Jacquelin Esque, MD
photo: Jamie Manser
Youth with Autism Spectrum Disorder (ASD) have higher rates of sleep problems compared to the general population. It is estimated that 50-80% of kids and teens with ASD diagnoses report difficulty with sleep. The most commonly reported sleep problems are initiating and maintaining sleep, frequent and prolonged nighttime awakenings, early morning awakening and irregular sleep-wake schedules. Polysomnography differences in individuals with ASD include prolonged sleep latency, reduced total sleep time, lower sleep efficiency, reductions in both rapid eye movement (REM) sleep and non- REM sleep and a lower number of REMS during REM density. Poor sleep has a huge impact on kids with ASD and we see higher rates of self-injury, anxiety, aggression, hyperactivity, inattention, as well as increase in core symptoms of ASD like repetitive behaviors and social reciprocity in those children with ASD that are sleeping more poorly. Poor sleep also impacts the entire family – increasing parental/guardian stress by directly impacting the family’s sleep as well as how poorer daytime functioning impacts quality of life for the whole family.
What should we do to address poor sleep in children and teens with ASD diagnoses?
Screen and Determine Particular Sleep Difficulty:
- All youth with ASD should be screened for sleep problems: Consider use of the Modified Simonds and Parraga Sleep questionnaire or Children’s Sleep Habits Questionnaire
- The most commonly identified sleep problem is insomnia. If concern for insomnia:
- Ask about sleep history, sleep environment
- Sleep diaries may be helpful to further assess
- Ensure part of screening is assessing for Obstructive Sleep Apnea (OSA)
- ASD is not a risk factor itself for OSA, but kids with ASD may have other risk factors such as obesity, hypertrophy of adenoids and tonsils or craniofacial abnormalities.
- Consider referral to sleep specialist for sleep studies such as polysomnography (PSG) if concerns for OSA, Parasomnias or Narcolepsy (additionally would require Multiple Sleep Latency Test)
- When considering value of sleep study, need to account for potential challenges this may create for individuals with ASD based on their sensory sensitivities
- Consider Restless Leg Syndrome and screen for iron deficiency
- Consider nocturnal seizures given high rates of comorbid ASD and Epilepsy
Behavioral Treatment Options:
- Parent education is first line approach – apply similar principles to sleep interventions in children without ASD who have insomnia:
- Correcting problematic behaviors, using positive bedtime routines, graduated extinction, and slowly making bedtime earlier as sleep consolidation improves (sleep restriction with bedtime fading).
- For kids with ASD, use of a visual schedule of bedtime routine may be helpful.
Pharmacological Treatment Options:
- There are no FDA approved medications for sleep in children and adolescents although still see medications often prescribed for sleep
- The majority of evidence we have is for use of melatonin:
- Melatonin is not regulated by the FDA
- In most cases in kids with ASD, melatonin is used as a hypnotic and given shortly before desired sleep onset (30-45 minutes).
- Meta-analyses using melatonin for children with ASD and sleep problems have shown significant improvement in sleep-onset latency and sleep duration. No improvement seen in nighttime awakenings.
- Side effects include headaches and somnolence although generally well-tolerated. Studies did not see issues with growth or pubertal development after 2 years although longer term studies are needed.
- Although minimal data supporting these options, other considerations could include:
- Alpha-agonists (guanfacine and clonidine) – particularly if there is comorbid ADHD and/or tics disorders
- SSRIs if there is comorbid depression or anxiety
- Second generation antipsychotics (Abilify and risperidone) if primary use is for irritability/aggression associated with ASD.
- We need more studies looking at other options that may be beneficial.
Sleep problems in children with ASD are common and impact quality of life for these individuals and their families. Identifying sleep concerns and addressing them with treatment can be extremely beneficial for your patients with ASD.
References
- Hirota T, King BH. Autism Spectrum Disorder: A Review. JAMA. 2023;329(2):157–168. doi:10.1001/jama.2022.23661 https://jamanetwork.com/journals/jama/fullarticle/2800182
- Kyle P. Johnson, Paria Zarrinnegar. Autism Spectrum Disorder and Sleep. Child and Adolescent Psychiatric Clinics of North America, Volume 30, Issue 1, 2021,Pages 195-208,https://doi.org/10.1016/j.chc.2020.08.012.
- Cuomo, B.M., Vaz, S., Lee, E.A.L., Thompson, C., Rogerson, J.M. and Falkmer, T. (2017), Effectiveness of Sleep-Based Interventions for Children with Autism Spectrum Disorder: A Meta-Synthesis. Pharmacotherapy, 37: 555-578. https://doi-org.ezproxy1.library.arizona.edu/10.1002/phar.1920
- Papadopoulos, N., Sciberras, E., Hiscock, H., Williams, K., McGillivray, J., Mihalopoulos, C., Engel, L., Fuller-Tyszkiewicz, M., Bellows, S.T., Marks, D., Howlin, P. and Rinehart, N. (2022), Sleeping Sound Autism Spectrum Disorder (ASD): a randomised controlled trial of a brief behavioural sleep intervention in primary school-aged autistic children. J Child Psychol Psychiatr, 63: 1423-1433. https://doi-org.ezproxy4.library.arizona.edu/10.1111/jcpp.13590