Sleep Issues in Autism – Beth Malow, M.D.

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).