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SLEEP DISORDERS in CHILDHOOD and ADOLESCENCE
Dr Wendy Duncan Child Adolescent and Family Unit Charlo7e Maxekhe Johannesburg Academic Hospital
“Sleep that knits up the un ravelled sleave of care The death of each day’s life, sore labour’s bath Balm of hurt minds, great nature’s second course, Chief nourisher in life’s feast” William Shakespeare, Macbeth
SLEEP……
• Defined -‐ basis of an individual’s observable behavior as well as neurologic and physiologic acLvity.
• Behaviorally – state of decreased responsiveness and interacLon with external sLmuli.
• Biologic perspecLve -‐ period of intense physiologic and neurologic acLvity.
(McClaughlin et al., Child Adol Psych Clin N Am 2009)
OUTLINE • 1. Normal Sleep • 2. ClassificaLon of Sleep Disorders • 3. NeurocogniLve Effects of Sleep DisrupLon • 4. Intrinsic Sleep Disorders • 5. Extrinsic Sleep Disorders • 6. Parasomnias • 7. Sleep Disturbances in Childhood-‐Onset Psychiatric Disorders
• 8. The Management of Sleep Disorders
NORMAL SLEEP
NORMAL SLEEP
INFANTS (0 to 12 months) • DramaLc changes in behavioural sleep pa7erns and structure
• 64% Lme asleep • Polyphasic sleep/wake pa7ern ± 50-‐60 mins • Sleep pa7ern strongly influenced by hunger, less so by light-‐dark cues
• Two stages: – Quiet sleep (14%) – NREM; steadily increases – AcLve sleep (50%) – REM precursor; (McClaughlin et al., Child Adol Psych Clin N Am 2009)
INFANTS (0 to 12 months)
TODDLER/PRESCHOOL (1 – 5 yrs)
• NormaLve decrease in total amount • Greatest changes ajer 2 years • Reduced dayLme napping • Night wakings are common – ultradian rhythm of sleep cycles
MIDDLE CHILDHOOD (6-‐12 yrs)
• Sleep 10 hours per night • Spontaneous waking • More morning sleepiness, more unintenLonal naps
• Girls sleep more than boys • Slow wave sleep (SWS) é and REM latency ê
ADOLESCENCE (12-‐18 yrs)
• Consistently sleep less, although needs not so • Sleep ave. 7.5-‐8 hours • Numerous associated factors: – Homework, school demands – Extracurricular acLviLes – Decreased parental influence – Employment – Leisure acLviLes esp. electronic – Biologic processes
CLASSIFICATION
• InternaLonal ClassificaLon for Sleep Disorders, 2nd EdiLon (ICSD-‐2)
• DSM-‐IV-‐TR • ICD-‐10-‐CM • DiagnosLc ClassificaLon, Zero to Three (DC 0-‐3R)
ICSD-‐2 • DYSSOMNIAS • A. Intrinsic Sleep Disorders
– 1. Psychophysiologic Insomnia. . . . . . . . . . . . . . . . . . . . . . . 307.42-‐0 – 2. Sleep State MispercepCon. . . . . . . . . . . . . . . . . . . . . . . . . 307.49-‐1 – 3. Idiopathic Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780.52-‐7 – 4. Narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 – 5. Recurrent Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . 780.54-‐2 – 6. Idiopathic Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . 780.54-‐7 – 7. Post-‐traumaCc Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . 780.54-‐8 – 8. ObstrucCve Sleep Apnea Syndrome. . . . . . . . . . . . . . . . . . 780.53-‐0 – 9. Central Sleep Apnea Syndrome. . . . . . . . . . . . . . . . . . . . . 780.51-‐0 – 10. Central Alveolar HypovenClaCon Syndrome. . . . . . . . . . . 780.51-‐1 – 11. Periodic Limb Movement Disorder . . . . . . . . . . . . . . . . . . 780.52-‐4 – 12. Restless Legs Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 780.52-‐5 – 13. Intrinsic Sleep Disorder NOS. . . . . . . . . . . . . . . . . . . . . . . 780.52-‐9
ICSD-‐2 • B. Extrinsic Sleep Disorders • 1. Inadequate Sleep Hygiene. . . . . . . . . . . . . . . . . . . . . . . . . 307.41-‐1 2.
Environmental Sleep Disorder. . . . . . . . . . . . . . . . . . . . . . 780.52-‐6 3. AlLtude Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289.0 4. Adjustment Sleep Disorder . . . . . . . . . . . . . . . . . . . . . . . . 307.41-‐0 5. Insufficient Sleep Syndrome. . . . . . . . . . . . . . . . . . . . . . . 307.49-‐4 6. Limit-‐sepng Sleep Disorder . . . . . . . . . . . . . . . . . . . . . . . 307.42-‐4 7. Sleep-‐onset AssociaLon Disorder. . . . . . . . . . . . . . . . . . . . 307.42-‐5 8. Food Allergy Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . 780.52-‐2 9. Nocturnal EaLng (Drinking) Syndrome. . . . . . . . . . . . . . . 780.52-‐8 10. HypnoLc-‐Dependent Sleep Disorder . . . . . . . . . . . . . . . 780.52-‐0 11. SLmulant-‐Dependent Sleep Disorder. . . . . . . . . . . . . . . . 780.52-‐1 12. Alcohol-‐Dependent Sleep Disorder . . . . . . . . . . . . . . . . . 780.52-‐3 13. Toxin-‐Induced Sleep Disorder. . . . . . . . . . . . . . . . . . . . . . 780.54-‐6 14. Extrinsic Sleep Disorder NOS. . . . . . . . . . . . . . . . . . . . . . 780.52-‐9
ICSD-‐2
• C. Circadian-‐Rhythm Sleep Disorders • 1. Time Zone Change (Jet Lag) Syndrome. . . . . . . . . . . . . . . 307.45-‐0 • 2. Shij Work Sleep Disorder. . . . . . . . . . . . . . . . . . . . . . . . . 307.45-‐1 • 3. Irregular Sleep-‐Wake Pa7ern. . . . . . . . . . . . . . . . . . . . . . . 307.45-‐3 • 4. Delayed Sleep-‐Phase Syndrome. . . . . . . . . . . . . . . . . . . . . 780.55-‐0 • 5. Advanced Sleep-‐phase Syndrome . . . . . . . . . . . . . . . . . . . 780.55-‐1 • 6. Non-‐24-‐Hour Sleep-‐Wake Disorder. . . . . . . . . . . . . . . . . . 780.55-‐2
7. Circadian Rhythm Sleep Disorder NOS. . . . . . . . . . . . . . . 780.55-‐9
ICSD-‐2
• PARASOMNIAS • A. Arousal Disorders • 1. Confusional Arousals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐2 • 2. Sleepwalking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐0 • 3. Sleep Terrors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐1
• B. Sleep-‐Wake TransiCon Disorders • 1. Rhythmic movement Disorder . . . . . . . . . . . . . . . . . . . . . . . 307.3
2. Sleep Starts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐2 • 3. Sleep Talking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐3 • 4. Nocturnal Leg Cramps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729.82
ICSD-‐2 • C. Parasomnias Usually Associated with REM Sleep • 1. Nightmares . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐0 • 2. Sleep Paralysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780.56-‐2 • 3. Impaired Sleep-‐Related Penile ErecLons. . . . . . . . . . . . . . 780.56-‐3 • 4. Sleep-‐Related Painful ErecLons. . . . . . . . . . . . . . . . . . . . . 780.56-‐4 • 5. REM Sleep-‐Related Sinus Arrest. . . . . . . . . . . . . . . . . . . . 780.56-‐8 • 6. REM Sleep Behavior Disorder. . . . . . . . . . . . . . . . . . . . . . 780.59-‐0
• D. Other Parasomnias • 1. Sleep Bruxism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.8 • 2. Sleep Enuresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788.36-‐0
OUTLINE • 1. Normal Sleep • 2. ClassificaLon of Sleep Disorders • 3. NeurocogniLve Effects of Sleep DisrupLon • 4. Insomnias • 5. Hypersomnias • 6. Parasomnias • 7. Sleep Disturbances in Childhood-‐Onset Psychiatric Disorders
• 8. The Management of Sleep Disorders
NEUROCOGNITIVE EFFECTS of SLEEP DISRUPTION
NEUROCOGNITIVE EFFECTS of SLEEP DISRUPTION
• Many children don’t get enough sleep – Family schedules – ChaoLc living arrangements – TV/computer/cell phone usage in the bedroom – Ajerschool acLviLes – ……….
NEUROCOGNITIVE EFFECTS of SLEEP DISRUPTION
H/acCvity Impulsivity
AWenCon problems
ADHD symptoms
Aggression Poor School Fn
Depression Anxiety
Sleep Hygiene
✔ ✔ ✔ ✔ ✔ ✔
Sleep RestricCon
✔ ✔ ✔ ✔ ✔ ✔
Circadian Rhythm
✔ ✔ ✔ ✗ ✔ ✔
SDB ✔ ✔ ✔ ✔ ✔ ✔
RLS/PLMD ✔ ✔ ✔ ✔ ✗ ✔
Narcolepsy ✗ ✔ ✔ ✗ ✔ ✔
Insomnia ✗ ✔ ✔ ✔ ✔ ✔
(O’Brein, Child Adol Psych Clin N Am, 2009)
ICSD-‐2 • DYSSOMNIAS • A. Intrinsic Sleep Disorders
– 1. Psychophysiologic Insomnia. . . . . . . . . . . . . . . . . . . . . . . 307.42-‐0 – 2. Sleep State MispercepCon. . . . . . . . . . . . . . . . . . . . . . . . . 307.49-‐1 – 3. Idiopathic Insomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780.52-‐7 – 4. Narcolepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 – 5. Recurrent Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . 780.54-‐2 – 6. Idiopathic Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . . . . . 780.54-‐7 – 7. Post-‐traumaCc Hypersomnia. . . . . . . . . . . . . . . . . . . . . . . 780.54-‐8 – 8. ObstrucCve Sleep Apnea Syndrome. . . . . . . . . . . . . . . . . . 780.53-‐0 – 9. Central Sleep Apnea Syndrome. . . . . . . . . . . . . . . . . . . . . 780.51-‐0 – 10. Central Alveolar HypovenClaCon Syndrome. . . . . . . . . . . 780.51-‐1 – 11. Periodic Limb Movement Disorder . . . . . . . . . . . . . . . . . . 780.52-‐4 – 12. Restless Legs Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . 780.52-‐5 – 13. Intrinsic Sleep Disorder NOS. . . . . . . . . . . . . . . . . . . . . . . 780.52-‐9
INSOMNIA
• DEFINITION • “repeated difficulty with sleep iniLaLon, duraLon, consolidaLon, or quality that occurs despite age-‐appropriate Lme and opportunity for sleep and results in dayLme funcLonal impairment for the child and/or family.”
(Mindell et al, Pediatrics, 2006)
PSYCHOPHYSIOLOGIC INSOMNIA
• Prevalence 1-‐6% in general paediatric samples • CondiLoned sleep problems, associated with somaLsed tension or cogniLve arousal – Group 1 – lifelong difficulty iniLaLng and maintaining sleep (Idiopathic Insomnia)
– Group 2 – temperamental & self-‐regulatory problems. Assoc ψ disorders
– Group 3 – symptoms that onset with a senLnel event, have persisted ( Reid & Huntley, Child Adol Clin N Am, 2009)
TRANSACTIONAL WORLD CULTURE
Values Beliefs Media
FAMILY Marital Stress Siblings
INFANT Health status Temperament Development Allergies
CAREGIVER Physical Health Mental Health Childhood experiences ParenLng
SLEEP-‐WAKE CONSOLIDATION/PROBLEMS
DYAD InteracLon RegulaLon
ENVIRONMENT SES Employment Stress Daycare Social Support
Fig 5.9.3. Sleep Disorders, TF Anders, Lewis’s Child & Adol Psych)
BEHAVIOURAL INSOMNIA of CHILDHOOS
• 3 types • Sleep-‐onset AssociaLon Type (10-‐30%) • Limit-‐sepng Type • Combined • Poor parental limit sepng • Can’t fall asleep without certain ‘rituals’ • DifficulLes returning to sleep • Infants and Toddlers at risk
RISK FACTORS for INSOMNIA • Medical problems • PrecipitaLng events • A7achment*
– Disorganized – Maternal psychopathology, ambivalence – Modeling fear and frustraLon OR excess dependency
• Temperament and Personality • Child Psychopathology • Environmental and Circadian Factors • Other sleep disorders • Co-‐sleeping • Sleep schedules and RouLnes (*Anders et al, Psychiatry, 1994)
NEUROCOGNITIVE EFFECTS of SLEEP DISRUPTION
H/acCvity Impulsivity
AWenCon problems
ADHD symptoms
Aggression Poor School Fn
Depression Anxiety
Sleep Hygiene
✔ ✔ ✔ ✔ ✔ ✔
Sleep RestricCon
✔ ✔ ✔ ✔ ✔ ✔
Circadian Rhythm
✔ ✔ ✔ ✗ ✔ ✔
SDB ✔ ✔ ✔ ✔ ✔ ✔
RLS/PLMD ✔ ✔ ✔ ✔ ✗ ✔
Narcolepsy ✗ ✔ ✔ ✗ ✔ ✔
Insomnia ✗ ✔ ✔ ✔ ✔ ✔
(O’Brein, Child Adol Psych Clin N Am, 2009)
NARCOLEPSY • Life-‐long neurologic disorder of sleep-‐state dissociaJon, in
which segments of REM intrude into wakefulness. • IrresisLble dayLme sleepiness • Cataplexy i.e. episodes of muscle weakness in response to
emoLonal triggers such as laughter, fright, anger, or surprise
• Hypnagogic hallucinaLons • Sleep paralysis i.e. transient inability to move while drijing
off to sleep • Disrupted nocturnal sleep. (Kotagal, Child Adol Psych Clin N Am, 2009)
NARCOLEPSY • Prevalence: 0.02-‐0.05% • HistocompaLbility AnLgens DQB1 or DQA1 in almost 100% of sufferers
• These children take long naps and are not refreshed
• DayLme sleepiness – AutomaLc behaviour – Impaired memory and concentraLon – EmoLonal problems
• May have associated periodic limb movements
NARCOLEPSY
• Nocturnal polysomnography (PSG)
• MSLT which determines that REM latency is much shorter, <8 mins
• Treat with medicaLons that enhance alertness
• Lifelong treatment
OBSTRUCTIVE SLEEP APNOEA SYNDROME (OSAS)
• Occurs in ± 2% of children • Significant health problems, including growth retardaLon
• Associated with significant hypersomnia • Impact on cogniLon is age-‐dependent • Behavioural dysregulaLon is common – SDB is 5x more frequent in ADHD. If have ADHD more likely to have SDB
– Aggression
OBSTRUCTIVE SLEEP APNOEA SYNDROME (OSAS)
RESTLESS LEG SYNDROME • Characterized by disagreeable leg sensaJons that usually occur prior to sleep onset and that cause an almost irresisJble urge to move the legs
• Increasing recogniLon of RLS in children; occurs at rates of ±2%
• Primary • Secondary – Iron deficiency – Peripheral Neuropathy – MedicaLons
• Strong associaLon with hyperacLvity • Higher rates depression and anxiety • Responds to Dopaminergic therapy
PERIODIC LIMB MOVEMENT DISORDER
• Episodic limb movements during sleep, generally involving movement of the leg along with the extension of the ankle and toe
• Movements are ojen associated with a parLal arousal or awakening
• Usually unaware of the limb movements or the frequent sleep disrupLon
• Associated with anxiety and depression
ICSD-‐2
• C. Circadian-‐Rhythm Sleep Disorders • 1. Time Zone Change (Jet Lag) Syndrome. . . . . . . . . . . . . . . 307.45-‐0 • 2. Shij Work Sleep Disorder. . . . . . . . . . . . . . . . . . . . . . . . . 307.45-‐1 • 3. Irregular Sleep-‐Wake Pa7ern. . . . . . . . . . . . . . . . . . . . . . . 307.45-‐3 • 4. Delayed Sleep-‐Phase Syndrome. . . . . . . . . . . . . . . . . . . . . 780.55-‐0 • 5. Advanced Sleep-‐phase Syndrome . . . . . . . . . . . . . . . . . . . 780.55-‐1 • 6. Non-‐24-‐Hour Sleep-‐Wake Disorder. . . . . . . . . . . . . . . . . . 780.55-‐2
7. Circadian Rhythm Sleep Disorder NOS. . . . . . . . . . . . . . . 780.55-‐9
DELAYED SLEEP PHASE SYNDROME
• DSPS occurs when sleep period is delayed in relaLon to required or desired sleep-‐wake Lmes
• Common in adolescence; 0.13-‐3% • Circadian cycle changes during adolescence, phase preference for eveningness (owl), as opposed to morningness (lark)
• Associated with pubertal development
DELAYED SLEEP PHASE SYNDROME
DELAYED SLEEP PHASE SYNDROME
• ComorbidiLes – a7enLon-‐deficit hyperacLvity disorder (ADHD)-‐like behaviors
– depressive symptoms – dayLme sleepiness, – a7enLon, – emoLonal outbursts, and – poor school achievement – increased frequency of physical injuries
• REVISION of SCHOOL STARTING TIMES* (*Wahlstrom et al, NASSP BulleLn, 2002)
ICSD-‐2
• PARASOMNIAS • A. Arousal Disorders • 1. Confusional Arousals. . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐2 • 2. Sleepwalking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐0 • 3. Sleep Terrors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.46-‐1
• B. Sleep-‐Wake TransiCon Disorders • 1. Rhythmic movement Disorder . . . . . . . . . . . . . . . . . . . . . . . 307.3
2. Sleep Starts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐2 • 3. Sleep Talking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐3 • 4. Nocturnal Leg Cramps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729.82
PARASOMNIAS
• DSM-‐IV-‐TR – “disorders characterized by abnormal behavioral or physiological events occurring in associaLon with sleep, specific sleep stages, or sleep-‐wake transiLon’’
• ICSD-‐2 – “clinical disorders that are not abnormaliLes of the processes responsible for sleep and awake states per se, but rather are undesirable physical phenomena that occur predominantly during sleep. The parasomnias are disorders of arousal, parLal arousal, and sleep-‐stage transiLon”
PARASOMNIAS
• Most DO NOT develop psychiatric disorders • Time-‐limited, developmental experience • Arise during transiLons between various brain states
• Many during stages 3 and 4 of NREM sleep
PARASOMNIAS • RECOGNIZED ‘TRIGGERS’: • Anything that increases deep sleep:
– fevers – sleep deprivaLon – drugs and alcohol – sedaLves, hypnoLcs, anLhistamines, and sLmulants, and other
medicaLons • Psychologic disorders and traumaLc experiences • SeparaLon anxiety, stress, and trauma • Childhood psychiatric disorders, parLcularly
– ADHD – Anxiety
• Physiological issues • Developmental in nature e.g. enuresis
(Bloomfield & Shatkin, Child Adol Clin N Am, 2009)
PARASOMNIAS • DISORDERS OF AROUSAL – Sleepwalking ‘Somnambulism’ – Sleep Terrors – Confusional Arousals
• Typically occur during the transiLons between the deep, slow wave sleep of NREM (stages 3 and 4) and lighter REM sleep
• Strong geneLc element • CorrelaLons anxiety disorders • May co-‐occur
SLEEP TERRORS • Easily confused with nightmares. • Sits up in bed with glazed eyes and screams inconsolably. • A7empts to comfort or awaken ojen only exacerbate their
distress • Flushed face, tachycardia, and diaphoresis • Occur during the first third of the night, last 30 seconds and 3
minutes • Lies back down and fall asleep with • Li7le/ no recollecLon of the episode on waking in the
morning. • Approximately 6%
SLEEP TERRORS
• MANAGEMENT • Reassurance • Don’t awaken • Safety measures • Good sleep hygiene • Scheduled awakenings • Treat other 1° condiLons • Rx -‐ clonazepam
ICSD-‐2 • C. Parasomnias Usually Associated with REM Sleep • 1. Nightmares . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307.47-‐0 • 2. Sleep Paralysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 780.56-‐2 • 3. Impaired Sleep-‐Related Penile ErecLons. . . . . . . . . . . . . . 780.56-‐3 • 4. Sleep-‐Related Painful ErecLons. . . . . . . . . . . . . . . . . . . . . 780.56-‐4 • 5. REM Sleep-‐Related Sinus Arrest. . . . . . . . . . . . . . . . . . . . 780.56-‐8 • 6. REM Sleep Behavior Disorder. . . . . . . . . . . . . . . . . . . . . . 780.59-‐0
• D. Other Parasomnias • 1. Sleep Bruxism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306.8 • 2. Sleep Enuresis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788.36-‐0
NIGHTMARES • Disturbing, frightening, or unse7ling dreams that cause a person to awaken from sleep.
• Content varies with age • Occur in later part of the night during REM sleep • Exclude other sleep disorders • Associated with: – TraumaLc experiences – MedicaLon withdrawal – Psychiatric antecedents – NB anxiety disorders and PTSD – Early behavioural disturbances – Media exposure
SLEEP BRUXISM
• involuntary, nonfuncLonal movement of the masLcatory system
• reported in 7% to 15.1% of children
• associated with nighpme arousals
• DayLme cogniLve and behavioural problems
• Ψ problems 3-‐4x more likely to brux
SLEEP ENURESIS
• Unconsciously wets the bed at night while asleep
• Not specific to one type of sleep • Prevalence: 15-‐25% • Primary vs Secondary • AssociaLons with ψ disorders • Persistence is risk for development of emoLonal problems
SLEEP DISTURBANCES in CHILDHOOD ONSET PSYCHIATRIC DISORDERS
• 1. ADHD • 2. Mood Disorders • 3. Anxiety Disorders • 4. AuLsLc Spectrum Disorders • 5. Trauma • 6. Substance Use Disorders
SLEEP PATTERNS IN ASD
• Highly prevalent; 40-‐80%
• High rates of Circadian Rhythm Disorders (30%) esp DSPS
• Biologically determined substrate – influences developmental trajectory
• Independent risk factor for sleep problems
NEUROBIOLOGY of ASD and SLEEP
• Key neurotransmi7er systems • Interneurons using GABA are disrupted • GeneLc suscepLbility on chromosome 15q • Abnormal melatonin regulaLon • Disturbed serotonin producLon
(Johnson, Child Adol Psych Clin N Am, 2009)
SLEEP PATTERNS IN ASD
• INSOMNIA • Environmental & Behavioural factors • Non-‐behavioural insomnia – GastrointesLnal problems esp reflux – Epilepsy
• DifficulLes regulaLng emoLons • MedicaLons – MPH, SSRIs, asthma Rx
• Circadian Rhythm DysfuncLon
SLEEP PATTERNS IN ASD • OTHER SLEEP DISORDERS • Non-‐rapid eye movement (NREM) arousal disorders – confusional arousals – sleepwalking – sleep terrors.
• Precipitants include sleep deprivaLon, medical illness, emoLonal stress, sleep apnea, and other condiLons that disrupt normal sleep.
• Rapid eye movement (REM) sleep behavior disorder – RBD – reported in a case series – Increased phasic-‐muscle acLvity in REM sleep.
• Rhythmic movement disorder (RMD) • PLMD
SCREENING FOR SLEEP DISORDERS
• BEARS* – BedLme problems – Excessive dayLme sleepiness – Awakenings at night – Regularity of evening sleep Lme and morning awakenings
– Sleep-‐related breathing problems • Screening quesLonnaires • OTC treatments • Substances in Adolescent (*Owens & Dalzell, Sleep Med, 2005)
MANAGEMENT of SLEEP DISORDERS
• A symptom and not a diagnosis • Diagnosis of underlying issues, concurrent medical and neuropsychiatric issues NB
• Comprehensive sleep history assessing – sleep habits – sleep hygiene – bedLme rouLne and sleep schedules – sleeping environment – severity, frequency, and duraLon presenLng complaints – previous a7empts at treatment (Owens & Moyuri, Child Adol Clin N Am, 2009)
BEHAVIORAL MANAGEMENT
• Graduated exLncLon – Ignoring inappropriate behaviour – ToleraLng crying
• Parental educaLon • Healthy, consistent bedLme rouLnes
(Mindell et al, Pediatrics, 2006)
PHARMACOLOGICAL MANAGEMENT
• Alpha Agonists • Melatonin • AnLhistamines • Benzodiazepines • AnLdepressants • AnLpsychoLcs • Herbal remedies (Owens & Moturi, Child Adol Psych Clin N Am, 2009)
ALPHA AGONISTS
• Clonidine and Guanfacine -‐ noradrenergic alpha-‐2 agonists (2nd most common)
• Target sleep onset delay in children with ADHD
• No RCTs. Clonidine studied in relaLon to ADHD
• IniLated as a bedLme dose of 0.05 mg and gradually Ltrated by 0.05 mg every 3 to 5 days based on tolerability and efficacy
MELATONIN • Significant circadian phase-‐shijing (chronobioLc) and sleep-‐promoLng (hypnoLc) properLes
• Treatment of circadian rhythm disorders • BUT poor bioavailabilty and rapid first-‐pass metabolism
• Studied in broad range of neuropsychiatric disorders
• Well tolerated BUT ? Impact on hypothalamic-‐gonadal axis
• What about agomelaLne?
ANTIHISTAMINES
• The most commonly used in paediatric pracLce • Diphenhydramine • Minimal effects on sleep architecture • No more effecLve than placebo ? • DPH -‐ 0.5 mg/kg to maximum dose 25 mg/d • Hydroxyzine – 0.5mg/kg • Fair number of side effects • NB Adolescents
BENZODIAZEPINES and BZP RECEPTOR AGONISTS
• reduces sleep onset latency; improves iniLaLon and maintenance of non-‐REM sleep; most suppress slow-‐wave sleep
• Limited uLlity in childhood • PLMD • Avoid in OSAS • BZRAs associated with various parasomnias in childhood and adolescents
ANTIDEPRESSANTS • Lack of evidence, but commonly used • TCAs -‐ potent REM suppressants; tend to suppress slow-‐ wave sleep
• Trazadone -‐ inhibits uptake of serotonin and blocks histamine receptors. Cause REM suppression and increases in slow-‐wave sleep
• SSRIs -‐ – suppress REM sleep – prolong REM onset – increase the number of rapid eye movements (REM density) polysomnographic finding i.e.‘‘prozac eyes’’
– exacerbate symptoms of restless legs syndrome and periodic limb movements
ANTIPSYCHOTICS
• Limited data – Use with cauLon • May exacerbate SDB • When disconLnued cause REM rebound
HERBAL REMEDIES
• Untested on paediatric populaLons • Some efficacy and safety for valerian root* • Significant safety concerns – Kava kava è necroLzing hepaLLs – Tryptophan è eosinophilic myalgia syndrome
• No efficacy – Lemon balm – Camomile – Passion flower
• Lavender aroma therapy (Zigler et al, Eur J Med Res, 2002)
“Soon will I rest, yes, forever sleep. Earned it I have. Twilight is upon me, soon night must fall.”
Yoda
THANK YOU