Autism spectrum disorders (ASD) are complex neuro developmental disorders characterized by social interaction/communication challenges and restrictive, stereotyped behavior patterns. Sleep disturbances in ASD are common, including difficulties initiating and maintaining sleep, frequent and prolonged night awakenings, irregular sleep–wake patterns, short sleep duration, and early-morning waking.1 Between 44% and 83% of children and adolescents with ASD report coexisting sleep abnormalities, adversely affecting daily functioning.2 Although up to 40% of typically developing children and adolescents have sleep problems, these often lessen with age. In children and adolescents with ASD, sleep problems often persist.3 Sleep disturbance severity is associated with poor physical health and quality of life.4 Poor sleep quality and insufficient nighttime sleep can exacerbate core and associated ASD features, contributing to negative effects on mood and emotional regulation, behavior, and cognitive functioning. Children and adolescents with intellectual disabilities and severe symptoms associated with ASD are at especially high risk for sleep problems.5–7 Sleep disturbances are associated with communication deficits and restrictive and repetitive behaviors in ASD.8,9 Sleep disorders negatively affect sleep and quality of life of affected individuals and their families.10 Disordered sleep is also associated with daytime behavioral disturbances,11–13 increased injury risk,14,15 obesity,16 and poor academic performance17–19 in general pediatric populations.
Contributors to circadian rhythm misalignment potentially include dysregulated melatonin synthesis or altered melatonin secretion patterns, circadian clock gene anomalies,20 and decreased awareness of social and environmental clues that help habituate sleep–wake cycles. Abnormalities in GABAergic, glutamatergic, serotonergic, and dopaminergic systems in ASD are also possible contributors. Coexisting conditions such as epilepsy, nocturnal gastroesophageal reflux disorder (GERD), anxiety, depression, bipolar disorder, psychosis, and attentiondeficit/hyperactivity disorder (ADHD) can further contribute to sleep problems. Core or co-occurring ASD symptoms such as intellectual disability, sensory integration deficits, ritualistic or self-injurious poor communication skills, and limited responsiveness to social cues can interfere with sleep training and exacerbate or prolong sleep problems.
Children and adolescents with ASD and sleep disturbances often receive combined medication, behavioral, and complementary and alternative medicine (CAM) treatments. Exogenous melatonin is a synthetic form of endogenous melatonin, a hormone that is the primary biomarker for circadian sleep regulation. Melatonin has chronobiologic (circadian) functions and hypnotic effects. Over-the-counter (OTC) preparations are considered supplements and not subject to US Food and Drug Administration (FDA) purity regulations. Pharmaceutical grade preparations are prescribed for exact dosing. Behavioral therapies for children aged ≤5 years include unmodified, graduated extinction; positive routines; and bedtime fading.21 Older children and adolescents may respond to cognitive-behavioral therapy (CBT) adapted from adult paradigms.22,23 These interventions are short-term, multicomponent, goal-oriented psychotherapeutic treatments aiming to modify thinking patterns and behaviors that perpetuate insomnia (e.g., irregular sleep–wake schedules, poor sleep hygiene, and maladaptive habits).
This guideline addresses the following question:
In children and adolescents with ASD, which pharmacologic, behavioral, and CAM interventions improve (1) bedtime resistance, (2) sleep onset latency (SOL), (3) sleep continuity, (4) total sleep time (TST), and (5) daytime behavior?