Sleep Problems for Youth with Autism: Common, Treatable, At Times Challenging 7/6/22

Sleep disturbances are common among children and adolescents with Autism Spectrum Disorder (ASD). Up to 80% of parents in one review of youth with ASD reported prolonged sleep disturbances (Malow et al., 2016).  Many studies have explored epidemiology, phenomenology and treatment strategies for insomnia in children with ASD or other neurodevelopmental or psychiatric disorders. While primary care providers, neurologists and child psychiatrists employ disparate treatment approaches (Bruni et al., 2018), the recent literature supports the following key points.

  • Educating about sleep is the first step. This includes creating predictable routines, minimizing screen time and other basics of sleep hygiene.   SmartCare Current Topics in Autism lecture has useful information  for families.  https://www.youtube.com/watch?v=tUjYD7oci-8
  • Prior to initiating treatment, clinicians should assess for co-morbidities and iatrogenic causes of sleep disturbance, including medications. (Buckley et al., 2020)
  • Behavioral interventions are first line. No one approach fits all children, but there are many options to consider.
    • Adjust sleep setting (dark, non-stimulating, no electronics).
    • Promote self-soothing skills.
    • Avoid naps four hours prior to sleep.
    • Consider “bedtime fading” – parents delay bedtime by 30 minutes, then move bedtime earlier and earlier over several days.
    • Increase daytime light exposure in the morning.
    • Use graduated extinction of disruptive nighttime behaviors – parents allow incrementally more time before comforting, with incrementally shorter periods of comfort. Or alternatively, parent stays in the room but provides little interaction.
    • Referral to therapist who can provide cognitive behavioral therapy (CBT) for sleep.
  • For children who continue to have difficulty despite parent education and behavioral interventions, Melatonin is the first line pharmacologic treatment
    • Melatonin has the most robust evidence for children with ASD, is safe and effective, and prolonged release may be the most effective formulation.
    • Side effects are minimal, though there is ongoing research about the impact of altered endocrine physiology associated with long-term use in animal models.
  • In general, some children taking medications for sleep may have worse daytime behavior than children not taking sleep medications, while for others poor sleep can lead to more challenges in functioning (Malow et al., 2016).
  • Second-line medications with some evidence in the literature include alpha agonists, such as clonidine and anti-histamines, such as diphenhydramine or hydroxyzine. There are fewer studies supporting these, and they are associated with more sedation.

Bruni, O., Angriman, M., Calisti, F., Comandini, A., Esposito, G., Cortese, S., & Ferri, R. (2018). Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities. In Journal of Child Psychology and Psychiatry and Allied Disciplines (Vol. 59, Issue 5, pp. 489–508). Blackwell Publishing Ltd. https://doi.org/10.1111/jcpp.12812

Gringras, P., Nir, T., Breddy, J., Frydman-Marom, A., & Findling, R. L. (2017). NEW RESEARCH Efficacy and Safety of Pediatric Prolonged-Release Melatonin for Insomnia in Children with Autism Spectrum Disorder (Vol. 56). www.jaacap.org

Lalanne, S., Fougerou-Leurent, C., Anderson, G. M., Schroder, C. M., Nir, T., Chokron, S., Delorme, R., Claustrat, B., Bellissant, E., Kermarrec, S., Franco, P., Denis, L., & Tordjman, S. (2021). Molecular Sciences Melatonin: From Pharmacokinetics to Clinical Use in Autism Spectrum Disorder Melatonin: From Pharmacokinetics to Clinical Use in Autism Spectrum. Disorder. Int. J. Mol. Sci, 22, 1490. https://doi.org/10.3390/ijms

Malow, B. A., Katz, T., Reynolds, A. M., Shui, A., Carno, M., Connolly, H. v., Coury, D., & Bennett, A. E. (2016). Sleep difficulties and medications in children with Autism spectrum disorders: A registry study. Pediatrics, 137, S98–S104. https://doi.org/10.1542/peds.2015-2851H

McDonagh, M. S., Holmes, R., & Hsu, F. (2019). Pharmacologic Treatments for Sleep Disorders in Children: A Systematic Review. Journal of Child Neurology, 34(5), 237–247. https://doi.org/10.1177/0883073818821030

Ming, X., Gordon, E., Kang, N., & Wagner, G. C. (2008). Use of clonidine in children with autism spectrum disorders. Brain and Development, 30(7), 454–460. https://doi.org/10.1016/j.braindev.2007.12.007

Williams Buckley, A., Hirtz, D., Oskoui, M., Armstrong, M. J., Batra, A., Bridgemohan, C., Coury, D., Dawson, G., Donley, D., Findling, R. L., Gaughan, T., Gloss, D., Gronseth, G., Kessler, R., Merillat, S., Michelson, D., Owens, J., Pringsheim, T., Sikich, L., … Ashwal, S. (2020). Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 94(9), 392–404. https://doi.org/10.1212/WNL.0000000000009033

 

 

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