Sleep Problems Disturb Children With Autism Spectrum Disorder

The rate of sleep problems is higher in children with autism spectrum disorder (ASD)-occurring in 50% to 80% of these children, per parent reporting-than in their typically developing peers (9% to 50%). With proper assessment and treatment, however, primary care physicians can help improve their sleep habits and quality.

A literature review that we at the Mayo Clinic conducted describes the various types of sleep disorders children with ASD face, possible causes, and approaches to patient assessment and treatment.¹Making the Diagnosis
If a child with autism has several daytime behavioral problems, particularly aggression, hyperactivity, and inattentiveness, the primary care physician seeking a diagnosis of sleep issues should ask about nighttime function. If the child is not sleeping well at night, the behavioral changes occurring in daytime may be related to nocturnal sleep.

Incorporating sleep history into the general assessment of a child with ASD is a good idea. Key questions include the following:

• Where does the child sleep-in his or her own bed or in the parents’ bed?

• Are there any prolonged rituals the child needs, extending beyond 10 or 15 minutes? (They may be activating rather than sleep-enabling.)

• What kind of bed is the child sleeping in? For example, if it is a high bed without side rails in the middle of a room that has a high-arched ceiling, that may trigger anxiety about falling asleep; a child in a cocoon-like bed in the corner of the room may sleep better.

Differences in Sleep Issues
Children with ASD sometimes take into bed whatever exciting or unusual events happened within 4 or 5 hours of sleep onset and incorporate these events into sleep. Because they cannot rid memories from their mind easily, unnecessary information lingers into their sleep.

A big factor that needs more study is anxiety. Children with ASD easily become anxious and have a hard time dealing with it. They may be anxious about some recent event that a typically developing child could deal with, rationalize, or get over, and it may linger. They may become anxious over seemingly minor issues.

Melatonin Deficiency
Some children with ASD have melatonin deficiency and a delayed sleep phase. For most persons, the sleep phase starts at about 9:30 to 10 PM. For children with ASD, the sleep phase may be delayed until midnight or 1 AM-the child may not be able to fall asleep until then. If that’s the case, and the child needs to get up early in the morning to go to school, he is relatively sleep-deprived. That can be another reason why the child has daytime behavioral problems.

I suggest that determination of whether a child has melatonin deficiency is a process of exclusion. If the child is having restless sleep, shows behavioral symptoms, has a hard time falling asleep and staying asleep, is not receiving a medication that disrupts sleep, does not have epilepsy, and is not waking up many times at night, it may be concluded, by process of exclusion, that low levels of melatonin are involved. Tests that can be done on urine and saliva are accurate but not readily available.

Melatonin is not FDA-approved as a drug but is approved as a natural substance or food. Rigorous data about melatonin safety and efficacy are not available. However, the medicine has been shown to be effective in numerous studies conducted in children with neurological development disorders like ASD, and there are no known significant adverse long-term consequences.

For some reason, melatonin seems to work better in children who have neurological developmental problems than in typically developing children. Perhaps that is because children with ASD may have a true deficiency.

Melatonin therapy may be used for several months and then stopped to see whether the process is persisting or has resolved.

Targeting Treatment
Because ASD is a heterogeneous group of problems and children with the condition are different, primary care physicians and child development specialists need to identify the factors that most likely are causing the sleep problem in each child, targeting 1 or 2 specific issues at a time. For example, a child may have sleep-onset association disorder and is used to certain behaviors that facilitate sleeping, such as being rocked to sleep in a parent’s lap and then being put in his own bed. Once the child gets used to that pattern, he may want that when he gets up at night.

Although risperidone and selective serotonin reuptake inhibitors generally are effective for ASD, they may have a negative effect on a child’s sleep. Risperidone antagonizes dopamine in the brain; restless legs syndrome may be an adverse effect. If a child is receiving a medication such as risperidone, and sleep problems are worsening, the clinician might consider reducing the dosage slightly to see whether that eliminates the sleep problem.

Reference
1. Kotagal S, Broomall E. Sleep in children with autism spectrum disorder. Pediatr Neurol. 2012;47:242-251.