A Systematic Review of Behavioral Interventions for Pediatric Insomnia in Youth with Autism Spectrum Disorder

Background: Sleep problems, including pediatric insomnia, are common among youth with Autism Spectrum Disorder (ASD), affecting between 40-80% of this population. Behavioral interventions for insomnia (including preventative parent education, graduated extinction, and cognitive behavioral therapy for insomnia or CBT-I) have shown to be effective for youth with ASD. However, the last published review that included both parent-mediated and individual interventions was in 2014, and this review was significantly limited by the inclusion criteria.

Objectives: The purpose of this project is to systematically review the empirical evidence regarding the efficacy of behavioral interventions for the clinical management of pediatric insomnia in youth with ASD.

Methods: This review included studies using behavioral treatment for sleep problems in children and adolescents with ASD. Inclusion criteria includes: (1) Intervention studies published in a peer reviewed journal between 1970 and July 2018 (dissertations or non peer reviewed articles were excluded from review); (2) behavioral interventions or psychoeducational programs with behavioral components were implemented; (3) participants included children diagnosed with Autism Spectrum Disorder; (4) participants included were children (0-17.9 years) with insomnia, defined as bedtime problems or night wakings for younger children, and/or difficulties initiating and maintaining sleep in older children and adolescents; (5) inclusion of continuous data of continuous variables (sleep onset latency, number of night wakings, duration of night wakings, and sleep efficiency), as measured by parent report, child report and/or actigraphy; and (6) published in English. All types of studies, including case-studies and single-subject designs, were included in analyses. See Table 1 for summary of guidelines by which the classification was established, as adapted from Sackett (1993).

Results: 22 studies met criteria for review. 5 studies were randomized control trials. 7 studies were within-subjects designs, 9 studies were single-subject designs, and 2 studies were case-series. 4 of the studies included young children (mean=3.67 years), 13 included school-age children (mean=6.53 years) and 2 studies included adolescents (mean age=15.56). Only one study met Sackett evidence level I (large, high quality RCT). 5 studies met evidence level II, 6 met evidence level IV and 10 studies met evidence level V criteria. See Table 1 for more details.

Conclusions: Despite some promising additions to the literature in recent years, there remains a significant need for additional research on behavioral interventions for youth with pediatric insomnia and ASD. However, the preliminary published studies support the use of sleep education, positive reinforcement, parent education and graduated extinction as effective interventions for this population. Future research should focus on developing randomized clinical trials with larger sample sizes and appropriate control groups.