Triple Board Associate Professor Department of Psychiatry Division of Child amp Adolescent Psychiatry Adjunct associate professor Departments of Pediatrics and Educational Psychology University of Utah ID: 779344
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Slide1
Why is sleep such a big deal?
Triple BoardAssociate Professor, Department of Psychiatry, Division of Child & Adolescent PsychiatryAdjunct associate professor, Departments of Pediatrics and Educational PsychologyUniversity of Utah
By
Deborah
bilder
,
m.D.
Slide2Disclosures
Consultant, Advisory Board and Steering Committee member for BioMarin PharmaceuticalsScientific and Clinical Advisors B
oard member for
Audentes
Therapeutics
Slide3Overview
What happens during sleep? Why does sleeplessness stress us out? Autism + Sleep disturbance = Agitation
Slide4What does a sleep-deprived child look like?
TiredIrritable Hyperactive Hungry
Slide5The physiology of Falling asleep
When the night falls, and the light dims, our circadian clock takes actionThe circadian clock signals the pineal gland produces and releases melatonin, and we fall asleep
Slide6X
Slide7Light
Major regulator of the circadian clockThe summer equinox is a bipolar stress test* Even if the rest of the room is dark, if you are looking at light, light is influencing your circadian rhythm “Blue light has a dark side”1
*the world according to me
1. https
://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side
Slide8Once asleep
Slide9Dornbush MP, Pruitt SK. Teaching the Tiger. Page 18
Slide10Cortisol and our stress response
Connected to emotional and physiologic regulators in our brain and throughout our body
Johnson
et al.
Pediatrics
2013; 131(2):319-327
Slide11Diurnal Cortisol curve
Slide12Cortisol curve during depression
Wong
et al.
PNAS
2000; 97(1): 325-330
Slide13Sleep dictates our stress response system
Cortisol release follows a daily rhythm that synchronizes with our sleep cycle
Slide14When you mess with one, you mess with both
Balbo et al
.
Int
J
Endocrinol
2010;
2010
:
759234
Sleep cycle and cortisol rhythm
Slide15Sleep cycle and cortisol rhythm
When both are already messed up, it is far easier to fix sleep than it is the cortisol rhythm That’s why: I always start with sleepI will not move beyond the topic of sleep until restorative sleep has been achieved
Slide16Oster
et al.
Endocr
Rev
2017; 38(1):3-45
Slide17Purpose of sleep
Restores our brain’s ability to thinkConsolidates memory Maintains mood stability and emotional regulationMaintains our cardiovascular system Influences our immune response
Slide18Autism and sleep
60% to 86% of children with ASD have insomnia Insomnia: delayed sleep onset, intermittent awakening, premature awakeningInsomnia in children with ASD significantly affects parent’s sleep and increase parental stress
Souders
MC
et al.
Curr
Psychiatry Rep
2017; 19:34
Slide19Causes of insomnia in asd
Behavioral insomniaSleep apnea, nocturnal seizures, restless leg syndrome, discomfort (reflux, constipation)Circadian rhythm gene variants Abnormal melatonin releaseArousal and sensory dysregulationPsychosocial stress
Souders
MC
et al.
Curr
Psychiatry Rep
2017; 19:34
Slide20Melatonin
Melatonin is made from serotonin The most consistent biomarker in autism is elevated serotonin – we don’t know whyMultiple (10+) treatment studies support the use of melatonin (3 to 5 mg) about 30 minutes before bedtime for insomnia in children with ASD
Gabriele S et al
Neuropsychopharmacology
2014 24(6),
919–929;
Souders
MC
et al.
Curr
Psychiatry Rep
2017; 19:34
Slide21Autism and cortisol rhythm: ASD vs.
Neurotypical With normal IQthe same awakening response and total amount of cortisol released throughout the dayFlattened daytime decline in cortisol with higher cortisol nadir in eveningElevated evening cortisol associated with daily stress and sensory sensitivitySubgroup (about 25
%) had a particularly flattened cortisol
rhythm
Greater within child variation of cortisol over days
With co-occurring ID:
Elevated cortisol through the day with flattened daytime and nighttime slopes
Relationship between cortisol levels and impairments in social interaction and language
Elevated cortisol response to stressor
Corbett BA et al. J Psychiatric
Neurosci
. 2008; 33(3),227-234; Corbett BA et al. Autism Res 2009; 2:32-39;
Tomarken
AJ et
al.
Psychoneuroendocrinology
2015
; 217-226; Corbett BA et al.
Psychoneuroendocrinology
2006; 31(1):59-68
Slide22Autism and stress response
Corbett BA et al. Psychoneuroendocrinology
2006; 31(1
):
59-68; Corbett
BA et al. J Psychiatric
Neurosci
. 2008; 33(3),227-234
;
Stressor was mock MRI scanner
When mean
IQ =
77 of ASD group, significantly increase cortisol response to stressor
However, when repeated in ASD group with normal IQ, no difference initial or subsequent stress responses between ASD and NT groups
ASD group with normal IQ showed significant within child variable in cortisol rhythm compared to NT group
Slide23Psychiatric
ComorbidityIn both children and adults:At least 70% have or have had at least one additional psychiatric diagnosis
Anxiety and ADHD are particularly prevalent
Also, Major
Depressive
Disorder, Bipolar Disorder, and Psychosis
> 1 is
common
Leyfer
OT et al.
J Autism Dev
Disord
2006;36:849-861
Buck TR, et al.
J Autism Dev
Disord
2014
Slide24Treatment Hierarchy
Sleep DisturbanceMania/BipolarDepression/AnxietyADHD
Slide25Correcting sleep disturbance
Autism Treatment Network’s Sleep Tool KitSleep hygiene: setting your child up for successComfortable bedroom (right temperature, quiet, and dark)All nighttime caregivers follow the same, set routine“Choose a Bedtime…and Keep It”
https://
www.autismspeaks.org/tool-kit/atnair-p-strategies-improve-sleep-children-autism
Slide26More on sleep hygiene
Exercise is good, but not before bedtimeAvoid caffeine (soda) after 12 PMComfortable bedroom (right temperature, quiet, and dark)Teach your child to fall asleep alone
https://
www.autismspeaks.org/tool-kit/atnair-p-strategies-improve-sleep-children-autism
Slide27Short of general anesthesia,
no medication will get your teenager to sleep if he/she has something better to do
Slide28Medication (+ Sleep hygiene)
Medication selection depends on what physiologic/psychiatric phenomenon is interfering with sleepMedication intervention may involve discontinuing rather than starting a medicationIf sleep disturbance is primary:melatonin (without other active ingredients)other medications: clonidine, trazodone, mirtazapine
Slide29Big Picture
Sleep and stress response are intrinsically linked Most pathologic emotional experiences are related to an abnormal stress responseFixing sleep disturbance is an ideal place to startGood sleep hygiene is the cornerstone of any effective sleep treatment plan
Melatonin (without any other active ingredients)
Slide30The clients and families we serve
acknowledgments