Umbrella Review and Meta-Analysis: The Efficacy of Nonpharmacological Interventions for Sleep Disturbances in Children and Adolescents

Abstract

Objective: We conducted an umbrella review of systematic reviews (SRs), with or without meta-analysis (MA), of randomized controlled trials (RCTs) assessing nonpharmacological sleep interventions for children and adolescents across various clinical populations.

Method: We searched multiple electronic databases up to January 24, 2024. Meta-analyzable data from RCTs in the retrieved SRs/MAs were pooled using Metaumbrella. Primary outcomes were subjective/objective child sleep parameters. Additional outcomes included child health/functioning and parental sleep/health. The quality of the MAs/SRs was assessed with Assessment of Multiple Systematic Reviews (AMSTAR-2), and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results: We included 93 SRs/MAs covering 393 RCTs, with 25 (17%, 39%, and 30%: high, moderate, and low quality) providing data for quantitative synthesis. Behavioral interventions, usually multicomponent including parent training, psychoeducation, and/or specific sleep therapy/strategies, showed beneficial effects on night waking, sleep duration, overall sleep disturbance, mood/depression, and maternal sleep quality (standardized mean difference [SMD] = 0.10-0.80) in participants with sleep problems without a formal sleep disorder diagnosis. For those with a formal diagnosis (mainly insomnia), benefits were found for night waking, sleep efficiency (subjective/actigraphically measured), and sleep onset latency (mean SMD = 0.49-0.97). Those with attention-deficit/hyperactivity disorder (ADHD) improved in bedtime resistance, night waking, parasomnias, sleep anxiety, ADHD symptoms, sleep disturbance, and quality of life (mean SMD = 0.18-0.49). For those with autism, sleep disturbance improved (mean SMD = 0.70). However, all findings were of low to very low certainty of evidence.

Conclusion: Among nonpharmacological interventions for sleep difficulties in youth, only behavioral interventions are supported by meta-analytic evidence, yet with small-to-moderate effect sizes and limited certainty of evidence.

Plain language summary: This "umbrella review" (a review of reviews) analyzed 93 systematic reviews and meta-analyses of randomized controlled trials examining nonmedication sleep interventions for children and adolescents. The authors found that behavioral interventions, including parent training and psychoeducation, had positive effects on sleep issues like night waking, with effect sizes ranging from small to moderate. Improvements were also seen in children with ADHD and autism. However, the quality of the evidence for these benefits was rated as low to very low. This suggests that while behavioral approaches may help, more robust evidence is needed to confirm their benefits.

Study preregistration information: The efficacy and tolerability of nonpharmacological interventions for sleep problems in children and adolescents: protocol for an umbrella review of systematic reviews and meta-analyses of randomised controlled trials. https://osf.io; j9qna/.

Keywords: grade; meta-analysis; nonpharmacological; sleep; umbrella review.