The following is a summary and interpretation of one of the lectures at the University of Washington Autism Awareness Month series. We are attending all of the talks offered this month in honor of Autism Awareness, so follow our blog or like our facebook page for the most up-to-date autism-related information. For more information on Autism Awareness Month resources and/or this series, check out our previous blog post.
The presenters Kelly Johnson, Ph.D. & Ella Vanderbilt-Adriance, Ph.D. started the lecture by discussing the effects of impaired sleep. Sleep has been shown to affect emotional and mental function, including increased irritability, increased anxiety, and decreased ability to learn and comprehend. But many don’t know that lack of sleep also affects the physical body by decreasing metabolic rate, impairing immune system function, and preventing proper tissue healing and regeneration.
Lack of sleep for a child often results in greater problems for the whole family. The child’s sleep issues may impact parents’ and siblings’ sleep patterns, often leading to tension in family and school relationships, poor parental and child productivity, fatigued driving, increased frustration with daily tasks, and the tendency to make poorer dietary decisions.
Consistent, adequate, and restorative sleep is necessary for kids to survive and thrive. But why should we prioritize sleep over other issues? Because proper sleep can make every aspect of the treatment regimen – including medical, school, and work appointments - more effective. It takes a great deal of energy to make lifestyle changes, and proper sleep can help you and your family get the most out of each of these therapies.
Sleep Architecture
A common misconception about children’s sleep is that waking at all during the night – even for a brief period – is abnormal. It’s completely normal sleep architecture to wake during the night; the stages of sleep and brain function during the night should prompt short periods of (often subconscious) waking. In newborns and infants this waking can occur 3-5 times per night, while older children can experience decreased instances of night waking. Night waking can become problematic when the child is woken further by an emotional or physical cause such as the need to urinate or the inability to self-soothe.
Many children have problems sleeping due to being ‘overtired.’ This state can lead to a state of hyperactivity before bed. The chart below was emphasized during the lecture as being broad expectations for sleep needs based on age (including naps). These needs obviously vary depending on the individual child.
Specifically, children with ASD are more likely to struggle with falling asleep, staying asleep, bedwetting, repetitive behaviors on falling to sleep, and greater daytime fatigue. They also typically sleep at least an hour less than other children on average, and spend less time in REM as compared to children without an ASD diagnosis. It is being found in recent research that a child with ASD may have impairments or neurological differences in REM stages of sleep; REM is important for learning and consolidating memories, so problems entering this stage of sleep can set the child up for trouble in school and other therapies.
Kids of all abilities that have trouble sleeping tend to experience more:
- Attention Difficulties
- Hyperactivity
- Repetitive Behaviors
- Mood Problems
- Social Interaction Problems
Sleep Disorders
Three types of insomnia were discussed at length:
- Falling Asleep/Primary Insomnia – This type of insomnia can be refusal to got to bed OR taking long time to fall asleep. It can be related to aspects of the physical state of the child, discipline, and parental expectations. Using the chart above, many parents discover that their expectations for their child’s sleep duration are unrealistic. Normal developmental changes may impair sleep for brief periods of time, and it’s important to take these broader changes into account. Limit-setting – such as discontinuing screen and electronic use for several hours before bedtime – can improve the ability of children to fall asleep. Anxiety and ADHD can also cause problems falling asleep, as can medical issues like restless leg syndrome, constipation, reflux, and skin conditions like rashes.
- Staying Asleep – As mentioned above, night-waking can be a problem for children who do not fall asleep on their own at bedtime, due to the lack of ability to self-soothe at normal wakeful periods during the night. Partial awakenings become full awakenings in this way. Nighttime feedings can also contribute, causing the need to urinate and leading to full awakening.
- Non-restorative Sleep – It’s important to consider sleep apnea as a cause when normal amounts of sleep do not result in a ‘rested’ feeling in the morning. In this condition, there are short periods in which breathing actually stops during the night. Signs of this condition may include snoring, heavy sweating, morning headaches, and falling asleep during the day. Another medical issue that can cause non-restorative sleep is restless leg syndrome. Look at the state of the bed in the morning, and if there has been excessive movement of covers, consider this condition. Seizures can also be at fault, leading to disturbed deeper stages of sleep without recollection of any wakings.
Other Sleep Disorders (not discussed in depth at this lecture):
- Parasomnias (including night-terrors and sleep-walking)
- Narcolepsy and Hypersomnia
- Restless Leg Syndrome and Periodic Limb Movement Disorder
- Sleep-Disorded Breathing
- Sleep Apnea
- Sleep-related Rhythmic Movements
- Sleep Phase Disorders
- Bedwetting
How to Talk to your Primary Care Physician about Sleep Problems
- Be prepared for the sleep-centered visit, as often there is a lot to cover in a very short allotment of appointment time.
- Try to express your concerns clearly. It’s important to mention all symptoms associated with sleep, including changes in emotional state, and difficulties at school.
- Ask questions pertaining to whether or not the doctor believes sleep may be a cause for the child’s issues.
- Follow-up if indicated by the physician.
When a Referral is Made: Sleep Clinic Models
- Medical Professional Only – These professionals assess and treat sleep problems from a medical standpoint, with an overnight sleep study if indicated.
- Psychology/Behavioral Professional Only – This professional would be looking at sleep from a behavioral and/or environmental approach.
- Combined – A multidisciplinary team (that works together sequentially on your case, through referrals) and also an interdisciplinary team (that works together at the same time on your case) are options for this combined approach.
UW Sleep Consultation Clinic
The University of Washington Sleep Consultation Clinic has a three-session consultation model for children and adolescents (up to age 18) with ASD. Families meet with medical doctor and psychologist initially to explore environmental, behavioral, and medical reasons for sleep disturbances.
Session 1:
- overview of sleep problem and sleep behaviors
- medical history
- sleep-focused medical exam
- associated behavioral and/or psychological issues
Then information is provided on normative sleep patterns, and basic sleep hygiene recommendations are reviewed. Parents are also asked to keep a sleep diary, with time to bed, time asleep, nighttime waking (time of waking and duration), descriptions of nighttime waking, time awake in morning, and naps (time of naps and duration) as parameters. It’s important to get objective data on sleep for each child, as sometimes our recollections of events – especially when fatigued ourselves – may not be entirely accurate.
Session 2:
- data from sleep diary is reviewed
- discuss potential medical issues and medications (prescription and over-the-counter such as melatonin)
- continue with sleep diary to monitor changes based on individualized treatment plan (discussed below)
An individualized treatment plan is created at this session that may or may not include aspects of sleep hygiene, exercise 4-6 hours before bedtime, visual schedules, and caffeine discontinuation including soda, medications and chocolate. Sensory recommendations may also be made including weighted blankets and self-soothing objects. Behavioral sleep interventions may include:
- Graduated Extinction – This form of putting a child to sleep involves setting a timer and doing periodic check-ins with minimal comforting, increasing the time period between check-ins over the course of a night. This method is good for kids who have trouble falling asleep.
- Bedtime Fading - This method uses the time that the child usually falls asleep (not goes to bed) plus 30 minutes to set a new bedtime. The technique can be good for a child who is resistant to going to bed earlier in the evening.
- Sleep Restrictions – This technique is good for children with disruptive behavior and also for those who have trouble staying asleep. To try the method, figure out how much time the child is actually asleep (time falling asleep and time waking). Then delay the child’s bed time so they are only in bed for 90% of the normal sleep duration, ensuring the child is adequately tired before going to bed. This technique also reduces the amount of time a child spends in bed awake, and therefore reinforces the association of lying in bed with being asleep.
- Scheduled Awakenings – This technique is good for children with sleep terrors and those with trouble staying asleep. This tactic involves waking children before they would normally get up on their own, with awakenings getting fewer and further between until finally phased out altogether.
Session 3:
- problem-solving visit with psychologist
- review data with sleep diary
- provide additional recommendations for follow-up with psychological or behavioral therapists
UWAC Medical Director Kyle Steinman MD., MAS was present for the question and answer session at the end of the talk. One of the questions asked was regarding the use of and details on melatonin as a sleep aid. Dr. Steinman stated that melatonin is not an FDA-regulated medication, but is one of the most well-studied supplements in research. There are side effects that have been shown in single studies, but have not shown relevance in continued research. Dr. Steinman believes that melatonin always needs to be used in the setting of other behavioral and environmental sleep hygiene changes. He also pointed out that one can build tolerance to melatonin, meaning that many individuals will need a higher dose of the medication with continued use to achieve the same desired effect. Dr. Steinman uses medications only as temporary measures to help get through troublesome or problematic times along with sleep hygiene changes. The goal is always to change sleep through relevant and individualized behavioral and/or environmental changes, using prescription and other drugs only when absolutely necessary.
Our Thoughts:
We agree with Dr. Steinman’s approach on the use of melatonin and other pharmaceuticals in improving sleep (but always check with your doctor before taking a new supplement). We believe that it is important to address the cause(s) in any disordered sleep situation, and that melatonin deficiency is not frequently a true cause. Therefore, melatonin supplementation is a palliative treatment as opposed to a long-term solution. Changes such as those to sleep hygiene can take time to be effective, and because sleep is so important on a daily basis, temporary supplementation is useful for some children. For example, melatonin or other herbal sleep aids may help a child (and their supporting family members) get enough sleep to function while addressing other causes of sleep disturbance through dietary, social, behavioral, and/or psychological interventions.
In order to fully understand why melatonin should be used only temporarily, it’s important to examine the way in which the body produces and regulates melatonin levels. Melatonin is a hormone that is produced in the pineal gland of the brain only in the absence of light, and aids in regulating sleep-wake cycles. Melatonin levels rise as the sun goes down, remain high overnight, and begin to decrease in the early morning as the sun begins to rise. But in our technological society, lights are available to us throughout the day and night. Unfortunately, even artificial light sources – such as TV, computer, e-reader, and phone screens – inhibit the production of melatonin in the brain. This is why it is incredibly important to avoid screens for at least 2 hours before bedtime.
Melatonin supplements or prescriptions will raise melatonin levels in the bloodstream. When the body senses that there is melatonin in the bloodstream, the pineal gland reduces it’s production of melatonin. Withdrawal of a melatonin supplement coupled with a decrease in production of melatonin by the pineal gland could result in rebound insomnia. This is an additional reason why we view melatonin as a temporary aid – rather than a permanent solution – for disordered sleep.
Another possible cause of nighttime wakings that was not discussed in this presentation is hypoglycemia, or low blood sugar. In some patients, blood sugar can dip at certain points of the night which can cause waking accompanied by rapid heart rate, flushes of heat, and other symptoms that are similar to a panic attack. We recommend that patients eat a small, protein-rich snack before bed. It’s important that this snack is not primarily composed of simple carbohydrates – such as cereal, cookies, or crackers – because these types of foods can lead to a rapid rise followed by a rapid drop in blood sugar levels, in essence exacerbating the hypoglycemic state in the middle of the night. Good ideas for protein snacks – as long as these are not allergenic for your child – are hummus with vegetables, nut butter with a small amount of fruit, low sugar yogurt with almonds, or a hard-boiled egg. Balancing blood sugar throughout the day can also help your child to get a full night’s sleep, so giving your child high-protein and low sugar foods at each meal can also be beneficial.
While the diagram of sleep stages included in this presentation is helpful, sleep does not always follow a strict pattern from stage 1, stage 2, stage 3 or stage 4, then REM. Understanding the variation in this pattern can help you to understand how sleep apnea can disrupt sleep. More accurately, what happens after the brain reaches REM state is that we usually cycle between stage 3 and back to REM again. When a person has an episode of apnea, however – which almost always occurs during REM – his or her body is either awakened completely or moved into stage 1 again. As a result, the brain needs to cycle back through stages 1, 2, 3, and 4 again, or start ‘at the beginning’ so to speak. Because most of our restorative sleep occurs in stages 3 and 4, being awakened repeatedly from REM to stage 1 can significantly decrease the length of time a child or adult spends getting restorative sleep.
We work with patients, in the home and in the office, to ensure good sleep hygiene practices are in place. We find that these measures, though very straightforward and seemingly simple, are the most helpful in producing long-term change for kids with sleep issues. A more complete list of sleep hygiene guidelines than was covered in the presentation can be found on the National Sleep Foundation website, and is listed below:
- Avoid napping during the day; it can disturb the normal pattern of sleep and wakefulness.
- Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
- Exercise can promote good sleep. Vigorous exercise should be taken in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night’s sleep.
- Food can be disruptive right before sleep; stay away from large meals close to bedtime. Also dietary changes can cause sleep problems, if someone is struggling with a sleep problem, it’s not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine.
- Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle.
- Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on, or bring your problems to bed.
- Associate your bed with sleep. It’s not a good idea to use your bed to watch TV, listen to the radio, or read.
- Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the room should not be too hot or cold, or too bright.
We’d like to thank Kelly Johnson, Ph.D. & Ella Vanderbilt-Adriance, Ph.D. as well as Dr. Kyle Steinman MD., MAS for their presence and contributions to this lecture.
The authors of this post, Dr. Carrie McMillin ND and Dr. Bethany Glynn ND, are currently taking patients in the Seattle and Greater Eastside areas. To make an appointment, or to learn more about their practice, call 206-456-6965 or visit IntegraNaturalWellness.com.
