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

A community-based sleep educational intervention for children with autism spectrum disorder

BACKGROUND

Sleep problems are common in children with autism spectrum disorder (ASD). Sleep education, effective in improving sleep in ASD, may be difficult to access. We determined if community-based pediatric therapists could successfully deliver sleep educational interventions to caregivers of children with ASD.

METHODS

A seven-week feasibility study was conducted consisting of 10 children and caregivers. This feasibility study informed the development of a 16-week preliminary effectiveness study, which consisted of 33 children and caregivers. Children, ages 2-12 years, with a clinical diagnosis of autism and caregiver-reported sleep onset delay of 30 min were included. Community therapists underwent comprehensive training in sleep education and then met with caregiver participants to provide sleep education to each family. Semi-structured qualitative interviews were conducted with all families who completed study procedures.In the feasibility and preliminary effectiveness studies, child participants wore an actigraphy watch (at baseline and after sleep education) and caregivers completed the Child Sleep Habits Questionnaire and Family Inventory of Sleep Habits at baseline and after sleep education; the Child Behavior Checklist was also completed by caregivers in the preliminary effectiveness study.

RESULTS

Educator fidelity to the manualized curriculum was maintained. Caregivers showed appropriate understanding, comfort, and implementation of the curriculum. Qualitative and quantitative measures, including caregiver surveys and actigraphy, showed improvements in child sleep and behavior.

CONCLUSIONS

Community-based therapists can successfully deliver sleep education to families of children with ASD, which has favorable implications for improving access to care in this population.

Autism Spectrum Disorder and Sleep

Children and adolescents with autism spectrum disorder (ASD) experience sleep disturbances, particularly insomnia, at rates much higher than the general population. Daytime behavioral problems and parental stress are associated with the resultant sleep deprivation. Behavioral interventions, parental education, and melatonin are effective treatments. The epidemiology of sleep disturbances in youth with ASD is reviewed in this article as well as the latest in treatments.

Drug Treatment of Epilepsy Neuropsychiatric Comorbidities in Children

There is increasing recognition that epilepsy can be associated with a broad spectrum of comorbidities. While epileptic seizures are an essential element of epilepsy in children, there is a spectrum of neurological, mental health and cognitive disorders that add to the disease burden of childhood epilepsy resulting in a decreased quality of life. The most common comorbid conditions in childhood epilepsy include depression, anxiety, autism spectrum disorders, sleep disorders, attention deficits, cognitive impairment, and migraine. While epilepsy can result in comorbidities, many of the comorbidities of childhood have a bi-directional association, with the comorbid condition increasing risk for epilepsy and epilepsy increasing the risk for the comorbid condition. The bidirectional feature of epilepsy and the comorbidities suggest a common underlying pathological basis for both the seizures and comorbid condition. While recognition of the comorbid conditions of pediatric epilepsies is increasing, there has been a lag in the development of effective therapies partly out of concern that drugs used to treat the comorbid conditions could increase seizure susceptibility. There is now some evidence that most drugs used for comorbid conditions are safe and do not lower seizure threshold. Unfortunately, the evidence showing drugs are effective in treating many of the childhood comorbidities of epilepsy is quite limited. There is a great need for randomized, placebo-controlled drug trials for efficacy and safety in the treatment of comorbidities of childhood epilepsy.

Neurodevelopmental Disorders Commonly Presenting with Sleep Disturbances

There are multiple disorders of neurodevelopment that present with co-occurring sleep disturbances. Many of these neurodevelopmental disorders (NDD) include sleep disturbances in their diagnostic criteria. Neurobiological, genetic, and environmental factors overlap to cause different sleep disorders in individuals with NDD. Caregivers often present reporting either insomnia or hypersomnia, and based on the clinical history and findings from diagnostic tests, an appropriate diagnosis can be made. It is crucial that clinicians understand the different presentations of sleep disturbances in individuals with NDD.

Challenges in Treating Children With Autism Spectrum Disorder: Implications for Psychiatric-Mental Health Nurse Practitioners

Children who present to behavioral health care with autism spectrum disorder (ASD) often have overlapping symptoms and co-occurring disorders, such as attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, sleep-wake disorders, and/or emotional/behavioral dysregulation. The challenge for psychiatric-mental health nurse practitioners is to identify the modifiable symptoms and diagnosable disorders and develop a comprehensive treatment plan that reduces risk factors and promotes improved functioning. The current article presents an overview of evidence-based treatment strategies for co-occurring conditions. A child- and family-based collaborative approach with clear treatment goals in the context of an inter-professional care team, which includes the primary care provider, therapists, other relevant specialists, and teachers, has been shown to support children with ASD in becoming more successful in managing everyday stressors and regulating emotions and behaviors. Evidence-based assessment, monitoring, and educational resources for clinicians and parents are provided. [Journal of Psychosocial Nursing and Mental Health Services, 58(12), 7-12.].

Efficacy and safety of supplemental melatonin for delayed sleep-wake phase disorder in children: an overview

Delayed sleep–wake phase disorder (DSPD) is the most frequently occurring intrinsic circadian rhythm sleep–wake disorder, with the highest prevalence in adolescence. Melatonin is the first-choice drug treatment. However, to date melatonin (in a controlled-release formulation) is only authorised for the treatment of insomnia in children with autism or Smiths-Magenis syndrome. Concerns have been raised with respect to the safety and efficacy of melatonin for more general use in children, as melatonin has not undergone the formal safety testing required for a new drug, especially long-term safety in children. Melatonin is known to have profound effects on the reproductive systems of rodents, sheep and primates, as well as effects on the cardiovascular, immune and metabolic systems.

The objective of the present article was therefore to establish the efficacy and safety of exogenous melatonin for use in children with DSPD, based on in vitro, animal model and clinical studies by reviewing the relevant literature in the Medline database using PubMed.

Acute toxicity studies in rats and mice showed toxic effects only at extremely high melatonin doses (>400 mg/kg), some tens of thousands of times more than the recommended dose of 3–6 mg in a person weighing 70 kg. Longer-term administration of melatonin improved the general health and survival of ageing rats or mice. A full range of in vitro/in vivo genotoxicity tests consistently found no evidence that melatonin is genotoxic. Similarly long term administration of melatonin in rats or mice did not have carcinogenic effects, or negative effects on cardiovascular, endocrine and reproductive systems.

With regard to clinical studies, in 19 randomised controlled trials comprising 841 children and adolescents with DSPD, melatonin treatment (usually of 4 weeks duration) consistently improved sleep latency by 22–60 min, without any serious adverse effects. Similarly, 17 randomised controlled trials, comprising 1374 children and adolescents, supplementing melatonin for indications other than DSPD, reported no relevant adverse effects. In addition, 4 long-term safety studies (1.0–10.8 yr) supplementing exogenous melatonin found no substantial deviation of the development of children with respect to sleep quality, puberty development and mental health scores. Finally, post-marketing data for an immediate-release melatonin formulation (Bio-melatonin), used in the UK since 2008 as an unlicensed medicine for sleep disturbance in children, recorded no adverse events to date on sales of approximately 600,000 packs, equivalent to some 35 million individual 3 mg tablet doses (MHRA yellow card adverse event recording scheme).

In conclusion, evidence has been provided that melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in children, provided that it is administered at the correct time (3–5 h before endogenous melatonin starts to rise in dim light (DLMO)), and in the correct (minimal effective) dose. As the status of circadian rhythmicity may change during long-time treatment, it is recommended to stop melatonin treatment at least once a year (preferably during the summer holidays).

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Melatonin improves sleep onset without serious adverse effects in youths with DSPD. Change th text after the fourth bullet into: Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin for indications other than DSPD, dose not cause relevant adverse effects.

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Long term melatonin treatment does not impair sleep, puberty, and mental health.

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Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin should be administered at the correct time and in the minimal effective dose.

Sleep-Wake Disorders in Childhood

PURPOSE OF REVIEW

The presentation of sleep issues in childhood differs from the presentation in adulthood and may be more subtle. Sleep issues may affect children differently than adults, and distinct treatment approaches are often used in children.

RECENT FINDINGS

Sodium oxybate was approved by the US Food and Drug Administration (FDA) in October 2018 for an expanded indication of treatment of sleepiness or cataplexy in patients with narcolepsy type 1 or narcolepsy type 2 aged 7 years or older, with side effect and safety profiles similar to those seen in adults. Restless sleep disorder is a recently proposed entity in which restless sleep, daytime sleepiness, and often iron deficiency are observed, but children do not meet the criteria for restless legs syndrome or periodic limb movement disorder.

SUMMARY

Children's sleep is discussed in this article, including normal sleep patterns and effects of insufficient sleep. Sleep disorders of childhood are reviewed, including insomnia, obstructive sleep apnea, restless legs syndrome, parasomnias, narcolepsy, and Kleine-Levin syndrome. Children with neurologic issues or neurodevelopmental disorders frequently have sleep disorders arising from an interaction of heterogeneous factors. Further attention to sleep may often be warranted through a polysomnogram or referral to a pediatric sleep specialist. Sleep disorders may cause indelible effects on children's cognitive functioning, general health, and well-being, and awareness of sleep disorders is imperative for neurologists who treat children.

Behavioural Treatments for Sleep Problems in Children with Autism Spectrum Disorder: a Review of the Recent Literature

PURPOSE OF REVIEW

Behavioural sleep problems in children with autism spectrum disorder (ASD) are common and burdensome for both the child and their family. We provide an up-to-date review on behavioural sleep interventions and their core features and conclude with expert recommendations regarding the modification of interventions for children with ASD.

RECENT FINDINGS

In the past 3 years, four original research studies (n ≥ 10) have evaluated behavioural sleep interventions for children with ASD (one RCT, three pre-post studies). All four studies reported significant improvements across various sleep outcomes and daytime behaviours. The interventions varied, however, in assessment comprehensiveness, nature of implementation support, length and delivery of intervention, outcome measurements, and follow-up periods. Clinically, behavioural sleep interventions are regarded as the first-line of treatment for sleep problems experienced by children with ASD. However, there is still much to be learnt regarding their clinical effectiveness.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.

Complementary and Alternative Treatments for Autism Spectrum Disorders: A Review for Parents and Clinicians

Complementary and alternative therapy (CAT) methods for children with autism spectrum disorders (ASD) are widespread in European countries and the Russian Federation; however, their efficacy and safety is not routinely considered by parents and clinicians when recommended or used. The current narrative review presents the most widely known CAT interventions for children with ASD synthesizing data from meta-analyses, systematic reviews, and randomized controlled trials obtained from the PubMed database based on the safety-efficacy model. We have found that, of the reviewed CATs, only the melatonin intervention can be considered safe and effective for children with ASD with comorbid sleep problems. The methods that were classified as safe but had inconclusive efficacy are recommended to be implemented only when they do not interfere with front line treatment for ASD, Applied Behavior Analysis (ABA). Methods with the lack of current evidence for the efficacy such as auditory integration therapies, bioacoustic correction, sensory integration therapy, micropolarization, animal assisted therapy, and dietary interventions should not be recommended as alternative treatments and can only be used as complimentary to ABA-based interventions. We advise against the use of chelation, hyperbaric oxygen therapy, and holding therapy due their documented harmful psychological and physical effects. When considering CAT for ASD we recommend parents and clinicians use the criteria suggested by Lofthouse and colleagues [59]: only the therapies that are safe, easy, cheap, and sensible can be recommended and used, as opposed to therapies that are risky, unrealistic, difficult, or expensive that should not be recommended or utilized.