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Identify whether sleep problems in children with autism spectrum disorder (ASD) may be caused by medication or other medical conditions and if so, address these factors, say new recommendations issued this week from the American Academy of Neurology (AAN).

If insomnia and disrupted sleep appear to be more behavioral in nature, a number of strategies may be effective for children and adolescents with autism, advised Ashura Williams Buckley, MD, of the National Institute of Mental Health in Bethesda, Maryland, and co-authors, in a practice guideline published in .

Up to 40% of children and teens in the general population have sleep problems at some point during childhood, but these typically diminish with age, noted Williams Buckley. But 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," she said in a statement.

While autism symptoms may exacerbate sleep problems, the opposite also may be true, she pointed out. "Sleep problems can make behavioral issues in children and teens with autism even worse," she said. "That's why it is important for 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."

To develop the guidance, panel members conducted a systematic review of studies about sleep disturbance in children with autism published through December 2017. The review showed a "dearth of evidence-based treatments" for sleep dysregulation in autism, the panelists noted.

Of 1,987 abstracts, 139 were potentially relevant, and 12 met criteria for data extraction. Eight studies were rated Class III or higher and were included in the panel's review. None examined drug approaches like antidepressants, alpha-adrenergic agonists, benzodiazepines, anti-seizure medicines, or antipsychotics.

Recommendations

The AAN panel's first recommendation was for healthcare providers to determine whether medications or co-existing conditions underlie sleep problems, and if so, to address them. This is especially important because children with autism have an increased risk of conditions that could contribute to sleep disturbance, such as apnea, epilepsy, depression, anxiety, bipolar disorder, ADHD, and gastrointestinal illness.

The guideline writers also advised clinicians to counsel parents about behavioral strategies, including:

• Setting up a consistent sleep routine with regular bedtimes and wake times
• Developing and adhering to pre-bed calming rituals
• Choosing a bedtime close to the time a child begins to fall asleep

"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," Williams Buckley pointed out. Family-based cognitive behavioral therapy also may improve aspects of sleep.

If behavioral strategies are not helpful and contributing conditions and medications have been addressed, clinicians should offer melatonin, starting with a low dose. They should advise patients to use a pharmaceutical-grade preparation, if possible. Melatonin is the most commonly dispensed hypnotic drug in children, but and some formulations are contaminated with other products like serotonin, they cautioned.

No insomnia drugs are FDA-approved for pediatric use, the guideline authors noted.

Clinicians should counsel patients and parents that melatonin may have adverse effects like morning drowsiness, increased enuresis, headache, or dizziness, and should let them know long-term safety information is lacking.

"Given that many children with ASD use melatonin for months or years, the lack of long-term safety data is concerning," the authors wrote. "Melatonin affects the hypothalamic–gonadal axis and can potentially influence pubertal development."

Melatonin alone may be just as helpful for some patients as combining melatonin with behavioral strategies, they added.

Panel members found no evidence that weighted blankets or special mattress technologies improve sleep when used routinely. "If asked about weighted blankets, clinicians should counsel that the trial reported no serious adverse events with blanket use and that blankets could be a reasonable nonpharmacologic approach for some individuals," they wrote.

Future research is needed about the long-term use of melatonin and about children with ASD and concomitant mood disorders, the authors noted. "Research tying the underlying neurobiology in early-life sleep disruption to behavior might help clinicians and researchers understand which treatments might work for which people with ASD," they added.

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