Addressing Sleep Issues in Children, Teens With Autism

In new guidelines issued today by the American Academy of Neurology (AAN), researchers provide sleep intervention recommendations to families, neurologists, and other healthcare providers in making decisions on the best treatments available for children and teens with autism spectrum disorder (ASD).¹

Published in the journal Neurology, lead guideline author Ashura Buckley, MD, pediatric neurologist and sleep medicine research physician at the Intramural Research Program at the National Institute of Mental Health, highlights that while sleep issues are prominent in children and teens, up to 40%, these issues usually subside with age, contrary to that found in people with ASD.

"For children and teens with autism, sleep problems are more common and more likely to persist, resulting in poor health and poor quality of life. Some sleep problems may be directly related to autism, but others are not. Regardless, autism symptoms may make sleep problems worse," said Buckley.

Sleep problems are a common comorbidity for children with autism, contributing to difficulties initiating and maintaining sleep, frequent and prolonged night awakenings, irregular sleep—wake patterns, short sleep duration, and early-morning waking. In a study published in Pediatrics, researchers suggested that nearly 80% of autistic preschoolers have disrupted sleep, a figure representing a risk more than twice as common as that found in the general population or those with other developmental conditions not characteristic of ASD.²

Maintaining optimal sleep is vital for those with ASD as sleep disturbances can exacerbate core and associated condition features, such as communication deficits and restrictive, repetitive behaviors. To address this underlying issue, researchers from AAN sought to develop recommendations based on current pharmacologic and nonpharmacologic strategies for treating sleep disturbances in children and adolescents with ASD.

Study authors conducted a systematic review including studies on ASD and sleep problems in children and teens, aged ≤ 18 years, through December 2017. Based off review findings, researchers indicated 4 notable types of sleep problems in those with ASD:

• Refusing to go to bed, stalling, or needing a parent or caregiver present until the child falls asleep
• Trouble falling asleep and staying asleep
• Sleeping for only short periods of time or not getting enough total sleep each night
• Daytime behavior problems associated with insufficient sleep at night

Study authors recommended that when sleep problems occur in patients with ASD, healthcare providers should first identify if these issues are caused by medications or other medical conditions. As individuals with ASD are more likely to use medications that disrupt normal sleep patterns (anti-seizure medicines, psychotropic medication), determining whether prescribed medications are the primary reason would ameliorate potential delays in exploring further treatments.

The use of behavior-modification strategies were the next recommendation by researchers if sleep issues appear to be more influenced by environment and family factors. "Behavior-modification strategies are a good place to start because they do not cost anything, there are no side effects and they have been shown to work for some people," said Buckley.

Strategies such as consistent sleep routine with regular bedtimes and wake times, choosing a bedtime close to when the child usually gets sleepy, and not allowing use of electronic devices like computers or televisions close to bedtime, were noted as being effective in children with ASD.

If both prior recommendations do not apply to an individual with ASD, study authors additionally recommended the use of melatonin, whether in addition to or without behavioral therapy. The review found that melatonin use alone may be just as helpful in some patients as when melatonin is combined with behavioral strategies.

While prior studies have shown that the combination of behavioral therapy and melatonin did not change daytime behavior problems or symptoms of ASD in the short term, study authors highlight that more research is needed to determine long-term safety of melatonin as possible side effects include headache, dizziness, diarrhea, and rash. Delineating the form of melatonin is key to effective care as well, with over-the-counter versions representing an unreliable efficacy. Using melatonin products labeled, “pharmaceutical grade,” was recommended by researchers.

As sleep issues can intensify symptom exacerbations for patients with ASD, Buckley stressed the importance of “parents and caregivers to work with healthcare providers to find a way to improve a child's sleep because we know that good quality sleep can improve overall health and quality of life in all children.”

Reference

1. 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 [published online February 12, 2020]. Neurology. doi: 10.1212/WNL.0000000000009033.
2. Reynolds AM, Soke GN, Sabourin KR, et al. Sleep problems in 2- to 5-Year-Olds with autism spectrum disorder and otherdevelopmental delays [published online February 11, 2019]. Pediatrics. doi: 10.1542/peds.2018-0492.