Fetal Alcohol Spectrum Disorders and Sleep

Sleep behavior issues are common in children with FASDs and may include any combination of:

• Increased bedtime resistance
• Greater sleep anxiety
• Delayed sleep onset
• Increased incidence of parasomnias (e.g., nightmares and enuresis)
• Shorter overall sleep duration (waking earlier than necessary or desired by the family)
• Frequent nighttime awakenings
• Difficulty returning to sleep after nighttime awakenings, which frequently resulted in problematic and sometimes unsafe behaviors such as climbing on furniture, accessing dangerous household items (e.g., knives), or excessive eating.

These sleep problems are thought to be related to sensory processing disorders frequently seen in FASD. The number and severity of problematic sleep-related symptoms were highly correlated with scores indicating pathology on the Sensory Profile, a caregiver report of sensory reactions displayed by a child to given inputs and their behavioral and emotional responses to such. [Wengel: 2011] The brainstem reticular formation, important in sensory processing, must be down-regulated in order to facilitate the induction of sleep. This down-regulation causes the brain to “filter out” irrelevant or nonthreatening stimuli in order to maintain sleep, while maintaining the capability for arousal in case a threatening or noxious stimulus is perceived. It is posited that in children with FASD, their inability to ignore irrelevant stimuli and down-regulate may be at least partially responsible for their difficulties with both delayed sleep onset and with nighttime awakenings. In addition, abnormalities in the hypothalamic-pituitary axis resulting from in-utero alcohol exposure are thought to contribute to the sleep difficulties and associated hypervigilance often seen in children with FASD. Animal models have also demonstrated increased nighttime wakefulness and decreased sleep hours overall in those exposed prenatally to alcohol.

Children with FASDs have a distinctive sensory processing profile that is most often characterized by a predilection for sensation-seeking, but poor registration (e.g., understanding) of what is actually occurring around them. [Jirikowic: 2008] These children tend to have a high neurological threshold and feel under-stimulated; hence, the seeking of additional sensation appeals to them. Additionally, children with FASD are more likely to fall into the clinically concerning range on both long- and short-form Sensory Profile tests in the domains of tactile sensitivity, auditory filtering, and movement sensitivity. Low scores (indicative of more significant pathology) on the short sensory profile were predictive of more significant behavioral problems, as measured by the Child Behavior Checklist. Thus, sensory processing problems tend to correlate both with poorer sleep at night and more disruptive behavior during the day. [Franklin: 2008] As such, children with FASD will likely benefit from early consultation of Occupational Therapy in order to target sensory processing impairment that appear to lead to secondary disability via behavioral and sleep problems.