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Knowledge Database
• Slide Presentation for the lecture of: Jeremy Turk
South London & Maudsley NHS Foundation Trust, UK
•...
Sleep Disorders in Children & Young
People with Developmental
Disabilities
Jeremy Turk
Academic Child & Adolescent Mental ...
Turk, J. (2010)
Sleep Disorders in Children & Adolescents
with Learning Disabilities & Their
Managements
Advances in Menta...
Turk, J. (2014)
Use of Medication in Children & Young People
with Intellectual Disability & Challenging
Behaviours
“Intell...
Common Sleep Difficulties
Insomnia
Settling difficulties
Recurrent night time waking
Early morning waking
Nightmares,...
Sleep disorders in childhood
 15-20%, Isle of Wight study
 May be
– Settling difficulties (“sleep induction”)
– Repeated...
QUINE 1991:
Longitudinal study of sleep disturbance in 200 young
people with moderate-to-profound intellectual disability...
Sleep & Autism Spectrum Conditions:
44-83% sleep disturbance
Subjective & objective difficulties
- Falling asleep
- Stay...
Behavioural Techniques
Extinction
Positive reinforcement +/- fading
Shaping & graded approaches
Antecedent contingenci...
Sleep determinants:
Primarily social in people with average intellectual
abilities
– “zeitgebers”
Strong neurological co...
Melatonin (Turk, 2003; Turk, 2010)
N-acetyl-5-methoxytryptamine
Pineal indole
diurnal secretion variation
widely avail...
Tryptophan
Serotonin
N-acetylserotonin
Melatonin
(N-acetyl-5-methoxytryptamine)
JAN ET AL 1994:
 15 children, most with multiple neurological
disabilities
 improved sleep
 “significant health, behavi...
JAN & ESPEZEL 1995:
 Subsequent report
 full or partial correction of sleep-wake cycle
disturbance in almost 90 children...
MELATONIN IN SPECIFIC
GENETIC DISORDERS:
 O’Callaghan et al. 1999:
7 individuals with tuberous sclerosis and
severe slee...
Gringras et al., 2012
 Randomised double masked placebo controlled trial for sleep
problems in children with neurodevelop...
Melatonin is:
 Highly beneficial, short-term, rapid-onset & safe treatment for intractable
sleep disturbance
 Therapeuti...
Other Options:
α-2A noradrenergic receptor agonists
– Clonidine, Guanfacine
– Lack appetite and sleep disturbance
– Good ...
Clonidine (Ingrassia & Turk, 2005)
α2A noradrenergic receptor agonist
Shown efficacy for anxiety, overactivity, impulsiv...
Acebutolol:
selective beta-1 adrenergic agonist
De Leersnyder et al (2003)
melatonin antagonist
nine children with Smi...
Puttaswamaiah & Turk (2015)
Prader-Willi Syndrome & dysfunctional sleep-
wake cycle
Asleep mid-afternoon on return from ...
Anxiety
SSRIs especially mildly calming & sedating
ones e.g. sertraline, citalopram
Beta blockers e.g. propranolol
Alph...
Anticonvulsant Mood & Behaviour
Stabilisers:
Carbamazepine, sodium valproate, lamotrigine
Excellent anticonvulsants with...
Clinical Guidelines
Always commence with sleep hygiene
measures & behavioural approaches
Sleep induction: melatonin
Sle...
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Jeremy Turk: Sleep Disorders in Children and Adolescents with Developmental Disabilities and their Managements - Slide presentation

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

  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 & Young People with Developmental Disabilities Jeremy Turk Academic Child & Adolescent Mental Health, Institute of Psychiatry, King’s College, University of London & Child & Adolescent Mental Health Neurodevelopmental Services, South London & Maudsley Mental Health Foundation NHS Trust
  3. 3. Turk, J. (2010) Sleep Disorders in Children & Adolescents with Learning Disabilities & Their Managements Advances in Mental Health & Learning Disabilities Volume 4, Issue 1, 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 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 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: 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: 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 Techniques Extinction Positive reinforcement +/- fading Shaping & graded approaches Antecedent contingencies Discriminant Learning Regular, structured, predictable & calming bedtime routine
  10. 10. Sleep determinants: Primarily social in people with average intellectual abilities – “zeitgebers” Strong neurological components in children and young people with developmental disabilities
  11. 11. Melatonin (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)
  13. 13. JAN ET AL 1994:  15 children, most with multiple neurological disabilities  improved sleep  “significant health, behavioural & social benefits” BUT  responses not always complete  responses varied considerably depending on type of sleep disturbance  not double-blind
  14. 14. JAN & ESPEZEL 1995:  Subsequent report  full or partial correction of sleep-wake cycle disturbance in almost 90 children with a range of developmental disabilities, neurological disorders & chromosomal anomalies  continuing strict environmental sleep structuring important  side effects & tolerance not noted
  15. 15. MELATONIN IN SPECIFIC GENETIC DISORDERS:  O’Callaghan et al. 1999: 7 individuals with tuberous sclerosis and severe sleep problems small but significant improvement in total sleep time non-significant improvement in sleep onset time ? Responders & non-responders  McArthur & Budden 1998: improved sleep-onset latency, total sleep time & sleep efficiency in 9 individuals with Rett syndrome
  16. 16. Gringras 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:  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: 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. Clonidine (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: 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) 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. Anxiety 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 & Behaviour 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 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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