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Sleep

Sleep disorders include challenges with the  quality, timing, and total amount of sleep that impacts daily functioning and distress [1]

Much of the sleep research in autism has been conducted on children and youth, suggesting the majority of children with autism (with a range of 50 to 80%) experience sleep challenges [2] with a pooled prevalence of 13% of youth with autism experiencing sleep disorders (versus 3.7% in neurotypical youth) [3] 

 

Autism is associated with differences in sleep patterns, including sleep discontinuity (repeated wakings) and shorter durations of REM sleep (that psychologically retorative stage of sleep associated with strange dreams) [4]. Sleep disorders usually improve or disappear with age in the neurotypical population, yet in autistic youth, sleep challenges are more likely to worsen or change with age and may include anxiety around going to sleep [4]  

 

Differences in sleep patterns seen in autism are thought to be related to disruptions in the circadian rhythm (sleep on/off clock), changes in how melatonin is produced, and mutations in CLOCK genes [5]

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The most common sleep disorder in autistic children is chronic insomnia (defined as sleep on-set problems associated to multiple night awakenings that last for at least three months), followed by secondary insomnia [6]

 

 A diagnostic pathway to assess sleep problems exists for children with autism [7] and includes keeping a sleep diary (hours slept, bed time, time up, number of awakenings), together with actigraphic recording (for at least 1 week) to  assess sleep-wake behaviour. Actigraphy collects data regarding body movement when sleeping, describing daily sleep-wake cycles [8]. Alternatively, a video polysomnographic recording with EEG may be needed when nocturnal epilepsy is queried or there is suspicion of a major sleep disorder (breathing challenges or sleep movement disorders [9,10]

 

 

Treatments of sleep disorders in autism include both pharmacological and non-pharmacological interventions [11].

  • Sleep hygiene and behavioral treatment are effective [11]

    •  Basic sleep hygiene includes an appropriate bedtime, a positive bedtime routine, and reduction of media exposure [12] and should be performed in a gradual way so as not to create potential dysregulation due to changing routines

    • Consider sleep tools, such as a weighted blanket for autistic individuals who like deep pressure

  •  There is a link between sleep-wake cycles and melatonin secretion [13] and melatonin treatment can improve sleep duration and sleep onset latency, but not nighttime awakenings

    • Recommendations on the use of melatonin in autistic children/adolescents [14]  suggests giving 1-3 mg of melatonin 30 min before bedtime. 

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​References
 

  1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders. 5th Ed. Text Revision.  American Psychiatric Association.

  2. Mazzone L, Postorino V, Siracusano M, et al. (2018). The relationship between sleep problems, neurobiological alterations, core symptoms of Autism Spectrum Disorder, and psychiatric comorbidities. Journal of Clinical Medicine, 7, 102. https://doi.org/10.3390/ jcm7050102

  3. Cortese S, Wang F, Angriman M, et al. (2020). Sleep disorders in children and adolescents with Autism Spectrum Disorder: Diagnosis, epidemiology, and management. CNS Drugs, 34, 415-423. https://doi. org/10.1007/s40263-020-00710-y

  4. Miano S, Bruni O, Elia M, et al. (2007). Sleep in children with autistic spectrum disorder: A questionnaire and polysomnographicstudy. Sleep Medicine, 9, 64-70. https:// doi.org/10.1016/j.sleep.2007.01.014

  5. Tordjman S, Anderson GM, Kermarrec S, et al. (2014). Altered circadian patterns of salivary cortisol in low-functioning children and adolescents with autism. Psychoneurocrinology, 50, 227-245. https://doi. org/10.1016/j.psyneuen.2014.08.010

  6. Miano S, Peraita-Adrados R. (2014). Pediatric insomnia: clinical, diagnosis, and treatment. Review of Neurology, 58, 35-42.

  7. Miano S, Ferri R. (2010). Epidemiology and management of insomnia in children with autistic spectrum disorders. Paediatr Drugs, 12, 75-84. https://doi. org/10.2165/11316140-000000000-00000

  8. Morgenthaler T, Alessi C, Friedman L, et al (2007). Standards of Practice Committee, American Academy of Sleep Medicine. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep, 30, 519-529. https://doi.org/10.1093/ sleep/30.4.519

  9. Aurora RN, Zak RS, Karippot A, et al (2011). American Academy of Sleep Medicine. Practice parameters for the respiratory indications for polysomnography in children. Sleep, 34, 379-388. https://doi. org/10.1093/sleep/34.3.379

  10. Aurora RN, Lamm CI, Zak RS, et al. (2012). Practice parameters for the non-respiratory indications for polysomnography and multiple sleep latency testing for children. Sleep, 35, 1467-1473. https://doi. org/10.5665/sleep.2190

  11. Malow B, Adkins KW, McGrew SG, et al. (2012). Melatonin for sleep in children with autism: a controlled trial examining dose, toler- ability, and outcomes. Journal of Autism and Developmental Disorders, 42(8), 1729-37. author reply 1738. https://doi.org/10.1007/s10803-011-1418-3.

  12. Engelhardt CR, Mazurek MO, Sohl K. (2013). Media use and sleep among boys with autism spectrum disorders, ADHD, or typical development. Pediatrics, 132, 1081-1089. https://doi.org/10.1542/peds.2013-2066

  13. Gringras P, Nir T, Breddy J, et al. (2017). Efficacy and safety of pediatric prolonged-release melatonin for insomnia in children with autism spectrum disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 56, 948-957.e4. https://doi.org/10.1016/j.jaac.2017.09.414

  14. Bruni O, Alonso-Alconada D, Besag F, Bi- ran V, Braam W, Cortese S, Moavero R, Parisi P, Smits M, Van der Heijden K, Cu- ratolo P.  (2015). Current role of melatonin in pediatric neurology: clinical recommendations. European Journal of Paediatric Neurology, 19(2), 122-33. https://doi.org/10.1016/j.ejpn.2014.12.007.

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