AAN guideline for treating insomnia in children and adolescents with autism spectrum disorder

Reference

Williams Buckley A, Hirtz D, Oskoui M, et al. Practice guideline: Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2020;94(9):392-404.

Synopsis

The AAN uses a reasonable process to develop their guidelines: perform a formal systematic review of the relevant literature, weigh the recommendations based on the best evidence, and limit the potential influence of conflicts of interest. This AAN panel acknowledges the variability in how autism spectrum disorder is defined. To inform this review, they used a librarian to conduct a literature search and methodologists to synthesize the relevant data. Finally, they used various approaches to reaching consensus when the data were limited. Only 8 studies met their inclusion criteria. The final guideline addresses 6 broad outcomes: bedtime resistance, sleep onset latency, sleep efficiency, nocturnal awakenings, total sleep time, and daytime behaviors. One study that evaluated, in a factorial design, the effects of melatonin, family-based cognitive behavioral therapy (CBT), or placebo on bedtime resistance (refusal, stalling, or needing parental presence) found that all the active treatments were effective. Three studies pooled into a meta-analysis demonstrated that melatonin caused an approximately 30-minute reduction in sleep onset latency. Three studies found that CBT had no net effect on sleep onset latency. Only one study evaluated the effects of weighted blankets and of sound-to-sound mattress technology on sleep onset latency, so stay tuned. Additionally, only a single study evaluated melatonin's effects, CBT, weighted blankets, and fancy mattresses on sleep efficiency. A meta-analysis of 3 studies found that melatonin had no effect on nocturnal awakenings but increased total sleep time by 53 minutes. The data for the effects of CBT, weighted blankets, or fancy mattresses on total sleep time and daytime behaviors were limited to single studies (as was the effect of melatonin). Putting it all together, melatonin and melatonin plus CBT are probably effective for all 6 outcomes, except daytime behaviors. Similarly, CBT alone is possibly effective for all but daytime behaviors. Informational packets on sleep hygiene given to parents were not effective for any outcome. Weighted blankets or fancy mattresses have not been adequately studied. Although few trials of melatonin reported no adverse effects, the authors, appropriately raise caution about persistent drowsiness, headache, rash, hypothermia, and dizziness.