To label or not to label- My personal experience

Soon after the day that my husband made the ground breaking revelation that my son Jeremy was “just odd like me” and implied that it was ‘no big deal’, I went in search for answers.

It was reassuring that my husband loved me, ‘oddness’ and all and that it was no concern for him, but my childhood was intrinsically traumatic. I suffered from chronic and severe anxiety related to social situations, including at school and university, because I was aware that my conversation skills were very poor and I could not relate well to my peers.

When I heard about Autism Spectrum Disorder (ASD)*, I thought that it might be the explanation I was looking for but I wasn’t convinced of it. It is hard to be sure if you have autism because the descriptions of autism are usually from a health professionals perspective (what they see in you) and therefore don’t match the personal experience of autism (what you see and experience yourself). In addition, each person with autism is unique. Autism is very complex especially to someone who knows very little about it and at that stage I knew very little about it.

I thought that if I arranged for myself to be assessed and was found to have autism, then surely that is what Jeremy would have too, it seemed sensible to me to assume that Jeremy had inherited his differences from me, given we were mother and son, even though our differences were different.

I made an appointment with a private psychologist that specialized in autism. My brother wrote a short letter about me at my request and I tricked my mother into providing information on my childhood with the pretence of needing it for mainstream counselling.

Why did I trick my mother (who I love very much and who is now very supportive of our diagnoses) into providing information about my childhood? Unfortunately, my mum did not want me to seek a diagnosis of autism in the beginning. She kept talking about not wanting me to have a ‘label’ and she made many distressed phone calls to my siblings about it. In lieu of mum’s strong objections to my seeking a diagnosis, I was afraid that she would refuse to provide information or would provide biased information about my childhood if she knew the true purpose of the request and so I lied.

It’s a myth that people with autism cannot tell a lie. I can tell a lie if I feel the need to. However, I probably feel the need to lie less often than others (such as ‘white lies’) and maybe because I am less comfortable with the concept of lying and less practiced at lying I may not be as convincing. People who know me would most likely say that I tell lies a lot less than most people, but if I had to lie to save my life I would AND I would do it with conviction. I considered that getting an accurate account of my childhood was crucial for getting an accurate diagnosis and so I perceived the need to tell a lie on that occasion.

I can’t recall exactly how I felt about mum’s objections, by that stage mum and I had disagreed on several parenting strategies already and the shock of her disapprovals had worn off. I disregarded her opinion and her feelings (validating someones feelings was something I was yet to learn about) because her argument didn’t make sense to me.

Many people show resistance getting a diagnosis because of the fear of being labelled. It is true that labeling can be associated with stigma. Stigma is defined as ‘the co occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised1. So perhaps those people afraid of labels have good reason for concern.

However, a recent study has shown that it is the social behaviours characteristic of autism and not the diagnostic label that results in stigmatizing attitudes towards people with autism2. People often notice the different behaviours that people with autism display and misinterpret the reasons for the behaviour attributing them to naughtiness, laziness, rudeness, incompetence or parenting styles etc. I wanted to have a working template for understanding myself that wasn’t based on any of those negative assumptions.

Differences need to be understood properly without value judgment. Having a template on which to study and understand those differences benefits from a label. It has been shown that a reduction in stigmatization of people with autism is associated with increased knowledge of autism (the ‘label’) in addition to more direct contact with people with autism3.

In years to come, when differences are properly understood and celebrated, assuming that we are gradually making inroads in that direction and that is debatable, then we can do away with diagnostic categories and focus on individual strengths and challenges and provide more individualized rather than categorized support.

Unfortunately, I lack the conviction that most lay people can fully comprehend and/or be open to the myriad of differences in brain and body function that exist independent of ‘good’ and ‘bad’ value judgments and how the dominant environment discriminates against them (with or without intent for harm). I’d still like to be proven wrong.

In addition, I needed the ‘label’ to know how to support Jeremy to the best of my ability (including seeking professional support). I didn’t want my sons to experience the extent of anxiety and confusion that I experienced during my childhood. Without the ‘label’ and the associated evidence-based information about how to support it, I personally feel that I could not have understood and supported my children as well as I have.

The psychologist that assessed me asked me what I knew about autism and I replied that I didn’t know much about it because I didn’t want to “waste too much time researching a condition that I may not have”. If you have read any of my other posts you could probably assume that when I decide to research something, I invest a lot of time into it because detail, specific relevance and accuracy are important to me (a few of my autistic traits).

After, two half day consultations the psychologist confirmed that I had Asperger’s Syndrome (an ASD). After I received the diagnosis I met up with my brother and he asked how the appointments went and I said “Just call me Spergs”. Of course, since then I have learned that many people with Asperger’s Syndrome prefer the abbreviation ‘Aspie’. Now, they have removed the diagnostic term Asperger’s Syndrome and instead use the all-encompassing diagnostic term of Autism Spectrum Disorder (ASD)*.

My mum was upset for a while after I received my diagnosis until she talked to one of my sisters who said to her “but mum, it doesn’t change who she is”. That comment wouldn’t have a lot of impact if it was said to me in passing because it is one of several expressions that does not make a lot of sense to me but it proved very useful for mum. I’ve since heard that variations on that phrase have been useful for others when they are informed of a diagnosis of autism and so perhaps it means something to you the reader.

The revelation of ‘it doesn’t change who she is’ was a turning point for mum and these days mum will gladly pass on any information that she comes across on autism because she is now not only accepting of all of our diagnoses but even interested and proactive.

After my diagnosis, I immediately began borrowing books from the AMAZE library. The first books I borrowed were autobiographies of people with autism, which I believe is a good place to start because you get to know people with autism, their strengths and their challenges, rather than just learning about ‘impairments’ from textbooks and manuals.

I was advised not to book Jeremy in for an assessment until he turned three years old because I was told that it was easier to delineate autism from typical development at that age. Booking Jeremy in for an assessment for autism with a psychologist and a paediatrician (he was already seeing a speech pathologist for speech delay) came with fresh and more openly objecting disapprovals particularly from my husband and some members of his family. It was one thing to insist on having myself assessed but not a child and their own ‘flesh and blood’.

When there is something I believe in I will pursue it at all cost (another of my autism traits). After reading more about autism and after my own diagnosis, I was certain that Jeremy also had autism. Actually, that is not true….there was a little voice in my head that said “Maybe everyone else is right. Maybe it is my anxiety and obsessive nature inventing problems” but I felt that the moment that I showed any doubt was the moment people could talk me out of investigating it further. Although, the fact that I seemed so sure that Jeremy would be diagnosed was ‘off-putting’ for many people too, I don’t think there was any approach that could have helped me escape unfavourable judgment and criticism during that process.

I retrospectively documented Jeremy’s behaviour and health from birth and early childhood right up to his assessment, took photos of his many ordered arrangements of toys and secretly videotaped his play. My husband referred to my ‘quest’ to have Jeremy diagnosed as ‘obsessive’.

I was aware that my determination to have Jeremy assessed and my detailed documentation could be labelled as obsessive but now my husband is fully supportive of the diagnosis, early intervention and support that Jeremy has had (and continues to receive) and it is clear that my determination and attention to detail was justified. Although, twenty pages was more than necessary (I can laugh at myself, although it is easier after the fact), it was helpful for the pyschologist to peruse (especially given my poor verbal recounting ability) and it was cathartic.

It was those early months of seeking a diagnosis and the lack of support during that process, which were the most difficult for me. That was my experience and may not reflect what other people remember about it because people’s stories are always different when told from another person’s point of view. I know however, that my experience is similar to that of many other people who have sought a diagnosis for themselves or their children. Fortunately, since then, after dissemination of information and the fear of change has abated, my family including my in-laws have become much more accepting and supportive.

Regardless of the benefits of diagnosis for my sons, I am so glad that I received a diagnosis because now I have a means of understanding myself, which was very important to me. I wanted to know why I was different to most other people and now I know.

More importantly, I like myself better now because I believe that my social challenges are paired with equally unique strengths. Refer to my post on ‘Autistic traits and ability’ for a more detailed explanation of this concept.

With more awareness of my poor social skills, I have been more consciously attempting to improve my basic conversation and social skills, which resulted in increased anxiety for me initially. I have also made slight adjustments in my appearance*, validate people’s feelings more (because feelings make sense because they exist and don’t need a logical explanation) and tend to mock social conventions less than I used to. However, I don’t believe my identity has been compromised. If fact, I have a better understanding of what matters to me and I am more outspoken about what I believe in.

In addition, I have learned so much about autism and it has helped me to have a better understanding of people generally, sometimes above and beyond typical assumptions that other people might make and I will cover this in my next post.

*I will refer to Autism Spectrum Disorder as ‘autism’ for the rest of this post because I am uncomfortable with the use of the term ‘disorder’.

*The activist in me is uncomfortable with the fact that I felt the need to change my appearance. However, essentially changing my appearance, in this instance, mean’t wearing ‘joggers with jeans’ less often and paying attention to what most other people wear so that I can copy those aspects that I am most comfortable with. Often, it is a case of ‘No, I’m not wearing that’, ‘No,  not that’, ‘Ok maybe I could wear that sometimes’. I still don’t wear make-up and I wear my hair in a pony tail almost every day and I have no problem with the way other people chose to dress. In fact, I feel more comfortable around people who wear ‘joggers with jeans’.

References:

  1. Hatzenbuehler, M. L. Phelan, J.C. Link, B.G. Stigma as a fundamental cause of population health inequalities. American Journal of Public Health 2013; 103(5):813-821
  2. Butler, R.C and Gillis, J.M. The Impact of Lavels and Behaviors on the Stigmatization of Adults with Asperger’s Disorder. Journal of Autism and Developmental Disorders 2011; 41:741-749
  3. Milacic-Vidojevic, I. Gligorovic, M. Dragojevic, N. Tendency towards stigmatization of families of a person with autistic spectrum disorders. International Journal of Social Psychiatry 2012; DOI: 10.1177/0020764012463298

Autism and sensitivity

After writing my last post on autism stigma and Autism Speaks and commenting on the posts of others on the same topic, I began to feel anxious, depressed, faint and nauseous. These are feelings that I am accustomed to having before, during and after many social interactions in person and online, whenever they extend past pleasantries and into the murky territory of feelings.

Some parents of children with more intense autism felt that Autism Speaks validated their experiences and that the opposition to it by some of the autistic community invalidated their experiences. The anger, isolation and sadness of some parents of children with more intense autism and their opposing opinions and feelings were overwhelming for me.

I began to question the effect that speaking out about issues that mattered to me was having on my mental health and daily functioning. I wondered if I had been overreacting all this time, that perhaps all the things that matter so much to me was of much less consequence then I attributed to them such as sexism, racism and disabilism. In my heart, I know that raising awareness of these issues is important but the diverse reactions to expressing my concerns on issues important to me plunge me into despair.

I wondered how I could be more resilient and it occurred to me to write about something different, something more factual, like explaining a particular evidence-based therapy for autism. Instantly, the idea of delving into routine instruction made me feel better and it occurred to me that ‘facts’ were comforting for me by allowing me to escape from ‘feelings’. I began to wonder whether other people with autism chose facts over feelings to avoid overwhelming emotional responses.

Instantly, I thought of my son Jeremy, whose favourite reading material is non-fiction. Most nights, Jeremy settles himself to sleep every night by doing mathematics problems from age-appropriate exercise books that he has asked me to buy for him. Jeremy finds many fictional TV shows, movies and story books disturbing especially when viewing them for the first time. The moment that the central problem of the story develops, Jeremy runs from the room upset. It could certainly hold true for Jeremy that facts represent a comfortable alternative to the potentially overwhelming emotional challenges of fiction.

Our extreme emotional reactions to things tended to imply that we are more sensitive to feelings rather than oblivious to them as is often perhaps inaccurately assumed of people with autism. So I decided to look into that idea of emotional sensitivity in autism and I came across an article that immediately resonated with me; The Intense World Theory- A Unifying Theory of the Neurobiology of Autism (2010)1*. In this lengthy, well-referenced article the researchers discussed their theory of autism, the evidence that supports their theory (although it still remains a theory) and they compared it to other theories of autism such as the Weak Central Coherence Theory, Theory of Mind and Empathizing-Systemizing Theory1.

The Intense World Theory of Autism ‘proposes that autistic traits could emerge if a molecular syndrome is activated that sensitizes gene expression pathways to respond excessively to environmental stimulation’1. The molecular syndrome is proposed to cause hyper-reactivity and hyper-plasticity of neuronal microcircuits in the brain to produce hyper-functionality1. This could result in hyper-perception, hyper-attention, hyper-memory and hyper-emotionality1.  Clearly, hyper-emotionality sounded very familiar to my current state of mind.

According to Markram & Markram (2010) ‘Hyper-capabilities are one positive aspect of such a brain, sensory overload, avoidance of stimulus-loaded situations and rapid lock-down into behavioural routines are the downside of it’1. Although, I would argue that the ‘downside’ sometimes has an ‘upside’.

I was already aware that sensory processing differences2;3 and higher anxiety levels4;5;6 are very common among children with autism. I was also aware that the repetitive behaviours of autism have been shown to be related to anxiety7 and sensory processing5. Together with my own experiences and those of my boys, the Intense World Theory of Autism seemed to fit very well.  

Damian (my other son), Jeremy and I, are all hyper-sensitive to certain stimuli such as noise, touch and movement and we exhibit the pros and cons that are associated with our preferential processing and learning. When I mention preferential, I mean the brains preference rather than our own conscious choice, although conscious choices may also come into play when we become consciously aware of what we find more comfortable or bearable.

One thing that didn’t seem to fit with regard to the Intense World Theory was that it did not refer to hypo-sensitivities. However, those people with autism who exhibit hypo-sensitivities in some areas often also exhibit hyper-sensitivities in other areas and vice versa2;8. In addition, hypo-sensitivities could have similar outcomes due to the need to attend to specific stimuli which are not typical, rather than avoid stimuli as in hyper-sensitivities.

I can do things that some of the autism theories say that I shouldn’t be able to do (such as empathize) from time to time, as can many other people with autism, it is just not my brains preference to attend to those functions due to preferentially attending to other and/or to avoid specific intensely experienced stimuli (and the resultant reduced practice also contributes to my overall performance).

The Intense World Theory of Autism left me with an explanation for the way I react to my environment, physically, emotionally and socially and still left me with self respect. It fits with everything I’ve written so far about autism in my blog and that realisation temporarily diverted my attention from what I find difficult to what seems to flow for me (nicely fitted facts and theory) and I feel much better for it.

My lesson from all of this was that I don’t have to give up trying to make a difference by promoting awareness of sensitive issues but sometimes allowing myself to be diverted (if I find myself becoming overwhelmed) by plain facts or quiet routine might just be what the doctor ordered.

Anyway, I will leave you with a youtube song that I enjoyed listening to, it is not pitch perfect but I like it and it helps to increase awareness of the sensitivity of people with autism http://www.youtube.com/watch?v=Sse0CXDuv64

*The Intense World Theory of Autism article can be obtained for free via the following PubMed link: www.ncbi.nlm.nih.gov/pubmed/?term=Markram+autism+theory+intense

References:

  1. Markram, K. & Markram, H. The intense world theory: A unifying theory of the neurobiology of autism. Frontiers in Human Neuroscience 2010; 4:224, 48 pages DOI: 10.3389/fnhum.2010.00224
  2. Lane, A.E. Dennis, S.J. Geraghty, M.E. Brief report: Further evidence of sensory subtypes in autism. Journal of Autism and Developmental Disorders 2011; 41:826-831
  3. Ben-Sasson, A. Hen, L. Fluss, R. Cermak, S.A. Engel-Yeger, B. Gal, E. A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. Journal of Autism and Developmental Disorders 2009; 39: 1-11
  4. Reaven, J and Hepburn, S. The parent’s role in the treatment of anxiety symptoms in children with high-functioning autism spectrum disorders. Mental Health Aspects of Developmental Disabilities 2006; 9(3): 1-7
  5. Sukhodolsky, D.G. Scahill, L. Gadow, K.D. Arnold, E.L. Aman, M.G. McDougle, C.J. McCracken, J.T. Tierney, E. Williams White, S. Lecavalier, L. Vitiello, B. Parent-rated anxiety symptoms in children with pervasive developmental disorders: Frequency and association with core autism symptoms and cognitive functioning. Journal of Abnormal Child Psychology 2008; 36:117-128
  6. White, S.W. Oswald, D. Ollendick, T. Scahill, L. Anxiety in children and adolescents with autism spectrum disorders. Clinical Psychology Review 2009; 29(3):216-229
  7. Boyd, A.B. Baranek, G.T. Sideris, J. Poe, M.D. Watson, L.R. Patten, E. Miller, H. Sensory features and repetitive behaviors in children with autism and developmental delays. Autism Research 2010; 3(2): 78-87
  8. Lane, A.E. Young, R.L. Baker, A.E.Z. Angley, M.T. Sensory processing subtypes in autism: Association with adaptive behavior. Journal of Autism and Developmental Disorders 2010; 40:112-122

Who exactly does ‘Autism Speaks’ speak for?

It would be remiss of me not to share what is happening on the world stage with regard to the organization Autism Speaks and its most recent alarming contributions to autism stigma. As such this post is dedicated to concerns regarding the ability of Autism Speaks to speak on behalf of people with autism.

According to their website, Autism Speaks is the “world’s leading autism science and advocacy organization, dedicated to funding research into the causes, prevention, treatments and a cure for autism; increasing awareness of autism spectrum disorders; and advocating for the needs of individuals and their families”.

I do not like to discredit people or organizations when their intent is for good, but Autism Speaks appears to have disregarded the pertinent advice of adults with autism, on many occasions, regarding more inclusive language and practices and as such is deserving of being called out for their errors of judgment.

Unfortunately, Autism Speaks has many times created substantial negative publicity towards people with autism, which is not in line with the evolving understanding of autism and they are facing a backlash from many members of the autism community.

Recently, Autism Speaks put out a ‘call to action’ that offended many members of the autism community. In fact, it offended author, speaker and educator and autism consultant John Elder Robison, so much that he resigned from his Science and Treatment Boards at Autism Speaks.

Autism Speaks ‘call to action’ was a generalized series of negative portrayals of children with an Autism Spectrum Disorder (ASD) and their families. In their ‘call to action’, Autism Speaks refer to the “autism crisis” and repeatedly and emphatically state what they believe ASD is. Specifically, they asserted that:

“Life is lived moment-to-moment. In anticipation of the child’s next move. In despair. In fear of the future”

“We’ve let families split up, go broke and struggle through their days and years”

“These families are not living”

“Don’t our families deserve it? American has always been about its great people”

People with an ASD are among our great people, my family is living and I am not in despair.

Of course, some people may view their lives and challenges like Autism Speaks suggests, but as the world’s largest autism science and advocacy organization how could they possibly not see how prejudiced and fear mongering their messages are towards ASD and hence people with an ASD.

Lydia Brown a disability rights activist, scholar and writer, exposed an even more alarming development in her blog of an alliance between the Judge Rotenberg Center (JRC) and Autism Speaks. The JRC is the only facility in the United States that makes extensive use of aversives, including electric shock and withholding of food in its treatment and behavioural interventions for students with special needs.

What we are also grappling with here is the dichotomy of disability discourse. The Medical Model of Disability determines disability as the result of impairment in the individual. No account of the effect of the environment is taken into consideration1. The Social Model of Disability determines the disadvantage or restriction of activity is caused by a contemporary social organization which does not take into account people with impairments and thus excludes them from mainstream social activities2. Social stigma then contributes to further health inequities through affecting availability of resources, social relationships, psychological and behavioral responses and stress3.

In a sobering article by Reindal (2000), on the ethics of gene therapy with regard to disability, Reindal argues that social models of disability and the views of the individuals with impairments should be given greater priority in academic discussions1. A major concern with the dependence on the medical model of disability is that it leads to value judgments by the unimpaired resulting in the consideration that the lives of those with an impairment as less worthy1. Reindal (2000) also argues that as a consequence of the medical model, resources are directed into impairment-related research and intervention in lieu of social change for the inclusion of people with impairments1. Autism Speaks is a prime example of this in action.

In his analysis of the social model of disability with regard to ‘learning disabilities’ as opposed to physical disabilities, Goodley (2010) outlines important considerations including embracing notions of distributed competence, ability, intelligence, capacity and ‘differently articulate’, sensitivity to the social nature of all human beings (and their abilities) and recognizing the social and cultural formations of (in)ability2. Autism Speaks is failing in this regard.

Autism Speaks does not even have one openly autistic person serving on the Board of Directors or working in a leadership role as an executive or administrator so how could they possibly speak for people with autism?

You can read more about the Autism Speaks controversy at the following sites:

www.forbes.com/sites/emilywillingham/2013/11/13/why-autism-speaks-doesnt-speak-for-me/

www.adiaryofamom.wordpress.com/2013/11/12/no-more-a-letter-to-suzanne-wright/

References:

  1. Reindal, S.M. Disability, gene therapy and eugenics – a challenge to John Harris. Journal of Medical Ethics 2000; 26:89-94
  2. Goodley, D. ‘Learning difficulties’, the social model of disability and impairment: Challenging epistemologies. Diability & Society 2001; 16(2): 207-231
  3. Hatzenbuehler, M. L. Phelan, J.C. Link, B.G. Stigma as a fundamental cause of population health inequalities. American Journal of Public Health 2013; 103(5):813-821

Sleep Arghhh! (Part 2: Light and melatonin treatments)

This post addresses special circumstances where people may require more than just behavioural treatment for sleep disturbances.

The following topics will be covered: Jet Lag, Shift Work Disorder, Delayed Sleep Phase Disorder (more common in adolescence) and treatment of sleep disturbance in people with an Autism Spectrum Disorder (ASD).

Feel free to skip to the heading that interests you but I strongly recommend reading the background information on the body clock and the effects of artificial light on sleep (first two headings). I will summarize some of the main points and terms at the end of these two sections to make it a little easier to understand.

It is important that you refer to the additional information on exogenous melatonin*at the end of this post, as melatonin may pose risks for certain groups of people.

Sleep and the Body Clock

Sleep is maintained by two processes; a homeostatic process where the less sleep you get the more tired you feel and the easier it is to fall asleep and a circadian process1;2.

At the centre of the circadian process of sleep is the ‘body clock’. The suprachiasmatic nuclei, located in the hypothalamus, are the site of the body clock2. Among other functions, the body clock promotes activity in the daytime and recovery and restitution during the night2.

The body clock coordinates the secretion of melatonin by the pineal gland3. The body clock, secretion of melatonin and core body temperature rhythms are synchronized to one another and responsible for the regulation of circadian rhythms including the sleep-wake, neuroendocrine and core body temperature cycles2.

The body clock and circadian rhythms will operate in the absence of environmental cues with a period that is a little over 24 hrs (hence the use of the term circadian)2. This period of time is intrinsic to the body clock2.

Light is a powerful suppressor of melatonin secretion, and as a result melatonin is mainly produced during the night4;5. Melatonin acts as a ‘darkness’ indicator and acts to synchronise the sleep-wake cycle with the light-dark cycle2;6.

FYI: There is not enough evidence that diet can shift the body clock timing2. Therefore there will be no discussion of diet this in this post. Exercise may assist to synchronize the body clock to the optimal sleep –wake cycle but to a much lesser extent than light as it exerts a much weaker effect2. I will not expand on the effects of exercise in this post. Perhaps I will revisit it in a later post.

When the body clock sleep-wake cycle does not match the light-dark cycle or the demands of the environment it may result in sleep disorders such as in the case of travel across multiple time zones (jet lag), night shift work and delayed circadian phase disorder (more common in adolescence). Fortunately, light therapy and exogenous melatonin* can be useful to manage these disorders and I will expand on the use of these later in this post.

Summary:

Among other functions the body clock is responsible for coordinating the sleep-wake cycle i.e. when you wake and when you sleep. The body clock helps to coordinate the sleep-wake cycle by producing more melatonin at night, which has a hypnotic effect (makes you sleepy). The sleep-wake cycle is programmed to repeat approximately every 24 hours, with the ideal starting and finishing times for sleep determined by the body clock.

The light-dark cycle refers to the environmental cycle of day and night. Day is usually defined by light and night by dark. We are usually more active during the day and less active during the night.

Usually when the sleep-wake cycle (determined by the body clock) is synchronized with the light-dark cycle (determined by the environment) then the better the quality of sleep at the set times.

Effects of Artificial Light on Sleep

Czeisler (2013) quotes Thomas Edison, in his perspective article on artificial light and the sleep-wake cycle: ‘The use of electricity for lighting is in no way harmful to health, nor does it affect the soundness of sleep’5. On the contrary, Czeisler (2013) argues that the invention of the electric light is the primary reason why people now experience insufficient sleep with the more recent invention of Light Emitting Diodes (LEDs) compounding the problem.

Why is artificial light (regardless of the source) such a problem for night-time sleep? The answer is simple, light exposure after sunset signals ‘daytime’ to the body clock, delaying the secretion of melatonin and shifting the sleep-wake cycle later 5. Demands of the day (eg. work, school) are likely to result in us needing to wake before the delayed sleep component of the sleep-wake cycle is complete resulting in less sleep and increased sleepiness

LED lighting is unique in several aspects to other sources of artificial light. Solid-state LED lighting tends to be more durable, compact, versatile and energy efficient5. It is widely used in TVs and computer screens, laptops, tablets and hand-held devices5.

Solid-state white light is more rich in blue light than other artificial light sources and melatonin secretion is most sensitive to blue and blue-green light5;7;8. In fact, night-time exposure to LEDs has been shown to be more disruptive to circadian rhythms, melatonin secretion and sleep than other artificial lighting5;7;8.

It is not surprising to me that we are more sensitive to the light reflected from the sky, water, grass and trees (blue and blue-green). It would make sense that our bodies would be optimally evolved to synchronize with our natural environment. If grey buildings and smog filled skies are all we have access too, perhaps that impacts our quality of sleep too?

It is undeniable that exposure to bright light (regardless of the source of light) in the evening does affect the soundness of sleep (most of the references for this post will support that). Therefore an important good sleep habit is to avoid bright light sources and LED technology such as televisions, tablets and computers close to bedtime.

Summary:

Light exposure in the evening suppresses the secretion of melatonin and delays the sleep-wake cycle. The sleep-wake cycle remains the same length of time (of approximately 24 hours) but the start and finish of sleep is delayed  i.e. the body finds it easier to go to sleep later and wake up later and the quality of sleep at this new set 24 hour period is therefore better. This is unlikely to be ideal if sleeping-in is not compatible with daytime functioning and waking up earlier will result in a reduced duration of sleep and increased daytime sleepiness.

Jet Lag

Jet lag is a sleep disorder that results from crossing time zones too rapidly for the body clock’s sleep-wake cycle to adapt6.

The symptoms of jet lag consist primarily of insomnia and daytime sleepiness but can also include increased stress, diminished physical performance, cognitive impairment and gastrointestinal disturbances2;6.

Jet lag is distinct from nonspecific travel fatigue, which occurs as a consequence of prolonged immobility, irregular sleep times and mealtimes, dehydration and other factors associated with travel that are not related directly to the crossing of time zones6.

It usually only takes a day or two to recover from travel fatigue with adequate diet, rest and sleep but symptoms of jet lag persist until the body clock is synchronized with the new light-dark cycle, which is often much longer6.

Jet lag symptoms vary between individuals and some people experience little to no jet lag while others who take the same flight are extremely affected9.

Fortunately, for those who are more extremely affected, carefully timed exposure to light has been shown to help hasten the adjustment of the body clock’s sleep-wake cycle by delaying or advancing it. Appropriately timed melatonin ingestion can also be useful in preventing jet lag2;6;9.

However, if you are only staying for a few days or less before returning home, it may be easier to try to maintain the sleep-wake schedule from home after arrival at your destination but this may not suit your travel arrangements or obligations6.

If you are staying for longer than three days and/or maintaining your home sleep-wake schedule is not suitable, a simple recommendation for travel across up to eight time zones is to seek exposure to bright light in the morning after eastward travel and in the evening after westward travel 6. You might want to think of a simple phrase to help you remember when to seek light exposure like ‘Easty toast, Westy roast’ (I’m sure you can think of a better phrase).

Because advancing the clock is usually more difficult than delaying it, some experts recommend that all flights that cross more than 8 to 10 time zones be treated as if they were westward2;6 (Gutsy Easty roast, Westy roast’).

For Eastward flights it may be of benefit to partially adjust the sleep-wake cycle to the new time zone in the days before the flight by combination of advancing sleep time (bringing bedtime forward by 1-2 hrs per day) with bright light on rising for the 3 days before the flight2;6. Advancement of more than this amount is likely to cause sleep disturbances and be difficult to implement2.

Melatonin* may also be used to advance the body clock before eastward flights by ingestion in the evening in the days before departure2.

With regard to melatonin, as many as one in two people who use exogenous melatonin* to combat jet lag may benefit3 (Waterhouse 2003). It is not known whether exogenous melatonin* works due to it’s natural hypnotic effect or because it promotes adjustment of the body clock3. Generally 3-5mg of melatonin* taken close before bedtime has been shown to be effective in improving sleep during jet lag2;9.

Melatonin* is not approved by the Food and Drug Administration (FDA) for any indication6. However, no major or consistent adverse events have been reported in the clinical trials that have been performed to date6. Waterhouse (2003) explains that ‘no pharmacological company wants to pay for the toxicological studies and the data assembly required to obtain a product license because it cannot have exclusivity’3. This is of concern given the likely benefits to many groups of people and professionals3.

Short acting hypnotics have also been found to reduce insomnia related to jet lag2;6. I will not to go into detail about these but you can enquire with your local medical practitioner.

With regard to daytime functioning, there is evidence that caffeine can temporarily alleviate fatigue from jet lag throughout the day2. The drug Modafinil may also be useful for alleviating fatigue during the day2;6 and seems to be without side effects2

Please refer to the table attached below, which is copied from the review by Sack (2010) for more detailed advice on how to minimize travel fatigue and jet lag6.

For the Jet Lag section

Delayed Sleep Phase Disorder (DSPD) (more common in adolescence)

Delayed sleep phase disorder represents a state where the sleep-wake cycle is delayed 3-6 hours relative to the most functional or ‘normal’ sleep-wake cycle1;10. When obliged to interrupt the sleep-wake cycle, due to work or school or other commitments, people will suffer from the usual symptoms of insomnia such as excessive sleepiness and have difficulty waking up in the morning1;10.

Although DSPD is not common in the general population, it is more common among adolescents (7-16%)1;10. Untreated DSPD is likely to negatively impact upon academic performance and psychological health among adolescents and underlying depression is often comorbid with DSPD10.

Effective treatments for DSPD include chronotherapy, timed bright light exposure and exogenous melatonin* 1;10.

Chronotherapy is a lengthy and demanding treatment and requires specialist guidance and the full support of family. It involves gradually delaying bedtimes by 3 hours every 2 days, until the bedtime has moved around the clock (by about 20 hours) to reach the desired bedtime1;10.

Bright light exposure in the early morning for example 6-8am for about 1 -3 hours is usually effective in advancing the sleep-wake cycle1;10. Bright natural light is ideal but if not available bright artificial light is a suitable substitution10.

In the treatment of DSPD, exogenous melatonin* should be given 4-6 hours before bedtime1;10. You may notice that the timing is earlier for the administration of melatonin in DSPD compared to the treatment of other sleep disturbances but this is shown to be the most effective timing for this condition1;10.

Regardless of the treatment regime, good sleep habits are still important, including limiting the use of technology at night (especially one hour or less before bedtime), establishing regular sleep and wake times, and avoiding caffeine (especially four hours or less before bedtime)10.

Specialist assessment and diagnosis is recommended so as not to be confused with people who have delayed sleep patterns without functional impairment or with other sleep disorders.

Circadian Rhythm Sleep Disorder, Shift Work Type (Shift Work Disorder)

Symptoms of shift work disorder (SWD) results when people are required to work and sleep at times at times that do not match their body clocks sleep-wake cycle causing insomnia and excessive sleepiness which may persist for several days even after returning to usual sleep-wake times1.

The prevalence of SWD is approximately 10% in night and rotating shift workers1.

Obviously there are Occupational Health and Safety risks involved with being excessively sleepy in the workplace and on the drive home from work. Shift work is associated with increased injuries and accidents11.

Effective treatments for SWD include bright light therapy and exogenous melatonin*1;11. This can help to adjust the body clocks sleep- wake cycle for shift workers on permanent night shift or slowly rotating shifts11. The body may not be able to adapt effectively to rapidly rotating schedules11.

Exposure to bright light during night shift work is recommended either a 3-6 hr continuous block or intermittently for 20 minutes every hour during the shift1. Light exposure during the morning should be avoided by wearing dark sunglasses when leaving work and blocking light entering bedroom windows11. It is recommended that shift workers try to sleep as soon as possible after their shift1;11.

When attempting to sleep during the day, good sleep habits such as having a quiet, dark sleeping environment are important1;11. Short acting hypnotic medications may also be useful1.

Melatonin* ingested early in the day can improve daytime sleep but does not improve night-time alertness1.

To increase alertness during the night, short scheduled naps during the night-time shift may be useful1. Caffeine during the first couple of hours of the night shift is also helpful1. Modafinil is a stimulant approved by the Food and Drug Administration (FDA) for the treatment of excessive sleepiness in SWD1.

Shift work is associated with many other health conditions such as depression and obesity, therefore it is recommended that shift workers receive appropriate medical assessment and support for SWD and other comorbidities1;11.

Autism Spectrum Disorder and Melatonin

As mentioned in my previous post on sleep, there is a higher rate of sleep disturbances among people with an ASD. Although behavioural treatments are generally considered the first step in treatment of sleep disturbances, exogenous melatonin* has a special role in people with an ASD who have sleep disturbances.

I also mentioned in my previous post on sleep that even with good sleep habits, my son Jeremy still had trouble going to sleep at night. On hearing about Jeremy’s difficulty going to sleep his pediatrician recommended trialing exogenous melatonin*. The pediatrician advised us to give melatonin* to Jeremy 30 minutes before bedtime. We commenced at the lower dose of 2mg of melatonin* and we were instructed to gradually increase the dose if needed.

It is safe to say that we did not need to increase the dose. Exogenous melatonin* has been a huge success in helping Jeremy to fall asleep within a much shorter time. Jeremy is very happy about finding it easier to go to sleep and is no longer excessively sleepy in the mornings either. Of course, all that is anecdotal and so now I will provide the compelling evidence regarding the effectiveness of exogenous melatonin* in managing sleep disturbances in children with ASD.

All studies on people with an ASD have shown differences in melatonin production compared to people without an ASD4;12. In particular, people with an ASD are much more likely to have a lower night- time secretion of melatonin4;12. The melatonin production differences of ASD appear to be genetic12;13 and heritable with parents without an ASD also showing reduced production of melatonin12.

Exogenous melatonin* has been more extensively studied in children with insomnia than any other sleep-promoting medication14;15. Exogneous melatonin* is shown to be effective with good tolerability in the short and long term for reductions in sleep latency and sleep duration in children with ASD with sleep disturbances when given prior to bedtime14;15.

Even though the administration of exogenous melatonin* is considered to be a Complementary and Alternative Therapy (CAT)* it is one of best studied CATS for ASD16. Lofthouse et al.(2012) reviewed the CATS most commonly used by people with an ASD and made recommendations for the use of only three CATS in specific circumstances, one of those was the use of exogenous melatonin*16. Lofthouse et al. (2012) determined melatonin* to be sensible, easy, cheap and safe and recommended it for trial for people with an ASD who experience sleep delay16.

More recently a review of the literature concluded that the administration of exogenous melatonin for people with an ASD, that have sleep disturbances related to abnormalities in endogenous melatonin secretion, is now evidence-based17.

Miano & Ferri (2010) recommends a combination of melatonin* and behavioural interventions as a first –choice treatment for children with an ASD with sleep disturbances because behavioural intervention alone may not be sufficient due to the low level of endogenous melatonin observed in children with ASDs15.

One recent well conducted study by Malow et al. (2012) demonstrated that exogenous melatonin* significantly improved sleep latency among children of 3-10 yrs of age with sleep onset delay. Melatonin* was effective at a dose of 1-3mg for the majority of children, when given 30 minutes before bedtime18. Daytime behaviour also significantly improved in all areas measured (hyperactivity, withdrawn and affective problems and stereotyped and compulsive subscales) and the side effects of melatonin* ingestion were minimal18.

Although melatonin* is safe and well tolerated, Malow et al.(2012) recommends that melatonin* is used under the guidance of an appropriate medical professional  ‘because of the importance of assessing children with ASD and insomnia for medical, neurological, and psychiatric comorbidities, which may cause or contribute to insomnia’18.

* In this blog ‘exogenous melatonin’ refers to melatonin that is artificially produced and ingested as a supplement. ‘Endogenous melatonin’ is melatonin that the body naturally produces.

Exogenous melatonin is not approved by the Food and Drug Administration because it has not undergone the appropriate testing to obtain a license. This contributes to its classification as a Complementary and Alternative Therapy (CAT).

Herxheimer and Petrie (2002) state that ‘The pharmacology and toxicology of melatonin and pharmaceutical aspects of its formulation have not been systematically studied, very likely because the drug cannot be patented and the cost of the work cannot readily be recouped from sales of the drug’9. Melatonin cannot be patented because it is a naturally occurring hormone. Waterhouse (2003) recommends that a cost-benefit analysis should be conducted and would likely indicate that it is in the public interest for public funding to be contributed to the relevant testing3.

Two categories of people should avoid exogenous melatonin until more is known: anyone taking Warfarin or another oral anticoagulant3;9 and people with epilepsy3 (Waterhouse 2003 BMJ).

Another concern regarding exogenous melatonin use is that no official standards of melatonin supplement purity exist3. In the US, Thailand and Singapore it is freely sold as a “dietary supplement” in health food stores and pharmacies3. Waterhouse (2003) recommends purchasing it from a ‘large reputable pharmacy chain’ and to ‘hope for the best’3. In Australia it can be purchased from compounding pharmacies via prescription and therefore may be more expensive but more regulated than over-the-counter versions in other countries.

References:

  1. Barion, A. & Zee, P. A clinical approach to circadian rhythm sleep disorders. Sleep Medicine 2007; 8(6):566-577
  2. Waterhouse, J. Jet lag: Trends and coping strategies. The Lancet 2007; 369: 1117-1129
  3. Waterhouse, J. The prevention and treatment of jet lag. BMJ 2003; 326:296-297
  4. Tordjman, S. Anderson, G. Bellissant, E. Botbol, M. Charbuy, H. Camus, F. Graignic, R. Kermarrec, S. Fougerou, C. Cohen, D. Touitou, Y. Day and nighttime excretion of 6-sulphatoxymelatonin in adolescents and young adults with autistic disorder. Psychoneuroendocrinology 2012; 37:1990-1987
  5. Czeisler, C. Perspective: Casting light on sleep deficiency. Nature 2013; S13 DOI: 10.1038/497S13a
  6. Sack, R. Clinical practice. Jet lag. The New England Journal of Medicine 2010; 362(5):440-447
  7. Cajochen, C. Frey, S. Anders, D. Spati, J. Bues, M. Pross, A. Mager, R. Wirz-Justice, A. Stefani, O. Evening exposure to a light-emitting diodes (LED)-backlit computer screen affects circadian physiology and cognitive performance. Journal of Applied Physiology 2011; 110:1432-1438
  8. West, K. Jablonski, M. Warfield, B. Cecil, K. James, M. Ayers, M. Maida, J. Bowen, C. Sliney, D. Rollag, M. Manifin, J. Brainard, G. Blue light from light-emitting diodes elicits a dose-dependent suppression of melatonin in humans. Journal of Applied Physiology 2011; 110:619-626
  9. Herxheimer, A. & Petrie, K. Melatonin for the prevention and treatment of jet lag (Review). Cochrane Database of Systematic Review 2002; Issue 2. Art. No.: CD001520.
  10. Bartlett, D. Biggs, S. Armstrong, S. Circadian rhythm disorders among adolescents: assessment and treatment options. Medical Journal of Australia 2013; 199(8):S16-S20
  11. Burgess, H. Sharkey, K. Eastman, C. Bright light, dark and melatonin can promote circadian adaptation in night shift workers. Sleep Medicine Reviews 2002; 6(5):407-420
  12. Melke, J. Goubran-Botros, H. Chaste, P. Betancur, C. Nygren, G. Anckarsater, H. Rastam, M. Stahlberg, O. Gillberg, C. Delorme, R. Chabane, N. Mouren-Simeoni, M-C. Fauchereau, F. Durand, C. Chevalier, F. Drouot, X. Collet, C. Launay, J-M. Leboyer, M. Gillberg, C. Bourgeron, T. and the PARIS study. Abnormal melatonin synthesis in autism spectrum disorders. Molecular Psychiatry 2008; 13(1): 90-98
  13. Jonsson, L. Ljunggern, E. Bremer, A. Pedersen, C. Landen, M. Thuresson, K. Giacobini, M. Melke, J. Mutation screening of melatonin-related genes in patients with autism spectrum disorders. BMC Medical Genomics 2010; 3(10):1-7
  14. Cortesi, F. Giannotti, F. Ivanenko, A. Johnson, K. Sleep in children with autistic spectrum disorder. Sleep Medicine 2010; 11:659-664
  15. Miano, S. & Ferri, R. Epidemiology and management of insomnia in children with autistic spectrum disorders. Pediatric Drugs 2010; 12(2):75-84
  16. Lofthouse,N. Hendren, R. Hurt, E. Arnold, LE. Butter, E. A Review of Complementary and Alternative Treatments for Autism Spectrum Disorders. Autism Research and Treatment 2012; Article ID 870391, 21pages
  17. Rossignol, D. & Frye, R. Melatonin in autism spectrum disorders. Current Clinical Pharmacology 2013; Ahead of print.
  18. Malow, B. Adkins, M. McGrew, S. Wang, L. Goldman, S. Fawkes, D. Burnette, C. Melatonin for sleep in children with autism: A controlled trial examining dose, tolerability, and outcomes. Journal of Autism and Developmental Disorders 2012; 42(8): 1729-1737

Sleep Arghhh! (Part 1: Behavioural treatment)

I picked up the car in my hand and in one adrenaline charged action tossed it all the way from Campbelltown to Glenelg. There was no driver in the car, it was a tormenting noise polluter that made my baby toss and turn in his cot, on the verge of waking. One by one, I threw every car that threatened to pass by my baby’s window to the other side of Adelaide, an imagining that somehow channeled some of the excess adrenaline away from my anxious sleep deprived brain.

The sleep clinic had helped, such that now I could achieve more than 3hrs of sleep in a 24 hour period but Jeremy would always prove challenging with sleep and I could expect another 2 years of sleep deprivation until he finally slept through the night consistently.

Jeremy temporarily started sleeping through the night at around 18 months of age (shortly after Damian was born) but the very night that Damian started sleeping through the night not long afterwards (at 2 months of age) Jeremy started waking again. Not long after that, I voluntarily admitted myself (on recommendation from my sister) to a mother-baby unit at a private psychiatric hospital, even though I knew that it wasn’t post natal depression that contributed to my highly anxious state (they diagnosed me with post natal adjustment syndrome). I knew that sleep deprivation and Jeremy’s behaviour was a major contributor to my reduced ability to function.

You see, when Jeremy wasn’t asleep he was demanding of my attention every single second. Unless, I entertained him constantly with singing and dancing, reading books and playing with baby toys he immediately became upset. Entertainment was the only thing that soothed him. I had to play games with him while he fed, while he watched passing vehicles at busy intersections (he enjoyed that) and while watching children playing in parks (he also enjoyed that). Even one thing at a time was not enough for Jeremy.

I could not go to the toilet or shower without having to entertain Jeremy at the same time there with me. I could not do any housework or cook while he was awake, and I scoffed commercial premade meals down as quickly as I could for sustenance and there was no time for snacks. At the best of times, I crave sleep and food and always have.

There was one defining moment when Jeremy was content on his own, lying on a rug in our lounge room for a whole 2 minutes. I was so stunned that I took a photo of him although I didn’t need to because the image is still clear in my mind. It was the only time as a baby that he was content without being entertained. Don’t ask me why… there was nothing extraordinary about that day, and that location or the events that led up to it.

You may think it strange that I choose to have another baby so close in age after Jeremy but the decision was partially made to give him a sibling to play with and it was a great decision. Damian and Jeremy are the best of friends (and the worst of enemies) with similar interests and it has taken an enormous pressure of me. In addition to the fact that it soothed him, I reassure myself that Jeremy benefited greatly from the early intensive attention in terms of learning through play, even though (when combined with sleep deprivation) it severely compromised my mental health.

As a result of this experience, I developed a strong interest in sleep and would like to share with you some of the more useful evidence-based recommendations for sleep in young children (over 6 months of age) including children with ASD that I have implemented, which have been successful in helping my boys to get a healthy and consistent amount of sleep.

In this blog (Part 1), I shall begin with an introduction to sleep and sleep problems among children with or without Autism Spectrum Disorders (ASDs) and then discuss the evidence supporting the first line of treatment for sleep problems, namely behavioural –educational interventions1.

What is sleep?

According to the scientific literature sleep is a ‘reversible condition of reduced responsiveness usually associated with immobility’2. Does anyone else find that description funny? We all know what sleep is, right!?

Why sleep?

During sleep different areas of the brain responsible for different functions are activated and deactivated in specific patterns for specific purposes2. Sleep contributes to many physiological processes such as immunity, hormonal regulation, thermoregulation and ontogenesis2. Sleep also contributes significantly to neurological and psychological functions such as memory and learning, and emotion and reward processing2;3.

Sleep problems

The nature of sleep problems among typically developing children and children with an ASD are similar however the prevalence of sleep problems is greater among children with an ASD. 20-40% of typically developing children are affected by sleep problems3;4;5 compared with 40-80% of children with an Autism Spectrum Disorder1;3;6;7.

Insomnia is the predominant sleep problem in children with an ASD8 who have been shown to exhibit shorter sleep time, lower sleep efficiency and differences in some of the stages of sleep and the activity within these stages3;6;7*compared to typically developing peers.

Moturi and Avis (2010) define insomnia in children as repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite age- appropriate time and opportunity for sleep, which results in daytime functional impairment for the child and/or family9.

Sleep problems in people with ASD appear to be characteristic of the ASD rather than the person’s IQ level or age6;10 and the sleep –wake cycle of infant children with ASD has also been shown to have greater sensitivity to noise11. Has anyone else been told by their mother that you should be able to vacuum under your sleeping baby?

It is clear in the scientific literature that there are both substantial environmental and genetic influences on sleep behaviour and sleep problems12;13. Before Jeremy was born I was aware that genetics was not strongly in my favour for a content sleepy baby. A prospect that I thought was amusing until I experienced the true impact of a baby disturbed by gastroesophageal reflux disease (GERD), communication difficulties due to ASD and sleep problems.

My husband was regularly referred to as a very difficult baby due to sleep problems and was primarily responsible for a major age gap between him and his next sibling. As a baby, I slept reasonably well but was described by my mother as a “colicky baby” because when I was awake I cried excessively.

Sleep problems can result in significant impairments in daytime behaviour, memory and learning for young children3. In fact, there is a bidirectional relationship (i.e. one contributes to the other and vice versa) between the core symptoms of ASD and sleep problems3;10.

The sleep problems of children also impact upon their families with parents experiencing reduced sleep4;14 and the consequences of reduced sleep which include maternal depression4;15 and increased parenting stress15 resulting in overall decreased family functioning. When compared to parents of typically developing children, parents of children with ASDs reported poorer sleep quality, earlier morning wake time and shorter sleep duration14.

Behavourial interventions for sleep problems

In a recent review of the scientific literature, preventative behavioural – educational interventions have been found to promote maternal and infant sleep improve maternal mood, decrease fatigue and reduce parenting stress in both mothers and fathers with significant benefits for maternal depression maintained for up to 2 years15.

In fact, the effects on maternal depression, of behavioural interventions for infants with or without reported sleep problems, were so significant and long lasting that it led a team of researchers to conclude that ‘managing infant sleep represents a feasible, acceptable, low-intensity, and cost-effective preventive intervention approach for maternal depression’16.

Proper assessment of the cause of the sleep problems is important to determine the approach17. Wiggs et al. (2000) gives the example that ‘difficulty falling asleep may be due to a sleep-wake cycle disorder, limit setting sleep disorder, or anxiety-related sleep disorder and they would therefore require different treatment approaches, directed at the underlying disorder and not at the presenting symptoms’17.

My two sons both developed sleep problems at different times related to anxiety such as the fear of the dark and for Jeremy anxiety surrounding whether or not his dad would be at home or at work when he awoke. The simple and effective solution for Jeremy’s issue was to ensure that his dad said ‘goodbye’ every morning even if that meant waking him up a little earlier. Damian’s anxieties regarding his fear of monsters and the dark were a little more involved but with the help of a child psychologist (with experience in ASD) we successfully overcame that sleep problem too.

It is not uncommon for behavioural sleep problems to co-exist with sleep disorders so behavioural intervention is often still recommended in addition to other treatments17.

In general, the most effective forms of behavioural interventions include implementation of consistent bedtime routines incorporating quiet soothing activities18 and extinction-based (removing reinforcement to reduce a behaviour) interventions such as ‘controlled crying’ and ‘camping out’16;19.

A bedtime routine consists of implementing the same activities in the same order immediately before bed18. Bedtime routines were found to be highly effective to reduce the time taken to go to sleep once in bed (latency to sleep onset) and in the number and duration of episodes of night waking with an associated improvement in maternal mood18.

Extinction –based interventions such as controlled crying and camping out are only recommended for infants and children over the age of 6 months15. Meltzer et al. (2011) explain that at this time in their development sleep begins to consolidate, with infants establishing a circadian rhythm and no longer needing to feed during the night15.

‘Controlled Crying’ involves having ‘parents respond to their infant’s cry at increasing time intervals, allowing the infant to fall asleep by itself’19. Commonly used time intervals are 2 minutes apart: 2 min, 4 min, 6min, 8 min, and 10 min. I used time intervals that doubled in length: 1 min, 2 min, 4 min, 8 min, and 16 min with my boys. I rarely got passed the first two intervals before they settled.

‘Camping Out’ involves having the ‘parents sit with their infant until the infant fell asleep and gradually removed their presence’19 usually over a period of several weeks.

Behavioural techniques have been shown to be effective for treating sleep problems in children and adolescents with chronic physical illness, psychological problems and intellectual disabilities17. Although, it is generally recommended that more gradual methods of extinction rather than complete extinction are implemented for children with particular physical illnesses (such as asthma or epilepsy) or for those who might damage themselves or their environment if not attended to17. In addition, nighttime respite care is also recommended to be of benefit for parents of children with chronic illness and sleep problems for overall improved outcomes for the children and parents15.

Please refer to the following link for more detailed instruction on how to help your child sleep better using the behavioural techniques mentioned above http://raisingchildren.net.au/articles/controlled_comforting.html

Another behavioural approach that has shown some evidence of success in children with other diagnoses includes sleep scheduling, which involves implementing consistent and appropriate sleep and wake times17. This can be achieved by starting with a later bedtime to link bedtime and sleep onset and then gradually moving the sleep time forward by 15 to 30 minutes17. This was found to be even more effective when a ‘response cost’ component was added17. The response cost component involved removing the child from the bed for 1 hour if not asleep within 15 minutes, to better improve the link between bed and sleep17.

Bedtime routines and extinction techniques appear to be effective for children with sleep problems who also have a diagnosis of ASD6;8;20. Vriend et al. (2011) recommends that behavioural techniques should be tailored to each child with an ASD taking into account the preferences and competencies of their families1.

For children with ASD successful extinction techniques  have included visual representations of bedtime routines, positive reinforcement procedures such as praise and rewards for compliance, and regardless of compliance with nighttime routines parents were encouraged to give the child plenty of positive attention during the day20.

In children with other diagnosed conditions, it is important not to assume that the sleep problem is an inevitable and untreatable part of that child’s other condition17. I made that mistake with Jeremy. After employing all the recommended behavioural interventions for sleep and then some, I assumed that Jeremy’s difficulties going to sleep and resultant late sleep onset and reduced sleep duration was just a byproduct of Jeremy’s uniqueness that was unavoidable.

I can’t recall exactly when we implemented a consistent bedtime routine and bedtimes for our boys but we have had those strategies in place for many years now and I had taught Jeremy from an early age (using extinction techniques, general education about sleep through books and discussion, positive reinforcement of compliance) that he was to lie in bed until he fell asleep and not play or yell out at night time.

Jeremy had become very obliging after all our interventions and often lay in bed quietly for over an hour before going to sleep regardless of the bedtime. It was during an appointment with a pediatrician to address another health complaint that the pediatrician asked about his sleep and suggested trialing melatonin and I am so glad that the pediatrician was so thorough for Jeremy’s sake. I will elaborate more on this in my Part 2 of my sleep blogs (coming soon).

Although, there are few arguments against a good bedtime routine as being beneficial for children’s sleep, parents may find extinction techniques anxiety-provoking in the short term due to ‘post extinction bursts’. Post extinction bursts may occur during implementation of extinction techniques and are characterized by a temporary escalation of targeted behaviour such as more intense crying before finally settling20.

In the case of extinction techniques, although they are generally accepted by the scientific community and health professionals as successful and beneficial techniques for improving sleep problems, one group of researchers suggests that the ethics of the techniques are questionable21.

An article by Blunden et al. (2011) claims that extinction techniques are ‘morally wrong’ because we are not meeting the ‘needs’ of our infants by ‘ignoring their cries’ and that nighttime crying has been unnecessarily ‘pathologized’21.

Blunden et al. (2011) states that although, long term negative consequences of extinction techniques to the child’s development have not been reported and are therefore ‘unknown’, ‘caution should be extreme’ when considering applying extinction techniques21.

However, in the same article Blunden et al. (2011) acknowledges that ‘sleep disruption to due to infant sleep problems is frequently associated with parental ‘depression and other physical and mental health issues’, sleep disturbances are a concern for parents in that they ‘are the most common issue for which medical assistance is sought by parents in the first year of their infants’ life’ and that ‘these methods all achieve a relatively rapid reduction in night time protests, encourage ‘self-settling’ or solo re-initiation of sleep, and improve sleep consolidation with low relapse rates’21

A response to the article by Blunden et al. (2011) was published (which tends to happen when inflammatory opinion pieces are published) to counter their arguments. Sadeh et al. (2011) accuses the authors of being ‘dismissive of the very real consequences it (sleep problems) has on children and families’ and of advocating against solo sleeping when the evidence does not support that22. The article also argues that the ‘vast majority of modern behavioural techniques are based on some degree of continued caregiver response to the infant throughout the sleep initiation or resumption process’21.

In addition Sadeh et al. (2011) also pointed out the potential detrimental effects of sleep problems to the infant, in that sleep problems are associated with ‘perceived difficult infant temperament, increased likelihood of later behaviour problems, compromised cognitive abilities and increased body weight’ and that ‘infants who develop total reliance on parental soothing behaviours are more likely to wake-up more often and require extensive parental interventions’22.

In fact, well conducted longitudinal articles4;16;23 on the long term effects of ‘graduated extinction’ techniques and ‘camping out’ have shown them to be safe for use in infants, with children in the treatment and control groups showing no differences in mental health outcomes (externalizing or internalizing problems) in the years following implementation of the techniques.  Parenting practices were also shown to be no different between parents of the treatment and control groups in terms of parenting practices (harsh discipline versus nurturing) and mothers often reported an improved relationship between themselves and their child16.

In the early weeks, I chose not to co-sleep with Jeremy in the same bed because his sleep was even worse when lying next to me. He was never able to sleep next to me effectively. I believe this was partly because of his need to sleep on a significant slope due to GERD and partly because he associated me with play and attention.  In desperation, I even tried sleeping holding Jeremy in a baby carrier on my belly one night propped up by pillows, but it was not a position I could safely hold or sleep in.

When Jeremy was a few weeks old, I had to move him into another room because he frequently made loud grunting noises while he was asleep that kept me awake throughout the night. I later attributed the grunting noises to his speech delay and ongoing articulation difficulties. He didn’t cry or babble like other babies and his distress sounds were different.

As mentioned previously, I attended a sleep clinic for Jeremy (when he was 8 weeks old) which helped make sleep manageable for us. The sleep clinic helped me to incorporate more effective swaddling, routine and settling/re-settling techniques.

I also chose to use controlled crying when Jeremy was 6 months old due to his sleep problems, which improved the night-time settling process for us, but there was still a long way to go to before we all achieved good night sleeps.

Personally, I am completely supportive of people of the infant sleeping choices people make. I believe people should make choices that they are comfortable with that may also change depending on the circumstances. I also believe that it is irresponsible to judge a person’s choices without empathy for the unique circumstances that each person and family faces especially when the evidence does not support one choice over another.

Note: Always address any medical concerns including sleep and behavioural concerns with your child’s GP and/or Pediatrician.

*A discussion of the stages of sleep (macro architecture) and the brain activity during the stages of sleep (micro architecture) is beyond the scope of this blog. Please refer to the articles by Cortesi et al. (2010) and Limoges et al. (2005) for a detailed account of the macro architecture and micro architecture of sleep in children and adults respectively6;10.

References:

  1. Vriend, J.L. Corkum, P.V. Moon, E.C. Smith, I.M. Behavioral Interventions for sleep problems in children with autism spectrum disorders: Current findings and future directions. Journal of Pediatric Psychology 2011; 36(9):1017-1029
  2. Perogamvros, L. Dang-Vu, T. T. Desseilles, M. Schwartz, S. Sleep and dreaming are for important matters. Frontiers in Psychology 2013; 4(474) doi: 10.3389/fpsyg.2013.00474
  3. Maski, K.P. Kothare, S.V. Sleep deprivation and neurobehavioral functioning in children. International Journal of Psychophysiology 2013; 89:259-264
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