Sleep Issues and ASD – 2018

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).