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Jeremy Turk: Sleep Disorders in Children and Adolescents with Developmental Disabilities and their Managements

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Jeremy Turk: Sleep Disorders in Children and Adolescents with Developmental Disabilities and their Managements

  1. 1. Knowledge Database • Slide Presentation for the lecture of: Jeremy Turk South London & Maudsley NHS Foundation Trust, UK • Topic of lecture: Sleep Disorders in Children and Adolescents with Developmental Disabilities and their Managements • The lecture was given at Beit Issie Shapiro’s 6th International Conference on Disabilities - Israel • Year: 2015
  2. 2. Sleep Disorders in Children & YoungSleep Disorders in Children & Young People with DevelopmentalPeople with Developmental DisabilitiesDisabilities Jeremy TurkJeremy Turk Academic Child & Adolescent Mental Health,Academic Child & Adolescent Mental Health, Institute of Psychiatry, King’s College, University of LondonInstitute of Psychiatry, King’s College, University of London && Child & Adolescent Mental Health Neurodevelopmental Services,Child & Adolescent Mental Health Neurodevelopmental Services, South London & Maudsley Mental Health Foundation NHS TrustSouth London & Maudsley Mental Health Foundation NHS Trust
  3. 3. Turk, J. (2010)Turk, J. (2010) Sleep Disorders in Children & AdolescentsSleep Disorders in Children & Adolescents with Learning Disabilities & Theirwith Learning Disabilities & Their ManagementsManagements Advances in Mental Health & LearningAdvances in Mental Health & Learning DisabilitiesDisabilities Volume 4, Issue 1,Volume 4, Issue 1, pp. 50-59.pp. 50-59.
  4. 4. Turk, J. (2014) Use of Medication in Children & Young People with Intellectual Disability & Challenging Behaviours “Intellectual Disabilities & Challenging Behaviour” ACAMH Occasional Papers No. 32 (eds: Lovell, M. & Udwin, O.) London: Association for Child & Adolescent Mental Health pp. 36-44.
  5. 5. Common Sleep DifficultiesCommon Sleep Difficulties Insomnia Settling difficulties Recurrent night time waking Early morning waking Nightmares, night terrors, sleep talking, sleep walking, sleep reversal, sleep paralysis
  6. 6. Sleep disorders in childhoodSleep disorders in childhood  15-20%, Isle of Wight study  May be – Settling difficulties (“sleep induction”) – Repeated night-time waking – Early morning waking – Parasomnias e.g. sleep walking, night terrors  Strong association with – daytime behavioural difficulties – maternal stress & depression – Family discord & parental separation – Poor educational attainments & socialisation
  7. 7. QUINE 1991:QUINE 1991: Longitudinal study of sleep disturbance in 200 young people with moderate-to-profound intellectual disability 51% settling problems 67% waking problems 32% of parents reported rarely getting enough sleep
  8. 8. Sleep & Autism Spectrum Conditions:Sleep & Autism Spectrum Conditions: 44-83% sleep disturbance Subjective & objective difficulties - Falling asleep - Staying Biochemical & genetic associations - Low plasma & saliva melatonin levels ? Low melatonin CNS receptor sensitivity ? Lack of circadian secretion rhythm
  9. 9. Behavioural TechniquesBehavioural Techniques Extinction Positive reinforcement +/- fading Shaping & graded approaches Antecedent contingencies Discriminant Learning Regular, structured, predictable & calming bedtime routine
  10. 10. Sleep determinants:Sleep determinants: Primarily social in people with average intellectual abilities – “zeitgebers” Strong neurological components in children and young people with developmental disabilities
  11. 11. MelatoninMelatonin (Turk, 2003; Turk, 2010)(Turk, 2003; Turk, 2010) N-acetyl-5-methoxytryptamine Pineal indole diurnal secretion variation widely available as food supplement in North America unlicensed for children & young people in U.K. - only prescribable on named patient basis
  12. 12. Tryptophan Serotonin N-acetylserotonin Melatonin (N-acetyl-5-methoxytryptamine) Tryptophan Serotonin N-acetylserotonin Melatonin (N-acetyl-5-methoxytryptamine)
  13. 13. JAN ET AL 1994:JAN ET AL 1994: 15 children, most with multiple15 children, most with multiple neurological disabilitiesneurological disabilities improved sleepimproved sleep ““significant health, behavioural & socialsignificant health, behavioural & social benefits”benefits” BUTBUT responses not always completeresponses not always complete responses varied considerably depending onresponses varied considerably depending on type of sleep disturbancetype of sleep disturbance not double-blindnot double-blind
  14. 14. JAN & ESPEZEL 1995:JAN & ESPEZEL 1995: Subsequent reportSubsequent report full or partial correction of sleep-wake cyclefull or partial correction of sleep-wake cycle disturbance in almost 90 children with adisturbance in almost 90 children with a range of developmental disabilities,range of developmental disabilities, neurological disorders & chromosomalneurological disorders & chromosomal anomaliesanomalies continuing strict environmental sleepcontinuing strict environmental sleep structuring importantstructuring important side effects & tolerance not notedside effects & tolerance not noted
  15. 15. MELATONIN IN SPECIFICMELATONIN IN SPECIFIC GENETIC DISORDERS:GENETIC DISORDERS: O’Callaghan et al. 1999:O’Callaghan et al. 1999: 7 individuals with7 individuals with tuberous sclerosistuberous sclerosis andand severe sleep problemssevere sleep problems small but significant improvement in total sleepsmall but significant improvement in total sleep timetime non-significant improvement in sleep onsetnon-significant improvement in sleep onset timetime ? Responders & non-responders? Responders & non-responders McArthur & Budden 1998:McArthur & Budden 1998: improved sleep-onset latency, total sleep timeimproved sleep-onset latency, total sleep time & sleep efficiency in 9 individuals with& sleep efficiency in 9 individuals with RettRett syndromesyndrome
  16. 16. Gringras et al., 2012Gringras et al., 2012  Randomised double masked placebo controlled trial for sleep problems in children with neurodevelopmental disabilities  146 children aged 3-16  Total sleep time  by 22.4 minutes  Sleep onset latency  by 37.5 minutes  Melatonin  earlier waking times than placebo  Children fell asleep significantly faster  But woke earlier  And gained little additional sleep on melatonin  Child behaviour & family functioning outcomes favoured melatonin but were not significant  But parents loved it!
  17. 17. Melatonin is:Melatonin is:  Highly beneficial, short-term, rapid-onset & safe treatment for intractable sleep disturbance  Therapeutic dose not predicted by: – severity of sleep disturbance – severity of intellectual disability – presence/absence of autism  Habituation common but not universal  Concomitant psychological, behavioural, educational, family & social interventions essential  No obvious short-term adverse effects but long-term safety has not been confirmed  No adverse effects other than habituation up to 5 years after commencement  Modified-release version (Circadin) probably no better than immediate- release – but cheaper!
  18. 18. Other Options:Other Options: α-2A noradrenergic receptor agonists – Clonidine, Guanfacine – Lack appetite and sleep disturbance – Good for tic disorders – But sedation & ↓ blood pressure Tricyclic antidepressants – Imipramine, Amitriptyline – Good for anxiety, depression, enuresis, tics, insomnia – May need to do ECG ? Calming SSRIs – as above
  19. 19. ClonidineClonidine (Ingrassia & Turk, 2005) α2A noradrenergic receptor agonist Shown efficacy for anxiety, overactivity, impulsiveness, inattentiveness Mildly sedating, mildly hypnotic Good for tics & Tourette’s Good for repeated night time waking No effect on appetite Can drop your blood pressure 25-300 μg daily in divided doses
  20. 20. Acebutolol:Acebutolol: selective beta-1 adrenergic agonist De Leersnyder et al (2003) melatonin antagonist nine children with Smith-Magenis syndrome severe and intractable sleep difficulties successful suppression of inappropriately high morning melatonin levels improved behaviour and concentration, a reduction in delays in sleep onset, increased sleep duration and delayed waking Suggestion of usefulness in Prader-Willi syndrome – but exclude sleep apnoea first!
  21. 21. Puttaswamaiah & Turk (2015)Puttaswamaiah & Turk (2015) Prader-Willi Syndrome & dysfunctional sleep- wake cycle Asleep mid-afternoon on return from school Awake early night and thereafter No response to behavioural approaches No response to evening melatonin Striking, rapid improvements with mid- afternoon acebutolol
  22. 22. AnxietyAnxiety SSRIs especially mildly calming & sedating ones e.g. sertraline, citalopram Beta blockers e.g. propranolol Alpha agonists e.g. clonidine In extremis, low-dose short-term risperidone – can commence as low as 0.125mg twice daily
  23. 23. Anticonvulsant Mood & BehaviourAnticonvulsant Mood & Behaviour Stabilisers:Stabilisers: Carbamazepine, sodium valproate, lamotrigine Excellent anticonvulsants with good safety profiles Beneficial in bipolar/cyclical mood disorders Emerging evidence base for child & adolescent fluctuating mood disorders Now used increasingly for cyclical (and not so cyclical) mood and behaviour challenges in children & young people with complex, multiple & severe developmental disabilities Balancing mood & behaviour can enhance sleep.
  24. 24. Clinical GuidelinesClinical Guidelines Always commence with sleep hygiene measures & behavioural approaches Sleep induction: melatonin Sleep maintenance: clonidine Early morning waking (especially in association with anxiety or mood disorder: sedating SSRI In extremis, low-dose short-term risperidone – can commence as low as 0.125mg
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