Sleep disorders in autism and ADHD: psychological basis

1
Sleep disorders in autism and ADHD psychological
basis

• Luci Wiggs
• Oxford Brookes University
• Department of Psychology

2
Sleep disorders in autism

• Physiological sleep abnormalitieseg. REM sleep
  melatonin profile (Ornitz 1985 Nir et al 1995)
• Sleep disorders
• eg. REM sleep behaviour disorder (Thirumali et
  al 2002)
• sleep/wake cycle disorders (Inanuma 1984)
• Sleeplessness problems (see Richdale 2001
  Wiggs Stores 2004 Malow et al 2006)

3
Associations with childhood sleeplessness

• Challenging daytime behaviours in child
• Child/adult anxiety/depression
• Reduced attention and social skills
• Creativity and short term memory
• Maternal sleep disruption
• Maternal sleepiness
• Maternal lack of perceived control
• Maternal psychiatric disturbance
• Parental stress
• Child abuse
• (Wiggs Cipolla (in preparation) Gregory et
  al 2006 Wiggs Stores 1996 1998 1999 2001
  2004 Minde et al 1994 Quine 1992 Chavin and
  Tinson 1980)

4
Resolving child sleeplessness has benefits..

• for children
• ? security, happiness,
• ? behaviour problems
• for parents
• ? depression, stress
• ? belief in their parenting skills, coping
• for the family unit
• ? positive parent/child interactions
• Sanders, Bor Dadds (1984) Durand Mindell
  (1990) Quine 1992 Seymour et al (1993) Minde,
  Faucon Falkner (1994) Wiggs Stores (2001)

5
Sleeplessness in children with autism spectrum
disorders

• Sleeplessness rate about 66 (range 49-89)
• (Richdale 2001 Wiggs Stores 2004 Krakowiak
  et al 2008)
• Behavioural (82), circadian (18), anxiety
  (18), other (43)
• (Wiggs Stores 2004)
• Objective confirmation lacking/contradictory/confi
  rmatory
• (Hering et al 1999 Wiggs Stores 2004 Oyane
  Bjorvatn 2005 Malow et al 2006)

6
Sleep disorders in autism

• High rates in children intellectual
  disabilities
• (Patzold et al 1998 Krakowiak et al 2008)
• More prevalent in children with ASD than other
  disability groups (Wiggs and Stores 1996
  Krakowiak et al 2008)
• Younger age, hyper-sensitivity, epilepsy, ADHD,
  medication use and family history of sleep
  problems related to presence of sleep problems in
  children with autism (Liu et al 2006)
• Parents sleep compromised (Lopez-Wagner et al
  2008 Meltzer 2008)

7
Sleep disorders/disturbance in children with ADHD

• Restless legs syndrome (RLS)
• Periodic limb movement disorder (PLMD)
• Sleep disordered breathing (SDB)
• Behavioural sleep disorders

8
Sleep disturbance as a cause of ADHD symptoms?

• Sleep related breathing disorders (eg. OSA)
• (Crabtree et al 2003 Guilleminault et al 1981)
• Periodic limb movement disorder
• (Picchietti et al 1999 Chervin 2002 Golan et
  al 2004)
• ADHD symptoms reversed by treatment of sleep
  disorder
• (Konofal et al 2001 Hansen and Vandenberg 1997
  Dahl et al 1991 Guilleminault et al 1982)

9
Behavioural sleep disorders and ADHD

• Children with ADHD (without OSA) and their
  parents report more bedtime difficulties and
  nightwaking than controls (Owens et al
  2000Corkum et al 2001 Hvolby et al 2009)
• No significant difference between objective sleep
  of ADHD with sleeplessness and controls (see van
  der Heijden et al 2005 Owens 2005)
• Objective sleep of children with ADHD more
  disturbed/shorter than controls (Owens 2009)

10
Sleep and ADHD

• Frequent sleep problems in 89 ADHD group
• (n71 stimulant medication free)
• Symptoms of SDB n47
• Sleeplessness (behavioural) n28
• RLS n25
• Rhythmic movement disorder n16
• Sleeplessness (unspecified) n15
• Sleeplessness (anxiety) n11
• Delayed sleep phase syndrome n7
• Other (arousal disorders, nightmares etc) n 6
• No actigraphic differences between ADHD and
  controls
• ADHD subtypes no differences
• (Wiggs, Montgomery and Stores 2005)

11

Elements of sleep are learnt behaviours

• How we prepare for bed
• How we settle to sleep
• Where we settle to sleep
• What we do when we wake up

Sleep behaviours can be learned incorrectly or
not learned at all
12
Behavioural Insomnia of Childhood(International
Classification of Sleep Disorders 2005)

• Sleep onset association insomnia
• Falling asleep extended and requires special
  conditions
• Sleep onset associations are problematic/demanding
  
• Sleep delayed or disrupted without the conditions
• Limit setting insomnia
• Difficulty initiating or maintaining sleep
• Stalling or refusing to go to bed/refusal to
  return to bed following a nighttime waking
• Caregiver not setting sufficient/appropriate
  limits to establish appropriate sleep behaviour
  in the child
• Combined type

13
Psychological aspects of Behavioural insomnia

• Parents judgement
• Childs judgement
• Mismatch between parents/children
• Judgments informed by cultural, social and
  historical norms

14
Sleep and cognition

• 8-10 year olds (n123)
• Modified Pre-Sleep Arousal Scale (Nicassio 1985)
• Cognitive arousal and, less strongly, somatic
  arousal predicts sleep disturbance and insomnia
  symptoms (child self report and parental report)
• Gregory, Willis, Wiggs, Harvey and the STEPS
  team (2008). Pre-sleep arousal and sleep
  disturbances in children.
• Sleep, 31, 1745-1747.

15
Are family factors related to child sleeplessness?

• Association with psychopathology, family
  conflict, stress in mother and child
• (Gregory et al 2005 2006 Wiggs Stores 1996
  1998 1999 2001 2004 Ohida et al 2004 Liu et
  al 2000 Minde et al 1994 Quine 1992 Chavin and
  Tinson 1980)
• Mothers cognitions about infant sleep related to
  infant sleep patterns
• (Toselli et al 1995, Morrell 1999, Sadeh et al
  2007)

16
Conclusions

• Sleep disturbance in children with Autism and
  ADHD is a big clinical problem!
• Behavioural sleeplessness appears to feature
  prominently for children with Autism and ADHD
• Other psychological processes may also be
  relevant (eg. child and family cognitions)
• Holistic assessment of child and family required