Managing insomnia in children with autism spectrum disorder
According to CDC, 1 in every 88 children in the United States has been diagnosed with an autism spectrum disorder (ASD). This estimate has increased by almost 80% since CDC’s first report in 2007. One underappreciated aspect of ASD is the high prevalence of insomnia and other sleep-related problems, with some estimates being between 44% and 83%. Problems experienced by children with an ASD may include taking longer than expected to fall asleep, having a shorter sleep duration, early waking, and daytime sleepiness. These difficulties may be due in part to concomitant conditions such as anxiety. Although the underlying etiology of sleep disturbances is unclear, alterations in neurotransmitters such as serotonin, GABA (gamma-aminobutyric acid), and melatonin may be involved.
Parents may approach pharmacists with concerns about their child’s insomnia. Behavioral approaches should always be encouraged by pharmacists and other health professionals, though research on the effectiveness of behavioral strategies in managing insomnia in ASD has been mixed.1
A few techniques include developing a regular bedtime routine, avoiding stimulating activities before bed, and ensuring an appropriate environment for promoting sleep. Parents should be encouraged to work closely with their child’s pediatrician. The Autism Treatment Network has developed a toolkit of behavioral interventions for sleep disorders, and it is currently being evaluated as a resource for families.
Prescription drugs (e.g., clonidine, risperidone, donepezil) have been used to manage sleep disorders in children with ASD. The selection of the specific therapies is frequently based on the presence of concomitant conditions such as seizure disorders.
Melatonin is a commonly used and modestly effective therapy in treating insomnia in some children who have ASD.1 In a double-blind, placebo-controlled trial, 146 children with neurodevelopmental disorders were randomized to receive immediate-release melatonin or placebo administered 45 minutes before bedtime for 12 weeks. All participants were started at a dosage of 0.5 mg, which could be increased depending on treatment response. Patients in the melatonin group fell asleep faster but awoke earlier compared with those in the placebo group. Adverse events were similar between the two groups. Also, melatonin was most effective for children with the longest sleep latency.2
The optimal dosage of melatonin for insomnia in children with ASD has not been established, and several different dosing schedules have been studied. A lower dosage (0.3 mg or 0.5 mg) should be used initially and increased based on the child’s response to melatonin. Melatonin products that are synthetically produced should be used because products made from bovine pineal glands have a potential risk of contamination. Although melatonin has minimal adverse effects, nausea, vomiting, headache, irritability, and a morning “hangover” effect can occur rarely. Children with ASD who are using melatonin for insomnia should be monitored by a pediatrician.
Behavioral interventions are the standard of treatment and should be attempted before considering therapy with melatonin. This can be challenging, especially because parents may be overwhelmed and not getting sufficient sleep.
Parents should not administer their own prescription hypnotics (e.g., zolpidem) or OTC products such as diphenhydramine to their children. Although diphenhydramine has been used in children with insomnia and ASD, parents should first talk with the child’s pediatrician.
Pharmacists can help parents manage insomnia in children with ASD by understanding the approach to treatment and counseling on the proper use of melatonin.
- Malow BA, Byars K, Johnson K, et al. A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders. Pediatrics. 2012;130(suppl 2):S106–24.
- Gringras P, Gamble C, Jones AP, et al. Melatonin for sleep problems in children with neurodevelopmental disorders: randomised double masked placebo controlled trial. BMJ. 2012;345:e6664.