Dose-Dependent Effectiveness of Weighted Blankets on Sleep in Children with Autism Spectrum Disorder

Motherisk Int J 2020;1;26

 

Gideon Koren MD FRCPC FACMT (1), Sharon Peleg MSc (2) and Liad Cohen Heiman (2)

Adelson School of Medicine (1) and Ariel Developmental Clinic (2), Ariel University, Ariel, Israel 40700

Address for correspondence: Gideon Koren MD FRCPC FACMT

Tel 972587194777

gidiup_2000@yahoo.com

 

Abstract:

While an estimated 3.7% of children and youth suffer from an ICD9 diagnosis of sleep disorder (1), the prevalence among children exhibiting autistic spectrum disorder (ASD) ranges between 44-83% (2). This leads to  a wide range of adverse effects on behaviour, mood, neurobehavioral functioning, including attention, cognition, memory, school performance, and heavy impact on parental stress and family life (3). Most of these children receive sleep medications, often with partial response and adverse effects (4). Sensory integration is a popular and widely used therapy for children with ASD, with weighted blankets (WB) reported in numerous references (  ). Yet, very few controlled studies currently exist to support this practice, with contradictory results.

 

Objective:

To evaluate the effects of weighted blankets supplied by one manufacturer on sleep patterns of mostly ASD youngsters.

 

Patients and methods:

Twenty one children (age range 6.5-18yr) with either ASD (n=16), ADHD (n=1), CP (n=1) and insomnia not otherwise defined (n=3) with severe and chronic forms of insomnia, received a 6 kg WB .

 

Results:

In practically all cases there was a rapid and immediate improvement, in most cases resulting in all night sleep.

 

Discussion:

A few previous studies reported on modest /no effect of WB, resulting in unenthusiastic response by the pediatric community. The present study suggests a dose response effect that should be thoroughly investigated.

 

Introduction:

A recent study of pediatric primary pediatric care has detected 3.7% prevalence of ICD-9 sleep disorders[1]. In contrast, other epidemiological studies detected higher pervalence, with behavioral insomnia of childhood inflicting 20-30% of youngsters [2]. This means that most cases are not identified by pediatricians as a serious source of morbidity. Among children along the autistic spectrum disorder (ASD) the prevalence of sleep disorder ranges between 44-83% [3]. This results in a wide range of adverse effects on behaviour, mood, neurobehavioral functioning, including attention, cognition, memory, school performance, and heavy impact on parental stress and family life [4]. The majority of these children receive pharmaceutical products, especially those with ASD, other neurodevelopmental disorders, chronic medical conditions and psychiatric disorders. These include different benzodiazepines, chloral hydtate, clonidine, zolpidem, trazadone, melatonin, and sedative antihistamines [4].Sedatives with respiratory properties may be dangerous tor children with co morbid sleep-related breathing disorders (e.g. obstructive sleep apnea). There are also widely used herbal preparations, including valerian, chamomile, kava and lavender [4].

Sensory integration modalities, such as weighted blankets, are used in occupational therapy practice to assist with emotion and physical regulation. Overall the existing experience suggests that the additional pressure stimulation from the weighted blanket induces a calming effect by decreasing agitation and increasing sleep quality [5].

However, the effectiveness of these methods has been only sparsely studied, and most pediatricians are not familiar with this method. A recent systematic review of 8 studies suggested a potential for effective use “in limited settings and populations” [6]. There is presently only one randomized controlled trial of using weighted blankets for sleep disorder in autistic children [7]. After randomizing 73 children with ASD and using objective measures, the weighted blanket did not help prolonging sleep, fall asleep significantly faster or wake less often, when compared to the control blanket. Of interest though, the authors summarized that “the weighted blanket was favored by children and parents, and blankets were well tolerated”.

The objective of the present study was to quantify the effect of weighted blankets supplied by one manufacturer on sleep patterns of mostly ASD youngsters.

 

Patients and methods:

Starting in 2019, Samuel and Joseph Frid, owners of one of Israel’s oldest manufacturers of blankets and other sleep products, have been approached to provide weighted blankets for children and adult with sleep disorders. They established a follow up program where they collected data on the nature and characteristics of the sleep disorder, the diagnosis of the individual, their compliance with using the blanket and the effects on sleep routines, as well as changes in other physical or psychological response. All children received single 6 kg blankets.

Sleep characteristics reported by the parents included: Difficulties in falling asleep (DFA), numerous wakeups (NW), all night sleep (ANS), and 1 or more wakeups during the night (XW).

 

Results:

Twenty one children (age range 6.5-18yr) with either ASD (n=15), ADHD (n=2), CP (n=1) or insomnia not otherwise diagnosed (n=3) with severe and chronic forms of insomnia, received 6 kg single WB. In practically all cases there was a rapid and immediate improvement, in most cases resulting in all night sleep (n=16), fewer wakeups (n=1) and a single wakeup (n=4). There was not a single case experiencing no response. In 8 cases the parents reported improvement in neuropsychological functioning and in 5 children the sedatives could be discontinued (Table).

 

Discussion:

Studies based on polysomnographic data and parental reports indicate reduction in total sleep time and more undifferentiated sleep in ASD. Both pharmacological and behavioral interventions have been tried for ASD in children. Among medications, melatonin has gained more evidence of safety, alone or in conjunction with behavioral therapy.

Weighted blankets have been shown effective for insomnia in psychiatric patients using the Insomnia Severity Index with large effect size (Cohen d 1.9) [8]. During a 12 month open follow up phase, participants chose to continue the WB maintaining the effect of sleep. Importantly, the improved sleep was associated with improvement in daytime symptoms and levels of activity[8].

Experience with WB for ASD induced insomnia is relatively sparse. In 2014 Gringras and colleagues reported the results of a randomized crossover controlled trial where a commercially available WB was compared to regular blankets in 73 ASD children[7]. Using objective measures, the primary endpoint was total sleep time measured by actigraphy over each 2-week periods. Secondary endpoints included actigraphically- recorded sleep onset latency, sleep efficiency, assessment of child behavior, family functioning and adverse events.

In Gringras’ study the total sleep time was not different between the two treatment periods (452.8 +/- 65 min. with WB vs. 455+/- 65.8 min. with control blanket when using actigraph, nor were there differences in parents’ sleeping diaries [528 (127.1) min.vs 513(154)] min. outcomes. Surprisingly and statistically different , the WB was favoured by both parents and children. The parents marked the WB significantly higher: The WB was ranked “very much better” in 15% vs. only in 1% of controls”much better “ in 36% vs. 15%; ) and 35% were calmer with WB, vs only 14% with the control blankets. The authors summarized that “ WB did not help in sleep of ASD for longer period of time, or falling asleep faster”[7].

The children randomized by Gringras et al appeared to enjoy on average 7-8 hours of sleep, much better than our cohort of children, suggesting that our patients suffered a worse level of insomnia.  In our series of 21 children, mostly with ASD, there was a dramatic improvement in total sleep time, in induction of sleep or in both in all cases.  In most cases the children responded to the WB with ability to sleep the whole night. There was no case with lack of response, and in a single case where a young child did not comply with staying under the blanket, but once he fell asleep he was covered with the WB and enjoyed a whole night sleep. Our study was based on parental reports and we did not conduct somnographic measurements. We believe that these parental reports are accurate, as the described sleep disorders have been a major challenge to these families, and the majorly disrupted sleep patterns had immense impact on the parents too, affecting their wellbeing. Indeed, the improvement in their children’s sleep is mentioned by many of them as a miracle for both the children and themselves.

 

The weighted blanket in Gringras’ study weighed 2.25 kg (small) or 4.5 kg (large) Although the authors were aware that blinding child and parent to the different weights of study and control blanket was impossible, they matched the control blankets by size, color, and texture of the material

Two sizes of blankets (small: 147 × 76 cm; large: 152 × 152 cm) according to the size of child were used, consistent with recommendations by manufactures and therapists.

In our present series all children received 6kg WB, which is substantially heavier than Gringras’ choice, despite similar age distribution (8.7 -9.9 yr. mean age in Gringras vs. 9.7 yr. in our series), and in none of them were there reported adverse effects.

Following Gringras’ study no further comparative trials in children were reported, and it is possible that the narrow interpretation of Gringras’ results caused clinicians to write this method off as non- effective. In a recent meta- analysis of sleep-based interventions for children with ASD, Cuomo et al summarized that no single intervention is effective across all sleep problems in children with ASD[9]. However, melatonin, behavioral interventions, and parent education/education program interventions appear the most effective at ameliorating multiple domains of sleep problems compared with other interventions. WB were not found to be effective.

Our study suggests that there is a dose-dependent effect of WB, which can explain the dramatic differences from Ginras’ RCT who used 2.5-4.5 kg WB, as compared to 6kg by the present series. Moreover, Gringras’ summary, based on their objective measures of effectiveness clearly downplayed the significant effect on subjective reports by both parents and children.

More studies are needed with higher weights of WB, as this method has the potential of substantial improvement in sleep among children, mostly ASD, with severe sleep disorders.

 

References:

1)      Melzer L, Johnson C, Crosette J, et al. Prevalence of diagnosed sleep disorders in pediatric primary care practices. Pediatrics 2020;125:e1410-18

2)      Mindell JA, Kuhn BR, Lewin DS et al. Behavioral treatment of bedtime problems and night waking in infants and young children. Sleep 2006; 29:1263- 76

3)      Miano S, Ferri R. Epidemiology and management of insomnia in children with autistic spectrum disorders. Ped Drugs 2010;12;75-84

4)      Owens JA, Babcock D, Blumer J et al. The use of pharmacotherapy in the treatment of pediatric insomnia in mrimary care: rational approaches. A consensus meeting summary. J Clin Sleep Med. 2005;1;49-59

5)      Ackerley b, Badre G, Olausson H. Positive effects of a weighted blanket on insomnia. 2015;2:1022 J Sleep Med Disord

6)      Eron K, Kohnert L, Watters A, et al. Weighted blanket use: a systematic review. Am J Occup Ther 2020; 74:74(2) DOI 10.5014/ajot.2020.037358

7)      Gringras P, Green D, Wright B, et al. Weighted blankets and sleep in autistic children- a randomized controlled trial. Peditrics 2014; 134: 298-306

8)      Ekholm B, Spulber S, Adler M. A randomized control study of weighted chain blankets for insomnia in psychiatric disorders. J Clin Sleep Med 2020;m16:1567-77

9)      Cuomo BM, Vaz S, Lee BAL et al. Effectiveness of Sleep‐Based Interventions for Children with Autism Spectrum Disorder: A Meta‐Synthesis.  Pharmacotherapy 2017;  https://doi.org/10.1002/phar.1920S

 

 

 

Table: Study cohort, demographics and response to Weighted blankets

sex age weight Diagnosis* Blanket Weight (Kg) Sleep before* Sleep after* Comments
F 12 40 ASD 6 DFA;NW ANS
M 7 35 ASD 6 DFA;NW ANS
M 9 32 ASD 6 DFA;NW 1WN
M 10 34 ASD 6 DFA;NW 1WN
M 11 31 ASD 6 DFA;NW IWN
F 6.5 31 ASD 6 NW ANS Improvement in concentration and learning
F 12 50 ASD 6 NW ANS Decrease in sedatives
F 7 33 ASD 6 DFA;NW Fewer wakeups (3-4)
M 11 32 ASD 6 NW ANS Less aggressive;calmer
M 11 40 ADHD 6 DFA; NW ANS Improved functioning
F

 

18 60 Insomnia 6 NW ANS Calmed; no fatigue
F 10 35 Insomnia 6 NW ANS Calmed and happier, lowered sedative pills
F 8 30 ASD 6 NW ANS
F 12 27 ASD 6 NW ANS Initially -refused the blanket; when put on her after falling asleep- works effectively
F 10 25 CP 6 DFA;NW ANS Can sleep with extended torso
F 7 25 insomnia 6 NW 1WN
F 3.5 15 ASD 6 NW ANS d/c sedatives
F 16 50 ADHD 6 DFA-NW ANS Better functioning during the day
M 14 40 ASD 6 DFA-NW ANS On methylphenidate
M 9 33 ASD 6 DFA-NW ANS To wake up- the WB is changed to regular blanket. d/c sedatives
M 11 28 ASD 6 DFA-NW ANS To wake up- the WB is changed to regular blanket. d/c sedatives

 

 

 

 

*

DFA- Difficulties in falling asleep

NW- Numerous wakeups

ANS- All night sleep

ASD- Autism spectrum behaviour

CP- Cerebral palsey

ADHD- Attention deficit hyperactivity disorder

1W 1 wakeup during the night, returned to sleep