Get Some Sleep!

Any time I think about how to get any of my children to go to sleep, visions of the 1980’s movie Three Men and a Baby pop in my head. The thought of the dads all standing around the crib and singing “Good Night Sweetheart” brings a smile to my face. Sadly, this is not the reality for parents dealing with children on the spectrum.  ASD children have more trouble with sleep compared to their neurotypical peers.¹ Abnormal sleep affects up to 89% of these chronically ill children.^2-3 REM sleep, important for restful sleep and healing, is the most affected phase of sleep in children with autism.⁴ Parents of children on the spectrum with sleep issues amazingly have sleep issues as well!⁵ Dyssomnia, trouble falling asleep and/or staying asleep, is among the most commonly reported issues.⁶ It creates added stress during possibly the most difficult time of the day, bedtime.  Parents and children alike are low on energy and patience at this time.  If sleep is further disrupted, a vicious cycle of dyssomnia, daytime sleepiness and lack of energy ensues.  This stress carries over to the next day in that everyone is sleep deprived, including the child that so desperately needs the sleep in order to heal.  As parents, however, it is important to keep in mind that your child is not a research statistic.  The reasons for his or her lack of sleep are multiple and tuning in to what may be going on inside may be the key to solving them.

Questioning the cause

The following questions can lead parents to the underlying causes for their child’s dyssomnia, which then can lead to focused strategies to improve both falling asleep and staying asleep.  In addition to the symptoms that may manifest during the day, symptoms that may show during the night are also listed.  These symptoms may be the same or different depending on how it manifests. This is a sample list of common symptoms and each child’s symptoms are as individualized as they are.

• Does he have a headache?
  • Many children on the spectrum suffer from chronic headaches that manifest in behaviors such as hyperactivity, head banging, hitting, biting, and/or inattention.
    • Sleep time symptoms:  trouble falling asleep, multiple waking episodes, eye squinting, head squeezing, constant head movement

• Are seizures keeping him awake or waking him up?
  • Seizures are present in as many as 25-35% of children with ASD.⁶They are not always the tonic/clonic, or grand mal seizures most commonly associated with epilepsy.  These are characterized more commonly as absence or subclinical.
    • Absence seizures are characterized by a sudden onset impairment of consciousness, interruption of ongoing activities, a blank stare, or possibly a brief upward rotation of the eyes.  It may also interrupt normal sleep patterns in the brain, which may just disrupt brain activity enough to wake them from sleep.
    • Subclinical seizures may not have any specific symptoms other then the delays and behaviors commonly seen in ASD.^7,8 They may not be able to be diagnosed without an EEG interpreted by a neurologist trained to look for subclinical activity.  The interruptions in the brain can disrupt normal sleep patterns and cause dyssomnia.
    • Sleep time symptoms: trouble falling asleep, multiple waking episodes (some may wake with night terrors), abnormal deep breathing, stiffening of the limbs.  May also have sudden jerking movements or spasms.

• Is he sick?
  • When a child comes down with cold or flu-like symptoms, one of the first things affected is his sleep.  It is assumed that the child will have trouble going to sleep and may have multiple wakings through the night.  Children on the spectrum have abnormal responses to viruses and bacterial infections.  Some may have worsening behaviors due to the immune dysregulation that may cause abnormal cytokine activation in the brain.⁹ Others may not be able to mount a response at all due to immune deficiency.  Either way, if there is anyone else sick in the family or among close friends, sickness needs to be investigated.
  • If sickness is suspected, the child should be examined by a practitioner with knowledge of the immune dysregulation found in this population.  They will be able to take a detailed history and physical that may show signs and symptoms of overlooked infections. Testing may include looking for specific titers and inflammation that will pinpoint the source of the infection.
    • Sleep time symptoms: Congestion, runny nose, fever, drooling, foul breath, foul smell from nasal breathing, snoring, sleeping improved when more upright.

• Does he have allergies?
  • Environmental, medication or supplement, food?  These allergies may manifest differently than the classic skin hives, facial swelling, and trouble breathing.  Children with autism have been shown to have markedly dysregulated immune systems.¹⁰ The reactions to antigens may be hyperactive or deficient dependent on the dysregulation.  Sleep may be affected.  Look for any symptom changes that coincide with changes in the season or temperature, medication changes, and/or changes in diet, any of which may set off an allergic mediated reaction that manifests in a change in sleep patterns.
    • Sleep time symptoms: mouth breathing, nasal “whistle,” runny nose, facial scratching, excessive earwax, worsening symptoms of allergies when sleeping (mold, dust mites in bed)

• Is he breathing OK when he sleeps?
  • Sleep disordered breathing encompasses disorders related to airway obstruction and includes obstructive sleep apnea (OSA.)  Obstructive sleep apnea has become a growing problem in children with autism and more research is being done to identify the conditions that may be causing the sleep disturbances and targeting interventions that can improve sleep in this population.¹¹ Sleep disordered breathing can add to the vicious cycle of dyssomnia and daytime sleepiness.12
    • Sleep time symptoms:  abnormally deep breathing, periods of apnea (no breathing) that can last more than a few seconds and usually end with a gasp for air, frequent wakings, night terrors.

• Does he have a stomach ache?
  • Chronic inflammation in the bowel is more common in children with ASD than the general pediatric population.^13-14 Look for signs of hyperactivity/lethargy, food aversions/cravings and physical signs that can be clues to an underlying issue.^15-16
  • Physical signs include:
    • Posturing: walking on toes, leaning over chairs, armrests, tables
    • Nausea/refusal to eat: feeling nauseated from maldigestion, allergies, or inflammation can cause food aversions and/or refusal to eat entirely
    • Reflux will cause painful heartburn that worsens when lying down
    • Bloated belly from slow motility through the intestines and trapped gas
    • Constipation- less then one BM a day consistently.  Hard, pebble shaped stool with a great deal of straining.  Long strands of stool that come after days with no BMs
    • Diarrhea
    • Sleep time symptoms:  burping, refusal to lay down due to burning with reflux, night diarrhea (sometimes massive), bloated belly, refusal of any food close to bedtime.

• Is he anemic?
  • There is an increased incidence of low ferritin associated sleep disturbances in children diagnosed with autism vs. neurotypical peers.¹⁷ The low ferritin is associated most commonly with lack of adequate intake of iron.
  • Supplementing with iron greatly improved the sleep of those whose ferritin was low, therefore demonstrating a correlation between the two in children with autism.

Strategies for a “Good” night

Identifying the underlying causes of sleep disruptions can alleviate the majority of sleep issues by understanding and treating the cause itself.  For many, however, the issues may be too many at once or too subtle to identify.  For all families dealing with sleep problems, some changes can make a significant improvement in sleep and may solve the problem all together. Improving your sleep routine, sleep environment, and choosing the right foods for sleep will put you and your child on the right path to improved sleep and wellness.

• Sleep routine: refers to the variety of different practices to have normal, quality nighttime sleep and full daytime alertness.  By improving the sleep routine, children’s brains will start winding down naturally as time comes for their bedtime.
  • Avoid napping during the day (if possible)
  • Dedicate time every day for exercise
  • Ensure adequate exposure to natural light
    • New research is being done looking into sleep routine and waking rhythms utilizing light therapy to wake up at a consistent time refreshed
  • Establish a bedtime routine
    • Create a consistent bedtime and wake-up time
    • Starting 45 min. to 1 hour prior to bedtime:
      • Give last small snack (if haven’t already done)
      • Change into pajamas
      • Go to the bathroom
      • Wash hands
      • Brush teeth
      • Quiet activity/reading a book out loud prior to bed
  • Try to avoid emotionally upsetting conversations or activities before bedtime.

• Sleep environment: When setting up the area where sleep is to occur, there are factors to consider.  By keeping these in mind, creating a sleep haven will allow the best scenario for the child to both fall asleep and stay asleep.
  • Noise
    • Keep outside noise to a minimum.
    • Consider a sound machine/fan running to decrease outside noise.
      • There is some controversy on sound machines as they may cause dependency on some sort of noise to fall asleep.  In instances of very light sleepers or easily distracted children, a noise machine or other white noise may be beneficial to eliminate the constant distractions of noise outside the sleep environment.
  • Light
    • Dark is best!
    • Use room darkening shades
    • Keep door closed (if possible)
    • No night light (if possible)
      • Melatonin (sleep hormone) is activated by darkness.  More light in the room will lessen its effects.
  • Essential Oils
    • Lavender, Geranium, and Roman Camomile are great for calming prior to sleep.  They can be put into a diffuser in the bedroom or diluted and rubbed on the feet prior to bedtime.
  • Distractions
    • Keep alarm clock out of sightline
    • No TV’s, video games, radios, computer, phones, etc. in bedroom
  • Temperature
    • Keep the room at a comfortable, cool temperature as the body reaches its lowest temperature at night and a cooler ambient temperature will be more conducive to restful sleep.  Keeping the thermostat at or below 70^◦ may help, but warmer pajamas or an extra blanket may be necessary.
    • Hold off on the larger, heavier blankets if they get too warm or cause your child to sweat profusely at night.  Better to layer and then take off one by one if your child becomes too warm.  Wash sheets (in unscented detergent) frequently as they may become soiled and uncomfortable quickly.
      • On the other hand, if the child is comforted by the weight of a heavy quilt due to sensory issues, a weighted blanket may be just the thing for sleep.
  • Bed
    • Be sure to have a bed that is comfortable, but firm and large enough to allow a good night’s sleep.

• Sleep time Foods: What you eat and when you eat it can play a role in worsening or improving dyssomnia.  A nighttime “treat” can turn into a sleep disaster.  Whereas, the right healthy snack given 1-2 hours prior to going to bed will actually help induce sleepiness and maintain sleep throughout the night.

• • FOODS TO AVOID: Simple carbohydrate snacks, especially those high in junk sugars, are less likely to help you sleep. You’ll miss out on the sleep-inducing effects of tryptophan, and you may set off the roller-coaster effect of plummeting blood sugar followed by the release of stress hormones that will keep you awake.
    • Food/beverages to avoid prior to going to bed:
      • Caffeine
      • Food dyes/preservatives
      • Heavy protein snacks
      • Heavy sugary snacks
      • Highly refined carbohydrates
      • Fried foods
      • Large amounts of fluids

• • FOODS TO CHOOSE: The best bedtime snacks are ones that have tryptophan, complex carbohydrates, protein, and some calcium. Here are some healthy alternatives that can assist in having a good night’s sleep.
    • Oatmeal: Oats are a rich source of sleep-inviting melatonin, and a small bowl of warm cereal with a splash of maple syrup or agave nectar is cozy and filling, which should help your child sleep better.  Gluten-free alternatives are available as well.
    • Bananas: well-known for being rich in potassium, they are also a good source of Vitamin B6 and magnesium.
    • Chamomile tea: Chamomile is such a staple of bedtime tea- it’s the perfect natural antidote for restless minds/bodies to induce better sleep.
    • Passion flower tea: Passion flower is also a great calming herb that can be used with or in rotation with Chamomile.
    • Almonds: Great alternative to a warm glass of milk.  Almond milk can be snooze-inducing, as it contains both tryptophan and a nice dose of muscle-relaxing magnesium to help you sleep better.
    • Poultry: Most people associate turkey with sleep producing tryptophan during their Thanksgiving feast.  In reality, turkey has no more tryptophan then most other commonly consumed poultry like chicken.  It is the combination of the carbohydrates and the tryptophan in the turkey as well as the amount that brings on the sleepiness after a large Thanksgiving feast.
    • Fish: Especially salmon, halibut and tuna boast vitamin B6, which is needed to make melatonin.  Not on the top of most children’s snack list, but can hopefully be incorporated.

• Sleep Supplements
  • Although food-based nutrition is always advocated, the chronic inflammation and allergies that so many ASD children suffer from may necessitate supplementation. All of the nutrients from the foods above come in a supplement form and can be taken in a combination sleep formula, or individualized according to specific deficiencies.
    • Magnesium/Calcium,
    • B vitamins
    • L-Tryptophan,
    • 5-HTP
    • Melatonin- The most common and most supported supplement for sleep is melatonin.  Melatonin has been used for many years to help induce sleep for occasional insomnia.  In 2009, the Autism Research Institute conducted a survey of over 27,000 parents of children with autism on the effectiveness of biomedical treatments.  Of all of the treatments that were specific to sleep, melatonin was rated the highest for beneficial effects.¹⁸ Recent literature also supports its safety and efficacy to improve sleep latency (inability to fall asleep), specifically in children with autism.^19-20 It has been used safely for many years, but should be ordered and followed by a practitioner familiar with the metabolic dysfunction associated with ASD and appropriate dosing.

• Homeopathy
  • Homeopathic remedies are a great option for any child, but especially for those who are very sensitive to supplements or changes in nutrition.21
    • Homeopathic Carbo Vegetabilis is for the child who awakens in the middle of the night with a stomachache.
    • Passiflora and Chamomilla are homeopathic versions of the herbs Passion Fower and Chamomile that promote calming.
    • Argentum Nitricum is a homeopathic remedy made from silver nitrate. Children who need this remedy usually cannot sleep if a room is too warm. They are restless before bedtime and have difficulty falling asleep.

Sleep disorders in autism are common and simple to diagnose on the surface, just ask any parent.  The difficulty lies in the underlying cause.  As described above, it is rarely just a bad habit to break and requires a deeper understanding of the medical conditions associated to narrow it down.  Even though it can be difficult to identify the exact cause, there are strategies that will benefit anyone having difficulties with sleep.  With the combination of identification and strategic planning for bedtime, significant improvements can be made-and parents may also get some sleep as well.

References

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2. Richdale, A.L.  Sleep problems in autism: Prevalence, cause, and intervention.  Developmental Medicine and Child Neruology 1999; 41, 60-66
3. Couturier, J.L., Speechley, K.N., Steele, M., Norman, R., Stringer, B., & Nicolson, R. Parental perception of sleep problems in children of normal intelligence with pervasive developmental disorder: Prevalence, severity, and pattern. Journal of the American Academy of Child and Psychiatry 2005; 44, 815-822
4. Thirumalai S. Shubin R., Robinson R., “Rapid Eye Movement Sleep Behavior Disorder in Children with Autism,” J Child Nerology 2002; 17: 173-178
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17. 18. Parental Ratings of Behavioral Effects of Biomedical Interventions ARI Publ. 34/March2009
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