Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial

Melatonin use in managing insomnia in children with autism and other neurogenetic disorders - An assessment by the international pediatric sleep association (IPSA)

Though it is widely prescribed for improving sleep of children with autism and other neurogenetic disorders, there is a need for practical guidance to clinicians on the use of melatonin for managing insomnia in this population. Because data were either lacking or inconclusive, a task force was established by the International Pediatric Sleep Association (IPSA) to examine the literature based on clinical trials from 2012 onwards. A summary of evidence pertaining to melatonin's utility and potential side effects, practice-related caveats, and insights for use are published herewith.

Immediate effects of Ramadan on objective time asleep in male youth football players from the Middle East: an interrupted time-series study

OBJECTIVE

To examine the abrupt effects of Ramadan onset on actigraphy-based time asleep in male youth Muslim football players.

METHODS

We adopted a quasi-experimental, interrupted time-series research design and tracked objective time asleep over a minimum of 12 consecutive nights in the two weeks prior to and immediately after Ramadan onset, respectively. Twenty-two, male academy student-athletes (chronological age range: 12.6 to 16.2 years) participated in the study (464 individual observations). Segmented generalized mixed-effects modelling estimated the effects of Ramadan onset on time asleep during the first period of night sleep only.

RESULTS

Ramadan onset led to an immediate mean reduction of 89 min (95% confidence interval [CI], 54 to 123 min) in time asleep during the first period of night sleep compared to pre-Ramadan sleep patterns. Model-adjusted estimated marginal means for time asleep were ~ 5.7 h (95%CI, 5.1 to 6.2 h) before and ~ 4.2 h (95%CI, 3.6 to 4.7 h) after Ramadan onset. Night sleep interruptions resulting in two or more fragmented periods accounted for 8% (95%CI, 2 to 21%) to 19% (95%, 11 to 29%) of sleep observations before and after Ramadan onset, respectively.

CONCLUSIONS

The onset of Ramadan determined an abrupt reduction in time asleep of ~ 1 h 30 min in the first period of a night cycle and contributed to additional problems of heterogeneous sleep fragmentation that can impact optimal school learning and youth athlete performance development processes.

Treatment for behavioral insomnia in young children with neurotypical development under 6 years of age: A systematic review

This literature review examines all treatments for behavioral insomnia in children under 6 years of age to determine which treatments have empirically demonstrated efficacy. Following PRISMA guidelines, three databases were investigated (Pubmed, Cochrane and Psychinfo) to select randomized controlled trials (RCTs) which assess treatments for behavioral insomnia in children under 6 years of age, all with neurotypical development. A total of 908 articles met the search criteria. 21 articles were selected and analyzed in their entirety for a total of 2363 children (ranging from 2 months to 6 years of age). Based on these studies, treatment of behavioral insomnia in young children under 6 years of age is primarily based on behavioral therapy. There is no evidence that pharmacological treatments are effective in the long term for neurotypical children. This review highlights the lack of RCTs in this field: new RCTs should be carried out among young children to refine and optimize the therapeutic approach and to address the risk of therapeutic abuse through the use of non-scientifically validated methods.

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.

Off-label psychopharmacological interventions for autism spectrum disorders: strategic pathways for clinicians

The prevalence of autism spectrum disorder (ASD) continues to see a trend upward with a noticeable increase to 1 in 36 children less than 8 years of age in the recent MMWR. There are many factors linked to the substantially increased burden of seeking mental health services, and clinically these individuals are likely to present for impairments associated with co-occurring conditions. The advances in cutting-edge research and the understanding of co-occurring conditions in addition to psychosocial interventions have provided a window of opportunity for psychopharmacological interventions given the limited availability of therapeutics for core symptomatology. The off-label psychopharmacological treatments for these co-occurring conditions are central to clinical practice. However, the scattered evidence remains an impediment for practitioners to systematically utilize these options. The review collates the crucial scientific literature to provide stepwise treatment alternatives for individuals with ASD; with an aim to lead practitioners in making informed and shared decisions. There are many questions about the safety and tolerability of off-label medications; however, it is considered the best practice to utilize the available empirical data in providing psychoeducation for patients, families, and caregivers. The review also covers experimental medications and theoretical underpinnings to enhance further experimental studies. In summary, amidst the growing clinical needs for individuals with ASD and the lack of approved clinical treatments, the review addresses these gaps with a practical guide to appraise the risk and benefits of off-label medications.

Mind and skin: Exploring the links between inflammation, sleep disturbance and neurocognitive function in patients with atopic dermatitis

Atopic dermatitis (AD) is a chronic, pruritic and inflammatory, dry skin condition with many known comorbidities. These include airway disease, food allergies, atopic eye disease and autoimmune conditions. Furthermore, there is often significant sleep disturbance as well as increased psychological distress and mental health problems. Severe AD therefore often has a significant impact on the quality of life of both patients and their families. In this review we discuss recent findings on the putative links between AD, its association with itch, sleep disturbance and neuropsychiatric morbidity, including the role of inflammation in these conditions. Itch was thought to predominantly drive sleep disruption in AD. We now understand changes in sleep influence immune cell distribution and the associated inflammatory cytokines, which suggests a bidirectional relationship between AD and sleep. We also increasingly recognize inflammation as a key driver in psychological symptoms and disorders. The link between cutaneous, systemic and possible brain inflammation could at least in part be driven by the sleep deprivation and itch-driven neuronal proliferation seen in AD.

An online survey among general pediatricians on melatonin use in children with chronic insomnia

OBJECTIVES

Although melatonin (MLT) is the molecule most used by pediatricians for sleep problems, scarce evidence exists on its use in healthy pediatric population. The objective of this study was to describe MLT use by Italian pediatricians in healthy children with chronic insomnia.

STUDY DESIGN

A cross-sectional open survey was administered to Italian pediatricians, between June and November 2022, collecting information about their use of MLT in healthy children: age range of patients, dosages used, time of administration, duration of treatment, association with other treatments, perceived efficacy, and side effects. Data were reported as frequencies with their respective 95% confidence intervals. Chi-square statistics assessed significant differences between pediatricians who had training in pediatric sleep and those who did not.

RESULTS

Among 428 respondents, 97.4% of pediatricians used MLT; 87.3% of them prescribed MLT in children aged 1-2 years, 62.1% in 2-5 years and 42.5% in 10-18 years. 84.9% of them suggested to take MLT 30 min before bedtime. 37.9% indicated to continue treatment for one month, 30.2% for 2-3 months. 74.1% of pediatricians usually prescribed MLT 1 mg/day. The most frequent treatment associated with MLT was sleep hygiene (85.4%). Almost all pediatricians found MLT effective in reducing difficulties falling asleep. Only 3.2% of them reported mild side effects.

CONCLUSIONS

MLT is widely prescribed by Italian pediatricians, but no consensus exists about its use in typically developing children. There is a need for clear guidelines to optimize the use of MLT in healthy children.

Enabling endpoint development for interventional clinical trials in individuals with Angelman syndrome: a prospective, longitudinal, observational clinical study (FREESIAS)

BACKGROUND

Angelman syndrome (AS) is a rare neurodevelopmental disorder characterized by the absence of a functional UBE3A gene, which causes developmental, behavioral, and medical challenges. While currently untreatable, comprehensive data could help identify appropriate endpoints assessing meaningful improvements in clinical trials. Herein are reported the results from the FREESIAS study assessing the feasibility and utility of in-clinic and at-home measures of key AS symptoms.

METHODS

Fifty-five individuals with AS (aged < 5 years: n = 16, 5-12 years: n = 27, ≥ 18 years: n = 12; deletion genotype: n = 40, nondeletion genotype: n = 15) and 20 typically developing children (aged 1-12 years) were enrolled across six USA sites. Several clinical outcome assessments and digital health technologies were tested, together with overnight 19-lead electroencephalography (EEG) and additional polysomnography (PSG) sensors. Participants were assessed at baseline (Clinic Visit 1), 12 months later (Clinic Visit 2), and during intermittent home visits.

RESULTS

The participants achieved high completion rates for the clinical outcome assessments (adherence: 89-100% [Clinic Visit 1]; 76-91% [Clinic Visit 2]) and varied feasibility of and adherence to digital health technologies. The coronavirus disease 2019 (COVID-19) pandemic impacted participants' uptake of and/or adherence to some measures. It also potentially impacted the at-home PSG/EEG recordings, which were otherwise feasible. Participants achieved Bayley-III results comparable to the available natural history data, showing similar scores between individuals aged ≥ 18 and 5-12 years. Also, participants without a deletion generally scored higher on most clinical outcome assessments than participants with a deletion. Furthermore, the observed AS EEG phenotype of excess delta-band power was consistent with prior reports.

CONCLUSIONS

Although feasible clinical outcome assessments and digital health technologies are reported herein, further improved assessments of meaningful AS change are needed. Despite the COVID-19 pandemic, remote assessments facilitated high adherence levels and the results suggested that at-home PSG/EEG might be a feasible alternative to the in-clinic EEG assessments. Taken altogether, the combination of in-clinic/at-home clinical outcome assessments, digital health technologies, and PSG/EEG may improve protocol adherence, reduce patient burden, and optimize study outcomes in AS and other rare disease populations.

Using pharmacotherapy to address sleep disturbances in autism spectrum disorders

INTRODUCTION

Sleep disorders are the second most common medical comorbidity in autism spectrum disorder (ASD), with effects on daytime behavior and functioning, mood and anxiety, and autism core features. In children with ASD, insomnia also has a negative impact on the whole family's quality of life. Therefore, treatment of sleep disturbances should be considered as a primary goal in the management of ASD patients, and it is important to clarify the scientific evidence to inappropriate treatments.

AREAS COVERED

The authors review the current literature concerning the pharmacological treatment options for the management of sleep-related disorders in patients with ASD (aged 0-18 years) using the PubMed and Cochrane Library databases with the search terms: autism, autistic, autism spectrum disorder, ASD, drug, drug therapy, drug intervention, drug treatment, pharmacotherapy, pharmacological treatment, pharmacological therapy, pharmacological intervention, sleep, sleep disturbance, and sleep disorder.

EXPERT OPINION

Currently, clinicians tend to select medications for the treatment of sleep disorders in ASD based on the first-hand experience of psychiatrists and pediatricians as well as expert opinion. Nevertheless, at the present time, the only compound for which there is sufficient evidence is melatonin, although antihistamines, trazodone, clonidine, ramelteon, gabapentin, or suvorexant can also be considered for selection.

Sleep disturbances in autism spectrum disorder: Animal models, neural mechanisms, and therapeutics

Sleep is crucial for brain development. Sleep disturbances are prevalent in children with autism spectrum disorder (ASD). Strikingly, these sleep problems are positively correlated with the severity of ASD core symptoms such as deficits in social skills and stereotypic behavior, indicating that sleep problems and the behavioral characteristics of ASD may be related. In this review, we will discuss sleep disturbances in children with ASD and highlight mouse models to study sleep disturbances and behavioral phenotypes in ASD. In addition, we will review neuromodulators controlling sleep and wakefulness and how these neuromodulatory systems are disrupted in animal models and patients with ASD. Lastly, we will address how the therapeutic interventions for patients with ASD improve various aspects of sleep. Together, gaining mechanistic insights into the neural mechanisms underlying sleep disturbances in children with ASD will help us to develop better therapeutic interventions.

Melatonin for sleep disorders in people with autism: Systematic review and meta-analysis

Melatonin is a potential therapeutic intervention for improving sleep quality in people with autistic spectrum disorder (ASD). We investigate the effect of using melatonin as a sleep disorder treatment in people with ASD. Interventionist studies were searched in seven databases. A total of 595 references were identified, 15 of which were eligible for the systemic review and meta-analysis. Melatonin use presented a positive effect on total sleep time (standardized mean difference- SMD = 0.78; 95%CI = 0.35; 1.21; I² = 91%), on sleep latency (SMD = 1.23; 95%CI = 0.35; 2.11; I² = 94%), and on sleep efficiency (SMD = -0.70; 95%CI = -1.23; -0.16; I² = 91%) when comparing the intervention group with the placebo/control group via the global analysis. According to the global analysis, the wake after sleep onset and night awakening parameters were not statistically significant. Melatonin has possible efficacy over total time, latency, and efficiency sleep parameters.

Melatonin for sleep disorders in children with neurodevelopmental disorders: protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials

INTRODUCTION

Neurodevelopmental disorders are a group of disorders thought to be associated with the functioning of the brain and the nervous system. Children with neurodevelopmental disorders often have sleep-related comorbidities that may negatively affect quality of life for both the children and their families. Melatonin is one of the most used interventions in children with neurodevelopmental disorders and sleep disorders. Previous reviews have investigated the effects of melatonin for sleep disorders in children with neurodevelopmental disorders, but these had important limitations, such as inadequate analysis of adverse effects, small sample sizes and short follow-up.

METHODS AND ANALYSIS

This is a protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. The protocol is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. We will search for published and unpublished trials in the Cochrane Central Register of Controlled Trials, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, PsycINFO, ClinicalTrials.gov and the International Clinical Trials Registry Platform. We will search the databases from their inception without language restrictions. We will also request clinical study reports from regulatory authorities and pharmaceutical companies. Review authors working in pairs will screen reports, extract data and conduct risk of bias assessments using the Cochrane Risk of Bias tool. We will include randomised clinical trials comparing melatonin versus placebo or no intervention for sleep disorders in children with neurodevelopmental disorders. Primary outcomes will be total sleep time and adverse effects. Secondary outcomes will be quality of life of the child and caregivers and sleep onset latency. Data will be analysed using random-effects and fixed-effect meta-analyses. Certainty of evidence will be assessed with Grading of Recommendations, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethical approval was not required for this protocol. The systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337530.

Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It?

Sleep is a vital physiological function that is impaired in ranges from 10% in the typically developing pediatric population to over 80% in populations of children with neurodevelopmental disorders and/or psychiatric comorbidities. Pediatric insomnia disorder is an increasing public health concern given its negative impact on synaptic plasticity involved in learning and memory consolidation but also on mood regulation, hormonal development and growth, and its significant impact on quality of life of the child, the adolescent and the family. While first-line treatment of pediatric insomnia should include parental education on sleep as well as sleep hygiene measures and behavioural treatment approaches, pharmacological interventions may be necessary if these strategies fail. Melatonin treatment has been increasingly used off-label in pediatric insomnia, given its benign safety profile. This article aims to identify the possible role of melatonin treatment for pediatric insomnia, considering its physiological role in sleep regulation and the differential effects of immediate release (IR) versus prolonged release (PR) melatonin. For the physician dealing with pediatric insomnia, it is particularly important to be able to distinguish treatment rationales implying different dosages and times of treatment intake. Finally, we discuss the benefit-risk ratio for melatonin treatment in different pediatric populations, ranging from the general pediatric population to children with different types of neurodevelopmental disorders, such as autism spectrum disorder or ADHD.

Sleep cycle in children with severe acute bronchopneumonia during mechanical ventilation at different depths of sedation

BACKGROUND

To investigate the characteristics of sleep cycle in children with severe acute bronchopneumonia treated with invasive mechanical ventilation at different sedation depths.

METHODS

We included 35 pediatric patients with severe acute bronchopneumonia treated using mechanical ventilation in Pediatric Intensive Care Unit of Shengjing Hospital of China Medical University. They were divided into deep sedation group (n = 21; ramsay score 5-6) and light sedation group (n = 14; ramsay score3-4) based on sedation depth achieved during mechanical ventilation. Long-term video electroencephalography (EEG) monitoring was performed within the first 24 h after starting mechanical ventilation and after weaning from mechanical ventilation and discontinuing sedatives and analgesics. The results were analyzed and compared with those of normal children to analyze changes in sleep cycle characteristics at different sedation depths and mechanical ventilation stages.

RESULTS

There were 29 cases altered sleep architecture. The deep sedation group had a significantly higher incidence of sleep architecture altered, total sleep duration, and non-rapid eye movement sleep-1 (NREM-1) loss incidence than the light sedation group. Moreover, the deep sedation group had a significantly lower awakening number and rapid eye movement sleep (REM) percentage than the light sedation group. The sleep cycle returned to normal in 27 (77%) patients without NREM-1 or REM sleep loss.

CONCLUSIONS

Deep sedation during mechanical ventilation allows longer total sleep duration, fewer awakenings, and an increased deep sleep proportion, but sleep architecture is severely altered. After weaning from mechanical ventilation and sedative discontinuation, lightly sedated children exhibit better sleep recovery.

Management of sleep disorders among children and adolescents with neurodevelopmental disorders: A practical guide for clinicians

There is a complex relationship between sleep disorders and childhood neurodevelopmental, emotional, behavioral and intellectual disorders (NDEBID). NDEBID include several conditions such as attention deficit/hyperactivity disorder, autism spectrum disorder, cerebral palsy, epilepsy and learning (intellectual) disorders. Up to 75% of children and young people (CYP) with NDEBID are known to experience different types of insomnia, compared to 3% to 36% in normally developing population. Sleep disorders affect 15% to 19% of adolescents with no disability, in comparison with 26% to 36% among CYP with moderate learning disability (LD) and 44% among those with severe LD. Chronic sleep deprivation is associated with significant risks of behavioural problems, impaired cognitive development and learning abilities, poor memory, mood disorders and school problems. It also increases the risk of other health outcomes, such as obesity and metabolic consequences, significantly impacting on the wellbeing of other family members. This narrative review of the extant literature provides a brief overview of sleep physiology, aetiology, classification and prevalence of sleep disorders among CYP with NDEBIDs. It outlines various strategies for the management, including parenting training/psychoeducation, use of cognitive-behavioral strategies and pharmacotherapy. Practical management including assessment, investigations, care plan formulation and follow-up are outlined in a flow chart.

Estimation of the minimal clinically important difference on the Aberrant Behaviour Checklist-Irritability (ABC-I) for people with intellectual disabilities who display aggressive challenging behaviour: A triangulated approach

BACKGROUND

The minimal clinically important difference (MCID) is relevant in the estimation of improvement in a patient outcome.

AIM

To determine the MCID on the Aberrant Behaviour Checklist-Irritability (ABC-I), widely used to measure the effects of intervention for aggressive challenging behaviour in people with intellectual disabilities.

METHOD AND PROCEDURES

We utilised distribution and anchor based methods to estimate the ABC-I MCID. We extracted data from 15 randomised controlled trials (RCTs) for meta-analysis. We conducted three online workshops with family carers and professionals to consider meaningful change in case vignettes of increasing severity of aggressive challenging behaviour.

OUTCOMES AND RESULTS

We did not find overlap in the range of values between the two approaches. The meta-analysis indicated a range of MCID on the ABC-I (0.05, 4.94) whilst the anchor-based estimation indicated a larger change (6.6, 16.6).

CONCLUSIONS AND IMPLICATIONS

The MCID is essential in interpreting the results from intervention studies. The present work was undertaken as part of a wider programme on the development and testing of a psychosocial intervention for aggressive challenging behaviour, and it is of interest to researchers in justifying how they choose and determine the MCID on the outcome of interest.

Assessing the potential for drug interactions and long term safety of melatonin for the treatment of insomnia in children with autism spectrum disorder

INTRODUCTION

Melatonin preparations are emerging first-line pharmacotherapy for insomnia in children and adolescents with autism spectrum disorder (ASD), but quality, formulation, consistency, dosing, and limited long-term safety data are of concern. The recent approval of pediatric-appropriate prolonged-release melatonin (Ped-PRM) addresses these aspects.

AREAS COVERED

A systematic search of PubMed and web of science for prospective, randomized, and controlled trials (RCTs) of melatonin preparations vs placebo in children and adolescents with ASD and the European public assessment report on Ped-PRM was conducted.

EXPERT OPINION

Melatonin is rapidly absorbed and undergoes first pass hepatic metabolism by cytochrome CYP1A2; over 80% is excreted in the urine as 6-sulfatoxymelatonin (inactive). Immediate-release melatonin (IRM) is short-acting (3-4 h), whereas PRM provides therapeutic levels throughout the night. Drugs interacting with CYP1A2 are likely to slow-down melatonin metabolism. High variability in bioavailability among subjects calls for dose optimization. Melatonin was essentially safe for short-term use (up to 3 months). Long-term data available for Ped-PRM demonstrate fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%) with no evidence of effects on height, BMI, or pubertal development, tolerance or withdrawal effects following long-term use of this product. Studies on long-term safety of IRM and oversight of melatonin supplement manufacture are warranted.

Sleep in Individuals with ADHD: Prevalence, Impacts, Causes, and Treatments

Sleep problems are common in children and adolescents with ADHD. This chapter covers the basics of sleep and the prevalence and types of sleep problems experienced by children and adolescents with ADHD. The impacts of sleep problems on the day-to-day lives of children with ADHD and their families are covered including impacts on child daily functioning and cognition, as well as family well-being. There is no one cause of sleep problems in children with ADHD with both biological and environmental factors implicated. There are a small number of randomized controlled trials that support the efficacy of treating sleep problems in children with ADHD using behavioral strategies. A small number of studies also have found improvements in sleep onset delay in children with ADHD following treatment with melatonin. Little is known about how to best support adolescents and adults with ADHD with sleep, although a small emerging literature largely in adults with ADHD suggests that bright light therapies could potentially be helpful given the extent of circadian involvement in the sleep problems experienced by individuals with ADHD. This chapter ends with consideration of future research directions largely related to approaches to supporting individuals with ADHD and sleep difficulties.

Autism Spectrum Disorder and Intellectual Disability: A Pilot Study Exploring Associations between Child Sleep Problems, Child Factors and Parent Factors

Sleep problems are common in children with autism spectrum disorder (ASD). However, few studies have undertaken group comparisons of sleep profiles and factors associated with poorer sleep between children with ASD without intellectual disability (ID; hereafter referred to as ASD) and ASD with co-occurring ID (hereafter referred to as ASD + ID). This study aimed to (1) compare child (sleep problems and emotional and behavioural problems (EBPs)) and parent factors (parenting stress and mental health) for children with ASD compared to children with ASD + ID, and (2) examine the associations between sleep problems and child and parent factors in both groups. Parents of 56 children with ASD (22 ASD, 34 ASD + ID) aged 6–13 years took part in the study. No statistically significant differences in sleep problems were found between children with ASD compared to children with ASD + ID. However, total EBPs were independently associated with child sleep problems in both groups. Further, ‘Self-Absorbed’ and ‘Communication Disturbance’ EBPs were significantly greater in the ASD + ID compared to the ASD group. Overall treatment outcomes for children with ASD may be further improved if consideration is given to the specific types of EBPs being experienced by the child and their association with sleep problems.

Decades of Progress in the Psychopharmacology of Autism Spectrum Disorder

Recent decades have been marked by a wave drug treatment research in autism spectrum disorder (ASD). This work has resulted in improved ability to treat commonly occurring behavioral challenges associated with ASD including most prominently irritability marked by aggression, self-injurious behavior, and severe tantrums. While treatment of interfering behavior has progressed in our field, there remain several areas of unmet medical need including most prominently a lack of any approved drug therapies for the core, defining symptoms of autism. We outline the progress to date in the field of autism drug treatment while taking a future look forward into how decades of work can inform better future steps in this field.

Ratings of the Effectiveness of Nutraceuticals for Autism Spectrum Disorders: Results of a National Survey

Autism spectrum disorder (ASD) often involves a wide range of co-occurring medical conditions (“comorbidities”) and biochemical abnormalities such as oxidative stress and mitochondrial dysfunction. Nutritional supplements (“Nutraceuticals”) are often used to treat both core ASD symptoms and comorbidities, but some have not yet been formally evaluated in ASD. The potential biological mechanisms of nutraceuticals include correction of micronutrient deficiencies due to a poor diet and support for metabolic processes such as redox regulation, mitochondrial dysfunction and melatonin production. This paper reports on the results of the National Survey on Treatment Effectiveness for Autism, focusing on nutraceuticals. The Survey involved 1286 participants from across the United States. Participants rated the overall perceived benefits and adverse effects of each nutraceutical, and also indicated the specific symptoms changed and adverse effects. From these ratings the top-rated nutraceuticals for each of 24 symptoms are listed. Compared to psychiatric and seizure medications rated through the same Survey, on average nutraceuticals had significantly higher ratings of Overall Benefit (1.59 vs. 1.39, p = 0.01) and significantly lower ratings of Overall Adverse Effects (0.1 vs. 0.9, p < 0.001). Folinic acid and vitamin B12 were two of the top-rated treatments. This study suggests that nutraceuticals may have clinical benefits and favorable adverse effect profiles.

Pediatric prolonged-release melatonin for insomnia in children and adolescents with autism spectrum disorders

Introduction: Insomnia is common among children and adolescents with Autism spectrum disorder (ASD). The first drug licensed for insomnia in this population, a pediatric-appropriate prolonged-release melatonin (PedPRM) formulation is described.Areas covered: Literature search on  PedPRM efficacy and safety profile in clinical trials, and a proposed decision-making algorithm to optimize outcome  in the treatment of insomnia in children and adolescents with ASD.Expert opinion: PedPRM treatment effectively improves sleep onset, duration and consolidation, and daytime externalizing behaviors in children and adolescents with ASD and subsequently caregivers' quality of life and satisfaction with their children's sleep. The coated, odorless and taste-free mini-tablets are well-accepted in this population who often have sensory hypersensitivity and problems swallowing standard tablet preparations. The most frequent long-term treatment-related adverse events were fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%) with no evidence of delay in height, BMI, or pubertal development, or withdrawal effects. The starting dose is 2 mg once daily independent of age or weight, escalated to 5-10 mg/day if predefined treatment success criteria are unmet. Slow melatonin metabolizers (~10% of children), may require lower doses. Given its long-term efficacy, safety and acceptance, PedPRM may ameliorate long-term consequences of insomnia in this population.

A Qualitative Investigation Into What Parents Want From an Online Behavioural Sleep Intervention for Children With Epilepsy

Many of the same sleep problems seen in typically developing (TD) children are frequently experienced by children with epilepsy (CWE). Behavioural sleep interventions (BSIs) are commonly and successfully used to treat these sleep problems in TD children and in some neurodevelopmental disorder populations. Therefore, BSIs should be effective in CWE, however, there are special seizure-related considerations for CWE and their parents which may be salient to consider in any future BSI development for this group. The current study sought to identify, from parents, if there were special considerations for the content and delivery of an online BSI for parents of CWE. Semi-structured interviews were conducted with nine mothers of CWE and thematic analysis was conducted on the interview data. Ten themes were apparent which represented what parents wanted from any online BSI for CWE. Parents wanted (i) other parents' views and real-life experiences to be included, (ii) recognition of how changes over time may influence the appropriateness of using various sleep-management options, (iii) to be presented with a range of sleep management options from which they could select, (iv) personalised information and suggestions for behaviour-change options, (v) help to address child anxiety around sleep, (vi) for the advice and behaviour-change options to be practical, (vii) general educational information about sleep and the relationship between sleep and epilepsy, (viii) for parental worries and concerns to be acknowledged, (ix) to receive help, support, and reassurance around children's sleep; and (x) to include the child in the intervention. It was clear that any online BSI would require specific adaptations and additions (to content and delivery format) to best meet the needs of parents of CWE. It is hoped that having identified what parents want from on online BSI for CWE will allow these factors to be acknowledged in future intervention development, with the intention to optimise parental engagement and intervention effectiveness. Practical suggestions for how these aspects could be integrated into any online BSI are suggested.

Development and Evaluation of the CASTLE Trial Online Sleep Intervention for Parents of Children with Epilepsy

Introduction: Many of the sleep problems experienced by children with epilepsy (CWE) have the same behavioural basis as common sleep problems seen in typically developing (TD) children. Behavioural sleep interventions (BSIs) are widely used to treat these sleep problems in TD children and are hypothesised to be effective for CWE. However, specific considerations need to be addressed and incorporated into a BSI for CWE to ensure the intervention is tailored to this population's needs. This paper details developing and tailoring an online BSI for parents of CWE, to be used in the CASTLE (Changing Agendas on Sleep, Treatment and Learning in Epilepsy) Sleep-E clinical trial. Method: In phase one, two existing theory-driven paediatric BSIs were adapted into a novel online behavioural sleep intervention (CASTLE Online Sleep Intervention or COSI) which specifically incorporated the needs and requirements reported by nine parents of CWE. Scoping their needs included conducting interviews with three CWE so that they could contribute to the overall intervention content. In phase two, six of these parents evaluated COSI, reviewing and feeding back on COSI until parental approval for content and functionality was achieved. Results: In phase one, a range of adaptations was made to the content and presentation of standardised intervention material to acknowledge and emphasise the key seizure-specific issues to ensure COSI best met parents of CWE's needs. Adaptations included embedding parent and child experiences in the intervention, including particular information requested by parents, such as the links between sleep and seizures and managing child and parental anxieties around sleep, as well as developing functionality to personalise the delivery of content. In phase two, parents confirmed that they found the final version of COSI to be functional and appropriate (after one round of review) for use by parents of CWE and that 100% would recommend it to other families who have CWE. Discussion: It is hoped that the use of evidence-based BSIs, adapted to consider salient epilepsy-specific factors, will increase parent-engagement, COSI's relevance for this particular patient group and overall efficacy in improving sleep in CWE. The effectiveness of COSI will be tested in the CASTLE Sleep-E clinical trial (https://castlestudy.org.uk/).

Melatonin Treatment and Adequate Sleep Hygiene Interventions in Children with Autism Spectrum Disorder: A Randomized Controlled Trial

Robust clinical evidence has not been available for melatonin, a drug commonly administered for treating sleep problems of children with autism spectrum disorder (ASD). In a phase 3 randomized, placebo-controlled clinical trial, we administered 1-mg melatonin (n = 65), 4-mg melatonin (n = 65), or placebo (n = 66) to196 children with ASD once daily before bedtime under adequate sleep hygiene interventions. The primary outcome was sleep onset latency (SOL) assessed with the electronic sleep diary. SOL shortened significantly in the 1- and 4-mg melatonin groups compared to the placebo group (- 22.0, - 28.0, and - 5.0 min, respectively; p < 0.0001 each). This therapeutic regimen of melatonin is a reasonable clinical approach to cope with ASD-emergent difficulties in children with ASD.

Melatonin: From Pharmacokinetics to Clinical Use in Autism Spectrum Disorder

The role of melatonin has been extensively investigated in pathophysiological conditions, including autism spectrum disorder (ASD). Reduced melatonin secretion has been reported in ASD and led to many clinical trials using immediate-release and prolonged-release oral formulations of melatonin. However, melatonin’s effects in ASD and the choice of formulation type require further study. Therapeutic benefits of melatonin on sleep disorders in ASD were observed, notably on sleep latency and sleep quality. Importantly, melatonin may also have a role in improving autistic behavioral impairments. The objective of this article is to review factors influencing treatment response and possible side effects following melatonin administration. It appears that the effects of exposure to exogenous melatonin are dependent on age, sex, route and time of administration, formulation type, dose, and association with several substances (such as tobacco or contraceptive pills). In addition, no major melatonin-related adverse effect was described in typical development and ASD. In conclusion, melatonin represents currently a well-validated and tolerated treatment for sleep disorders in children and adolescents with ASD. A more thorough consideration of factors influencing melatonin pharmacokinetics could illuminate the best use of melatonin in this population. Future studies are required in ASD to explore further dose-effect relationships of melatonin on sleep problems and autistic behavioral impairments.

Sleep, Growth, and Puberty After 2 Years of Prolonged-Release Melatonin in Children With Autism Spectrum Disorder

OBJECTIVE

A recent 3-month double-blind, placebo-controlled study demonstrated efficacy and safety of pediatric prolonged-release melatonin (PedPRM) for insomnia in children with autism spectrum disorder. This study examined the long-term effects of PedPRM treatment on sleep, growth, body mass index, and pubertal development.

METHOD

Eighty children and adolescents (2-17.5 years of age; 96% with autism spectrum disorder) who completed the double-blind, placebo-controlled trial were given 2 mg, 5 mg, or 10 mg PedPRM nightly up to 104 weeks, followed by a 2-week placebo period to assess withdrawal effects.

RESULTS

Improvements in child sleep disturbance and caregiver satisfaction with child sleep patterns, quality of sleep, and quality of life were maintained throughout the 104-week treatment period (p < .001 versus baseline for all). During the 2-week withdrawal placebo period, measures declined compared with the treatment period but were still improved compared with baseline. PedPRM was generally safe; the most frequent treatment-related adverse events were fatigue (6.3%), somnolence (6.3%), and mood swings (4.2%). Changes in mean weight, height, body mass index, and pubertal status (Tanner staging done by a physician) were within normal ranges for age with no evidence of delay in body mass index or pubertal development.

CONCLUSION

Nightly PedPRM at optimal dose (2, 5, or 10 mg nightly) is safe and effective for long-term treatment in children and adolescents with autism spectrum disorder and insomnia. There were no observed detrimental effects on children's growth and pubertal development and no withdrawal or safety issues related to the use or discontinuation of the drug.

CLINICAL TRIAL REGISTRATION INFORMATION

Efficacy and Safety of Circadin in the Treatment of Sleep Disturbances in Children With Neurodevelopment Disabilities; https://clinicaltrials.gov/; NCT01906866.

[Effect of general anesthesia on postoperative melatonin secretion in 4-to 6-year-old children with snoring]

OBJECTIVE

To evaluate the effect of general anesthesia on postoperative melatonin secretion in 4-to 6-year-old children with snoring.

METHODS

Twenty children with snoring aged 4-6 years of either gender (ASA grade Ⅰ and Ⅱ) were selected for adenoidectomy.Before, during and 3 days after the operation, salivary melatonin levels of the children were measured at 11 selected time points (T1-T11).The illumination intensity and body temperature of the children were recorded at each time point of measurement.The sleep time of the children in 3 days after the operation was recorded, and postoperative pain scores (FLACC) and Riker and Rehabilitation Quality Rating Scale-15(QoR-15) scores were assessed.Sleep Apnea Life Quality Evaluation Questionnaire (OSA-18) was used to evaluate postoperative recovery of the children at 28 days after the operation.The incidence of major adverse events of the children during hospitalization was recorded.

RESULTS

No significant difference was found in baseline salivary melatonin level among the 20 children before the operation.Salivary melatonin level at 7 am after the operation (T8) was significantly lowered as compared with that before the surgery (T4)(P < 0.05) but recovered at 7 am on the second day after the surgery (T11);salivary melatonin levels at T4, T8, and T11 exceeded 3 pg/mL on the third day.No significant difference was found in illumination intensity or body temperature across the time points when melatonin level was measured.The children showed no significant changes in FLACC score, Riker score or QOR- 15 score after the operation, but the OSA-18 score was significantly lowered after the operation (P < 0.05).None of the 20 children had such adverse events as respiratory depression, sinus bradycardia, sinus tachycardia, hypertension, hypotension, nausea or vomiting during hospitalization.

CONCLUSIONS

In preschool children with snoring, general anesthesia affects but does not inhibit melatonin secretion on the first night after surgery, and minor surgeries under general anesthesia in the morning do not cause significant changes in melatonin secretion to cause disturbance of the circadian rhythm in these children.

The Assessment and Treatment of Sleep Abnormalities in Children and Adolescents with Autism Spectrum Disorder: A Review

OBJECTIVE

To summarize causes, evaluation methods, and treatment of sleep disturbance in children and adolescents with autism spectrum disorder (ASD).

METHODS

A narrative literature and synthesis approach was used.

RESULTS/DISCUSSION

Sleep disturbances in this population are common and include insomnia, parasomnias, circadian rhythm disorders, and sleep-related movement disorders. Multiple factors may contribute to the higher rates of sleep disturbances in persons with ASD. Unfortunately, there are not evidence-based guidelines specific for the management of these sleep disorders in this population. There is also a lack of controlled clinical studies. Nevertheless, assessment of sleep problems using both subjective and objective methods are recommended to develop an individualized approach. Behavioural interventions are preferred first line treatment for insomnia. As adjunctive measures, pharmacotherapy may be warranted and choice should be guided based on accompanying symptoms. The most commonly used pharmacotherapy for sleep disturbance, primarily insomnia, include melatonin and alpha agonists. Not all currently used medications are approved for use for children and adolescents.

Melatonin Use in Pediatrics: Evaluating the Discrepancy in Evidence Based on Country and Regulations Regarding Production

Melatonin manufacturers in the United States have begun producing melatonin products specifically targeted for use in the pediatric population. This paper aims to critically evaluate the evidence available regarding the use of melatonin in children based on where the clinical trials are performed and the regulations regarding the production of melatonin in that country. Melatonin is regulated differently around the world with the least amount of regulation placed on OTC supplements in the United States. The majority of studies evaluating melatonin use in the pediatric population are conducted with children who have comorbidities, such as autism spectrum disorder or attention-deficit/hyperactivity disorder. Evidence supporting the use of US formulations of melatonin in the otherwise healthy pediatric population is non-existent. Based on the lack of safety regulations in place in the United States and the lack of evidence regarding US melatonin products, they should be used sparingly in the otherwise healthy pediatric population, if they are used at all.

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.

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.

A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials Evaluating the Evidence Base of Melatonin, Light Exposure, Exercise, and Complementary and Alternative Medicine for Patients with Insomnia Disorder

Insomnia is a prevalent disorder and it leads to relevant impairment in health-related quality of life. Recent clinical guidelines pointed out that Cognitive-Behavior Therapy for Insomnia (CBT-I) should be considered as first-line intervention. Nevertheless, many other interventions are commonly used by patients or have been proposed as effective for insomnia. These include melatonin, light exposure, exercise, and complementary and alternative medicine. Evaluation of comparable effectiveness of these interventions with first-line intervention for insomnia is however still lacking. We conducted a systematic review and network meta-analysis on the effects of these interventions. PubMed, PsycInfo, PsycArticles, MEDLINE, and CINAHL were systematically searched and 40 studies were included in the systematic review, while 36 were entered into the meta-analysis. Eight network meta-analyses were conducted. Findings support effectiveness of melatonin in improving sleep-onset difficulties and of meditative movement therapies for self-report sleep efficiency and severity of the insomnia disorder. Some support was observed for exercise, hypnotherapy, and transcranial magnetic resonance, but the number of studies for these interventions is still too small. None of the considered interventions received superior evidence to CBT-I, which should be more widely disseminated in primary care.

Efficacy and Safety of Melatonin Treatment in Children with Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder-A Review of the Literature

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are neurodevelopmental disorders with disturbed melatonin secretion profile and sleep problems. The growing incidence of ASD and ADHD inspires scientists to research the underlying causes of these conditions. The authors focused on two fundamental aspects, the first one being the presentation of the role of melatonin in ASD and ADHD and the second of the influence of melatonin treatment on sleep disorders. The authors present the use of melatonin both in the context of causal and symptomatic treatment and discuss melatonin supplementation: Dosage patterns, effectiveness, and safety. Sleep disorders may have a different clinical picture, so the assessment of exogenous melatonin efficacy should also refer to a specific group of symptoms. The review draws attention to the wide range of doses of melatonin used in supplementation and the need to introduce unified standards especially in the group of pediatric patients.

Sleep architecture and homeostasis in children with epilepsy: a neurodevelopmental perspective

Although the influence of sleep on epilepsy has long been recognized, this relationship has yet to be fully exploited to benefit patients. The past decade has seen significant advances in understanding paediatric sleep, providing a framework by which to properly evaluate the sleep of children with epilepsy, which itself has been subject to increasing scrutiny. The role of sleep in learning and the potential for interictal discharges to disrupt sleep-related memory consolidation provide a novel perspective for understanding the association of childhood epilepsy with a high rate of intellectual disability. In this review, I outline the evolution of sleep duration, architecture, and homeostasis across childhood, relating this to the development of cognitive functions. I describe how these may be disrupted or preserved in children with epilepsy; in particular, collating data from polysomnography. Finally, I explore how sleep may, in the future, be modulated to improve cognitive outcome in these patients. WHAT THIS PAPER ADDS: Children with epilepsy have less rapid eye movement sleep than controls, but this improves with seizure cessation. Deep or slow-wave sleep is highly conserved in children with epilepsy. Sleep homeostasis may be disrupted either at a local or global level by the presence of interictal epileptiform discharges.

Melatonin for children with autism spectrum disorder

Question I have several patients with autism spectrum disorder (ASD) who experience difficulties with sleep, affecting the quality of life of both the child and the family. Is melatonin an effective treatment for sleep problems in children with this condition?Answer Autism spectrum disorder is prevalent among children in Canada and globally, with most affected children experiencing troubles with sleep. Behavioural therapy is the first-line treatment for sleep problems in children with ASD, and melatonin has been reported to be effective and safe in this population as an alternative or adjunctive treatment. A new pediatric, prolonged-release formulation of melatonin is not yet available in Canada, but initial studies in Europe have indicated that it is a potentially effective treatment for sleep problems in children with ASD.

Understanding the role of sleep and its disturbances in Autism spectrum disorder

BACKGROUND

Several studies have established a positive relationship between sleep difficulties and symptomatology in ASD children. The rationale for this review is to describe and discuss the sleep difficulties, which are one of the significant complications associated with autism spectrum disorder (ASD).

PURPOSE

Many types of sleep disorders have been reported in ASD individuals, but still lack a comprehensive study and in-depth analysis. Despite the contribution of sleep problems to the overall symptoms of ASD, the symptoms of disturbed sleep experienced by many affected patients have only recently started to receive attention from clinicians and family members.

MATERIALS AND METHODS

This narrative overview has been prepared based on searching standard research databases with specific keywords; b. Additional search was made using the bibliographies of the retrieved articles; and c. author's collection of relevant peer-reviewed articles. Once selected, manuscripts are then compared and summarized based on the author's perspective. Results are based on a qualitative rather than a quantitative level.

RESULTS

This article highlights the role of sleep in the brain and neural development of children and emphasizes that the intensity of sleep problems is associated with an increased occurrence of ASD symptoms. It also suggests the significance of treating sleep problems in ASD individuals.

CONCLUSIONS

The review provides broader perspectives and a better understanding of sleep problems in pathophysiology, mechanism, and management with respect to ASD individuals. Finally, the implications for clinical practice and future agendas have also been discussed.

Scoping review of symptoms in children with rare, progressive, life-threatening disorders

BACKGROUND

Q3 conditions are progressive, metabolic, neurological or chromosomal childhood conditions without a cure. Children with these conditions face an unknown lifespan as well as unstable and uncomfortable symptoms. Clinicians and other healthcare professionals are challenged by a lack of evidence for symptom management for these conditions.

AIMS

In this scoping review, we systematically identified and mapped the existing literature on symptom management for children with Q3 conditions. We focused on the most common and distressing symptoms, namely alertness, behavioural problems, bowel incontinence, breathing difficulties, constipation, feeding difficulties, sleep disturbance, temperature regulation, tone and motor problems and urinary incontinence. For children with complex health conditions, good symptom management is pertinent to ensure the highest possible quality of life.

METHODS

Scoping review. Electronic database searches in Ovid MEDLINE, Embase and CINAHL and a comprehensive grey literature search.

RESULTS

We included 292 studies in our final synthesis. The most commonly reported conditions in the studies were Rett syndrome (n=69), followed by Cornelia de Lange syndrome (n=25) and tuberous sclerosis (n=16). Tone and motor problems were the most commonly investigated symptom (n=141), followed by behavioural problems (n=82) and sleep disturbance (n=62).

CONCLUSION

The evidence for symptom management in Q3 conditions is concentrated around a few conditions, and these studies may not be applicable to other conditions. The evidence is dispersed in the literature and difficult to access, which further challenges healthcare providers. More research needs to be done in these conditions to provide high-quality evidence for the care of these children.

The effects of a sleep/recovery supplement: 'Night Time Recharge' on sleep parameters in young adults

BACKGROUND

Concentrated cherry juice reportedly contains melatonin which, in turn, has been highlighted as an important regulator in initiating sleep.

AIM

The present investigation aims to clarify whether Night Time Recharge (NTR), a marketed sleep aid containing cherry extract, improves key sleep parameters in young, active adults with mildly poor sleep.

METHODS

A double-blind, randomized, placebo-controlled, cross-over study design was employed. Twenty participants (nine female) consumed either NTR or a placebo for seven days. Accelerometers were used to assess sleep quality and physical activity levels. Urinary levels of 6-sulphatoxymelatonin (6-SMT), a marker of melatonin synthesis, was assessed via enzyme-linked immunosorbent assay.

RESULTS

6-SMT levels increased following NTR treatment (28.95 ng/ml) compared with placebo (4.0 ng/ml) (p < 0.001). There was also a significant difference (p = 0.047) in dietary tryptophan consumption during the NTR treatment (1236 mg) versus placebo (1149 mg). No trace of melatonin was detected from our analysis of the supplement. NTR had no significant effect on any sleep parameters with the exception of sleep latency (p = 0.001).

CONCLUSIONS

As chemical analysis of NTR by liquid-chromatography mass-spectrometry identified no detectable melatonin, the tryptophan content of the supplement is a likely reason for improvement in sleep latency. These results are in contrast to previous studies which have found a positive effect on sleep following cherry supplementation. Future work should focus on sleep latency and investigating whether cherry juice is effective in participants with problems in initiating sleep.

Sleeping sound with autism spectrum disorder (ASD): study protocol for an efficacy randomised controlled trial of a tailored brief behavioural sleep intervention for ASD

INTRODUCTION

Sleep problems are a characteristic feature of children with autism spectrum disorder (ASD) with 40% to 80% of children experiencing sleep difficulties. Sleep problems have been found to have a pervasive impact on a child's socio-emotional functioning, as well as on parents' psychological functioning. The Sleeping Sound ASD project aims to evaluate the efficacy of a brief behavioural sleep intervention in reducing ASD children's sleep problems in a fully powered randomised controlled trial (RCT). Intervention impact on child and family functioning is also assessed.

METHODS AND ANALYSIS

The RCT aims to recruit 234 children with a diagnosis of ASD, aged 5-13 years, who experience moderate to severe sleep problems. Participants are recruited from paediatrician clinics in Victoria, Australia, and via social media. Families interested in the study are screened for eligibility via phone, and then asked to complete a baseline survey online, assessing child sleep problems, and child and family functioning. Participants are then randomised to the intervention group or treatment as usual comparator group. Families in the intervention group attend two face-to-face sessions and a follow-up phone call with a trained clinician, where families are provided with individually tailored behavioural sleep strategies to help manage the child's sleep problems. Teacher reports of sleep, behavioural and social functioning are collected, and cognitive ability assessed to provide measures blind to treatment group. The primary outcome is children's sleep problems as measured by the Children's Sleep Habits Questionnaire at 3 months post-randomisation. Secondary outcomes include parent and child quality of life; child social, emotional, behavioural and cognitive functioning; and parenting stress and parent mental health. Cost-effectiveness of the intervention is also evaluated.

ETHICS AND DISSEMINATION

Findings from this study will be published in peer-reviewed journals and disseminated at national and international conferences, local networks and online.

TRIAL REGISTRATION NUMBER

ISRCTN14077107 (ISRCTN registry dated on 3 March 2017).

Impact of a behavioral intervention, delivered by pediatricians or psychologists, on sleep problems in children with ADHD: a cluster-randomized, translational trial

BACKGROUND

We have demonstrated the efficacy of a brief behavioral intervention for sleep in children with ADHD in a previous randomized controlled trial and now aim to examine whether this intervention is effective and cost-effective when delivered by pediatricians or psychologists in community settings.

METHODS

Translational, cluster-randomized trial of a behavioral intervention versus usual care from 19th January, 2015 to 30th June, 2017. Participants (n = 361) were children aged 5-13 years with ADHD and parent report of a moderate/severe sleep problem who met criteria for American Academy of Sleep Medicine criteria for chronic insomnia disorder, delayed sleep-wake phase disorder, or were experiencing sleep-related anxiety. Participants were randomized at the level of the pediatrician (n = 61) to intervention (n = 183) or usual care (n = 178). Families in the intervention group received two consultations with a pediatrician or a psychologist covering sleep hygiene and tailored behavioral strategies.

RESULTS

In an intention-to-treat analysis, at 3 and 6 months respectively, the proportion of children with moderate to severe sleep problems was lower in the intervention (28.0%, 35.8%) compared with usual care group (55.4%, 60.1%; 3 month: risk ratio (RR): 0.51, 95% CI 0.37, 0.70, p < .001; 6 month: RR: 0.58; 95% CI 0.45, 0.76, p < .001). Intervention children had improvements across multiple Children's Sleep Habits Questionnaire subscales at 3 and 6 months. No benefits of the intervention were observed in other domains. Cost-effectiveness of the intervention was AUD 13 per percentage point reduction in child sleep problem at 3 months.

CONCLUSIONS

A low-cost brief behavioral sleep intervention is effective in improving sleep problems when delivered by community clinicians. Greater sample comorbidity, lower intervention dose or insufficient clinician supervisions may have contributed to the lack benefits seen in our previous trial.

Pediatric Prolonged-Release Melatonin for Sleep in Children with Autism Spectrum Disorder: Impact on Child Behavior and Caregiver's Quality of Life

A randomized, 13-weeks, placebo-controlled double-blind study in 125 subjects aged 2-17.5 years with Autism Spectrum Disorder or Smith-Magenis syndrome and insomnia demonstrated efficacy and safety of easily-swallowed prolonged-release melatonin mini-tablets (PedPRM; 2-5 mg) in improving sleep duration and onset. Treatment effects on child behavior and caregiver's quality of life were evaluated. PedPRM treatment resulted in significant improvement in externalizing but not internalizing behavior (Strengths and Difficulties questionnaire; SDQ) compared to placebo (p = 0.021) with clinically-relevant improvements in 53.7% of PedPRM-treated versus 27.6% of placebo-treated subjects (p = 0.008). Caregivers' quality of life also improved with PedPRM versus placebo (p = 0.010) and correlated with the change in total SDQ (p = 0.0005). PedPRM alleviates insomnia-related difficulties, particularly externalizing behavior in the children, subsequently improving caregivers' quality of life.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

Circadian melatonin profile in opium and amphetamine dependent patients: A preliminary study

Aim

The aim of this study was to investigate the relationship between opium and amphetamine dependency with the serum melatonin levels in the presence of circadian rhythm sleep disorders (CRSD).

Participants

Forty four male amphetamine-dependent and opium-dependent patients with CRSD and with more than one year substance dependency were enrolled in this study. Control group consisted of twelve healthy male subjects.

Design

The diagnoses of sleep disorders were established by a psychiatrist and were made on the basis of the criteria of ICSD-II using the patients’ sleep logs. Blood samples were drawn every 4 h through an intravenous catheter. Serum melatonin levels were assayed using an enzyme-linked immunosorbent assay (ELISA) kit. Repeated Measures Analysis of variance (ANOVA) was used to assess differences between the melatonin levels at six separate times.

Finding

The serum melatonin levels of the control subjects were significantly higher than both opium-dependent and amphetamine-dependent patients at 24:00, 4:00 and 8:00. The serum melatonin level of the opium-dependent patients were significantly lower than the amphetamine-dependent patients at 24:00 (26.9 ± 11.4 vs. 41 ± 19.4, respectively; p = 0.006) and were significantly higher than the amphetamine-dependent patients at 16:00 (12.7 ± 5.1 vs. 8.9 ± 4.1, respectively; p = 0.011).

Conclusion

This is an evidence of negative effects of substance dependence on circadian cycle of melatonin secretion among opium and amphetamine dependent patients.

•

Sleep problems in substance abuse patients may be caused by dysfunction of circadian rhythm.

•

High prevalence of circadian rhythm sleep disorders (CRSD) in substance dependent patients, possibly related to abnormal melatonin cycle.

•

Circadian rhythm-based interventions could play an important role in the prevention and treatment of substance use disorders.