• Educating about sleep is the first step. This includes creating predictable routines, minimizing screen time and other basics of sleep hygiene.   SmartCare Current Topics in Autism lecture has useful information  for families.  https://www.youtube.com/watch?v=tUjYD7oci-8
• Prior to initiating treatment, clinicians should assess for co-morbidities and iatrogenic causes of sleep disturbance, including medications. (Buckley et al., 2020)
• Behavioral interventions are first line. No one approach fits all children, but there are many options to consider.
  • Adjust sleep setting (dark, non-stimulating, no electronics).
  • Promote self-soothing skills.
  • Avoid naps four hours prior to sleep.
  • Consider “bedtime fading” – parents delay bedtime by 30 minutes, then move bedtime earlier and earlier over several days.
  • Increase daytime light exposure in the morning.
  • Use graduated extinction of disruptive nighttime behaviors – parents allow incrementally more time before comforting, with incrementally shorter periods of comfort. Or alternatively, parent stays in the room but provides little interaction.
  • Referral to therapist who can provide cognitive behavioral therapy (CBT) for sleep.

• For children who continue to have difficulty despite parent education and behavioral interventions, Melatonin is the first line pharmacologic treatment
  • Melatonin has the most robust evidence for children with ASD, is safe and effective, and prolonged release may be the most effective formulation.
  • Side effects are minimal, though there is ongoing research about the impact of altered endocrine physiology associated with long-term use in animal models.

• In general, some children taking medications for sleep may have worse daytime behavior than children not taking sleep medications, while for others poor sleep can lead to more challenges in functioning (Malow et al., 2016).

• Second-line medications with some evidence in the literature include alpha agonists, such as clonidine and anti-histamines, such as diphenhydramine or hydroxyzine. There are fewer studies supporting these, and they are associated with more sedation.

Bruni, O., Angriman, M., Calisti, F., Comandini, A., Esposito, G., Cortese, S., & Ferri, R. (2018). Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities. In Journal of Child Psychology and Psychiatry and Allied Disciplines (Vol. 59, Issue 5, pp. 489–508). Blackwell Publishing Ltd. https://doi.org/10.1111/jcpp.12812

Gringras, P., Nir, T., Breddy, J., Frydman-Marom, A., & Findling, R. L. (2017). NEW RESEARCH Efficacy and Safety of Pediatric Prolonged-Release Melatonin for Insomnia in Children with Autism Spectrum Disorder (Vol. 56). www.jaacap.org

Lalanne, S., Fougerou-Leurent, C., Anderson, G. M., Schroder, C. M., Nir, T., Chokron, S., Delorme, R., Claustrat, B., Bellissant, E., Kermarrec, S., Franco, P., Denis, L., & Tordjman, S. (2021). Molecular Sciences Melatonin: From Pharmacokinetics to Clinical Use in Autism Spectrum Disorder Melatonin: From Pharmacokinetics to Clinical Use in Autism Spectrum. Disorder. Int. J. Mol. Sci, 22, 1490. https://doi.org/10.3390/ijms

Malow, B. A., Katz, T., Reynolds, A. M., Shui, A., Carno, M., Connolly, H. v., Coury, D., & Bennett, A. E. (2016). Sleep difficulties and medications in children with Autism spectrum disorders: A registry study. Pediatrics, 137, S98–S104. https://doi.org/10.1542/peds.2015-2851H

McDonagh, M. S., Holmes, R., & Hsu, F. (2019). Pharmacologic Treatments for Sleep Disorders in Children: A Systematic Review. Journal of Child Neurology, 34(5), 237–247. https://doi.org/10.1177/0883073818821030

Ming, X., Gordon, E., Kang, N., & Wagner, G. C. (2008). Use of clonidine in children with autism spectrum disorders. Brain and Development, 30(7), 454–460. https://doi.org/10.1016/j.braindev.2007.12.007

Williams Buckley, A., Hirtz, D., Oskoui, M., Armstrong, M. J., Batra, A., Bridgemohan, C., Coury, D., Dawson, G., Donley, D., Findling, R. L., Gaughan, T., Gloss, D., Gronseth, G., Kessler, R., Merillat, S., Michelson, D., Owens, J., Pringsheim, T., Sikich, L., … Ashwal, S. (2020). Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 94(9), 392–404. https://doi.org/10.1212/WNL.0000000000009033

A good assessment of onset, extent, duration, onset, severity, triggers of the sleep problem, in conjunction with the standard review of systems, is the first step.  Once done, treatment options can be considered.

Cognitive Behavioral Therapy (CBT) interventions have a high rate of long-term efficacy, and CBT should be employed with all patients, even those with health care issues and medication needs.   When using CBT, the complications and risks associated with sleep aid medications can be avoided or minimized and for intractable cases, doses may be able to be contained.

CBT has been shown to be helpful as an adjunctive treatment for insomnia in depression when used with antidepressant medication. It has also been helpful with other co-morbid concerns, like chronic pain, fibromyalgia, substance abuse, and anxiety disorders. Some patients may be able to taper off of sleep medications after participating in CBT treatment for insomnia.   The central focus of CBT treatment is on improving the patient’s sleep hygiene.

Predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep difficulties. Some individuals may be particularly predisposed or vulnerable to sleep difficulties because of a dysfunctional biological sleep system. When such individuals are confronted with precipitating circumstances (for example: a stressful life event), they can develop an acute sleep disturbance. This sleep disturbance can be perpetuated if the patient develops poor sleep hygiene practices (for example: daytime napping, spending excessive time in bed, etc) to try to cope with the sleep difficulty.

Therefore, although predisposing and precipitating factors contribute to insomnia, poor sleep hygiene is seen as a critical sustaining element in the sleep disturbance. One key element of CBT for insomnia is to correct those sleep habits that ostensibly sustain or add to the patients’ sleep problems.

Modified CBT intervention can be provided in the primary care office, though referral to a formal program is appropriate for most as well.   CBT requires a discussion about the rationale for the treatment and some basic education about sleep norms, circadian rhythms, effects of aging, of medications and drugs and the effects of sleep deprivation.   Typical CBT techniques include sleep scheduling, stimulus control, relaxation, cognitive restructuring, sleep hygiene, and medication tapering techniques.   Typically the behavioral treatment uses stimulus control and sleep restriction strategies to normalize standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep profile and pattern. It is important to maintain and review sleep logs to help with troubleshooting problems that may occur along the way.

Here is a case example to illustrate the role that CBT for insomnia can play in the primary care setting:

35yo male with a history of Type I Diabetes well controlled on insulin and no previous psychiatric history who presents with longstanding (since high school) difficulty with initiating and maintaining sleep. Various medication trials (Benadryl, Ambien, Elavil, OTC agents) have worked for short periods of time but then cease to be helpful. He has been stable, denies other mood or anxiety symptoms and has been able to maintain working.   Education and guidance on sleep hygiene is helpful in some respects but medication requests recur.   A referral for a sleep study is made with normal findings and a recommendation for referral to a formal CBT sleep treatment group.

If you are interested in more information, here are some websites that might be useful:

http://www.med.unc.edu/neurology/sleepclin/jdedingrCBTManual.pdf

http://www.journalsleep.org/Articles/260209.pdf

https://adaa.org/sites/default/files/Runko_177.pdf

Mania and hypomania are mood states characterized by: elevated or irritable mood and a combination of symptoms such as increased energy, decreased need for sleep, irritability, feelings of inflated importance, excessive talkativeness (pressured speech), racing thoughts, exaggerated but poorly judged activities, and increased ‘pleasurable’ high risk behaviors. Mania or hypomania may also co-exist with depressive features in patients with bipolar profiles, so assessment may be challenging, but the presence of manic or hypomanic symptoms is a diagnostic key point. Input from relatives or others may be quite helpful in diagnostic assessment and treatment planning, as patients’ insight into their mood elevation may be impaired.

Levels of Care: When a patient presents with suspected manic or mixed affective symptoms, an early step in the process should include an evaluation as to the level of care needed. Assessment of the patient’s mood state, behavioral profile, and functionality are central to the triage and diagnostic process. Management options will range from acute referral for psychiatric care or prioritized referral for outpatient mental health care, but may also include primary care intervention to stabilize the patient’s symptoms while more intensive specialty care is being arranged. Medical evaluation of potential contributing factors will typically also be warranted as discussed further below.

Mania: In full blown manic states, patients typically present as pressured, intense and are often disorganized or showing restricted, hyper-focused interests. They often engage in harmful activities (e.g., reckless driving, substance use, sexual promiscuity) and may present with grandiose or even frankly delusional thinking, sometimes with psychotic symptoms such as hallucinations. Evaluation for both aggressive behaviors and suicidal tendencies needs to be undertaken and, most typically, referral for emergency psychiatric evaluation is warranted for stabilization and intensive treatment.

Hypomania: More subtle but still prominent changes in mood and behaviors are found in hypomanic states and deviations from a patient’s baseline personality is the central consideration to assess. Changes in sleep profile, an atypical sense of urgency about psychosocial issues, generalized psychological activation (rapid speech, internal thinking), and an altered level of judgment and insight about life activities are significant areas to note. A history of recurrent elevated mood episodes, not related to clear environmental stressors, may be diagnostically relevant.

Acute Stress Reactions: Differentiating manic symptoms from acute stress reactions to major life changes can be challenging as individuals’ responses to a variety of stressors (interpersonal problems, job crises, health problems, trauma exposure, etc.). Symptoms may include disruption in sleep, elevation of anxiety, and depressive mood and thought content. A central differentiating feature would be the absence of elevated mood and a coherence of the patient’s response to the stress.

Medical Concerns: Factors that may cause manic symptoms include medications such as antidepressants, which can trigger mania, as can stimulants and steroids (prescribed or used for body building). Recreational drug abuse or withdrawal may also trigger mania or mimic the symptoms, so obtaining a drug history and drug screen is recommended. Medical exam is important as manic symptoms may be mimicked in hyperthyroidism. A physical exam and a TSH level are indicated. Other medical differentials would include seizures or a stroke.

Primary Care Interventions: Recognition of the symptoms of mania and hypomania and review of the patient’s psychosocial functioning are first steps in PCP efforts. With a provisional diagnosis, medical evaluation and planning for appropriate referral are next steps.

When emergency referral is not needed, yet outpatient intervention is not readily available, efforts to manage disabling symptoms should be considered, typically focusing on sleep issues and psychomotor agitation. Typically, use of a sedating antipsychotic agent, such as quetiapine (Seroquel), or risperidone (Risperdal) in low to moderate dose range (Seroquel 50-100mg HS; Risperdal 1-2mg HS) could be considered as an initial intervention, with titration as indicated by patient response. Longer term treatments such as either lithium carbonate or an anticonvulsant mood stabilizer could also be considered as viable first line alternatives, but do require more lab monitoring (blood levels and LFTs with carbamazepine. Finally, short term use of a benzodiazepine might be considered for sleep and agitation.