Sleep disorders are far more common in children with autism spectrum disorders (ASDs) than in typically
developing children and may have a significant impact upon both child and family functioning. Children with ASDs
who sleep well show fewer behavioral problems and better social interactions than those who are poor sleepers. In
addition, sleep problems correlate with family stress and may effect daytime functioning. Sleep-related behavioral
problems and poor sleep hygiene are responsible for the majority of sleep disorders in children on the autism
spectrum. Potential medical causes of disordered sleep should be considered and treated appropriately. Medical
problems that may contribute to sleep difficulties include but are not limited to sleep apnea, gastroesophageal
reflux, abdominal pain related to constipation, asthma, and restless leg syndrome.
[Johnson: 2008]
A detailed sleep history should be obtained, including bedtime routine, onset and duration of sleep, nighttime
wakenings, snoring, restlessness, and sleep hygiene.
[Jan: 2008]
Individuals on the autism spectrum have been shown to have abnormalities in the regulation of
melatonin. The use
of melatonin at bedtime has been shown to improve sleep latency and to a smaller extent sleep duration. For
children age 2-6 years, begin at 0.5-1 mg and adjust upward to 3 mg as needed. Children older than 6 years of age
may respond to doses as low as 1 mg; adjust upward to 5 mg as needed. Melatonin, particularly at the higher end
of the dosage range, has an immediate hypnotic effect allowing parents to gauge effectiveness after the first few
doses. Adverse effects are rare and include vivid dreams and nightmares. Families should be informed that
melatonin is considered a supplement and is therefore not regulated by the US Food and Drug Administration.
[Andersen: 2008]
Low iron stores have been associated with periodic limb movement disorder/restless leg syndrome. In
children with restless sleep, consider obtaining a CBC and serum ferritin. Supplementation with iron to replenish
iron stores has had positive effect in individuals with restless sleep and low or low-normal serum ferritin levels.
Supplementation with 1-3 mg/kg elemental iron per day in one to three divided doses is recommended; iron may be
discontinued after 2-3 months if serum ferritin has normalized.
[Dosman: 2007]
The alpha-2 agonist
clonidine has shown effectiveness in improving sleep lantency and nighttime wakenings. The
half life of this medication is variable and it may cause daytime sedation and irritability. In addition, alpha-2 agonists
may cause hypotension, bradycardia, and EKG changes. Obtaining an EKG should be considered if an alpha-2
agonist is to be added to a stimulant medication. For children aged 3-5, begin with a dose of .025-.05 mg (1/4 to 1/2
of a 0.1 mg tablet) 30-60 minutes before bedtime. The dose may be adjusted upward to a maximal dose of 0.2 mg.
For children 6 years and older, begin with 0.1 mg and adjust upward to a maximal dose of 0.2 mg. When it is
discontinued, this medication should be tapered over 1 week to avoid rebound hypertension.
[Ming: 2008]
Consider referral to a pediatric sleep medicine specialist if questions remain regarding the nature of the sleep
disorder. A sleep study may help identify disorders such as obstructive sleep apnea and periodic limb movement
disorder.
Other classes of medications such as antidepressants, antipsychotics, and anticonvulsants have been used
successfully in the management of sleep disorders. These medications have not, however, been well studied in the
pediatric population and should be prescribed by or in consultation with a physician experienced in their use.
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Children with autism: effect of iron supplementation on sleep and ferritin.
Pediatr Neurol.
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