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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 Network(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) pharmacologictherapy 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 andadolescents 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
AUTHORS: Beth A. Malow, MD, MS,a,b,c Kelly Byars, PsyD,d
Suzanne E. Goldman, PhD,g Rebecca Panzer, MA, RD, LD,h
Daniel 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
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.
Approximately 1 in 110 children fulfillsthe Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition,Text Revision, diagnostic criteria forautism spectrum 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 thantypically 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 orother 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 problems such 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 theprevalenceof andmorbidityassociated with pediatric insomnia,there is evidence that sleepdisorders 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 screeningandintervention in typically developingchildren.17,18 Guidelines and empiricalsupport also exist for the effectivenessof 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 recentreview.22
To facilitate the evaluation of childrenwith 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 andto 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,andmanagement.
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 systemic review ofthe literature, expert opinion and con-sensuswasused to formthebasisof 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 Literature
We conducted a systematic 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; OregonHealthandScienceUniversity, 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 thepractice 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 practicepathway (Fig 2).
RESULTS
Results of the Literature Review
The search identified 1528 articles. Af-ter removing review articles, com-mentaries, casestudieswith 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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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.
Theevidencebase todateshows 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 nutritionalsupplement 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 onthese trials and on other series.30
Other 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 iden-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 sleepTA
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 aswell as supported as effective in thegeneral pediatric population. Bothstudies used extinction and positivereinforcement as treatments. Bothstudies 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 appropriate bedtimeand 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
Basedon the feasibility testing, a numberof observations resulted in the devel-opment of resources to assist cliniciansin theapplicationof thepracticepathway.After reviewing the literature and con-ducting pilot testing, the ATN SleepCommittee developed and refined theinsomniapracticepathwayandmade thefollowing 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 questionsare: (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
TABLE 3 Questionnaire to Help Identify Underlying Medical Conditions
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contributors that can affect sleep(including neurologic conditions andother sleep disorders that contrib-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 interventionsare the first line of treatment, afterexcluding medical contributors. How-ever, if an educational (behavioral)approach does not seem feasible,or the intensity of symptoms hasreached a crisis point, the use of phar-macologic treatment is 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 providedwith 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 familiesmay be challengedby difficult daytime behaviors in theirchild or by financial concerns. Thesechildren might require pharmacologictreatment. In addition, practitionersmaynot 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 basefor 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 nomedications 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 impairment orplacing 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 with 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 indicatedchallenges in implementing the practicepathway due to a number of conflicts,
including: (1)competingdemandsonthepediatric 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 ofa 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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This practice pathway expands the lit-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 otherdisorders of neurodevelopment couldalso benefit from this practice pathway,as they share common features withchildren who have ASD, including
comorbid conditions, parental stres-sors, and prevalent sleep problems.
The systematic review of the availabletreatment literature allowed for therecognition that evidence-based stan-dards for the behavioral, pharmaco-logic, and other treatments of insomniain ASD are not yet available. Thus, muchof these guidelines reflect expertopinion given the absence of data. Ad-ditional studies are needed to establishthe efficacy and safety of supplementalmelatonin, as well as other pharma-cologic agents, in large RCTs. Similarstudies are needed to address the ef-ficacy of parent-based sleep educa-tional programs to address insomnia,as well as the combination of theseeducational programs with pharma-cologic strategies. Finally, the roleof nonpharmacologic methods (apartfrom educational therapies) warrantsstudy as well. As additional researchstudies are performed, the clinicalpathwaywill likely requiremodification.However, it is expected that the over-arching approach to insomnia in thechild who has ASD will not change. Al-though the practice pathway waspiloted at 4 ATN sites, the next stepsinvolve the wide dissemination ofthe practice pathway into pediatric
practices. We would also like to developa practice pathway for nonmedicalhealth professionals who are likely toprovide behavioral interventions, in-cluding psychologists.
Strengths of the study include the gath-ering of the following groups: experts insleep medicine from a variety of dis-ciplines, including neurology, psychiatry,pulmonary medicine, and psychology;engaged pediatricians specializingin ASD; and parents of children whohave ASD. Weaknesses include limitedevidence-basedstudiesonwhich tobasethe practice pathway, making it neces-sary to rely on expert opinion.
CONCLUSIONS
The practice pathway regarding theidentification of insomnia in childrenwho have ASD requires future fieldtesting in clinical settings but repre-sents a starting point to managing in-somnia in a growing population ofchildren with the most commonneurodevelopmental disability.
ACKNOWLEDGMENTThevaluableassistanceof themembersof the ATN Sleep Committee in re-viewing this document is gratefullyacknowledged.
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