In a new guideline from the American Academy of Neurology (AAN), a multidisciplinary panel offers recommendations on the use of behavioral, nutraceutical, and complementary and alternative medicine (CAM) interventions for improving bedtime resistance, sleep onset latency, sleep continuity, total sleep time, and daytime behavior in children and adolescents with autism spectrum disorder (ASD). The full guideline was published in Neurology.

Assess Coexisting Medical Conditions and Concomitant Medications

Many children and adolescents with sleep disturbances and autism have coexisting conditions that contribute to poor sleep. Additionally, these patients are more likely to take medications that disrupt normal sleep patterns, such as stimulants.

Clinicians are encouraged to perform an assessment of pediatric patients’ coexisting conditions and their use of concomitant medications. Identifying conditions and/or medications that may be contributing to the sleep dysregulation can assist in designing a plan of action or alternative management strategy to address the associated sleep disturbances.

Medications potentially contributing to sleep disturbances should be reviewed, and clinicians and patients and their caregivers should discuss whether these medications should be stopped or adjusted.

Explore Behavioral Strategies

Several environmental and family factors contribute to sleep disturbances in children with ASD. Clinicians are encouraged to recommend or provide counseling to parents or guardians regarding strategies for improving sleeping habits, including first-line behavioral strategies. Behavioral strategies may be used either alone or with pharmacologic or nutraceutical strategies.

Currently, there are not a substantial number of studies that have investigated the effect of parental education and behavioral strategies for improving sleep in children and adolescents on the autism spectrum. In this AAN guideline, the panel recommends that parents impose a set bedtime and wake-up time for their child with ASD and ignore behavior that occurs following the bedtime and prior to the wake-up time.

Additionally, parents are recommended to ignore bedtime resistance that is either fixed or becomes progressively longer. Instead, it is recommended that parents respond with brief verbal reassurance that does not reinforce the resistant behavior.

Parents can also develop and adhere to regular and consistent pre-bed calming rituals for their child. In addition, parents could try to place their child in bed close to the time that child usually falls asleep. A family-based cognitive behavioral therapy program with or without melatonin may also be helpful, according to some studies. The AAN writing committee explained that the successful application of the recommended behavioral techniques will require a clinician who is knowledgeable and can motivate parents to implement these approaches consistently, despite inevitable challenges.

Use of Melatonin

Melatonin is an over-the-counter therapy for managing insomnia and sleep disturbances that may provide utility for children and adolescents with ASD. In cases where behavioral strategies have not proved to be successful, the AAN guideline recommends that clinicians offer melatonin to pediatric patients with ASD and sleep problems. In cases where contributing coexisting conditions and concomitant medication use have been addressed and have not alleviated sleep issues, melatonin could also be offered. Clinicians are recommended to write a prescription for melatonin or recommend a high-purity pharmaceutical-grade melatonin, when available.

In children and adolescents with ASD, the AAN guideline recommends offering melatonin at a starting low dosage of 1 mg/d to 3 mg/d, taken 30 to 60 minutes before bedtime. Doses can be titrated to effect without exceeding 10 mg/d. When appropriate, children and adolescents with ASD and sleep disturbances should be counseled by clinicians on the use of melatonin, and parents should know and understand the potential adverse events of this supplement. Parents should be made aware of the lack of long-term safety data of melatonin use in this patient population.

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Complementary and Alternative Medicine

Many families of children and adolescents with ASD seek CAM therapies. Sound-to-sleep (STS) mattress technology, a studied CAM strategy, may improve the percentage of time spent asleep while in bed, but there is no evidence to suggest this technology is effective for drastically reducing sleep disturbances in children and adolescents on the autism spectrum. There is also insufficient evidence to support STS mattress technology for improving daytime behavior in these patients. Evidence for weighted blankets, another nonpharmacologic CAM approach, has also not successfully proved superiority over control blankets.

Clinical Context of Recommendations

Sleep disruption can increase behavioral problems and reduce overall health in children and adolescents with autism. This guideline provides valuable utility in that it may help clinicians in the identification, evaluation, and successful management of these patients.

While several evidence-based treatments were explored and recommended in this guideline, none of the identified studies examined pharmacologic approaches for sleep dysregulation in children and adolescents on the autism spectrum, limiting the guideline’s approach to managing these patients with a standardized medication strategy. Regardless, the low rates of adverse effects associated with the recommended strategies make this guideline a potentially helpful resource for pediatric healthcare providers in clinical practice.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Buckley AW, Hirtz D, Oskoui M, et al. 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. 2020;94:393-405. doi: 10.1212/WNL.0000000000009033