoms include resistance to bedtime, sleep anxiety, problems falling asleep and staying asleep, GI discomfort, and much more (8:55). Malow emphasizes that sleep issues are highly treatable when standards of care and evaluation are evidence-based (5:00). 

Causes of sleep issues in autism

Causes of insomnia in all people result from the interaction of biological, medical, and behavioral drivers, many of which overlap. Biological causes include hormonal imbalances (e.g., melatonin), circadian clock factors, overarousal, sensory oversensitivity, anxiety, and ADHD. Medical drivers refer to things like sleep apnea, seizures, GI issues, and medications (10:20). Malow asserts that behavioral factors, such as exercise, caffeine intake, screen time, and parental stress, are the most critical drivers of sleep issues (12:15). She describes how to read data charts for sleep apnea and epilepsy (13:25). 

Arousal dysregulation, or feeling overstimulated, is tied to anxiety, sensory stimulation, and functional GI issues, which are all common features of autism (14:55). Malow explains that dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis occurs in both insomnia and autism and notes that studies of autonomic functions also reveal patterns of overarousal in autistic brain activity (15:13). Therefore, she continues, interventions that target hyperarousal provide opportunity for biomedical goals and observations, especially for autistic individuals (16:44).

Melatonin

The presenter defines melatonin as an endogenous hormone (released at night) that can cross the blood-brain barrier and is critical to circadian rhythm function (17:00). Melatonin supplements are known to help with anxiety, hyperarousal, and sleep-wake cycles. Malow underscores the need to consult a practitioner before adding melatonin to a diet or routine (19:00). 

Impact of sleep on social-emotional development in autism

Core presentations of autism, like difficulties with social interaction and communication, are often exacerbated by poor sleep (19:15). This is true, Malow asserts, whether or not a person is autistic (21:15). She explains that when we are sleep deprived, the amygdala and prefrontal cortex (emotional part of the brain) do not communicate well, which allows our emotions to “go wild” (22:15). Studies have found that fewer hours of sleep predict overall autism score and that co-occurring conditions and adolescent relationships are affected by poor sleep quality (24:03). 

Insomnia interventions

Behavioral approaches are critical to making a difference in sleep, especially for autistic individuals (24:55). Malow outlines the Sleep Habits Questionnaire, The Family Inventory of Sleep Habits (FISH), and polysomnography. She emphasizes sleep hygiene and making sleep observations comfortable and family-friendly (26:08). Components of successful sleep for any person include the amount, time, and regularity of sleep (29:15). She suggests visual schedules and checklists to help with bedtime routines and discusses strategies for sleeping through the night (31:15). Studies show that autistic children of parents receiving sleep education experienced significant improvements in sleep latency (time to fall asleep) and repetitive behaviors (33:30). Malow lists free online tools for parents and caregivers and emphasizes the importance of parent confidence and health (35:00). 

Pharmacological interventions

The speaker asserts that pharmacological treatments are best used only after behavioral interventions have been tried and did not work on their own (35:15). Melatonin is commonly used and is most effective in combination with behavioral strategies (36:25). Malow considers the advantages of prolonged-release Melatonin, noting that no long-term side effects have been identified (37:25). In a prospective study of 24 autistic children, no alterations to reproductive hormones were found. Still, more research needs to be done (38:55). Malow reiterates the need to discuss melatonin use with a care practitioner and combine it with lifestyle changes and behavioral strategies. She summarizes the presentation and highlights future areas of research (39:40). The speaker reiterates that sleep issues are highly treatable before opening the Q&A (40:45). 

Kenneth Sassower, M.D., answers questions about sleep issues experienced in autism. He discusses sudden changes in sleep cycles, considers interventions for epilepsy, and provides context on the use of melatonin, GABA, and other medications. The speaker highlights the importance of sleep hygiene and emphasizes behavioral strategies for improving sleep for children, families, and caretakers. Parental sleep deprivation is of critical importance in this segment of the population. 

In this webinar:

1:55 – Background and expertise
3:00 – Sudden changes in sleep cycles
12:15 – Epilepsy in autism
16:40 – Melatonin
24:25 – Extended-release
29:00 – GABA and magnesium
36:16 – Tryptophan with 5-HTP
37:45 – Sleep environments
41:00 – Causes of sleep issues
47:15 – Sleep hygiene
53:30 – Parental sleep deprivation

Question 1: Sudden changes in sleep cycles

Sassower explains how communication challenges can often hinder the detection and understanding of sleep issues in autistic individuals (3:00). Restless leg syndrome, diet, and bedtime routine all contribute to sleep onset and duration (5:25). The speaker emphasizes the need to rule out medical conditions such as chronic pain and sleep apnea, noting that in-lab monitoring is sometimes needed (7:30). Pulse oximetry, which measures oxygen desaturation throughout sleep, can be used to screen for sleep apnea (9:15). 

Question 2: Epilepsy in autism

As of 2016, researchers are still trying to understand specific details about why seizures occur and what role they play in sleep functioning (12:15). The speaker notes that children who experience seizures may find it harder to wake up in the morning and need more rest during the day (14:50). He outlines potential sleep interventions that support daytime function reiterating the connection between sleep and behavior (16:29).  

Question 3: Melatonin

Melatonin is produced in the brain’s pineal gland, which is sensitive to the dark-light cycle. Melatonin supplements/medications are proven to support sleep onset and, therefore, can help treat circadian rhythm (sleep clock) issues (16:40). Sassower notes that melatonin doesn’t help people stay asleep and so is not very effective for treating night wakings or epilepsy (18:25). Extended-release melatonin has seen some success in autistic patients, but the speaker avoids using it. He explains that melatonin isn’t meant to regulate sleep cycles, so he generally looks for another driver in cases of night wakings (21:30). If melatonin doesn’t affect sleep latency, it is best to halt its use and search for another option (24:44). 

The primary drivers of sleep issues are biological, medical, and behavioral factors (26:20). Therefore, treating medical conditions like sleep apnea, anxiety, or epilepsy can improve behavioral and social functioning during the day (27:40). 

Question 4: GABA and magnesium

Gamma-aminobutyric acid (GABA) is a neurotransmitter known to promote sleep depth, and GABA medications have seen safe success in inducing and maintaining sleep (29:00). GABA could be a promising intervention for major sleep issues like sleep apnea and epilepsy (31:00).

Magnesium is commonly used for headaches and restless leg syndrome. However, the speaker asserts that individuals should only supplement magnesium in their diet if their serum magnesium levels are below normal (33:45). Assessing calcium levels and other nutritional values is also helpful for sleep interventions. The speaker discusses the historical use of Tryptophan with 5-HTP, why it left the market, and its potential use compared to other available medications (35:16). 

Question 5: Sleep environments 

The presenter explains how screen time and other environmental factors impact sleep onset and efficacy (37:45). He notes that some people can only sleep with the light on and explains how this could be tied to anxiety, behavioral routines, fear, or several other medical and biological factors (39:00). Sassower explains that some people simply need more sleep than others. However, after a sudden shift in sleep patterns, it is essential to look for any critical changes that occurred around the same time (41:00). This includes new medications (over-the-counter), changes to diet, bedtime routines, daytime habits, etc. (44:30). The speaker touches on neural feedback as a behavioral treatment that helps with falling back to sleep (45:00). 

Question 6: Sleep hygiene

Sleep hygiene includes all daytime and nighttime routines that impact sleep efficacy (47:15). Sassower emphasizes behavioral management for sleep issues, including things as simple as brushing your teeth, changing clothes, and creating an environment conducive to sleep (51:15). Good sleep hygiene, he continues, means that you have tools and techniques to help support good, rejuvenating sleep.

Question 7: Parental sleep deprivation

Parental sleep deprivation is a critical aspect of sleep issue interventions in autism (53:30). In many cases if one person is awake at night, the whole family is awake, which can lead to stressors in relationships and daily functions for everyone (55:15). The speaker asserts the need for further investigation and focus on this subject because a significant segment of the autistic community is suffering from sleep deprivation (57:00). 

Developmental/behavioral pediatrician Gail Williams, M.D., discusses sleep disturbances related to autism spectrum disorder. She outlines physical and behavioral issues related to poor sleep patterns and considers their relationship to the neurobiology of individuals with autism. 

Williams also lists common sleep issues and highlights known diagnosis and treatment options while emphasizing the treatment of underlying conditions. The presentation includes her thoughts on behavioral therapies and melatonin and closes with Q&A, where she addresses advocacy issues and the importance of diagnosis and appropriate medical care. 

In this presentation: 

5:30 – Sleep patterns
7:10 – Sleep deprivation & prevalence
12:45 – Neurobiology & learning during sleep
17:35 – Impact of sleep problems in ASD
19:00 – Case study
20:40 – Sleep issues in ASD
28:50 – Diagnosing sleep disorders
36:25 – Treatment options
54:34 – Other resources
56:40 – Q&A session

Summary: 

Children generally spend 50% of their sleep cycles in rapid eye movement (REM). However, children with autism have significantly decreased REM time during sleep (5:30). Studies show 50 to 80% of children with autism experience sleep problems or disturbances (10:00, slide@12:00). Common sleep disturbances include nighttime wakings, sleep apnea, sleepwalking, etc. (9:30). Over time, and without proper treatment, these disturbances can lead to sleep deprivation, affecting the entire body and parent wellness (7:10). The impacts of sleep deprivation can include aggression, trouble concentrating, high blood pressure, increased appetite, memory issues, lower stress threshold, increased risk for heart problems, and a decrease in optimism and sociability (8:05). 

The presenter walks through the neurobiology of sleep disturbances specific to ASD and highlights the critical role of sleep in learning and behavioral regulation (12:45 – 17:15). Due to the neurobiological nature of autism, sleep problems can have particular impacts on stimming, behavioral issues, hyperactivity, self-care, and aggression (17:35). Common types of sleep issues in ASD include (20:40):

• Insomnia (22:02): difficulty falling and staying asleep and waking up too early; this is the most common sleep issue for individuals with autism.
• Obstructive sleep apnea (OSA) (23:55): obstructed airway leads to disordered breathing (i.e., loud snoring due to enlarged tonsils, etc.). 
• Parasomnia (25:30): non-REM arousal and disorders. These can include night terrors (25:58), sleepwalking (26:35), and confusional arousals (26:20). 
• Movement disorders (27:28): such as restless leg syndrome (RLS) or periodic limb movements. Iron supplements may help.

Williams outlines the standard practices for diagnosing sleep disorders (28:50, slide@31:18) and comments on the current push to automatically screen children diagnosed with ASD for sleep disorders. Diagnosis of sleep disorders generally involves a detailed sleep history (31:19), questionnaires (31:25), sleep diaries (33:35), actigraphy (34:15), and polysomnography (35:15, slide@36:17). Polysomnography is the “gold standard” for detecting OSA and many other disorders. It can be difficult for children as it is an overnight test using electrodes to measure brain waves (EEG), oxygen levels, heart rate, breathing, and eye and leg movements. 

The presenter outlines established options for treating sleep issues in individuals with autism (36:25, slide@37:49). She stresses the importance of treating underlying conditions such as anxiety, depression, GI issues, epilepsy, etc., as they often cause these disruptions. She also provides advice for implementing healthy sleep practices (40:15) via dietary changes, exercise, etc. Behavioral interventions, such as cognitive behavior therapy, visual schedules (44:30), and social stories (45:25), can assist with sleep disturbances and subsequent behavioral issues as well (44:30, slide@46:18). Williams discusses the use of melatonin (50:20, slide@53:38) as a safe and effective treatment for some sleep disturbances, noting the lack of long-term studies. She provides a list of more resources (54:34, slide@55:22) and closes with a question and answer session.

Handouts are online at:
https://www.ariconference.com/webinars/williams.pdf

Certificates of participation will be available after the webinar upon successful completion of a knowledge quiz at: https://www.classmarker.com/online-test/start/?quiz=eb6542ade492a5d7