Beth Malow, MD, shares current research updates on sleep and autism. She highlights the multifactorial nature of sleep patterns and how they affect daily functioning and core autism traits like emotion regulation. The speaker provides helpful sleep questionnaires and tips for minimizing sleep resistance and night waking. Malow outlines preliminary work from ongoing sleep education trials for parents and therapists and emphasizes the efficacy of behavior-based interventions. She provides contact information for potential study participants and notes the lack of research surrounding common medications before the Q&A. 

• Handouts are online HERE
• Articles on melatonin are HERE
• Interested in participating in research at locations described i Save n the webinar? Email the research team at sleeped@vumc.org

In this webinar:

1:00 – Introduction and case study
6:45 – Multifactorial sleep problems
12:13 – Emotion regulation and sleep
17:20 – Parent trainings for insomnia
23:00 – Sleep resistance and night waking
29:30 – Sleep education multicenter trials
36:30 – Medications
37:45 – Summary
39:00 – Q&A

Sleep in Autism

Dr. Malow notes the high prevalence of sleep problems in autistic children and how they impact both nighttime rest and daytime functioning (1:00). Various factors contribute to sleep issues in autism, which can generally be divided into biological, medical, and behavioral categories (7:45). 

Case Study

To illustrate the multifactorial nature of sleep issues, Malow presents a case study of Alex, a 10-year-old boy with autism, epilepsy, and anxiety. It takes him hours to fall asleep because he “cannot shut his brain down,” and he takes methylphenidate (Ritalin) in the morning and afternoon and lamotrigine (Lamictal) at night. Alex enjoys a soda and video games after dinner. He has restless sleep, snores loudly, and wakes multiple times at night. It’s also nearly impossible to wake Alex up in the morning for school. His teacher describes him as being sleepy as well as hyperactive in class. All of this leaves his parents exhausted and very overwhelmed (2:40). 

Due to his snoring, practitioners treated him for sleep apnea by removing his adenoids and tonsils. This helped his seizures and snoring, but the restlessness and night wakings continued (6:45). The speaker emphasizes a comprehensive approach to sleep issues that identifies co-occurring conditions, prioritizes behavioral strategies wherever possible, and uses medications sparingly. She reiterates the benefits of routines for people with autism (10:15)

Sleep, emotional regulation, behavior, and core symptoms

All daily functioning is improved when we sleep better; it’s like “hitting the reset button,” especially for emotion regulation. Malow outlines fMRI studies that show increased amygdala activation (fear and anxiety) and decreased connectivity between different parts of the brain after sleep deprivation (12:13). Similarly, in a study with more than 2,500 kids, those getting less than seven hours of sleep per night had higher severity scores for social communication and emotion regulation (15:15). The presenter asserts the significant relationship between sleep and behavior and suggests that if we improve sleep, daytime behaviors will also improve (16:35). 

Parent training for insomnia supports

In 2009, Malow published the Sleep Habits Questionnaire for Children With Autism Spectrum Disorders to help parents and caregivers manage sleep issues in autistic children (17:20). The questionnaire assesses components of successful sleep and daytime habits including exercise, abundant light, limited caffeine, limited naps, and selective bedroom use (using the bedroom only for sleeping) (19:18). The speaker describes the interaction of homeostatic and circadian rhythms throughout the day and emphasizes the importance of having the proper bedtime. For example, in Alex’s case study, 8 pm may be too early for his body to enter sleep mode, so she suggests pushing it back half an hour (21:00). 

Sleep resistance and night waking

For many autistic children, the “crying it out” method doesn’t work because the child doesn’t understand what is going on. If a child needs company to fall asleep, Malow suggests the rocking chair method, where you sit in the rocking chair with your back to the child, moving closer to the door each night until you have left the room (23:00). 

The first step in minimizing night waking is to help the child fall asleep on their own – “A child who can fall asleep on their own can go back to sleep on their own.’. It’s essential to respond quickly to distress and comfort and reassure but avoid over responding – be “brief and boring” (25:00). “Bedtime passes” can also be used as a ticket for a hug or class of water during the night. In this case, the child can use the pass or turn it in in the morning for a reward. This gives the child control over the situation and comfort, knowing they can have help if needed (26:30).

Malow notes that all of these learning materials are available for free at https://www.autismspeaks.org/tool-kit/strategies-improve-sleep-children-autism

Sleep education multicenter trials

Malow outlines a two-phased study in parents of autistic children with sleep onset delay at least 3 nights/week. In phase 1, parents were given sleep education, a pamphlet, or no intervention. In phase 2, parents were randomized into either group or individualized classes with a trained community therapist (29:30). The therapist training portion includes a manual, videos, and weekly Zoom meetings for practice and support. Following training, therapists identify families who could benefit from the program, and after consent is given, baseline assessments are completed. Therapists meet virtually to discuss challenging cases and billing issues (34:44). 

Preliminary results show that therapists achieved fidelity goals during training sessions and that parents achieved high scores in understanding, comfort, and implementation. Sleep patterns and core symptoms improved, and parents were delighted with the training overall (32:55). 

This training is now available in TN, NH, VT, GA, and CO. For more information, email the research team at sleeped@vumc.org

Medications

Malow expresses her reservations about medications due to the many side effects and unknown long-term implications. However, sometimes they are necessary. They can help manage parental overwhelm initially, but it’s good to wean off slowly as behavioral habits are adopted. Gabapentin, alpha-adrenergic agonists (clonidine), and mirtazapine are common medications that have been studied, but most others have not (36:30).

 The presenter summarizes her talk, reiterating the prevalence of sleep problems in autism and their impact on daily functioning. She emphasizes that once the root cause is identified, sleep problems are highly treatable, especially with behavioral strategies. Personalized, family-centered interventions are the most effective  (37:45). Malow touches on future research directions before the Q&A (39:00). 

Originally published March 18, 2025

Patricia Wright, PhD, MPH, and Katie Curran, MAAP, introduce Proof Positive – The Autism Well-being Alliance. The speakers describe positive psychology, its impact on well-being, and why it matters for autistic people and their communities. Curran details four skills to help with thinking positively and provides suggestions for practicing and applying them to daily life. The speakers emphasize the lack of focus on positive emotions in autism care and how this plays into isolation and mental health issues. They affirm that individuals “can control [their] own well-being” by employing positive psychology and training their minds to build on the things that go well each day. Wright and Curran outline Proof Positive’s free learning and teaching resources before the Q&A. 

Handouts are online HERE

In this webinar:

1:00 – Proof Positive and the need for positive psychology
5:00 – What is positive psychology
14:00 – PERMA + Snapshot for well-being
18:30 – What Went Well?
27:45 – Jolts of Joy
30:43 – Broaden and Build vs. Fight or Flight
39:44 – Showcase the Good
48:20 – Q &A

Background

Patricia Wright, PhD, MPH, Executive Director at Proof Positive, introduces The Autism Well-Being Alliance, a nonprofit dedicated to improving the well-being of autistic people and their families, providers, and communities. By intersecting positive psychology with autism services, Proof Positive spreads the science and skills of happiness (1:00). She notes high rates of underemployment and mental health issues in autistic adults and underscores how difficult it is to find and retain social service providers. Over the last decade, the demand for these roles has increased 41%, and the U.S. healthcare system is experiencing major staff shortages. Although well-being is a relatively new term within autism care vocabulary, Wright underscores its importance and potential for quality of life management (3:00). 

Why Positive Psychology

Katie Curran, MAPP, Chief Well-being Officer at Proof Positive, says that those who practice positive psychology experience increased well-being and life satisfaction, better sleep, stronger relationships, less depression, and more success in school and work (5:00). Positive psychology considers the components of a life full of purpose and what makes life worth living. In other words, Curran continues, it asks, “Who are you at your best, and how do we get more of it?” Over thirty years of research, six elements critical to human thriving have arisen (8:10): 

1. Positive emotions – A sense of inspiration; a wide variety of positive emotions felt most days
2. Engagement – A good sense of what interests you; ability to spend time in flow and follow interests
3. Relationships – Other people matter, and relationships are critical to who we are and how we navigate the good and bad times
4. Mattering – A sense that your life has meaning and purpose; a feeling of connection to something larger than yourself. 
5. Accomplishment – Having a healthy sense of where you are going in the future; you have goals you are pursuing, and you believe you can achieve them
6. Physical health – Sleep, nutrition, and movement are key to maintaining happiness; when we move, our muscles pump food to the brain.

These six aspects of human thriving, referred to as PERMA+, are critical to understanding and empowering people to impact their well-being. 

To explore the research behind these elements, visit Proof Positive’s Science Page. 

Skills for well-being support

Curran asserts that “You can control your well-being” and outlines four practical tools that enhance well-being skills. 

#1 – PERMA+ Snapshot

The PERMA+ Snapshot asks you to stop and reflect on your well-being around once a week (14:00). Proof Positive offers a well-being survey that helps measure well-being and provides suggestions about skills to practice. The speaker emphasizes that no matter where you are on the scales, you are improving your well-being simply by taking time to take this survey because you are telling yourself that you are important and worth spending time and energy on (17:30). She suggests referring back to the PERMA+ survey for snapshots and tracking personal well-being.

#2 – What Went Well?

The goal of this exercise is to train your brain to mindfully notice, remember, and track the good things that happen each day (18:30). The presenter notes that left on their own, our brains default to spotting danger and things that have gone wrong as a means of self-preservation and protection. However, we need to shift our focus and ensure that every day, we intentionally focus on things that have gone well. 

To practice What Went Well, Curran suggests using a journal or gratitude app on your device and setting a time to write down at least three things that went well each day. It’s also helpful to consider what made each good thing special and to share your list with a family member or friend (22:55). The presenter notes that people who do this exercise before bed fall asleep faster and sleep longer but also that anxiety tends to be worse first thing in the morning. Therefore, she continues, it can be good to capture What Went Well before bed and then read the list in the morning (23:40). The speaker provides a few more tips and free teaching resources from the Proof Positive Website. 

#3 – Jolts of Joy

The Jolts of Joy exercise teaches us to intentionally experience higher levels of well-being and bursts of positive emotions across the day (27:45). Curran describes the negativity bias, noting that across 130 languages, six of the seven shared words to describe emotions are negative – again due to survival because fear keeps us alive (30:45). Barbara Frederickson was the first researcher to ask what good our positive emotions are and why we feel hope. She discovered that where negative emotions trigger a fight or flight response, positive emotions trigger the broaden and build response. “Broaden and Build’ refers to how our minds open up for creativity and problem-solving when we feel good. The presenter explains it as the opposite of tunnel vision (related to stress), where our vision expands and we see more of the world around us. Because growth is a critical part of the human experience, positive emotions are just as essential to survival as negative ones (31:50). 

Practicing jolts of joy can be a solitary or group activity. Carrun suggests listing 10 ways you experience positive emotions, be it cat videos, family photo albums, music, etc. It is good to include a variety of positive emotions in the list. Place your list where it’s easy to see, and then be sure to engage in a minimum of three (3) Jolts of Joy every day (35:45). The presenter underscores the importance of positive emotions, noting that many emotion regulation programs do not include these in the curriculum (39:00). 

#4 – Showcase the Good

Responding to other people’s good news in a way that enhances their joy and enables them to relive the positive experience is a critical differentiator between thriving relationships (39:45). Shelley Gable’s research shows that there are four ways people tend to respond to good news and that three of the styles are detrimental to relationships where only one boosts them. The four response styles are outlined below using the example of responding to a child who got a 90% on their math test (39:45):

1. Passive – Quiet, understated support.
   1. “Hey, look! I got a 90% on my math test!”
   2. “Great Job.”
2. Passive Destructive – You ignore the information altogether or “change the channel.”
   1. “Hey, look! I got a 90% on my math test!”
   2. “Do you have your cleats? It’s almost time for soccer.” or “Oh, where is your sister? She got a 100% on her history test.”
3. Active Destructive – Someone brings good news, and you squish it – a literal joy killer.
   1. “Hey, look! I got a 90% on my math test!”
   2. “A 90%? I thought we studied so hard! What did you get wrong?”
4. Active Constructive – Authentically engaged and asking questions
   1. “Hey, look! I got a 90% on my math test!”
   2. “Wow! Great job! We studied so hard for that! What did your teacher say? How do you feel?”

Curran highlights that when we Showcase the Good, both parties experience increases in trust, belonging, and intimacy. How we celebrate the good together is at the center of positive relationships. To practice Showcasing the Good, the speaker suggests sharing good news, leaning in when someone else shares their good news, asking questions to help that person relive their experience, and utilizing your own strengths to show interest (what are you curious about? Let that guide your questions and observations) (46:00). 

Proof Positive provides free learning and teaching resources for parents, school teachers, and professionals to help intersect positive psychology with autism care strategies. Each skill has an associated resource bundle that you can use to boost positive thinking and well-being. Curran and Wright thank the attendees before opening the Q&A (48:20). 

Originally posted September 24, 2024

Dara S. Manoach, Ph.D., discusses research updates on autism and sleep. She outlines aspects of a good night’s sleep and emphasizes the role of sleep cycles in cognition, memory, and learning. The speaker considers how to treat neurodevelopmental disorders by targeting sleep spindle rhythms which affect thalamocortical neuronal loops, essential to memory and attention. Manoach outlines how spindle rhythms correlate to memory consolidation during sleep in schizophrenia and autism, and highlights technological advancements that allow for broader sample sizes and more accessible studies. The presenter notes potential treatment goals and ongoing research before the Q&A.

In this webinar: 

1:15 – A good night’s sleep
4:15 – The role of sleep in memory and learning
6:40 – Motor sequence tasks (MST)
9:23 – Sleep spindles and memory consolidation
14:30 – Thalamocortical circuitry
17:30 – Genetic underpinnings
22:20 – Sleep in autism
27:00 – Sleep-dependent memory consolidation in autism
29:00 – Ongoing work
35:15 – Accessibility and sample size
40:25 – Treatment goals
43:15 – Q&A

A good night’s sleep

Manoach explains that a night’s sleep is divided into REM and non-REM cycles, with non-REM further divided into three stages based on slow-wave activity. The speaker’s research focuses on non-REM Stage 2 sleep, which occurs in the early morning and is characterized by sleep spindle brain rhythms (1:15). Manoach considers how sleep affects cognition, highlighting that critical aspects of learning and memory occur during sleep (2:15). She cites ancient references to the interaction of memory and sleep (Quintilianus, 95 AD) and highlights a 2001 study that kicked off the current explosion in sleep and memory research (3:10). 

• Sleep, Learning, and Dreams: Off-line Memory Reprocessing (Stickgold et al., 2001)

Sleep, memory, and learning

The presenter cites studies showing that sleep prioritizes memory for emotional information and helps extract the main point of an idea or experience. Sleep also increases spatial navigation and facilitates language learning in infants (4:25). The speaker asserts that this body of work has led to a paradigm shift in understanding sleep as an active period of cognitive functioning that facilitates learning and memory (6:00). 

• The role of sleep in declarative memory consolidation: passive, permissive, active or none? (Ellenbogen et al., 2006)
• Sleep Preferentially Enhances Memory for Emotional Components of Scenes (Payne et al., 2008)
• Dreaming of a Learning Task Is Associated with Enhanced Sleep-Dependent Memory Consolidation (Wamsley et al., 2010)
• Sleep inspires insight (Wagner et al., 2004)
• The Sleeping Infant Brain Anticipates Development (Friedrich et al., 2017)

The speaker describes finger-tapping motor sequence tasks (MST) in which participants use a keyboard to type a number sequence as quickly and accurately as possible. The following day, they complete the MST again to test learning improvements after a night of sleep (6:40). Research shows significant improvement in MST results after 12-hour intervals with a sleep sequence (7:45). Time of MST training (10 AM vs 10 PM) did not affect following day outcomes, and a 12-hour interval with no sleep cycle did not yield performance improvements (8:15). These findings, Manaoch asserts, emphasize the critical role of sleep in memory and learning. 

• The acquisition of skilled motor performance: Fast and slow experience-driven changes in primary motor cortex (Karni et al., 1998)
• Practice with Sleep Makes Perfect (Walker et al., 2002)

Sleep spindles and memory consolidation

MST studies in people with schizophrenia show a normal amount of learning during training. However, after a night of sleep, MST performance did not significantly improve, meaning that individuals with schizophrenia do not get the same benefits from sleep as their peers (9:23). The speaker notes that this failure of overnight improvement occurred in the context of significantly reduced sleep spindles, which are a critical mechanism of memory consolidation (10:00). Manoach states that memory consolidation deficits are also characteristics of autism, though the link has been better established in schizophrenia literature (12:17). 

The presenter outlines her research model, highlighting the importance of forging empirical links in causal chains across genes, circuits, physiology, cognition, diagnosis, and treatment (13:04). She describes brain spindles as a rhythm of Stage 2 non-REM sleep, which is recorded on an EEG as one-to-two-second bursts of brain activity. Spindles are initiated in the thalamus and sent to the cortex via thalamocortical neuron loops (e.g., bursts of brain activity), regulated by the thalamic reticular nucleus (TRN). The TRN is essential for sensory gating, or filtering out sensory inputs. Manoach asserts that spindle deficits in schizophrenia suggest a problem in this circuitry related explicitly to TRN modulation (12:50). 

• A failure of sleep-dependent procedural learning in chronic, medicated schizophrenia (Manoach et al., 2004)
• Reduced Sleep Spindles and Spindle Coherence in Schizophrenia: Mechanisms of Impaired Memory Consolidation? (Wamsley et al., 2012)

She cites research showing that dysfunctional thalamocortical circuitry can lead to attention fragmentation and impaired sensory gating in schizophrenia (14:30). Studies also show hyperconnectivity between the thalamus and motor sensory cortex associated with spindle deficits. Therefore, she asserts that research to date suggests decreased spindles and increased connectivity reflect the same thalamocortical circuit dysfunction in schizophrenia (16:00). 

• The thalamic reticular nucleus: structure, function, and concept (Pinault, 2004)
• Oxidative stress-driven parvalbumin interneuron impairment as a common mechanism in models of schizophrenia (Stuellet et al., 2017). 
• Disorders of attention and perception in early schizophrenia (McGhie & Chapman, 1961)
• Translational utility of rodent hippocampal auditory gating in schizophrenia research: a review and evaluation (Smucny et al., 2015)
• Increased Thalamocortical Connectivity in Schizophrenia Correlates With Sleep Spindle Deficits: Evidence for a Common Pathophysiology (Baran et al., 2019)

Genetic underpinnings

Manoach cites two animal model studies that found spindle deficits in mice with schizophrenia risk gene CACNA1I. Spindle deficits were correlated with reductions in thalamocortical circuitry (17:30). The speaker explains that autism risk genes, like PTCHD1, are also implicated in TRN dysfunction and have been correlated with spindle reduction and reduced visual gating leading to fractured attention in animal models. These data, she asserts, directly link gating issues to attention deficits and spindle dysfunction (19:40). She explains how TRN mutations in early development can predispose individuals to neurodevelopmental conditions like autism (21:15). 

• A rare schizophrenia risk variant of CACNA1I disrupts CaV3.3 channel activity (Andrade et al., 2016)
• Effects of a patient-derived de novo coding alteration of CACNA1I in mice connect a schizophrenia risk gene with sleep spindle deficits (Goshal et al., 2020)
• Thalamic reticular impairment underlies attention deficit in Ptchd1Y/− mice (Wells et al., 2016)
• New views of the thalamic reticular nucleus in the adult and the developing brain (Mitrofanis & Guillery, 1993)
• Early motor activity drives spindle bursts in the developing somatosensory cortex (Khazipov et al., 2004)

Sleep in autism

The presenter explains that 80% of autistic children experience sleep disturbances, which can exacerbate symptoms and impact daily function. She outlines a recent home-sleep EEG study that revealed autistic people had worse sleep quality than their non-autistic counterparts, specifically related to sleep latency, sleep efficiency, night wakings/arousals, and percentage of time in non-REM Stage 1 sleep (22:20). The same study also found reduced spindle rates in Stage 3 non-REM sleep and reduced thalamocortical coordination, with later and more variable spindle peaks compared to controls (24:00). These data, Manoach explains, are consistent with disruption to TRN during sleep. She hypothesizes that, as in schizophrenia, there is less gating of auditory information due to TRN deficits in autism (26:00). 

• Dyscoordination of non-rapid eye movement sleep oscillations in autism spectrum disorder (Mylonas et al., 2022)
• Increased resting-state thalamocortical functional connectivity in children and young adults with autism spectrum disorder (Baran et al., 2022)
• Sensory experiences of children with autism spectrum disorder: In their own words (Kirby et al., 2014)

Sleep-dependent memory consolidation in autism

The presenter notes that MST studies in autism do not report deficits in sleep-dependent memory consolidation. Where typically developing individuals had normal spindle count, autistic participants showed an inverse number comparatively (27:00). Manoach considers the role of spindles if not memory. She posits that they may support overall sleep cycles and, therefore, spindle deficits may contribute to sleep disruption in autism (28:00). 

• Dyscoordination of non-rapid eye movement sleep oscillations in autism spectrum disorder (Mylonas et al., 2022)

Ongoing work

Manaoch’s ongoing work looks at the links between sleep disruption in autism and spindle deficits, circadian disruptions, thalamocortical circuit function (gating), EEG abnormalities, and relations to sensory sensitivities. She notes a pilot study on the physiological effects of melatonin (29:00). The speaker considers the issue of small sample sizes in sleep analysis and explains how they are scaling up research with a wearable sleep headband that can be used at home, making sleep studies more accessible (30:00). 

She outlines part of her lab’s work with closed-loop auditory stimulation (CLAS) during a nap, monitored by EEG (31:45). Results show that CLAS has a strong effect on slow-wave and sigma rhythms, but it did not lead to better memory in this study. However, researchers now posit that timing matters (32:45). Manoach explains that the closer CLAS occurs to a sleep upstate, the more likely it is to evoke a slow-wave and spindle creation (33:30). 

• The effects of closed-loop auditory stimulation on sleep oscillatory dynamics in relation to motor procedural memory consolidation Get access Arrow (Baxter et al., 2023)

Accessibility and large sample sizes

The speaker reiterates the usability of the new sleep headbands and discusses their ongoing piloting process spanning the entire U.S. (35:15). She notes experiment preparation, procedures, and support, emphasizing the accessibility of participating from home (35:55). Preliminary data show no spindle deficits in non-REM Stage 2 or Stage 3 as a whole. However, when assessed by sex, spindle deficits are constrained to males. Manaoch considers whether other inconclusive studies have considered sex and how results may differ if they had (36:30). She notes that spindle deficits have been observed in studies with only male participants and speaks to the importance of large, diverse sample sizes. The presenter notes that study protocols and tools have been adapted for those with profound autism, citing the lack of studies in this group and the need for broader samples (37:50). She briefly describes ongoing sleep biomarker studies and outlines potential treatment goals (40:25): 

• Correct thalamocortical circuit function
• Increase spindles or improve coordination 
• Improve sensory gating
• Restore sleep
• Support the daily life of those with autism and their caregivers

Manoach thanks and acknowledges her research team and funders (41:40). She highlights that her lab is actively recruiting participants for one of the sleep studies discussed and provides her contact information before the Q&A (43:15). 

To participate in the study mentioned in the presentation, see: Participate in our Research – Sleep, Cognition and Neuropsychiatry (SCAN) Lab

Originally published on April 16, 2024