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Sleep Disorders in Children & Young Sleep Disorders in Children & Young People with Developmental People with Developmental DisabilitiesDisabilitiesJeremy TurkJeremy TurkAcademic Child & Adolescent Mental Health,Academic Child & Adolescent Mental Health,
Institute of Psychiatry, King’s College, University of LondonInstitute of Psychiatry, King’s College, University of London
&&
Child & Adolescent Mental Health Neurodevelopmental Services,Child & Adolescent Mental Health Neurodevelopmental Services,
South London & Maudsley Mental Health Foundation NHS TrustSouth London & Maudsley Mental Health Foundation NHS Trust
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Turk, J. (2010)Turk, J. (2010)
Sleep Disorders in Children & Adolescents Sleep Disorders in Children & Adolescents with Learning Disabilities & Their with Learning Disabilities & Their
ManagementsManagements
Advances in Mental Health & Learning Advances in Mental Health & Learning DisabilitiesDisabilities
Volume 4, Issue 1, Volume 4, Issue 1, pp. 50-59.pp. 50-59.
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Turk, J. (2014)
Use of Medication in Children & Young People with Intellectual Disability & Challenging
Behaviours
“Intellectual Disabilities & Challenging Behaviour”ACAMH Occasional Papers No. 32
(eds: Lovell, M. & Udwin, O.)
London: Association for Child & Adolescent Mental Healthpp. 36-44.
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Common Sleep DifficultiesCommon Sleep Difficulties Insomnia
Settling difficulties
Recurrent night time waking
Early morning waking
Nightmares, night terrors, sleep talking, sleep
walking, sleep reversal, sleep paralysis
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Sleep disorders in childhoodSleep disorders in childhood 15-20%, Isle of Wight study May be– Settling difficulties (“sleep induction”)– Repeated night-time waking– Early morning waking– Parasomnias e.g. sleep walking, night terrors
Strong association with– daytime behavioural difficulties– maternal stress & depression– Family discord & parental separation– Poor educational attainments & socialisation
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QUINE 1991:QUINE 1991:Longitudinal study of sleep disturbance in 200 young
people with moderate-to-profound intellectual disability
51% settling problems
67% waking problems
32% of parents reported rarely getting enough sleep
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Sleep & Autism Spectrum Conditions:Sleep & Autism Spectrum Conditions:44-83% sleep disturbanceSubjective & objective difficulties
- Falling asleep- Staying
Biochemical & genetic associations- Low plasma & saliva melatonin levels
? Low melatonin CNS receptor sensitivity? Lack of circadian secretion rhythm
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Behavioural TechniquesBehavioural TechniquesExtinction
Positive reinforcement +/- fading
Shaping & graded approaches
Antecedent contingencies
Discriminant Learning
Regular, structured, predictable & calming bedtime routine
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Sleep determinants:Sleep determinants:Primarily social in people with average intellectual
abilities
– “zeitgebers”
Strong neurological components in children and young
people with developmental disabilities
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Melatonin Melatonin (Turk, 2003; Turk, 2010)(Turk, 2003; Turk, 2010)
N-acetyl-5-methoxytryptaminePineal indolediurnal secretion variationwidely available as food supplement in North America
unlicensed for children & young people in U.K. - only prescribable on named patient basis
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Tryptophan
Serotonin
N-acetylserotonin
Melatonin(N-acetyl-5-methoxytryptamine)
Tryptophan
Serotonin
N-acetylserotonin
Melatonin(N-acetyl-5-methoxytryptamine)
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JAN ET AL 1994:JAN ET AL 1994:JAN ET AL 1994:JAN ET AL 1994: 15 children, most with multiple neurological 15 children, most with multiple neurological
disabilitiesdisabilities improved sleepimproved sleep ““significant health, behavioural & social significant health, behavioural & social
benefits”benefits”
BUTBUT responses not always completeresponses not always complete responses varied considerably depending on responses varied considerably depending on
type of sleep disturbancetype of sleep disturbance not double-blindnot double-blind
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JAN & ESPEZEL 1995:JAN & ESPEZEL 1995:JAN & ESPEZEL 1995:JAN & ESPEZEL 1995: Subsequent reportSubsequent report full or partial correction of sleep-wake cycle full or partial correction of sleep-wake cycle
disturbance in almost 90 children with a range disturbance in almost 90 children with a range of developmental disabilities, neurological of developmental disabilities, neurological disorders & chromosomal anomaliesdisorders & chromosomal anomalies
continuing strict environmental sleep continuing strict environmental sleep structuring importantstructuring important
side effects & tolerance not notedside effects & tolerance not noted
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MELATONIN IN SPECIFIC MELATONIN IN SPECIFIC GENETIC DISORDERS:GENETIC DISORDERS:MELATONIN IN SPECIFIC MELATONIN IN SPECIFIC GENETIC DISORDERS:GENETIC DISORDERS: O’Callaghan et al. 1999:O’Callaghan et al. 1999:
7 individuals with 7 individuals with tuberous sclerosis tuberous sclerosis and and severe sleep problemssevere sleep problems
small but significant improvement in total sleep small but significant improvement in total sleep timetime
non-significant improvement in sleep onset non-significant improvement in sleep onset timetime
? Responders & non-responders? Responders & non-responders McArthur & Budden 1998:McArthur & Budden 1998:
improved sleep-onset latency, total sleep time improved sleep-onset latency, total sleep time & sleep efficiency in 9 individuals with & sleep efficiency in 9 individuals with Rett Rett syndromesyndrome
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Gringras et al., 2012Gringras et al., 2012 Randomised double masked placebo controlled trial for sleep
problems in children with neurodevelopmental disabilities 146 children aged 3-16 Total sleep time by 22.4 minutes Sleep onset latency by 37.5 minutes Melatonin earlier waking times than placebo Children fell asleep significantly faster But woke earlier And gained little additional sleep on melatonin Child behaviour & family functioning outcomes favoured melatonin
but were not significant But parents loved it!
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Melatonin is:Melatonin is: Highly beneficial, short-term, rapid-onset & safe treatment for intractable
sleep disturbance Therapeutic dose not predicted by:– severity of sleep disturbance– severity of intellectual disability– presence/absence of autism
Habituation common but not universalConcomitant psychological, behavioural, educational, family & social
interventions essentialNo obvious short-term adverse effects but long-term safety has not been
confirmedNo adverse effects other than habituation up to 5 years after
commencement Modified-release version (Circadin) probably no better than immediate-
release – but cheaper!
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Other Options:Other Options:α-2A noradrenergic receptor agonists– Clonidine, Guanfacine– Lack appetite and sleep disturbance– Good for tic disorders– But sedation & ↓ blood pressure
Tricyclic antidepressants– Imipramine, Amitriptyline– Good for anxiety, depression, enuresis, tics, insomnia– May need to do ECG
? Calming SSRIs – as above
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Clonidine Clonidine (Ingrassia & Turk, 2005)α2A noradrenergic receptor agonistShown efficacy for anxiety, overactivity, impulsiveness,
inattentivenessMildly sedating, mildly hypnoticGood for tics & Tourette’sGood for repeated night time wakingNo effect on appetiteCan drop your blood pressure25-300 μg daily in divided doses
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Acebutolol:Acebutolol:selective beta-1 adrenergic agonist De Leersnyder et al (2003)melatonin antagonistnine children with Smith-Magenis syndromesevere and intractable sleep difficultiessuccessful suppression of inappropriately high morning
melatonin levels improved behaviour and concentration, a reduction in
delays in sleep onset, increased sleep duration and delayed waking
Suggestion of usefulness in Prader-Willi syndrome – but exclude sleep apnoea first!
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Puttaswamaiah & Turk (2015)Puttaswamaiah & Turk (2015)
Prader-Willi Syndrome & dysfunctional sleep-wake cycle
Asleep mid-afternoon on return from schoolAwake early night and thereafterNo response to behavioural approachesNo response to evening melatoninStriking, rapid improvements with mid-afternoon acebutolol
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AnxietyAnxietySSRIs especially mildly calming & sedating
ones e.g. sertraline, citalopram
Beta blockers e.g. propranolol
Alpha agonists e.g. clonidine
In extremis, low-dose short-term risperidone –
can commence as low as 0.125mg twice daily
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Anticonvulsant Mood & Behaviour Anticonvulsant Mood & Behaviour Stabilisers:Stabilisers:Carbamazepine, sodium valproate, lamotrigineExcellent anticonvulsants with good safety profilesBeneficial in bipolar/cyclical mood disordersEmerging evidence base for child & adolescent
fluctuating mood disordersNow used increasingly for cyclical (and not so cyclical)
mood and behaviour challenges in children & young people with complex, multiple & severe developmental disabilities
Balancing mood & behaviour can enhance sleep.
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Clinical GuidelinesClinical GuidelinesAlways commence with sleep hygiene measures
& behavioural approaches
Sleep induction: melatonin
Sleep maintenance: clonidine
Early morning waking (especially in association
with anxiety or mood disorder: sedating SSRI
In extremis, low-dose short-term risperidone –
can commence as low as 0.125mg