Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians

Abstract

Aims: To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults.

Background: Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013.

Method: This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice.

Results: Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered.

Conclusions: Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

Keywords: Attention-deficit hyperactivity disorder; assessment; autism spectrum disorder; sleep–wake disorder; treatment.

Fig. 1

(a) Interactions between effects on sleep of decreases in melatonin caused by the melatonergic system and 5-hydroxytryptamine (5-HT) activity in patients with attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). (b) Interactions between effects on sleep of increased orexin in the melatonergic system and 5-HT activity in patients with ADHD and ASD. mPFC, medial prefrontal cortex; REM, rapid eye movement.

Fig. 2

Flowchart describing approach to the complex developmental phenotypes of autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption (SD). ^aSpecific scales are available for SD (Children's Sleep Habit Questionnaire (CSHQ; CSHQ-autism); Pittsburgh Sleep Quality Index (PSQI)), sleep hygiene (SH; Adolescent Sleep Hygiene Scale) and excessive daytime sleepiness (Epworth Sleepiness Scale). ^bTwo weeks movement-based data could add to assessment but does not substitute for clinical evaluation. ^cGold standard to detect such complex presentations as narcolepsy, periodic limb movement disorder (PLMD)/ restless leg syndrome (RLS), obstructive sleep apnoea (OSA) and complicated parasomnias, mostly recommended by sleep specialists. ^dLow-dose melatonin 0.5–1.0 mg as a chronobiotic 3–5 h before bed. Hypnotic dose 3–6 mg 30–60 min before bed. Melatonin slow/prolonged release (SPR): effective for refractory insomnia. ^eSupplement iron for ferritin <50 ng/mL. ASP, atypical sensory–perceptual disturbance; CBT, cognitive–behavioural therapy; IR, immediate release; SOL, sleep onset latency; SSADHD, Sleeping Sound with ADHD. Modelled on a figure from Shanahan et al. (2021) under terms of the Creative Commons Attribution License.