Comorbidity | Autism Expert Advices

People in the autism spectrum often have gastrointestinal problems, sensory disorders, and concerns. All of these can make it difficult for them to get the needed sleep. In addition, many children have poor sleep periods and other behaviors that make it difficult to fall asleep. This may include exposure to screens and electronic lights, as well as the lack of a soothing sleep. Although there are studies showing that sleep problems in autism are associated with comorbid disorders, psychoactive drugs such as psychostimulant used, age, IQ, and severity of autism, there are conflicting data. If was found that there is no relationship between age, gender, race, IQ, neuropsychological functions, learning ability, family functioning, and sleep problems. In other respect, it was found that there is a relationship between autism symptom severity, opposing behavior, aggression, attention deficit, impulsivity, hyperactivity, anxiety, depression and mood variability. Sleep problems are reported to be part of the autism symptom cluster. These sleep problems can be seen as difficulty in falling asleep, frequent waking up at night, early waking up, shortening of sleep time or nightmare disorder. Sleep disorders in children with ASD have been shown to be seasonal, especially in autumn and spring. It is known that the problems of children with autism such as poor night sleep, problems of not being able to sleep and frequently interrupted sleep affect the children, especially in the growing age. While the contribution of sleep to mental and physical development is too much to be underestimated, this problem of individuals with autism brings with it new problems. Children with poor sleep history and poor sleep patterns are more quickly alerted and exposed to stimuli. Repetitive behaviors, attention problems, disturbance in social relations and more anger can be counted as just some of the problems contributed by sleep problems. Chronic sleep disorders affect not only the child but also the parents and even siblings. The stressful and anxious times of parents affect their relationship with their children. Researchers show that 32% of children with autism have sleep apnea and this is a higher incidence than typically developed children have. This means that some children with autism who are vulnerable during sleep have less oxygen in their brain. Neurologists say sleep apnea is a concern for every child, especially for children with autism. It has also been found that there is a mutation in melatonin secretion in children with autism. It has been shown that they secrete lower melatonin hormone than normally developed people. There were even neurologists who stated that melatonin treatment for some children and adolescents might benefit sleep patterns. In addition, many neurologists think that sleeping in a poor hygienic environment, bad sleeping habits (sleeping by watching videos, abundant caffeine consumption before bedtime), epilepsy seizures, and many other possible factors should be taken into consideration when considering the sleeping problem at a larger angle. Common Sleep Problems and Disorders Among Individuals with Autism Sleep problems may vary according to age groups. In adolescents, prolongation of onset of sleep, frequent waking and feeling drowsy during the day are common, whereas sleep time resistance, sleep anxiety, parasomnia and night waking may occur more frequently in younger age groups. Children with autism may have 2-3 hours of awakening at night; during that time, they can laugh, cry, scream and play with toys. Insomnia: Acute insomnia, night wakes, decreased sleep efficiency, prolongation of sleep time, early waking, problematic sleep routines, drowsiness during the day Parasomnia: Sleepwalking, night terror, nightmare Circadian rhythm sleep disorders: Delayed sleep stage type, irregular sleep-wake rhythm, free-flow type, early sleep stage type, late sleep Hypersomnia: Kleine Levin syndrome Sleep-related movement disorders: Periodic limb movement disorder during sleep, restless leg syndrome Sleep-related breathing disorders: Sleep apnea Other sleep problems or disorders: Short sleep time, early waking It has been shown that children with autism with sleep problems have more social relationship problems and stereotypic behaviors. Non-functional routine behaviors and stereotypic behaviors can also cause sleep time resistance, sleep hygiene problems. It is also known that sleep disorder in children with autism is associated with cognitive problems. How Does Melatonin Help Individuals with Autism Sleep? Disruption on melatonin level is considered a contributing factor to many sleepless nights for children with autism and their families. Since melatonin is a very important hormone for sleeping and staying awake, disorganizing this hormone can make sleep an ongoing struggle. Regardless of the reason, non-relaxing sleep cycles specific to people with autism have been documented in several studies. Sleep cycles in the population include Phase 1, which is abnormally long and is the least restful and easily aroused. REM sleep is too short or even absent. The result is that many children with autism are chronically deprived of sleep. This can lead to aggression, hyperactivity and various compulsive behaviors. There is also a very serious health risk associated with poor sleeping habits, including the risk of cardiovascular and metabolic disease. Since melatonin is a part of the cause of sleep disorders in people with an autism spectrum disorder, treatment can be taken by taking melatonin supplements. Several studies have shown a measurable improvement in sleep with this supplement. In fact, it was observed that 63% of children with autism increased their restful sleep after taking melatonin. This was especially effective when children received melatonin together with behavior therapy at the appropriate time during the day. The current belief is that melatonin supplements support melatonin that children with autism cannot produce enough. So, melatonin points to the origin of the sleep disorder and corrects it. Most children with autism who take melatonin do not show any side effects. This may make melatonin supplementation one of the safer ways of eliminating sleep disorders associated with an autism spectrum disorder. Many parents are concerned about giving any kind of additional medication to their children. This also applies to whether the child is in the autism spectrum or neurologically distressed. Research shows that taking small amounts of melatonin is safe in children. Few children may show side effects such as headache and daytime fatigue. In addition, taking melatonin supplements may interact with certain types of drugs, such as diabetes medications. However, sleep disorders in people with autism spectrum disorder are special in many respects. In the first place, people with this condition may not be able to produce enough melatonin, so it may be necessary to melatonin supplementation for a comfortable sleep and this may be the only cure. Improvement in school performance was observed in children with autism who received melatonin treatment for severe insomnia. While there are small risks associated with all supplements, they are less common and less severe than the effects of sleep deprivation. It is necessary to talk to the pediatrician before using this supplement. Ultimately, each child has a unique state of health that must be considered before making any changes. Autism spectrum disorder is not the only disorder associated with sleep disorders. Many people in the modern world struggle to fall asleep to what they need, whether it is caused by an illness or a way of life. For many people, melatonin supplements can help ensure the health benefits of a well-organized circadian rhythm as well as the restful sleep they need. Effects of Sport on Sleep Disorder Problem in Children with Autism The negative effects of sleep problems on families and their children are enormous. In addition, children with autism often show psycho-motor performance impairment. Therefore, families and children need positive intervention methods. Sports and physical activities are an excellent option that has both low cost and no side effects, which positively affects sleep behavior and motor performance of children with autism. Through sports and physical activity, some sleep parameters have improved significantly or at least tend to improve. That is, the sport has led to increased sleep efficiency and shortened sleep delays. Morning moods, performance, and quality of life of children with autism tend to improve. In terms of motor skills, they show significant improvements. As a result, sleep disturbances are positively affected by physical activities and their motor performance improves significantly. In addition, it was reported that as a result of the doing sport of physical activity by the parents, children's attention increases and they gain new interests. Clinical Evaluation for Sleep Problems In terms of sleep, how lively and cheerful a child feels when he/she wakes up in the morning is important to assess the quality of sleep. At the same time, attention level, anxiety, depressive symptoms, and aggression should be examined carefully in this respect. Events that may affect sleep during the day should be evaluated. Pre-sleep routines and sleep environment should be questioned. Because children with autism cannot easily adapt to disruptions and changes in their routines. The games the child plays before sleep can disrupt the necessary inhibition of sleep. The duration of sleep, time to fall asleep, how many times he/she wakes up at night when he/she wakes up in the morning, and the number and times of nap during the day should be questioned. It is also very important to evaluate sleep hygiene. Sleep disrupting pathologies such as maxillary hypoplasia, retrograthia, macroglossia, adenoid, obesity should be evaluated. Sleep scales can be used to assess sleep. What Should Parents Do to Help Their Children with Autism Sleep? Although sleep is a common condition in many families, this process works slightly differently in families with individuals who got diagnose with an autism spectrum disorder. Sleep problems may occur in children with autism. To overcome sleep problems, it is necessary to pay attention to balanced nutrition of the child. They should also stay away from sugary foods and beverages when sleep time approaches. Precautions such as listening to calming music, telling relaxing stories, and having the child's bedroom dark, also make it easier for the child with autism to fall asleep. In children with poor sleep habits, parents need to offer different sleeping routines to their children. First, it may be a good start to shorten the time of watching videos in pre-sleep, consume less caffeinated beverages, not eat discomfort and energizing foods before bedtime, soothing massages or songs for relaxation. On the other hand, children with autism may have an anger attack at night. At this point, it is always useful to take a look at the processes that develop problem behavior, not sleeping. Parents should carefully review the process before the child shows this behavior. Usually, something is bothering a child before waking up from sleep. It could be a sound, smell, light or something else. Parents should not forget that children with autism are more sensitive than normally developed people. A sound, light, or other stimuli that we are accustomed to may sound like an impassable vortex for them, and we may not even find out why and how we are triggering these tantrums. For this reason, families should monitor their children frequently and check their response to environmental stimuli. In fact, by putting these processes into an opportunity teaching process, they can make experiments and identify their children’s sensitive points and reduce problem behaviors. In children diagnosed with autism, the sensitivity of families in their daily lives should also continue at night. By keeping a one-week observation record of children's nighttime sleep and taking into account the stimuli in the environment, parents can determine the time when the sleep problem persists. They can then reward their children without realizing it. This may extend this process. Therefore, families should approach as unresponsive as possible while observing. They only need to observe the process and then reward their children with autism if they have a good sleep. Of course, even if any hug is considered to be a reward, the child's problem behavior is followed by any reaction that he likes, food, an object is perceived as a reward. And this makes it the most important step that continues the quenching of problem behavior. To illustrate the sleep problem, imagine a child with an autism spectrum disorder who wakes up crying every night. No drug treatment and solution for months has worked. It was found that the child reacted to the call to prayer after the observation record was started. Then, during night's sleep and daily life, the call to prayer sound was constantly played in different sounds. In this way, it was observed that the sleep problem disappeared when training was staged. Therefore, in order to solve the sleep problems of children with autism, it is necessary to pay attention to environmental factors by observing the child first. And after the observations, sleep problems can be overcome by working on the cause that causes problem behavior when it is found. What Parents Should Do for Sleep Hygiene and Environment Regulation? The sleeping environment and routines of children with autism should be consistent. These routines should not undergo changes at night. Appropriate sleep time should be selected and followed. The child should be directed to routines that will bring him/her to sleep. Watching television and playing computer games should be reduced as much as possible. Emotional and behavioral arousal should be reduced at nights. As children with autism may have a sensitivity to some sounds, images, contacts and behaviors, bedding such as sleeping behaviors, bedspreads and blankets should be personalized. In particular, some bed, sheets and linen preferences can help him/her sleep. The larger room should be preferred instead of a cocoon-like bedroom. There should be a suitable position for the child to sleep. Appropriate temperature, light, and clothing should be selected. Setting limits for nap times can work at night in terms of sleep continuity. The bed should only be used for sleeping. Activities such as watching TV and reading books in bed should be avoided. Once the sleep environment has been properly maintained, the child should be put to sleep in the bed without external stimuli. Parents can wait quietly for 5 to 10 minutes near the bed for the child to sleep. They should never sleep together. When the time comes to sleep, a time limit of 10 to 15 minutes should be saved for the rituals. Massage for Children with Autism to Sleep Children with autism often do not like touching but prefer deep pressure instead. For this reason, massage could be one of the best solutions for both those who have difficulty in sleeping and those who have self-calming problems. There is no technical difference in massage in children with autism. However, the movements of the massaging should not be too fast. In other words, the main purpose of massage is giving deep pressure to children with autism. The timing of the massaging is another important consideration. It should be done especially before sleep or after taking a shower because these are times when admission is easier for children. Since the duration of the massaging is a detail that will be shaped according to the age of the child, it will not be possible to specify a clear figure. Another issue that should be emphasized is that the caregiver should not be stressed. In a scientific study, it was determined that the benefits of massage made by stressed caregivers were very limited or not. It is recommended that the person performing the massage is a mother, especially if the child is younger than 3 years. However, in cases where mothers have a busy or stressful day due to work or domestic burden, the father should offer massage support. There are some necessities that should be ready in the place massaging. A quiet, dark room with little light can be preferred. Some oils may also be used. Although there is evidence that lavender oil reduces stress, it is not preferred for children because of its pungent odor. There is no harm in using any baby oil considering allergic conditions. Each child with autism spectrum disorder is unique. That’s why the advice is given may not be sufficient or may not be appropriate for that child. It will be appropriate to evaluate children who have such sleep problems by an occupational therapist who specializes in sensory integration and is referred for sleep counseling. Treatment Methods for Sleep Problems Most children and adolescents with autism spectrum disorder have sleep problems. It is a very important factor affecting the quality of life for children/adolescents with autism and also their families. Etiologic treatment should be considered when planning treatment, and it should be kept in mind that the etiology is complex and multifactorial. If behavioral interventions and environmental regulation do not provide sufficient effect on the treatment of sleep problem, the medication should be added. Directly interfere with the structure that disrupts sleep. Melatonin is generally effective in starting and maintaining sleep in all people. When it comes to children with autism, it becomes even more important. Melatonin treatment can increase sleep time, shorten the onset of sleep, decrease nighttime awakening, improve sleep rhythm, and improve parasomnia disorders. With melatonin treatment due to sleep problems, social and behavioral improvement, regression in attention deficit and hyperactivity symptoms, decrease in depressive complaints, regression in stereotype and compulsive behaviors, regression in anxiety level and decrease in irritability can be observed. The time of taking melatonin should be 30-60 minutes before the child’s bedtime. Although there are no serious side effects, there are families who report side effects of fatigue, headache, severe drowsiness, dizziness, and diarrhea. It is well tolerated. Atypical antipsychotics such as risperidone, quetiapine, aripiprazole, olanzapine, and selective serotonin reuptake inhibitors can be added to the treatment since the depression, anxiety and conduct disorders are frequently associated with an autism spectrum disorder. Drugs used in the treatment of insomnia form a rebound if they are stopped quickly. Therefore, they should be discontinued by reducing the dose. If nightmares and night terrors are frequent and affect daily life, drugs that affect the structure of sleep and REM are frequently used. Medication should be avoided if episodes of sleepwalking and sleep terror are not severe. Benzodiazepines, on the other hand, reduce deep sleep while preventing waking. When cut, the risk of recurrence is high. Antidepressants are effective in small doses. The success rate is higher in individuals with autism spectrum disorder than normally developed individuals in drug therapy.