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A practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders

TitleA practice pathway for the identification, evaluation, and management of insomnia in children and adolescents with autism spectrum disorders
Publication TypeJournal Article
Year of Publication2012
AuthorsMalow, BA, Byars, K, Johnson, KP, Weiss, SK, Bernal, MPilar, Goldman, SE, Panzer, R, Coury, DL, Glaze, DG, Treatment, NSleep Comm
JournalPediatrics
Volume130
PaginationS106-24
Date PublishedNov
KeywordsAdolescent, AIM, Child, Child Development Disorders, Critical Pathways, Decision Trees, Guidelines as Topic, Humans, IM, Pervasive/co [Complications], Questionnaires, Sleep Initiation and Maintenance Disorders/di [Diagnosis], Sleep Initiation and Maintenance Disorders/et [Etiology], Sleep Initiation and Maintenance Disorders/th [Therapy]
Abstract

OBJECTIVE: This report describes the development of a practice pathway for the identification, evaluation, and management of insomnia in children 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, to capture best practices for an overarching approach to insomnia by a general pediatrician, primary care provider, or autism medical specialist, including identification, evaluation, and management. A field test at 4 ATN sites was used to evaluate the pathway. In addition, a systematic literature review and grading of evidence provided data regarding treatments of insomnia in children who have neurodevelopmental disabilities. RESULTS: The literature review revealed that current treatments for insomnia in children who have ASD show promise for behavioral/educational interventions and melatonin trials. However, there is a paucity of evidence, supporting the need for additional research. Consensus among the ATN sleep medicine committee experts included: (1) all children who have ASD should be screened for insomnia; (2) screening should be done for potential contributing factors, including other medical problems; (3) the need for therapeutic intervention should be determined; (4) therapeutic interventions should begin with parent education in the use of behavioral approaches as a first-line approach; (5) pharmacologic therapy may be indicated in certain situations; and (6) there should be follow-up after any intervention to evaluate effectiveness and tolerance of the therapy. Field testing of the practice pathway by autism medical specialists allowed for refinement of the practice pathway. CONCLUSIONS: The insomnia practice pathway may help health care providers to identify and manage insomnia symptoms in children and adolescents who have ASD. It may also provide a framework to evaluate the impact of contributing factors on insomnia and to test the effectiveness of nonpharmacologic and pharmacologic treatment strategies for the nighttime symptoms and daytime functioning and quality of life in ASD.

Summary

Lead Author
Beth A. Malow

Study Aims/Objectives
This report describes the development of guidelines for the identification, evaluation, and management of insomnia in children and adolescents with Autism Spectrum Disorders (ASD). The guideline’s purpose is to emphasize the need for screening sleep problems in ASD and to provide a framework for decision-making related to best practices in caring for children and adolescents with ASD in primary care settings.

Methods - Sample, Procedure, Study Measures, Analysis
The Sleep Committee of the Autism Treatment Network (ATN) and the National Initiative for Children’s Healthcare Quality (NICHQ) worked collaboratively to develop this guideline. Information in the guideline is based on expert consensus and was tested at 4 ATN sites. Additionally, a review of relevant literature was conducted followed by a grading of evidence by the review committee.

Results – Main Finding(s)
The literature review revealed that current treatments for insomnia in children with ASD show promise. Consensus among the ATN sleep medicine committee experts include: 1) All children who have ASD should be screened for insomnia 2) Screening should be done for potential contributing factors, including other medical conditions 3) The need for a therapeutic intervention should be determined 4) Therapeutic interventions should begin with parental education on practices that do not involve medications as a first-line approach 5) Medications can be considered when a parent is unwilling or unable to provide sleep education (e.g., under high levels of stress) 6) There should be follow-up after any intervention to evaluate how effective and tolerable the therapy is for the specific child.

Conclusion – Summary Statement
This insomnia guideline may help primary care providers identify and manage insomnia symptoms in children and adolescents with ASD. It may also provide a framework to evaluate the impact of contributing factors on insomnia and to test the effectiveness of treatment strategies for the nighttime symptoms, daytime functioning, and quality of life in children with ASD.

PubMed ID23118242