A Systematic Review of Non-Pharmacological Interventions on Sleep Problems in Youth with An Autism Spectrum Disorder

Background:  Four-fifths of children with an autism spectrum disorder (ASD) have at least one sleep problem (Liu et al., 2006). Sleep problems are more prevalent in ASD than the other disorders (Cotton & Richdale, 2006), and they predict more severe autism symptoms (Schreck et al., 2004). Parents of children with an ASD find non-pharmacological sleep interventions (NPSIs) more preferable and acceptable than sleep-enhanced medication (Williams et al., 2006).

Objectives:  The objectives of this systematic review are: (1) to identify the current NPSIs options for youth with an ASD, (2) to investigate the effectiveness of NPSIs for sleep problems in this population; (3) to examine the methodological quality of the evidence.

Methods:  Literature presented here is a subset from a project examining the effectiveness of NPSI on disordered sleep of youth with chronic health conditions. Literature from January 2000 to May 2012 in the Medline, CINAHL, and PsycINFO databases was searched to locate NPSI studies published in English that included children (2-11 years old) and adolescents (12-19 years old) with chronic health conditions; measured outcomes related to sleep; and used non-drug interventions. Additional studies were located by cross-checking reference lists. Studies were excluded if they used substance-based interventions, focused on sleep apnea, continuous passive airway pressure devices, hypnosis, and other interventions requiring specialized training beyond the scope of most entry-level health care providers. The Guidelines for Critical Review (GCR) protocols (Law et al., 2008) developed by researchers at McMaster University were used to analyze the quality of each reviewed study. The Effective Public Health Practice Project Quality Assessment Tool (EPHPP; Thompson et al., 2004) was used to synthesize and categorize the strength of the evidence.

Results:  Forty-one papers met the inclusion criteria. We extracted 19 that included participants with an ASD. Six of the studies were RCT design, 6 were single-case design, 5 were case study, and 2 were before-after design. Half of the 19 studies had less than 10 participants. A majority of studies included youth with an ASD in combination with those having other disabilities. The interventions were grouped into two categories: behavioral interventions (17 studies; extinction, graduated extinction, faded bedtime with response cost, non-specific behavioural intervention), and non-behavioral interventions (2 studies; chronotherapy, massage therapy). All of the research demonstrated positive findings and none reported adverse effects. Based on the EPHPP scores, the evidence for all interventions reviewed, except massage therapy, was weak. The methodological quality of the evidence for massage therapy was moderate, but only one study used this intervention. Common weaknesses of the studies were small samples, over-reliance on self-report outcome measures, and the lack of a clear description of the intervention under examination.

Conclusions:  Although strong evidence is lacking, the findings suggest that the NPSIs are promising and warrant further, more targeted and rigorous study. There is a clear need to improve the amount and quality of research on NPSIs for youth with an ASD.