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 process^1;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 night^4;5. Melatonin acts as a ‘darkness’ indicator and acts to synchronise the sleep-wake cycle with the light-dark cycle^2;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 light^5;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 lighting^5;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 disturbances^2;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 lag^2;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 westward^2;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 flight^2;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 lag^2;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 lag^2;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 day^2;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.

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 cycle^1;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 morning^1;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 bedtime^1;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 cycle^1;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 bedtime^1;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 condition^1;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 shift^1;11.

When attempting to sleep during the day, good sleep habits such as having a quiet, dark sleeping environment are important^1;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 comorbidities^1;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 ASD^4;12. In particular, people with an ASD are much more likely to have a lower night- time secretion of melatonin^4;12. The melatonin production differences of ASD appear to be genetic^12;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 medication^14;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 bedtime^14;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 anticoagulant^3;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 processing^2;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 problems^3;4;5 compared with 40-80% of children with an Autism Spectrum Disorder^1;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 stages^3;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 age^6;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 problems^12;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 problems^3;10.

The sleep problems of children also impact upon their families with parents experiencing reduced sleep^4;14 and the consequences of reduced sleep which include maternal depression^4;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 ASD^6;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 articles^4;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 respectively^6;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
4. Lam, P. Hiscock, H. Wake, M. Outcomes of infant sleep problems: A longitudinal study of sleep, behavior, and Maternal Well-Being. Pediatrics 2003; 111(3):203-207
5. Martin, J. Hiscock, H. Hardy, P. Davey, B. Wake, M. Adverse associations of infant and child sleep problems and parent health: An Australian population study. Pediatrics 2007; 119(5):947-955
6. Cortesi, F. Giannotti, F. Ivanenko, A. Johnson, K. Sleep in children with autistic spectrum disorder. Sleep Medicine 2010; 11:659-664
7. Giannotti, F. Cortesi, F. Cerquiglini, A. Vagnoni, C. Valente, D. Sleep in children with autism with and without autistic regression. Journal of Sleep Research 2011; 20:338-347
8. Miano, S. & Ferri, R. Epidemiology and management of insomnia in children with autistic spectrum disorders. Pediatric Drugs 2010; 12(2):75-84
9. Moturi, S. & Avis, K. Assessment and treatment of common pediatric sleep disorders. Psychiatry 2010; 7(6):24-37
10. Limoges, E. Mottron, L. Boldue, C. Berthiaume, C. Godbout, R. Atypical sleep architecture and the autism phenotype. Brain 2005; 128:1049-1061
11. Matsuura, H. Tateno, K. Aou, S. Dynamical properties of the two-process model for sleep-wake cycles in infantile autism. Cognitive Neurodynamics 2008; 2:221-228
12. Fisher, A. van Jaarsveld, C.H.M. Llewellyn, C.H. Wardle, J. Genetic and environmental influences on infant sleep. Pediatrics 2012; 129: 1091-1096
13. Wang, M. & Saudino, K. J. Genetic and environmental contributions to stability and change of sleep problems in toddlerhood. Journal of  Pediatric Psychology 2012; 37(6):697-706
14. Meltzer, L.J. Brief Report: Sleep in parents of children with autism spectrum disorders. Journal of Pediatric Psychology 2008; 33(4):380-386
15. Meltzer, L.J. & Montgomery-Downs, H.E. Sleep in the family. Pediatric Clinics of North America 2011; 58(3):765-774
16. Hiscock, H. Bayer, J.K. Hampton, A. Ukoumunne, O.C. Wake, M. Long-term mother and child mental health effects of a population-based infant sleep intervention: Cluster-randomized, controlled trial. Pediatrics 2008; 122(3):621-627
17. Wiggs, L. & France, K. Behavioural treatments for sleep problems in children and adolescents with physical illness, psychological problems or intellectual disabilities. Sleep Medicine Review 2000; 4(3):299-314
18. Mindell, J.A. Telofski, L.S. Weigand, B. Kurtz, E.S. A nightly bedtime routine: Impact on sleep in young children and maternal mood. Sleep 2009; 32(5):599-606
19. Hiscock, H. & Wake, M. Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood. BMJ 2002; 324: 1-6
20. Weiskop, S. Richdale, A. Matthews, J. Behavioural treatment to reduce sleep problems in children with autism or fragile X syndrome. Developmental Medicine & Child Neurology 2005; 47:94-104
21. Blunden, S.L. Thompson, K.R. Dawson, D. Behavioural sleep treatments and night time crying in infants: Challenging the status quo. Sleep Medicine Review 2011; 15:327-334
22. Sadeh, A. Mindell, J.A. Owens, J. Why care about sleep of infants and their parents? Sleep Medicine Reviews 2011; 15:335-337
23. Price, A.M.H. Wake, M. Ukoumunne, O.C. Hiscock, H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomized trial. Pediatrics 2012; 130(4):643-651