Supporting American Academy of Neurology’s new clinical practice guideline on evaluation and management of insomnia in children with autism

Citation:

Rosen CL, Aurora RN, Kapur VK, et al. Supporting American Academy of Neurology’s new clinical practice guideline on evaluation and management of insomnia in children with autism. J Clin Sleep Med. 2020;16(6):989–990.

The American Academy of Sleep Medicine (AASM) appreciates the invitation to endorse the practice guideline entitled “Treatment for insomnia and disrupted sleep behavior in children and adolescents with autism spectrum disorder” by the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology (AAN).¹

Two challenges that push families of children with autism spectrum disorder (ASD) to their limits are managing aggression and sleep problems. The guideline addresses persistent sleep disturbances, which are very common in this clinical population and often exacerbate the core features of autism, including aggression. If the clinician can “fix” nighttime sleep, both the child and the parent will be better rested in the morning, and the child’s daytime behaviors will improve, leaving the parent with more energy to manage family, work, and personal essentials.

Members of the AASM’s Guidelines Advisory Panel and 2 other content experts reviewed the guideline. The AASM appreciates the significant effort and expertise required to complete the guideline and is pleased to endorse it. This letter provides an overview of the guideline, focusing on areas of most interest to sleep medicine providers, as well as areas where the guideline may differ from methodology and recommendations of the AASM.² One area of difference is that the AAN used a different methodology for evaluating evidence than currently used by the AASM for developing clinical practice guidelines. The most significant methodologic difference is that they used a rating scheme similar to the Oxford method,³ which assesses the quality of individual studies based primarily on study design rather than Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology,⁴ which evaluates the overall quality of multiple studies reporting on a specified outcome.

The AAN guideline panel reviewed evidence supporting pharmacologic and nonpharmacologic strategies for treating sleep disturbances in children and adolescents with ASD to formulate treatment recommendations. The recommendations establish expectations for clinical evaluation to assess and address medications and coexisting conditions that could contribute to sleep disturbances. The recommendations also suggest to counsel parents about strategies for improving sleep habits using behavioral strategies as first-line treatment alone or in combination with pharmaceutical-grade melatonin if a behavioral approach alone does not improve the sleep disturbances. Finally, clinicians are encouraged to counsel patients that there is no significant evidence to support 2 complementary or alternative strategies—weighted blankets or a specific vibration-based mattress technology—often marketed for children with ASD.

The AAN’s recommendations largely align with the AASM’s 2005 consensus statement on the use of pharmacotherapy in the treatment of pediatric insomnia.⁵ The AASM 2005 statement recommends the use of medication be “diagnostically driven,” implemented in conjunction with empirically based behavioral treatment strategies and adequate sleep hygiene and specifically targets insomnia in children with neurodevelopmental disorders. Although the AASM’s 2017 Clinical Practice Guideline on the management of insomnia in adults recommended against the use of melatonin, this document did not evaluate melatonin as a treatment in children with autism.⁶

Given a paucity of data, the AAN guideline did not provide guidance about managing real-world “sleep crises” where severe sleeplessness disrupts child and family functioning. This issue is more likely to occur in children with ASD, who have greater intellectual disabilities or more severe symptoms. In this high-risk group, more intensive psychopharmacologic therapies are often required to manage comorbid psychiatric disorders that may be contributing to sleep disturbances. Examples of these comorbid psychiatric disorders include anxiety, bipolar disorder, depression, obsessive-compulsive disorder, disruptive behavioral disorder, or schizophrenia.

A limitation of the guideline is that the literature review ended in December 2017; there is a disclaimer that the report will not be continually updated.

The AAN guideline for the treatment of insomnia and disrupted sleep behavior in children and adolescents with ASD provides valuable guidance to clinicians where gaps in standardized care previously existed. In addition, the AAN guideline highlights the dearth of well-designed studies of sleep-related treatments for children with ASD. The AASM agrees that additional patient-centered research initiatives are critical for building a strong, evidence-based approach to treatment strategies that improve sleep-related health outcomes in this challenging population and identifying the characteristics of the patients most likely to benefit from the different strategies.

DISCLOSURE STATEMENT

Carol L. Rosen, MD; R. Nisha Aurora, MD, MHS; and James A. Rowley, MD are on the American Academy of Sleep Medicine Board of Directors. The authors report no conflict of interest.