Melatonin may help address sleep disorders in youths with autism
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The American Academy of Neurology published a clinical practice guideline to address sleep disturbances in children and adolescents with autism spectrum disorder, or ASD, which included a recommendation that they be offered melatonin if other strategies are not helpful.
Ashura Williams Buckley, MD, director of the sleep and neurodevelopment service at the National Institute of Mental Health, and colleagues reviewed studies published through December 2017 for children with ASD aged younger than 18 years in the United States and Europe.
They addressed the following question: “In children and adolescents with ASD, which pharmacologic, behavioral, and [complimentary alternative medicine] interventions improve (1) bedtime resistance, (2) sleep onset latency, (3) sleep continuity, (4) total sleep time, and (5) daytime behavior?”
“The approach to sleep disruption in children and adolescents with ASD is multifactorial,” Buckley told Healio. “Patients with autism deserve a comprehensive evaluation for the cause(s) of the sleep disruption. That includes a thorough review of behavioral practices around sleep; all medications and/or supplements they might be taking; and any co-occurring disorders that need to be managed to optimize sleep.”
Based on their review, Buckley and colleagues recommended that clinicians:
- assess children and adolescents with ASD for medications and coexisting conditions that may cause sleep disturbances, and address those issues;
- counsel parents on improving sleep habits “with behavioral strategies as a first-line treatment approach for sleep disturbance either alone or in combination with pharmacologic or nutraceutical approaches;”
- offer melatonin — preferably pharmaceutical grade — starting at a low dose if addressing medications and coexisting conditions and implementing behavioral strategies have not been successful, and counsel parents about potential adverse effects from melatonin and lack of long-term safety data.
“Clinicians should counsel that there is currently no evidence to support the routine use of weighted blankets or specialized mattress technology for improving disrupted sleep,” Buckley and colleagues added. “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.”
Buckley said a major limitation of the review was a lack of well-designed studies to inform best practices. The guideline is based on a total of eight studies.
“More research is needed and may help find new ways to treat sleep disruption in children and teens with autism,” Buckley said. “We need to design and conduct better and more varied research studies of sleep and ASD.” – by Ken Downey Jr.
Disclosures: Buckley reports serving on the editorial board for the journal Behavioral Sleep Medicine. Please see the study for all other authors’ relevant financial disclosures.
Perspective
Back to TopKristin Sohl, MD, FAAP
This is an updated guideline to the one the AAP published back in 2012 but very consistent with those and based on updated research.
Disrupted sleep behavior in children and adolescents with ASD is a significant issue that impacts daytime functioning and behavior. This practice guideline provides a systematic review assessing recent studies of treatment options for insomnia in this population.
The review emphasizes the primary importance of identifying and addressing underlying coexisting conditions and potential medication effects that can adversely affect sleep. Conditions such as sleep apnea, epilepsy, gastrointestinal reflux disease and co-occurring mental health conditions such as anxiety and ADHD may directly impact sleep quality and need to be assessed and managed.
Behavioral strategies including adherence to predictable, calming bedtime routines and clear parental expectations/response to bedtime resistance patterns remain standard first-line recommendations. Family-based cognitive behavioral therapy with or without melatonin also showed improvement in several aspects of sleep onset over short intervention intervals.
If management of coexisting conditions and application of behavioral supports prove unsuccessful in improving sleep, there is low to moderate confidence that melatonin improves various aspects of sleep in children and adolescents with ASD. Although the pharmaceutical-grade melatonin used in the studies showed results, it is unclear if over-the-counter preparations result in similar improvements.
Additionally, long-term safety data are lacking in the pediatric population, so risk-benefit conversations should be had with families and revisited at regular intervals. Integrative approaches to treatment are often considered by families. Weighted blankets are particularly common.
Studies show insufficient evidence for each of the reported sleep outcome measures. Disrupted sleep can significantly impact a family’s quality of life and a child or adolescent with autism’s daily functioning.
It is imperative that future research continue to explore the physiologic underpinnings of insomnia in individuals with ASD and seek to further explore behavioral and pharmacologic interventions.
Disclosure: Sohl reports no relevant financial disclosures.
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