Behavioural-based approaches, involve environmental modification, establishment of stimulus control, skill building and leveraging principles of reinforcement. Photo for illustrative purposes only. Image Credit: Shutterstock


  • Up to 80% of children with ASD have sleep difficulties
  • This could last into adulthood if left untreated, says Cleveland Clinic Children's researcher.
  • Certain behavioural-based approaches suggested alongside short-term use of medications, including melatonin and iron supplements, recommended.

Dubai: Behavioural therapy and certain short-term medication could help alleviate insomnia in children with autism spectrum disorder (ASD), according to an expert.

Cynthia Johnson, PhD, Director of Cleveland Clinic Children’s Center for Autism and Professor of Paediatrics, said insomina affects 8 out of 10 children ASD. She explained that behavioural-based approaches and short-term use of medications, such as melatonin supplements, may be helpful.

Behavioural approaches

Behavioural-based approaches, she said, involve the following:

  • Environmental modification,
  • Establishment of stimulus control,
  • Skill building, and
  • Leveraging principles of reinforcement.

The good news, said Dr. Johnson, is that several research projects where she has been involved in show behavioural strategies can make a significant difference in reducing insomnia.

“Short-term use of medications such as melatonin supplements might also be considered,” she added.

Sleep problems in individuals with ASD have been associated with poor social interaction, problems in communication, and overall autistic behaviour.

Family involvement

Many of the strategies can be successfully delivered by the child’s family, said Dr Johnson, who made the remarks on the occasion of World Autism Day (April 2).

The specialist says insomnia in kids with ASD can have a negative impact on both the wellbeing of sufferers and the wellbeing of their families.

What is autism spectrum disorder (ASD)?
ASD is a chronic nervous system condition brought on by genetic, metabolic, or other biological causes.

The World Health Organisation (WHO) estimates that one in 160 kids worldwide has ASD.

As a developmental disability, autism can cause significant emotional, social and behavioural dysfunction.

Sleep disorders co-occur in a huge portion of the patients with ASD.

Insomnia: Common in children with ASD

“Insomnia is significantly more common in children with ASD compared with the general paediatric population, and also persists for a longer period, carrying through to adolescence and adulthood, if left untreated,” says Dr Johnson.

She lists a number of behavioural traits of children with ASD, which may raise the risk of sleeplessness, including:

  • Rigidity and insistence on sameness,
  • Inadequate communication,
  • Anxiety, and
  • Hyperactivity.

Biological risk factors

Biological risk factors can also lead to certain effects — such as variations in brain development, changed melatonin secretion, or mutations in genes that control circadian rhythms.

In addition, clinical variables including untreated gastrointestinal issues and negative pharmaceutical side effects might also worsen sleep disorders.

Commenting on the impact of insomnia on a child, Dr. Johnson says, “Sleep plays an important role in the growth, development and wellbeing of children."

Studies have shown a lack of adequate, quality sleep can have negative effects on attention, daytime behaviour and the regulation of emotions, and could even impact children’s cardiovascular, metabolic and immune systems.

In addition to the child, the family will be impacted, Dr. Johnson adds.

“The child’s insomnia can affect other family members’ ability to function because, if the child is not sleeping, everyone’s sleep can be disturbed. This adds to parental stress in the long term, with parents dedicating a great deal of time to strategizing on how to get the child to sleep.”

Varying presentation

Insomnia presents in children with ASD varies from child to child, she said, adding: “Sleep problems may be irregular, cyclical or constant and they can take many forms.

For example, the child might resist bedtimes, or insist on elaborate bedtime routines, or might have difficulty falling asleep or staying asleep, or the child might wake up too early.”

Low ferritin levels is also a factor seen behind insomnia in children with ASD.

What can be done?

Interventions are not “one size fits all” solutions, she said.

“As each child responds differently to treatment strategies, parents should work together with an expert in ASD sleep disorders and behavioural interventions.

“The aim is to approach the problem collaboratively and systematically, exploring the day and nighttime routines of the child and family, and testing various preventative and skill-building strategies until the best solution is found.”

Dr. Johnson points out that treatment approaches are continuing to evolve, and new therapies have been found over the past decade and a half.

Behavioural-based approaches, supplements

Behavioural-based approaches involve environmental modification, establishment of stimulus control, skill building and leveraging principles of reinforcement.

Short-term use of medications such as melatonin supplements might also be considered, she says.

Studies also show that low ferritin levels can also be a factor in sleep disorders.

In 2013, a retrospective chart review of data involving 9,791 children with ASD conducted by researchers led by Julie Youssef, of the Department of Neurology, Boston Children's Hospital, Harvard Medical School, found that significantly low serum ferritin levels were associated with several sleep disorders — including:

  • Periodic limb movements during sleep,
  • Sleep fragmentations, and
  • Poor sleep efficiency.

Ferritin is a storage form of iron. The sudy found that iron supplementation was be effective in the treatment of low ferritin with sleep disorders.

Also, in a 2012 study led by Lynn M. Trotti, of the Department of Neurology, Emory University School of Medicine in Atlanta recommends  iron therapy for low ferritin level below 50 ng/mL for children with ASD facing sleep disorders.

Further research

A study, published in 2007 in Paediatric Neurology, conducted an open-label trial of oral iron supplement (6 mg elemental iron/kg/day) for 8 weeks in children with autism and showed improvement in sleep, with an increase in serum ferritin level.

However, potential side effects were cited, including “metallic” taste, vomiting, nausea, constipation, diarrhoea, and black/green stools.

Antipsychotics, antidepressants, and alpha (α) agonists have also generally been used alongside melatonin.

Experts, however, said that given the limited evidence for psycho-pharmacological treatments in autism, behavioural interventions are considered a primary mode of treatment.

Still, further research and information are needed to guide and individualise treatment for this population group.