Guidelines on Sleep in Youth With ASD

The American Academy of Neurology (AAN) released a practice guideline for the treatment of insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder.

Published in Neurology, the guideline addressed 4 types of sleep problems in this population: refusing to go to bed or needing a parent present until the child falls asleep, trouble falling asleep and staying asleep, sleeping for only short periods of time or not getting enough total sleep, and daytime behavior problems associated with insufficient sleep at night.

The guideline also addressed the importance of determining the nature of the cause of sleep problems—whether the causes relate to medications, medical conditions, or behavioral conditions—and the use of behavioral treatment options and melatonin.

Consultant360 reached out to lead author Ashura Williams Buckley, MD, who is the director of Sleep and Neurodevelopment Service at the National Institute of Mental Health in Bethesda, Maryland, and a member of the AAN.

Consultant360: Why was it important to develop this guideline dealing with sleep problems in children and adolescents with autism?

Ashura Williams Buckley: Good sleep is as important as good nutrition and daily exercise. Every child does better when these critical health areas are optimized. We know that people with autism spectrum disorder (ASD) are at higher risk of sleep disruption, particularly insomnia, throughout their lifetimes. Therefore, health practitioners are very likely to be asked to address insomnia and sleep disruption in this population. It is important for parents and practitioners to know that the AAN has taken a comprehensive look at the available literature and developed an evidence-based guideline.

C360: What were the key conclusions made in the new guideline, and were there any notable changes from the previous standard of care?

AWB: It is very important that the approach to sleep disruption in children and adolescents with ASD should be multifactorial. Patients with autism deserve a comprehensive evaluation for the cause(s) of the sleep disruption. That includes a thorough review of (1) behavioral practices around sleep, (2) all medications and/or supplements they might be taking, and (3) any co-occurring disorders that might need to be managed in order to optimize sleep. This includes other sleep disorders such as sleep disordered breathing and restless legs syndrome. We continue to uphold the generally accepted pediatric tenet that where behavioral approaches can improve behavior, they should be the first approach.

C360: Were there any notable limitations in the evidence assessed in the statement that could inform future research endeavors?

AWB: The major limitation is the very sparse evidence base that exists to answer these questions. We need more well-designed trials on which to base any future recommendations. We definitely need more comprehensive and inclusive studies of two things in particular: (1) what works to help improve sleep in people with ASD and (2) what is the underlying biology in sleep disruption in ASD. Well-informed answers rooted in neurobiology will greatly improve our therapeutic options.

C360: What are the take-home messages you hope that clinicians receive from this guideline?

AWB: The approach to optimizing sleep in children and adolescents with ASD is a process and often will require an ongoing partnership between the patient, their family, and their neurologist or other health care provider. Sleep needs and patterns will change throughout childhood and what worked well early in life to address insomnia may not work in adolescence. Sleep problems should be discussed early and revisited regularly and certainly at developmental milestones.

—Michael Potts

Reference:
Buckley AW, Hirtz D, Oskoui M, et al; Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder [published online February 12, 2020]. Neurology. https://doi.org/10.1212/WNL.0000000000009033.