Sleep is a fundamental process that we all need to maintain a healthy and functional state. As adults, we’re all aware of how a bad night’s sleep can affect our mood, motivation and concentration. But how can a child interpret these feelings? They don’t see the link between a good night sleep and a good day of play. Sleep is essential for correct neural development. But more often than not, children will experience some form of sleep disturbance and these are exacerbated in some neurodevelopmental disorders. When these disturbances become detrimental to a child’s quality of life and actually, the whole family, an investigation is needed to determine the underlying cause and discover solutions.
Carmen Schroder is a professor of child and adolescent psychiatry at Strasbourg University and specialises in sleep disorders. She will be a keynote speaker at the online ESCAP Expert Day on the 25th June. She is a strong advocator for bringing more awareness into childhood and adolescence sleep disturbances. She wants parents to have access to help and resources for their child experiencing sleep disturbances, and paediatricians and child and adolescent psychiatrists to do more routine initial assessments when evaluating a child.
In the video, she gives a sneak-peak of what she’ll discuss in her expert presentation. She’ll remind us all of the importance of sleep, and fundamentally, why we sleep. And emphasis that now more than ever people of all ages are experiencing disrupted sleep patterns. She’ll then delve into certain neurodevelopmental disorders, specifically autism, that are often associated with sleep disturbances and how to look for treatment strategies.
We continued to probe her for more insights into her work and she happily obliged.
Initial assessments and studying long-term sleep patterns in children
As a sleep expert, Carmen Schroder systematically asks about a child’s sleep pattern when consulting with parents. “Overall, it is important to state that sleep disturbances can inaugurate and co-exist with child psychiatric disorders, and they may continue even after the end of an acute episode (in which case they are a risk factor of relapse). In any case, there is always an impact of sleep disturbances on the child psychiatric disorder, and - inversely - most child psychiatric disorders are associated with some form of sleep disturbances. It is thus essential for the child psychiatrist to address sleep in clinical initial assessment and follow-up”.
“We always ask about a child’s sleep pattern from all ages, because sleep irregularities have been shown to be predictive factors for some psychiatric disorders that we see”. Longitudinal and cross-sectional studies are offering key understandings into sleep patterns and trajectories of sleep disturbances on behaviour, for example, the French ELFE birth cohort, is now reaching its 10th year of analysing 18,000 children. “Some longitudinal studies, either in process or already published, show that early sleep disturbances can be the first sign of neurodevelopmental disorders, and that sleep disorders have trajectories that evolve in the same way to child psychiatric symptoms, for example, longitudinal studies and birth-cohort studies have looked at the way these sleep disturbances evolve in parallel with symptoms of inattention or hyperactivity, which could later evolve into a full diagnosis of ADHD. I will explain about these specific studies in my talk, to stress how important it is to assess sleep behaviour in child consultations from a very early age. There is also a very strong link between sleep disturbances and suicidal behaviour. This is another important aspect because it shows us that sleep can be a sign of a higher risk of suicidal ideation or suicidal behaviour”.
“We also know that if we don’t address the sleep disturbances, they can become chronic. It tends to become an interactive process between parents and the child, it is not just the sleep disturbances but the whole environment that will contribute to the sleep disturbances becoming chronic. Chronic sleep disturbances in children have been shown to be one of the factors that can lead to increased anxiety and depressive symptomatology”.
Breaking the vicious cycle: a child that doesn’t sleep means parents that don’t sleep; it’s a family process.
“Severe sleep disturbances are among one of the factors that can lead to an explosion of the family system. Several studies in neurodevelopmental disorders show that the difficulties faced during the day are exacerbated when the child and parents can’t sleep during the night, actually, sometimes it’s the whole family that can’t sleep at night, for example, brothers and sisters can also be affected by the sibling that has the sleep disturbances. It can lead to significant decreases in the quality of life of the family, depressive and anxiety symptoms in parents, and studies have shown it can have huge impacts on the parent’s employment, specifically the mothers, and the parental couple. We have to take all this into account when we evaluate the effect of treatment on the sleep disturbances, especially to see if there are improvements in the whole family’s quality of life, not just the individual child”.
Treatment strategies in autism
After discussing the types of treatment strategies for children who exhibit sleep disturbances, Professor Schroder goes on to explain that some of her studies have looked at the effects of prolonged slow-release melatonin given specifically to patients with autism or some neurodevelopmental disorders. The reason for this she describes is “that a deficiency of melatonin secretion has been identified in some of these patients, so this is an etiological treatment approach, it is not a symptomatic approach, hence why we administer slow-releasing melatonin to supplement insufficient, endogenous secretion of melatonin. In autism, along with all the other behavioural approaches we use, the slow-releasing melatonin can be very successful, and improves a vast majority of sleep disturbances. But it does not apply to all cases of insomnia seen in children and adolescents, so it cannot be extrapolated to all sleep disturbances in this population”. She indicates that about 50-80% of children with autism express some form of sleep disturbances. “There’s a wide range of sleep disturbances. The most common are sleep onset disturbances and nocturnal awakenings. What is very common in autism and some neurodevelopmental disorders are long periods of awakening during the night, i.e. the child wakes up and is wide awake for two to three hours, they’re very active as if it were day. This is something we don’t tend to see in typically developing children. In cases of long nocturnal awakening where there is a significant decrease in total sleep time, treatment is warranted, and it’s where the prolonged slow-releasing melatonin is most effective”.
Targeting all stages of the sleep cycle
“We aim for a global approach to treat all stages of the sleep cycle, and all the sleep disturbances we can identify in a child. However, most studies have focused on two things: among the group of adolescents with sleep disturbances, the total sleep time is important, independent of the underlying disorder. Some studies have shown that if you lose one hour of sleep per night, it can expose you to significant risks of behaviour, such as suicidal behaviour, but if you can improve total sleep time by one hour, you will obtain significant positive effects on daytime behaviour and psychiatric symptomatology in a variety of different disorders. In neurodevelopmental disorders, a new parameter of interest is the continuous sleep during the night. It matters when a child wakes up. For example, if a child wakes up early in the night and then at the end of the sleep period, the child has had a long continuous sleep in between the two awakenings and this has less of an impact compared with a child that wakes up at midnight and then again at 3am, which prevents a long continuous sleep episode. This is particularly important for neurodevelopmental disorders. These parameters should be assessed thoroughly.”
Delving deeper into understanding the sleep cycle and the need for sleep we touched on the topic of genetics, which as Professor Schroder states “genetic studies on sleep disturbances are very interesting but are still in the research phase and not yet translated to a clinical setting”. She mentioned two important sleep parameters under genetic influence that can be assessed in the clinic. One is the sleep need, which is strongly genetically determined. For example, what is the sleep need of this specific child, and does it correlate to the sleep need of that child’s age group, but also to the sleep need of the parents. The second factor she describes is the chronotype of an individual; does the child go to sleep early and wake up early or the contrast, taking into account the chronotype of the parents. She further explains how polymorphisms in the melatonin pathway, specifically in the enzymes that control the process of melatonin production, have been identified in a subset of children with autism, but again, it’s still early days to be able to screen for these in the clinic.
The impact of COVID-19 on sleep disturbances
Lately, we can’t have a discussion without mentioning the impact of COVID-19. And indeed, its impact on sleep disturbances is dramatic. Professor Schroder explains that “sleep disturbances are the most common symptoms we see on the whole population during this pandemic. We realised this first during the first lockdown in March, where we checked in on hospital personnel such as nurses and doctors, and the most common complaint reported were sleep disturbances. In response to this, we set up sleep consultations for these staff members to get help for their sleep difficulties. The underlying reasons are, of course, on different levels. Firstly, uncertainty seen at the different stages of the pandemic increases stress and anxiety, and we all know the impact of these on sleep, and secondly, sleep rhythms have become dissolved, for example in the first lockdown, people were staying at home, going to bed later, spending more time using screens and all this has huge effects on a persons sleep quality and pattern”.
To address this at a public health level, she and her team worked with the French Society for Sleep Medicine and Sleep Research. “We have come together to prepare lots of brochures and online help to stress the importance of maintaining regular rhythms and positive behaviour that encourages good sleep for the adult population and parents of children and adolescents. These resources give parents concrete advice, for example, what can they do to maintain a healthy schedule? How to reduce screen time? For older adolescents, we’ve seen a huge demand for sleep consultations during this time, and we have designed specific programs to regulate this”. All these resources, (ebooks, brochures, web links) are available online, with further information from the French Society for Sleep and French Society for Paediatrics.
Professor Schroder is keen to present on sleep disorders at the ESCAP Expert day. She wants more awareness of the importance of a healthy sleep pattern on a child’s development both at a public and professional level. She will present at 10h00 CET on Friday 25th June. Find out all the details to register here.
Carmen M. Schroder et al., Pediatric Prolonged‑Release Melatonin for Sleep in Children
with Autism Spectrum Disorder: Impact on Child Behavior and Caregiver’s Quality of Life. Journal of Autism and Developmental Disorders. 2019,49(8):3218-3230.