pediatrics 2012 malow s106 24
TRANSCRIPT
A Practice Pathway for the Identification, Evaluation, and Management ofInsomnia in Children and Adolescents With Autism Spectrum Disorders
Beth A. Malow, Kelly Byars, Kyle Johnson, Shelly Weiss, Pilar Bernal, Suzanne E.Goldman, Rebecca Panzer, Daniel L. Coury and Dan G. Glaze
Pediatrics 2012;130;S106DOI: 10.1542/peds.2012-0900I
The online version of this article, along with updated information and services, islocated on the World Wide Web at:
http://pediatrics.aappublications.org/content/130/Supplement_2/S106.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned,published, and trademarked by the American Academy of Pediatrics, 141 Northwest PointBoulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academyof Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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A Practice Pathway for the Identification, Evaluation, andManagement of Insomnia in Children and AdolescentsWith Autism Spectrum Disorders
abstractOBJECTIVE: This report describes the development of a practice
path-
way for the identification, evaluation, and management of insomnia inchildren and adolescents who have autism spectrum disorders (ASDs).
METHODS: The Sleep Committee of the Autism Treatment Net
work(ATN) developed a practice pathway, based on expert consensus, tocapture best practices for an overarching approach to insomnia bya general pediatrician, primary care provider, or autism medical spe-cialist, including identification, evaluation, and management. A fieldtest at 4 ATN sites was used to evaluate the pathway. In addition, a sys-tematic literature review and grading of evidence provided dataregarding treatments of insomnia in children who have neurodevelop-mental disabilities.
RESULTS: The literature review revealed that current
treatments forinsomnia in children who have ASD show promise for behavioral/educational interventions and melatonin trials. However, there isa paucity of evidence, supporting the need for additional research.Consensus among the ATN sleep medicine committee expertsincluded: (1) all children who have ASD should be screened forinsomnia; (2) screening should be done for potential contributingfactors, including other medical problems; (3) the need fortherapeutic intervention should be determined; (4) therapeuticinterventions should begin with parent education in the use ofbehavioral approaches as a first-line approach; (5) pharmacologic
therapy may be indicated in certain situations; and (6) there shouldbe follow-up after any intervention to evaluate effectiveness andtolerance of the therapy. Field testing of the practice pathway byautism medical specialists allowed for refinement of the practicepathway.
CONCLUSIONS: The insomnia practice pathway
may help health careproviders to identify and manage insomnia symptoms in children and
AUTHORS: Beth A. Malow, MD, MS,a,b,c Kelly Byars, PsyD,dKyle Johnson, MD,e Shelly Weiss, MD,f Pilar Bernal, MD,a,cSuzanne E. Goldman, PhD,g Rebecca Panzer, MA, RD, LD,hDaniel L. Coury, MD,i and Dan G. Glaze, MDj
Departments of aNeurology and bPediatrics and cKennedy Center,Vanderbilt University Medical Center, Nashville, Tennessee;dDepartment of Pediatrics, University of Cincinnati College ofMedicine, Cincinnati Hospital Children’s Medical Center,Cincinnati, Ohio; eDepartment of Psychiatry, Oregon Health andScience University, Portland, Oregon; fHolland Bloorview KidsRehabilitation Hospital, Toronto, Ontario, Canada; gKaiserPermanente Northern, San Jose, California; hMassGeneralHospital for Children, Boston, Massachusetts; iDepartment ofPediatrics, Nationwide Children’s Hospital, Columbus, Ohio; andjDepartments of Neurology and Pediatrics, Baylor College ofMedicine, Houston, Texas
KEY WORDSactigraphy, education, sleep, sleep latency
ABBREVIATIONS
ASD—autism spectrum disorderATN—Autism Treatment NetworkCSHQ—Children’s Sleep Habits QuestionnaireNICHQ—National Initiative for Children’s Healthcare QualityRCT—randomized controlled trial
This manuscript has been read and approved by all authors.This paper is unique and not under consideration by any otherpublication and has not been published elsewhere.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0900I
doi:10.1542/peds.2012-0900I
Accepted for publication Aug 8, 2012
Address correspondence to Beth Malow, MD, MS, Burry Chair inCognitive Childhood Development, Director, Vanderbilt SleepDisorders Division, 1161 21st Avenue South, Room A-0116,Nashville, TN 37232. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.
adolescents who have ASD. It may also provide a framework to evaluatethe impact of contributing factors on insomnia and to test the effec-tiveness of nonpharmacologic and pharmacologic treatment strategiesfor the nighttime symptoms and daytime functioning and quality of lifein ASD. Pediatrics 2012;130:S106–S124
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SUPPLEMENT ARTICLE
Approximately 1 in 110 children fu
lfillsthe Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition,Text Revision, diagnostic criteria forautismspectrum
disorders(ASDs)as defined by delayed or abnormalsocial interaction, language as used insocial communication, and/or restrictedrepetitive and
stereotyped patternsof behavior, interests, and activities.1
Children who have ASD are at greaterrisk for developing sleep problems than
typically developing children. Researchhas documented that the prevalence ofsleep disturbances ranges from 53% to78% for children who have ASD com-pared with 26% to 32% for typically de-veloping children.2,3
The key components of
pediatric in-somnia are repeated episodes of dif-ficulty initiating and/or maintainingsleep, including premature awaken-ings, leading to insufficient or poor-quality sleep. These episodes result infunctional impairment for the child or
other family members.4 In typicallydeveloping children, the primary causeof insomnia is behaviorally based.5 Inthe ASD population, however, insomniais multifactorial. It includes not onlybehavioral issues but also medical,neurologic, and psychiatric comorbid-ities; it is also an adverse effect of themedications used to treat symptoms ofautism and these comorbidities.6
Typically developing children
who haveinsomnia are at increased risk forneurobehavioral
problemssuch asimpairments in cognition, mood, atten-tion, and behavior.5,7–9 Similar to thebehavioral morbidity associated withpediatric insomnia that is observed inthe general population, children whohave ASD and sleep problems are proneto more severe comorbid behavioraldisturbances compared with childrenwithout sleep disturbances.10 In addition,treating insomnia in children who haveneurodevelopmental disorders may im-prove problematic daytime behaviors.11
Despite the prevalence of and
morbidityassociated with pediatric insomnia,there is evidence that sleep disorders inchildren often go undetected and un-treated.12–14 Medical practitioners of-ten do not ask about sleep concerns orparents do not seek assistance.15 Manyparents have poor knowledge aboutsleep development and sleep prob-lems.16 This is particularly relevant tochildren who have ASD, in that parentsmay present to the pediatrician withconcerns regarding aggression, im-pulsivity, inattention/hyperactivity, orother behavioral issues that may besecondary to a sleep disorder. Thecontribution of the sleep disorder maybe undetected due to emphasis ontreating the behavioral issue as op-posed to identifying and treating theunderlying factors. This deemphasis ofunderlying factors may be due to theabsence of a standardized approachfor recognition and treatment of in-somnia in children who have ASD.
Guidelines exist for sleep screening
andintervention in typically developingchildren.17,18 Guidelines and empiricalsupport also exist for the effectiven
essof behavioral treatment of bedtimeproblems and night wakings in chil-dren.18–21 Specific behavioral treat-ments supported include the following:unmodified extinction: leaving thechild’s bedroom after putting the childto bed and not returning until morningunless the child is ill or at risk for in-jury; extinction with parent presence:parent is present in the room with thechild but does not interact with himor her; graduated extinction: parentreturns to child’s bedroom to attendto child on request or agitation butincreases the time in between requestsby the child for the parent to return;preventive parent education: providingeducation to parent on sleep habitsand bedtime routine; bedtime fading:delaying bedtime to promote sleep andthen “fading” or advancing bedtime
once child is falling asleep easier; andscheduled awakenings: awakening thechild before a spontaneous awakening.Extinction and parent education havestrong empirical support whereas theother interventions are less confidentlysupported.18 To our knowledge, how-ever, there are no published guidelinesrelated to management of insomniain children who have ASD, includingscreening and treatment. The evidencethat children who have ASD are atgreater risk for insomnia and itsmorbidity suggests that sleep screen-ing in this population of children isextremely important. The ideal evalua-tion of insomnia in children who haveASD involves a comprehensive sleepassessment, as outlined in a recent
review.22
To facilitate the evaluation of childr
enwith ASD for insomnia, the Autism Treat-ment Network (ATN) in association withthe National Initiative for Children’sHealthcare Quality (NICHQ) worked col-laboratively to develop the clinicalpractice pathway presented in this arti-cle. The intention of this clinical practicepathway is to emphasize the need forscreening of sleep problems in ASD a
ndto provide a framework for decision-making related to best practices in thecare of children and adolescents withASD in primary care settings, when seenby a general pediatrician, primary careprovider, or autism medical specialist.The pathway is not intended to serve asthe sole source of guidance in the eval-uation of insomnia in children who haveASD or to replace clinical judgment, andit may not provide the only appropriateapproach to this challenge.
METHODS
Guideline Development
The ATN Sleep Committee consists ofpediatric sleep medicine specialists aswell as developmental pediatricians,neurologists, and psychiatrists. The
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clinical practice pathway was designedto assist primary care providers andothers working directly with familiesaffected by ASD in addressing the chal-lenge of insomnia with regard to iden-tification, assessment, and management.
Insomnia was defined as
“repeateddifficulty with sleep initiation, duration,consolidation, or quality that occursdespite age-appropriate time and op-portunity for sleep that results in day-time functional impairment for thechild and/or family.”18 The responses ofthe parents to selected questions onthe Children’s Sleep Habits Question-
naire (CSHQ)23 identified those patientswho have insomnia.
After performing a systemi
c review ofthe literature, expert opinion and con-sensus was used to form the basis of thepractice pathway (Fig 1). The ATN SleepCommittee’s knowledge of the litera-ture and applicability to clinical prac-tice informed best practices, which inturn created an overarching approachto insomnia within ATN sites by theautism medical specialist.
Systematic Review of the Li
terature
We conducted a systemati
c literaturereview to find evidence regardingthe treatment of insomnia in children
diagnosed with ASD (questions andsearch terms available on request fromthe authors). We searched OVID, CINAHL,Embase, Database of Abstracts and Re-view Database of Abstracts of Reviewsand Effects, and the Cochrane Databaseof Systematic reviews databases, withsearches limited to primary and sec-ondary research conducted withhumans, published in the English lan-guage, involving children aged 0 to 18years, and published between January1995 and July 2010. Individual studieswere graded by using an adaptationof the GRADE system24 by 2 primaryreviewers and then reviewed by contentexperts for consensus. Discrepancieswere resolved by a third party.
Pilot Testing of the Pathway
The ATN selected 4 pilot sites (BaylorUniversity, Houston, Texas; OregonHealth and Science University, Portland,Oregon; Kaiser Permanente Northern,San Jose, California; University of Mis-souri, Columbia, Missouri) to test thefeasibility of the practice pathway andprovide information regarding neededmodifications. The pilot sites collecteddata to document adherence to the
practice pathway and participated inmonthly conference calls to provide
updates, understand variance, and re-commend changes. Working with theNICHQ, members of the ATN SleepCommittee refined and finalized thepractice pathway on the basis of feed-back from the pilot sites. In response torecommendations from the pilot sitesto increase feasibility, the NICHQ alsodeveloped a 1-page checklist designedto guide providers through the practice
pathway (Fig 2).
RESULTS
Results of the Literature Review
The search identified 1528 articles. Af-ter removing review articles, com-mentaries, case studies with fewer than10 subjects, studies that included chil-dren who did not have ASD, non-intervention trials, and articles thatdid not address our target questions,20 articles remained (Table 1). Wereviewed the literature for studies re-lated to other aspects of the practicepathway (eg, screening for insomnia,identifying comorbidities, importanceof follow-up) in the ASD populationand were unable to identify evidence-based reports for aspects other thantreatment. A comprehensive review25
and consensus statement26 relatedto the pharmacologic management of
FIGURE 1Checklist for carrying out the practice pathway in children who have ASD and insomnia. CSHQ, Children’s Sleep Habits Questionnaire.
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FIGURE 2Practice pathway for insomnia in children who have ASD.
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for6moto2y
treatm
en
tmg;oraltablet.Durati
on
andbehavioraldisord
ers
wakings)beforeandduri
ng
graduallyadvancedto
0.1
bedtime,latency,numb
erof
initialdose0.05mgan
dwithASD(NewJersey)andsle
ep
Caregiverreport(avera
ge
Included:19childrenaged4to16yClonidine1timeperd
ay,enceph
alopath
y d efinedcongenitaloracquir
ed
Excluded:childrennosographi
cally
(absenttoverysever
e)
hyperkinesi
a
earlywaking.Scored0to
4aggressiveness,a
nd
asleep,nightwakings,a
nd
ofseveremooddisorder
s,
disorders;di
fficultyfalling
withcontinuouspresence($
1y)
Evaluation(includedsl
eep
TIDfor60d
withASD(UniversityofBolog
na)
Included:25childrenaged2to20yNiaprazine1mg/
kgperdayBehavioralSummarized
Mingetal,200
846
control,levelII
IPre/post-no
Excluded:Notspec
ified
1506103d)
(meanduratio
n:
rangedfrom11to368
dmg).Treatm
entdurati
on
ofsleep(P=.002
)
interferingrepetitivebeha
vior
effects(range:7.5
–45
seenontheCGIseverityratin
gs
depression,insomnia,a
nd
symptomsandsi
de
sign
ificantimprovementwas
injury,irritability,anxi
ety,
onresponseoftarge
timprovedsleep.Statistic
ally
symptomsofaggression,s
elf-
individeddoses,bas
ed
nonresponders,3show
ed
alsoinclude
d
wasprescribedtotarg
et
maximumof45mgdai
lyshowedimprovedsleep.O
f17
assessingsleepqualityw
as
intellectualdisability.Mirtaza
pine
incrementsupto
aimproved).Fiveof9respond
ers
improvementite
m
(Indiana);20hadcomor
bid
increasesm
adein7.5-
mg
improvedorverymu
ch im
provement.Amod
ifiedCGI
adults,aged3to23ywithAS
D7.5mgdailywithdosa
ge
accordingtoaCGIscoreofm
uch
rateseverityan
d
Included:26childrenandyo
ung
MirtazapinestartingdoseofCliniciansusedtheCGIsc
aleto
Nineparticipantsresponded(d
efined
Wisconsin
)(Hemokinetics,Inc,Madi
son
TriTrac-
R3DErgometer
7-dsleepdiary
Handapraxiascal
e
Rossietal,199
945
control,levelII
IPre/post-no
Poseyetal,200
144
Excluded:NotspecifiedSF-36HealthSurvey
SyndromeRegist
er
recruitedfromAustralianR
ett
62femalesaged4to30
y8-wktrial;controlgroupinclude
d41y;recruitedfromprevio
us
SeverityInd
ex
twiceadayfor6mo
consistedof21femalesaged
7to
100mg/kgliquidL -
carnitineRettsyndromeSymptoms
Included:experimentalgr
oup
levelIII
Pre/post-control,
developmentaldisord
ers
andwakingsinchildrenwi
th
Clonidineimprovessleeplat
ency
stillexperiencednightwaki
ngs
experiencedimprovemen
ts;5
sleepmaintenancedisord
ers
duringtreatm
ent);16of17w
ith
beforetreatm
ent,0.5–
2h
improvedsleepinitiation(2–
5h
Sixteenof17childrenexperien
ced
ASD
nightwakingsinchildren
with
improvingsleeplatencya
nd
Niaprazineiseffective
in
bytheendofthetrial(P,.001)
improvementinsleepdisord
ers
Evaluationshow
ed
BehavioralSummari
zed
Comparedwithstartofthetreatm
ent,
childrenwithAS
Dimprovingsleepqualit
yin
Mirtazapineiseffective
in
Ellawayetal,200
143
syndrom
ewakingsinchildrenwithR
ett
sleep,ornumberofnig
ht
notduration,latency,day
time
improvessleepe
fficiencybut
supp
lementatio
nConclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
StudyandGrad
e
L- carnitine
ornightwakings(P=.25
)(P=.15),daytimesleep(P=.5
5),
duration(P=.57),laten
cy e fficiency(P,.03)butnot
sign
ificantlyimprovedsleep
controls,L-
carnitine
ComparedwithRettsyndro
me
Sampl
e
TABLE
1Continued
Excluded:notspec
ified
washou
tintravenously;
no
porcinesecreti
noflargerstudy(Californi
a)
intervention2CU/
kgwithautism
recruitedassubs
et
4wkplaceboand4wk
Included:17childrenaged3to
8y
individeddose
samaximumof3.5mg/
day
thentitratedt
ostartedat0.5mgnight
ly slowerdosing$45k
g
,20kg=similar,except
syndrome,and/
orweight,15kg
historyofneurolepticm
align
ant
previoustrialwithrisperido
ne,
sign
ificantm
edicalcondition,
gonadotropintestresultforgi
rls,
positiveb-
humanchorionic
maximumof2.5mg/
day
Excluded:Mentalage,18
mo,
20to44.9kg=0.5mgupt
o
RCT,levelII
I
Honomichletal,200
242RCT,levelI
I
NetworkwithAS
D
placeboorrisperido
ne
PediatricPsychopharm
acolog
y
6mo(responders)giv
en
fromResearchUnitso
n
Parentreportsleeplo
gIncluded:101childrenaged5to17y16wk(nonresponde
rs)to
Amanetal,200
541
interventions
Pharmacologic
StudyandGrad
e
TABLE
1ResultsofSystematicLiteratureReview
waking,m
orningris
e)
onset,time/
durationnight
Sleepdiary(bedtime,sle
ep
withASD
andnightwakingsinchildr
en
duration,bedtimeresista
nce,
improvesleep-
onsetdelay,
Secretindoesnotsign
ificantly
3–
7];post,m
ean:4.3[range:3–
8])
Sleepduration(Pre,m
ean:4.7[ra
nge:
3–
7];Post,m
ean:3.6[range:3–
5])
Nightwakings(Pre,m
ean:4.1[ra
nge:
[range:1–
3])
[range:1–
3];Post,m
ean:1.6
Sleep-
onsetdelay(Pre,m
ean:2.1
6–17];Post,m
ean:8[range:6–
13])
resistance(Pre,m
ean:9[ran
ge:
CSHQscores:Bedti
me
Secretindidnotsign
ificantlyaffect
CSH
Q
(parentreport
)mildorm
oderate/
severe
Adverseeventsscored
asM
ovementSca
le
Abnorm
alInvolunta
ry
ratesofadverseoutcom
es
butnotsleepduration;hi
gh
latencyinchildrenwithA
SD
Risperidoneimprovessl
eep
andconstipation(12%vs10
%)
di
fficultywaking(8%vs12%
),(10%vs33%),rhinitis(8%vs16
%),
(29%vs33%),excessiveapp
etite
somnolence(12%vs37%),enur
esis
versusrisperidone,respectiv
ely):
scoredasm
oderate(place
bo
6mo(29min).Adverseeve
nts
(17min;40min)butnotbeyo
nd
durationincreasedshort-
term
(P=.02;P=.05).Averagesle
ep
commoninrisperidonegro
up
Sleepproblemsandanxietyl
ess
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
Sam
ple
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SUPPLEMENT ARTICLE
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,4wk
takingsedativemedication
sfor
currentlyusingmelatoninan
d/or
Excluded:childrenpreviou
sly/
RCT,levelI
I
thelast6mo)
(UnitedKingdom)
awakening
)nightwaking4timesperweek
for
(atleast1hsleeplatencyand/
or
nightwakings,morni
ng
thenreversedfor4w
k
sleeptime,sleeplaten
cy,
for4wk,washout1wk
, withautism
andsleepingdi
fficulty
Parentalsleepcharts(tot
al
Placeboor5mgmelaton
inIncluded:7childrenaged4to1
6ysu
chasFragileXorRettsyndro
me
neurodevelopmentaldisorder
smedications,andthosewitho
ther
currentlyonpsychotro
pic
currentlyonmelatonin,th
ose
Sleepdi
fficultiesquestionnaire
Excluded:childrenpreviousl
yor
a1mowashout
moforeachagentwit
hTreatm
entphaselaste
d3
improvementof$50
%.
achieved,d
efinedasan
until“good”sleepw
as
psychotropicmedicatio
ns
amaximumdoseof10
mg
successfulandwerefree
of
nightsby2mgto
managementthatwas
not
bytheparentevery
3
Childrenhadundergonebeha
vior
Thedosewasincreas
ed
everymonthfor9m
o
and/
orreducedtotalsleeptime.
overtotheotheragen
t.timeawake)werecollect
ed
latency,excessivenightwa
king,
placeboandthencross
ed
sleeptime,nightwakin
gs,
withASDandprolongedsle
ep
beforeplannedsleep,
or
melatonintaken,bedti
me,
Included:20children,aged4to16yMelatonin2mg,30to40minDailysleepdiaries
(time
GarstangandWallis,200
627RCT,levelII
I
Wrightetal,201
149
[CI:9.68–
9.99])
8.75h[CI:8.56–
8.98];9.84h
baseline(8.05h[CI:7.65–
8.44];
Durationincreasedby1.79hver
sus [CI:0.04–
0.12])
[CI:0.20–
0.34];0.08
(0.35[CI:0.18–
0.53];0.26
pernightversusbaseli
ne
Wakingspernightdecreasedby0
.27 [CI:0.98–
1.13])
1.91h[CI:1.78–
2.03];1.06h
baseline(2.6h[CI:2.28–
2.93];
latencyimproved1.54hver
sus
valuesrespectively:Sl
eep
Baseline,placebo,andmelat
onin
wakingsandsleepdurati
on
latencynumberofnig
ht
treatm
enttoimprovesle
ep
Melatoninisaneffecti
ve
othersleepdisorde
rsparasomnia,sleepapnea
,or
treatm
ent(P=.04)butn
ot
Dyssomniasubscaleimproved
with
StudyandGrad
e
nightwaking
schildrenwithASDbutn
ot
latencyandtotalsleeptim
ein
Melatoninimprovessle
ep
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
notimprove(P=.2
)withplacebo.Nightwakings
did
melatonintreatm
entcomp
ared
longer(P=.002)durin
g(P=.004)andtotalsleeptimew
as
Meansleeplatencywaslow
er
Sampl
e
TABLE
1Continued
ferritin,transferri
n)
albumin,vitamin
B12,serum
Bloodsample(MCV,m
erc
ury,
powderedelementalir
on
microencapsulate
d
sign
ificantly(16to29mg/L)
DuringSleepScal
e60mg/
dayof
supp
lementatio
n
MeanferritinandMCVincreas
ed
PeriodicLegMoveme
nts
Ifnottolerated,receiv
ed
Excluded:currentlytakingi
ron
Scale(P=.82)
MovementsDuringSl
eep
(P=.83),orPeriodicLe
gwithferritin(P=.61),irritabili
tylatency;norelationwasfou
nd
35%hadimprovedsle
ep
(Toronto)
sign
ificantly(29%;P=.04)and
ferritinmeasuredpreviou
sly
scores,restlesssleepimpro
ved
Children
perdayfor8wk
diagnosedwithautism
wi
th
Perthesleepdisturbancesc
ale
SleepDisturbanceScale
for
6mgelementaliron/
kgIncluded:33childrenaged2to
5y
bodyweigh
tdailyintakeof3ml/
5lb
TIDwithfoodforatota
lSS-III;fulldose1ml/
5lb
Days50to90:continu
edtransitiontoSS-
III
Days35to50:gradu
al
vitaminC
) pyridoxamine,a2lipoica
cid,
B 6,pyridoxine,pyridox
al,
doseofSS-II
Excluded:notspecifiedDays25to34:heldmaximumBloodandurinesample(plasm
amultivitamin(Arizo
na)
thanstandardchildre
n’s
multivitaminsupplementso
ther
mo,andnoprevioususe
of
placebo(P=.03
)maximu
m
improvedcomparedw
ith
increasedlinearlyt
otreatm
enttherapiesinprevio
us2
withASDwithnochangesi
nasevidencedbyCGIsco
re(standardmultivitam
in),
Days0to24:1/8doseofSS-IICGISleepandgastrointestinalsymptoms
Included:25childrenaged3to
8y
Pre/post-
control,levelII
Dosm
anetal,200
748RCTlevelII
Excluded:notspec
ified
AdamsandHolloway,20
0447
Otherbiologicagen
ts
levelIII
casecontrol
,
Retrospectiv
e
StudyandGrad
e
TABLE
1Continued
movem
ent
slatency,orperiodicl
eg
affectirritability,sle
ep
childrenwithASDbutdoes
not
improvesrestlesssleep
in
Oralironsupplementati
onsc
oreinchildrenwithAS
DapositiveimpactonCGIsl
eep
vitaminC)m
ayha
ve
(includingvitamin
B6and
Moderate-
dosemultivitamin
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
Sampl
e
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beforebedtim
e$30minon$3nightsperweek
phase:inertliquid30m
inwithASDandsleep-
onsetdelayof
Actigraphy;CS
HQ
Two-
weekacclim
ation
Included:24childrenaged3to
9y
aged.4y
upto6mginchildren
inchildrenaged,4yan
ddosetomaximumof4
mg
Physiciancouldincrea
se
.15minduringthenigh
tFRischildrenawokefo
r
Childrenadvisedtogive2
mg
Malowetal,201
152
medicationsfor6mopreviou
sly
conditions,and/
ortaking
belowcutoff,coexisti
ng
diagnosisbutwithCARSsco
re
Excluded:childrenwithauti
smPre/post-
control,levelII
(Italy)
before
5AM.3timesperweek)
weeknightwakings,andwak
ing
minsleeplatency,.3timesp
er
study
,29.5withsleepdisorder(.45
n=16,respectivel
y)
withautism
andCARSsco
re
Included:25childrenaged2.6to9.6y6-to24-
mo(n=25and
Giannottietal,200
651
tolerate
dwithASD.Itissafeandwel
lparentingstressinchildr
en
daytimebehaviora
nd
andimprovesaspects
of
treatm
entofsleeplaten
cy,
Melatoninisaneffecti
ve
timeorwaketimeaftersleepons
et P,.0001)butnottotalslee
psleeplatency(42.9to21.6
min;
improvementsweresee
nin
statisticallysign
ificant
withacclim
ationphas
e),
Withmelatonintreatm
ent(comp
ared
and2mgCR)
duration,daynap
s)beforebedtime(1mgF
R
duration,nightwakingsa
nd
melatonin30to40mi
n
Sleepdiary(bedtime,riseti
me,
3mgcontrolled-
release
StudyandGrad
e
ASD
resistanceinchildrenwi
thnightwakings,andbedti
me
duration,latency,numbe
rof
treatm
enttoimprovesle
ep
Melatoninisaneffecti
ve
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
P,.001)
years1and2(63vs44vs44
;improvementinCSHQscore
sin
showedsign
ificant
Thosewhocontinued24
mo
irregularityin61%
(P,.001).
63%
(P,.001),andbedtime
parentalpresenceatbedtim
ein
cosleepingin55%
(P,.001),
from70to10min(P,.001),
awaketimeaftersleeponset
by
indurationby2.6h(P,.001),
diariesshowedimprovem
ents
improved(P,.01).Slee
pdisorderedbreathingal
so improved(P,.001).Slee
p-
sleepinessweresign
ificantly
wakings,anddayti
me
resistance,anxiety,ni
ght
regardinglatency,durati
on,
vs43;P,.001).CSHQvalue
s weresign
ificantlyimproved(65
CSHQvaluesfrombaselineto6
mo
CSH
Q
Sampl
e
TABLE
1Continued
comorbidity
withmajorpsychiatr
icpsychotropicmedication
sor
Excluded:childrentak
ing
Pre/post-
control,LevelII
problemsinlast3mo(Helsink
i)syndromeandseveresle
ep
diagnosedwithAsperg
er’s
Included:15children5to1
7y
Paavonenetal,200
350
Excluded:notspec
ified
RCTlevelII
washout
)reversedfor2wk(n
oproblems(Californi
a)
bedtimefor2wk,the
nsyndromewhoreportedsle
ep
given30minbefor
ewithautism
and/
orFragileX
Included:18childrenaged2to15yPlaceboor3mgmelato
nin
Wirojananetal,200
928
StudyandGrad
e
TABLE
1Continued
Actigraph
yQuestionnair
e
Teacher’sD
aytimeSleepi
ness
KarolinskaSleepinessSc
ale
CBCL
Children
SleepDisturbanceScale
for
to480.48650.71;P=.57
2).
orduration(477.40655.
56
5.57to86.0364.62;P=.33
1)
foundinsleepe
fficiency(85.136
Nosign
ificantchangesw
ere
6.12to17.8566.25;P=.04
8).
numberofwakings(from15.1
46
9.64;P=.002)butincreas
ed
(from40.02624.09to21.82
64.99;P=.041)andsleeplate
ncy
activity(31.3967.86to18.7
46
Problem
s30minbeforebedfor1
4d
Melatoninimprovednoctu
rnal
Received3mgofm
elatoninChildren’sSelf-
ReportforSleep
Bend,Orego
n)
Actiwatch(PhilipsRespiron
ics,
(P=.73;effectsize:0.35
40)
0.07butwereinsign
ificant
awakeningsw
ereimprove
dby
effectsize:2.80),a
nd
improvedby42min(P=.01
7;
effectsize:1.79),sleepon
set
participantsby28min(P=.1
0;
improvedin11of1
2effectsize:2.12),sleeplate
ncy
participantsby21min(P=.05
7;
ofnightwakings
)
durationimprovedin9of1
2duration,sleeponset,nu
mber
Comparedwithplacebo,sl
eep
Sleepdiary(sleeplaten
cy,
syndrom
e childrenwithAsperge
r’s
sleepe
fficiency,ordurationin
latencybutnotnightwaki
ngs,
nocturnalactivityandsle
ep
treatm
enttoimpro
ve
Melatoninisaneffecti
ve
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
waking
ssleeponsettimebutnotni
ght
duration,sleeplatency,
and
treatm
enttoimprovesle
ep
Melatoninisaneffecti
ve
Sampl
e
S114 MALOW et alDownloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
SUPPLEMENT ARTICLE
PEDIATRICS Volume 130, Supplement 2, November 2012 S115Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
nottobetakingmedicati
on
diagnosedwithASD,w
ere
withepilepsyand/
orif
Session1:goalsetti
ng
Excluded:excludedifdiagn
osed
(Australia
) perceivedsleepdi
fficulty
time)
(n=7)orASD(n=6)with
cosleeping,m
orningw
ake
follow-
upat3and12mo
eitherFragileXsyndro
me
weeklytelephoneca
lls;
13families)aged5ywit
hsleeponset,wakin
g,
Fivesessionsover7wkw
ithSleepDiary(behavior,light
sout,
Included:13children(acr
oss
concern
sindividualslee
p
Session3:addres
s
wakin
gandearlymornin
gminimizenightwaki
ng
waking
s
Latency,duration,ni
ght
Session2:Strategies
to
sleep
CSH
Qthatm
aycontributetodisord
ered
neurologic/
medicalconditions
routinebasedonFISHa
nd
habitsandabedtim
eapnea,narcolepsy,a
nd
sleepdisorderssuchassle
ep
daytimeandnightti
me
Session1:establish
ed
Excluded:childrenwithprim
ary
Actigraph
y
Caseseries,levelI
II
Weiskopetal,200
532
levelII
Pre/post-
nocontrol,
anissue
sleepbut50%stillconsideredsl
eep
100%ofparentsreportedimpro
ved
Durationwasvariableandunchan
ged
Nightwakingimprovedfor7of10(70
%)
addresse
d
Cosleepingwasal
soSession5:reviewsessi
onte
chniques
Session4:extincti
onsu
pportstrategi
es
instructionsandpartn
er
Session3:effecti
vere
presentation
reinforcementandvis
ual
interventionwi
thconsequences.Crea
ted
antecedentsa
nd
Session2:learningtheo
ry;
Sleeplatencyimprovedin6of10(60
%)im
provem
entand46.2%substant
ial
moderateimproveme
nt,
19.2%nochange,26.
9%
7.7%moderatedeteriorat
ion,
Baselinecomparedwith12
mo:improvem
entand41.3%substant
ial
moderateimproveme
nt,
27%nochange,23.
8%
4.8%moderatedeteriorat
ion,
1.6%substantialdeteriora
tion,
Baselinecomparedwith3
mo:improvem
ent
sand40.6%substant
ial
29.7%moderateimprove
ment,
sleepbehaviors,25%nocha
nge,
4.6%moderatedeteriorati
onof
Baselinecomparedwithinterven
tion:
developmentaldisabili
ties
notdurationinchildrenwit
hlatencyandnightwakings
but
parentsimprovedsle
ep
Educationalintervention
with
StudyandGrad
eConclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
wakin
gimprovementinearlymorn
ing
cosleeping;33%repor
ted
71%ofparentsreportedfewernig
htsP=1.0)
(24.569.8vs32.2624.7mi
n;
wakingaftersleepons
et
45.6627.6;P=.039)butn
ot
latency(62.2633.33min
vs
Actigraphyshowedimproveds
leep
Sampl
e
TABLE
1Continued
(Tennesse
e)
ASDwithsleepconcer
ns
follow-
up1moafterend
consecutivewee
ks;
3to10ywithclinicaldiagnosis
of
Included:20familiesofchildrenaged·Three2-
hsessionsfor3
Reedetal,200
931
intervention
s
Behavioral/
educational
to6mg
after4wk,increasedos
e
Allchildren:ifnorespons
e
after2wk
increaseddoseto3m
gtimeIfnorespons
e,
30to60minbeforebe
dofbipolardisorde
r
Excluded:childrenwithadiagnosisAged$6y,1.5mgmelatoninSleep
diary
enuresis
)sleepinessand/
orincreased
hadadverseeffects(morni
ng
treatm
ent.Threechildr
en
reportedworsesleepaft
er
amajorconcern,and1
%3mg
13%sleepproblemsremai
ned
medications
)by1mgevery2wkupto
sleepdisorder(Tenness
ee)
stillhadconcerns;fo
rseverityofASD,use
of
noresponse,increas
ed
60%hadimprovedsleepb
ut
otherpsychiatricconditio
ns,
beforebed.After2wk,i
frecommendedtotakemelat
onin
diagnosedwithautism
previo
usly
problemsnolongeraconcer
n;
(includingsleephygie
ne,
melatonin30to60mi
n
Afterinitiation,25%withsle
ep
Chartreviewofclinicnot
es
Included:107childrenaged2to18yAged,6y,.75-
1mg
otheradverseeffec
ts
notescalate
d)
Loosestoolsin1child;n
o
actigraphy,thedosew
as
changeinlaborator
yfindings.
nightsperweekb
yChildsubscaleonthePSI.
No
within30minon$5
compulsive,andtheDi
fficult
d efinedasfallingaslee
p
Scale
RBSstereotypeda
nd
responseoccurre
d,
prolactin).HagueSideEff
ects
hyperactivity,andaffec
tive,
sleepeducationtraini
ng
response(ifasatisfact
ory
testosterone,FSH,LH,
and
withdrawn,attention-
deficit/
mgto6mgbasedon
addressed,andparentsrecei
ved
cortisol,estroge
n,
duration,CBCLsubscale
sof
medicalcomorbiditiesw
ere
escalatedfrom1mgto
3renalfunction,corticotro
pin,
sleep-
onsetdelayandsleep
periods.Dosewa
sBeforemelatonintreatm
ent,
pr
ofileincludingliverand
notedinCSHQsubscales
of
protocolbasedon3-
wk
takingpsychotropicmedicati
ons.
fi ndings(CBC,m
etabol
ic
improvementswereal
so
Excluded:childrenwithepileps
yor
Optionalescalatingd
ose
CBCL,RBS,PSI.Laborat
ory
Sign
ificantlysignificant
levelIII
Pre/post-
Nocontrol,
Andersenetal,200
830Pre/post-
control,LevelII
StudyandGrad
e
TABLE
1Continued
childrenwithautis
mdaytimesleepiness
indisorderedbreathing,
or
waking,parasomnias,sl
eep
wakings,earlymorni
ng
andsleepanxietybutnotn
ight
resistance,latency,durat
ion,
parentsimprovesbedti
me
Educationalintervention
with
sleepiness(P=.09
6)
(P=.625),anddayti
me
sleep-
disorderedbreathing
(P=.508),parasomnia(P=.60
7),
(P=.022)butnotnightwakin
gs
(P=.003),andsleepanxi
ety
latency(P=.004),durati
on
bedtimeresistance(P=.00
1),
improvedCSHQscoresf
or
Educationalinterventionsho
wed
CSH
Q
childrenwithAS
Dsleepproblemsi
ntreatm
enttoredu
ce
Melatoninisasafe,effecti
ve
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
Sampl
e
S116 MALOW et alDownloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
SUPPLEMENT ARTICLE
PEDIATRICS Volume 130, Supplement 2, November 2012 S117Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
BEARS,B=Bedtimeproblems,E=ExcessiveDaytimeSleepiness,A=AwakeningsD
uringtheNight,R=RegularityandDurationofSle
ep,S=Snoring.
AdolescentSleepWakeSca
le40
BEAR
S17
BehavioralEvaluationofDisordersofSleepS
cale39
FamilyInventoryofSleepHabi
ts38
Adolescent
asleep,awakening,reinitiatingsleep,andwakef
ulness
Twenty-
eightitemsroleinto5subscales:goingtobed,falling
andsnorin
gwakecycles(bedtime,waketime)andaveragesleepd
uration;
children);awakeningsduringthenight;regularityof
sleep/
behaviorstypicallyassociatedwithdaytimesomno
lencein
fallingasleep);excessivedaytimesleepiness(i
ncludes
Fivesleepdomains:bedtimeproblems(di
fficultygoingtobedand
facilitators;andapnea/
bruxism
sensitivitytotheenvironment;disorientedawakenin
g;sleep
Fivetypesofsleepproblems:expressivesleepdisturb
ances;
routine,andsleepenvironm
ent
Twelveitems,includingdaytimeandprebedtimehabits
,bedtime
Assessessleepqualityinadolescentsaged11t
o21y
Parent
Assesses5sleepdomainsinchildrenaged5to
18y
Assessessleepbehaviorsinchildrenaged5to
12yaged3to10y
Autism
spec
ificquestionnaireassessingsleephygieneinchildren
Parent
Parent
Parent
disorderedbreathi
ng
maintenance,daytimesleepiness,sleeparousal,an
dsleep-
Twenty-
sixitemsthatroleinto6subscales:sleepinitiationand
SleepDisturbanceScaleforChildr
en37
Parent
5to15y
Characterizessleepdisordersoverthepast6moinchildr
enaged
developingchildr
en
autism
,developmentaldelaywithoutautism
,andt
ypically
AssessestheCSHQ(seeabove)inchildrenaged2to5.5y
with
Children(Goodlin-
Jonesetal,2008)23
Children’sSleepHabitsQ
uestionnaireinToddlersandPr
eschool
2000
)36
CSHQ(Owenset
al,
Questionnair
eRespondent
Form
at
Parent
SameastheCSHQ(abov
e)sleepines
sparasomnias,sleep-
disorderedbreathing,anddaytime
sleeponsetdelay,sleepduration,sleepanxiety,night
wakings,
Forty-
fi veitemsthatrollinto8subscales:bedtimeresistance,
medicaldimensionsinchildrenaged4to
10y
Assessessleepbehaviorsacrossarangeofbehavior
aland
Description
TABLE
2SleepQuestionnaireOptions
stimulatinghorm
one;LH,luteinizinghorm
one;MCV,m
eancorpuscularvolume;PSI,ParentalStressIndex;RBS,RepetitiveBehaviorScale;SI,SensoryIntegration;SS,SpectrumSupport;TTM,
ThaiTraditionalMassage.
CARS,ChildhoodAutism
RatingScale;CBC,completebloodcellcount;CBCL,ChildBehaviorChecklist;CGI,ClinicalGlobalIm
pression;CI,co
nfidenceinterval;CR,controlledrelease;FISH,FamilyInventoryofSleepHabits;FR,fastrelease;FSH,follicle-
Excluded:notspec
ified
day-
timebehavior)
providedstatisticsf
or
numbersnotprovided;o
nly
gettingoutofbed(actu
al
bed)
readingbeforebedti
me
self-
stimulatingbehavior,and
numberoftimeschildleftt
he
therapist)or15mino
f
fussing/
restlessness,crying,
stimulatingbehavior,
and
parents(trainedb
ywithautism
(Florid
a)
therapygroupwithregard
torestlessness,crying,s
elf-
massagetherapy
by
recruitedfromschoolforchild
ren
Greaterdeclinesforthemass
age
Sleepdiaries(fussin
g,
For1mo,received15-
min
Included:20childrenaged3to
6y
Excluded:nonespec
ified
df=16,160;P,.89)
aromatherapy(F=0.
59;
wasnotaffectedb
ydf=16;P=.21).Sleepdurati
on aromatherapy(
x2=20.19;
beforebe
d offootandleg∼2hour
sdifferwithandwitho
ut
P=.30).Nightwakingsdidn
ot
oil)over24dviamassa
ge
withautism
(UnitedKingdo
m)
onsettime(F=1.27;df=4.15,4
1.5;
onset,duration,wakin
gs)
lavenderoilingrapese
ed
aresidentialschoolforchildr
en
diagnosedwithASDfro
m statisticallysign
ificantsleep-
30-
minintervalrounds(sleep
aromatherapy(2
%
SleepdiaryrecordedbystaffonParticipantsdidnotdemons
trate
Included:12childrenaged12to15yThreeadministrati
onsof
treatm
ent(13massag
es)
thoseunabletocomplete80
%of
for8wk
contraindicationsforTTMa
nd
Excluded:thosewi
thTwo60-
minTTMandSI
RCT,levelI
V
Escalonaetal,200
135CaseserieslevelI
I
Williams,200
634RCT,levelI
I
(Thailand
)wereexperimental(SI+TT
M)
8wk
putintocontrolgroup(SI)and
30
Two60-
minTTMandSIfor
diagnosedwithautism
;30w
ere
Sleepdiar
yIncluded:60childrenaged3to10yTwo60-
minstandardSIor
Piravejetal,200
933
alternativemedici
ne
Complementarya
nd
StudyandGrad
e
TABLE
1Continued
withASDmorethanreadi
ng
gettingoutofbedinchildre
nself-
stimulatingbehavior,and
fussing/
restlessness,crying,
Massagebeforebeddecrea
seswaking
sonset,duration,andnig
ht
treatm
enttoaffectsle
ep
Aromatherapyisnotaneffec
tivestandardS
Inotm
orethancomparedw
ith
sleepinchildrenwithASD
but
TT,beforebedtimeimpro
ves
6.3respectively;P=.8
5)
statisticallysign
ificant(5.7vs
andmassagegroupsw
eren
ot
behaviorscoresofthecontr
ol
betweenpre-andpost-
sleep
vs8.2;P,.001).Thedifferenc
eimprovedsleepbehavior(1
3.9
5.3;P,.001).StandardS
I
Massageimprovedsleepscores(11
.5vs
Conclusions
Result
sConclusion
MeasuresUsedtoArrive
at
InterventionandDurat
ion
Sampl
e
S118 MALOW et alDownloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
SUPPLEMENT ARTICLE
insomnia in children (not specific toASD) were identified.The results of the systematic literaturereview demonstrate that treatmenttrials are limited in the ASD population.There are 3 categories of treatment:pharmacologic/biologic treatments,behavioral/educational
interventions,and complementary and alternativemedicine.
The evidence base to date shows
limitedevidence for the use of medications totreat insomnia in children who haveASD. The most evidence exists for theuse of supplemental melatonin, anindoleamine with sleep-promoting andchronobiotic (sleep phase shifting)properties considered a nutritional
supplement by the US Food and DrugAdministration. Several small,
ran-domized controlled trials (RCTs) dem-onstrated the efficacy of supplementalmelatonin in treating insomnia inchildren who have ASD,27–29 althoughlarger studies are needed. Melatoninseems to be relatively safe based o
nthese trials and on other series.30Other pharmacologic interventionssuch as risperidone, secretin, L-carni-tine, niaprazine, mirtazapine, and
clo-nidine, as well as multivitamins andiron, have limited evidence supportingtheir use in treating insomnia in ASD.The research evidence to date does notsupport the efficacy of other supple-ments or vitamins.
Behavioral interventions are clearlybeneficial for typically developing chil-dren experiencing significant insom-nia.21 However, few treatment
trialsfound that behavioral treatments pro-vide consistent success rates in chil-dren who have ASD, particularly thoseexperiencing sleep-onset insomnia. Thesystematic review of the literature ide
n-tified 2 studies examining the
efficacyof behavioral treatment of
insomniain children who have ASD.31,32 Each
ofthese studies demonstrated statisti-cally significant improvements in sleep
PEDIATRICS Volume 130, Supplement 2, November 2012 S119Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
posttreatment. Both studies used mul-ticomponent treatments, although theyvaried with respect to the specificcomponents of treatment. However,they were representative of treatmentscommonly used in clinical practice as
well as supported as effective in thegeneralpediatric
population.studies used extinction and positivereinforcement as
treatments.Both
studies provided parent training, asfollows: (1) identifying a treatmentgoal/treatment target for therapy; (2)discussion of how the sleep
problem ismaintained by conditioning/learning;and (3) emphasis on establishing a de-velopmentally
appropriatebedtime
and a consistent bedtime routine. Othertreatment components addressed in a
single study included sleep hygiene in-structions, use of effective instructions/directions to shape appropriate sleepbehavior, and use of the bedtime passprotocol.23 The studies did not addressrelative efficacy of these individual treat-ment components.Complementary and alternative medi-cine therapies addressed in the litera-ture review include massage therapyand aromatherapy.33–35 The systematicreview found no evidence to supportthese therapies for insomnia in chil-dren who have ASD. Neither of thegraded studies examining the efficacyof massage therapy or aromatherapyfor insomnia in children who have ASDled to statistically significant improve-ments in sleep posttreatment.33–35
Results of the GuidelineDevelopment
Based on the feasibility testing, a
numberof observations resulted in the devel-opment of resources to assist cliniciansin the application of the practice pathway.After reviewing the literature and con-ducting pilot testing, the ATN SleepCommittee developed and refined theinsomnia practice pathway and made the
following consensus recommendations:
A. General pediatricians, family careproviders, and autism medical spe-cialists should screen all childrenwho have ASD for insomnia.
This screening is best done by askinga short series of questions targetinginsomnia, such as those from theCSHQ, and asking if the parent consid-ers these a problem. These questions
TABLE 3 Questionnaire to Help Identify Underlying Medical Conditions are: (1) child falls asleep within 20minutes after going to bed; (2) childfalls asleep in parent’s or sibling’s bed;(3) child sleeps too little; and (4) childawakens once during the night. Thesequestions were selected on the basisof review of the CSHQ and expert con-sensus. The ATN database was alsoreviewed (n = 4887), and we foundthat 81% of parents who reportedthat their child awakening more thanonce during the night was a problemalso answered affirmatively to thequestion “Does your child awaken onceduring the night?” Therefore, to limitthe questions asked, we did not in-clude “Does your child awaken morethan once during the night?” Askingspecific questions is essential becauseparents may not volunteer concernsabout insomnia given their concernswith behavioral issues (although theseissues may be secondary to the in-somnia). Identifying significant insom-nia is paramount given its impact ondaytime functioning, not only for thechild with ASD but also the family. Table2 lists available questionnaires.
B. The evaluation of insomnia shouldinclude attention to medical
S120 MALOW et alDownloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on November 12, 2012
SUPPLEMENT ARTICLE
contributors that can affect sle
ep(including neurologic conditions an
dother sleep disorders that contr
ib-ute to insomnia).
These contributors should be
ad-dressed because their treatment mayimprove insomnia. Within the ATN, wehave developed a list of questions formedical contributors, including gas-trointestinal disorders, epilepsy, pain,nutritional issues, and other under-lying sleep disorders responsible forinsomnia, including sleep-disoderedbreathing and restless legs symptoms(Table 3) that pediatricians can in-corporate within their review of sys-tems. Psychiatric conditions, such asanxiety, depression, and bipolar disor-der, should be considered becausethese may contribute to insomnia. Fi-nally, because many medications con-tribute to insomnia, a careful review ofmedications should be performed.
C. Educational/behavioral
interventions
are the first line of treatment, after
excluding medical contributors. How-ever, if an educational (behavio
ral)approach does not seem feasibl
e,or the intensity of symptoms h
as
reached a crisis point, the use of phar-macologic treatment i
s considered.
Educational/behavioral
approaches tothe treatment of insomnia are advo-cated as a first-line treatment in typi-cally developing children.21 In childrenwho have ASD, educational/behavioralapproaches are also recommended,especially because these children maynot be capable of expressing adverseeffects caused by the medications. Thecore behavioral deficits associatedwith ASD may impede the establish-ment of sound bedtime behaviors androutines. These include: (1) difficultywith emotional regulation (eg, ability tocalm self); (2) difficulty transitioningfrom preferred or stimulating activi-ties to sleep; and (3) deficits in com-munication skills affecting a child’sunderstanding of the expectations of
parents related to going to bed and fall-ing asleep. Conversely, given preferencesfor sameness and routine, children whohave ASD may adapt well to establish-ment of bedtime routines, especially ifvisual schedules are implemented.
The ATN has developed an educationaltoolkit for parents that consists ofpamphlets to promote good sleephabits; a survey to assess for habitsthat may interfere with sleep; samplebedtime routines, including a visualsupports library, tip sheets for imple-menting the bedtime routine, andmanaging night wakings; and a sleepdiary. The toolkit is being tested forfeasibility in an ongoing research pro-ject funded by the Health Resourcesand Services Administration of parentsleep education at 4 ATN sites and isalso being used in clinical practicethroughout the network. As with othereducational/behavioral approaches,the success of this toolkit depends onappropriate implementation by par-ents, with the guidance provided bypractitioners an essential element formany families. Families can often beencouraged to implement educational/behavioral strategies when presentedwith these tools, especially if they re-ceive hands-on instruction in the toolsand are provided with an explanation ofwhy a behavioral approach is recom-mended. However, some families maybe in a state of crisis or may not bewilling or able to use the behavioraltools. These families may be challengedby difficult daytime behaviors in theirchild or by financial concerns. Thesechildren might require pharmacologictreatment. In addition, practitioners maynot be able to provide sufficient in-struction in the tools for a family to besuccessful with their implementation.Therefore, there is the option in thepractice pathway (Fig 2, Box 5b) ofmedication or consultation to a sleepspecialist if the family is unwilling orunable to use an educational approach,
depending on the comfort level of thepediatrician.
Behavioral Treatments for Insomnia
The behavioral treatments most com-monly used to treat insomnia in chil-dren who have ASD include behavioralmodification strategies such as extinc-tion (eg, withdrawal of reinforcementfor inappropriate bedtime behaviors)and positive reinforcement of adaptivesleep behavior. Sleep hygiene instruc-tions (eg, appropriate sleep schedulesand routines) often accompany behav-ioral modification protocols. Behavioralinterventions are effective in the treat-ment of insomnia in typically developingchildren.21 However, the evidence base
for effectiveness of such interventions inchildren who have ASD is limited. Thedata from the literature review providepreliminary support for the use of be-havioral modification to treat insomniain children who have ASD. These datawere the basis for the development of aneducational toolkit used to guide behav-ioral management of insomnia in theinsomnia practice pathway.
Alternative Treatments for Insomnia
The most common alternative therapywith a presence in the literature is mas-sage therapy.33,35 However, the results donot demonstrate consistent, statisticallysignificant improvements in sleep.
Pharmacologic Treatments forInsomnia
Although medications and supplementsare often used to treat insomnia experi-enced by children and adolescents whohave ASD, the evidence base for phar-macologic treatment is limited. At thistime, there are no medications approvedby the US Food and Drug Administrationfor pediatric insomnia. The most evi-dence exists for the use of melatonin.
D. Clinicians should assure timelyfollow-up to monitor progress andresolution of insomnia.
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Assuring adequate follow-up is crucialwhen treating children who have ASDand significant insomnia. Follow-upshould occur within 2 weeks to 1month after beginning treatment. Theprovider and family should expect tosee some benefits and improvementswithin 4 weeks. Follow-up may be con-ducted by telephone or in person.Timely follow-up allows for fine-tuningof treatment interventions, support ofparents, and provision of referrals ifneeded.In addition to short-termfollow-up (eg, 1–2 months), at long-term follow-up (eg, 1-year visit) thesteps from the beginning of the prac-
tice pathway should be repeated.
As outlined in the practice
pathway,treatment of insomnia can be initiatedby the general pediatrician, primarycare provider, or autism medical spe-cialist. Many children will improve withthese initial interventions. Consultationwith a sleep specialist is indicated ifinsomnia is not improving with theseinitial interventions or when the in-somnia is particularly severe, causingsignificant daytime
impairmentplacing the child at risk for harm whileawake during the night. For thosechildren who have ASD and are takingmultiple medications for sleep wheninitially assessed by the health careprovider, consultation wit
h a sleepspecialist may be indicated, dependingon the comfort level of the provider.Other indications for consultation witha pediatric sleep specialist may includewhen underlying sleep disorders areresponsible for the
sleeplessnesssymptoms (including
sleep apnea,restless legs syndrome, periodic limbmovements of sleep, and unusual night-time behaviors [parasomnias] such assleepwalking or sleep terrors).
Results of the Field Testing
Results of the pilot phase indicat
edchallenges in implementing the practicepathway due to a number of conflicts,
including: (1)competingdemands on thepediatric provider in a busy clinicalpractice; (2) knowledge level of the pe-diatric provider; and (3) when consul-tation to the sleep specialist occurs,ensuring communication back to thepediatric provider.
In response to these barriers, we de-veloped the following resources: (1)a short set of screening questions forinsomnia as well as a checklist formedical conditions contributing to in-somnia (Table 3); and (2) a sleep edu-cation toolkit, available in hard copy aswell as on the internal ATN Web site(www.autismspeaks.org/atn) that willfacilitate parent teaching.
Additional issues were identified re-lated to provider comfort level in thefollowing areas: (1) assessing formedical or sleep contributors them-selves rather than referring to a spe-cialist, which led us to modify thepractice pathway to allow for bothoptions; (2) providing education tofamilies in use of the toolkit, which af-fected the length at which follow-upoccurred (eg, a second visit witha nurse educator might be needed fortoolkit implementation if the providerwas too busy to educate families at thetime of the initial clinic visit); and (3)treating insomnia with medications ontheir own versus referring to a sleepspecialist. When a child was referred tothe sleep specialist, ensuring that thesleep specialist communicated backto the provider regarding recommen-dations was also an issue related toapplying the practice pathway in ourfield testing, particularly as related tofollow-up care.
We modified the flow of the practicepathway in response to feedback dur-ing the field testing. Initially, the prac-tice pathway prioritized evaluationand treatment of medical contributorsbefore implementing educationalmeasures, such as the toolkit. However,based on the feedback of clinicians, the
evaluation/treatment of medical con-tributors and the implementation ofeducational measures became a paral-lel process as opposed to a sequential
“first–then” approach.
DISCUSSION
We report here on the development o
fa practice pathway for the evaluationand management of insomnia in chil-dren who have ASD. There are severalkey points of this practice pathway.First, general pediatricians, primarycare providers, and autism medicalspecialists should screen all childrenwho have ASD for insomnia becauseparents may not volunteer sleep con-cerns despite these concerns beingcontributors to medical comorbiditiesand behavioral issues. Second, theevaluation of insomnia should in-clude attention to medical contributorsthat can affect sleep, including othermedical problems that encompassgastrointestinal disorders, epilepsy,psychiatric comorbidities, medications,and sleep disorders including sleep-disordered breathing, restless legssyndrome (unpleasant sensations in
thelegs associated with an urge to move),periodic limb movements of sleep(rhythmic leg kicks during sleep), andparasomnias (undesirable move-ments or behaviors during sleep,such as sleepwalking, sleep terrors, orconfusional arousals). In parallel withthis screening, the need for therapeu-tic intervention should be determined.We also determined that educational/behavioral interventions are the firstline of treatment, after excludingmedical contributors. If an educa-tional (behavioral) approach does notseem feasible, or the intensity ofsymptoms has reached a crisis point,the use of pharmacologic treat-ment is considered. Finally, cliniciansshould assure timely follow-up tomonitor progress and resolution ofinsomnia.
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SUPPLEMENT ARTICLE
This practice pathway expands the l
it-erature that currently exists for typi-cally developing children related toscreening and management.5,7–9 Therationale for developing a practicepathway that uniquely addresses thispopulation is because children whohave ASD, and their families, haveunique needs. For example, medical,neurologic, and psychiatric comorbid-ities are common in children who haveASD, as is the use of medications thatinfluence sleep. In addition, parents ofchildren who have ASD, struggling withthe stressors related to their child’sdisability and the often accompanyingbehavioral challenges, may not volun-teer sleep to be of concern. In turn,pediatric providers may not ask aboutsleep due to competing medical andbehavioral issues. Furthermore, sleepproblems are more common in chil-dren who have ASD than in childrenof typical development,2,3 and theirtreatment may impact favorably ondaytime behavior and family function-ing. Given these factors, we do recog-nize that children who have other
disorders of neurodevelopment couldalso benefit from this practice pathway,as they share common features withchildrenwho have ASD,
including
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A Practice Pathway for the Identification, Evaluation, and Management ofInsomnia in Children and Adolescents With Autism Spectrum Disorders
Beth A. Malow, Kelly Byars, Kyle Johnson, Shelly Weiss, Pilar Bernal, Suzanne E.Goldman, Rebecca Panzer, Daniel L. Coury and Dan G. Glaze
Pediatrics 2012;130;S106DOI: 10.1542/peds.2012-0900I
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