Cognitive behavioral treatment of insomnia in school‐aged children with autism spectrum disorder: A pilot feasibility study

Abstract

Insomnia is common in autism and associated with challenging behavior and worse parent sleep. Cognitive behavioral treatment for childhood insomnia (CBT‐CI) is efficacious in typically developing children, but not yet tested in school‐aged children with autism. This single arm pilot tested 8‐session CBT‐CI in 17 children with autism and insomnia (M age = 8.76 years, SD = 1.99) and their parent(s) (M age = 39.50 years, SD = 4.83). Treatment integrity was assessed for each session [delivery (by therapist), receipt (participant understanding), and enactment (home practice)]. Children and parents wore actigraphs and completed electronic diaries for 2‐weeks to obtain objective and subjective sleep onset latency (SOL), total sleep/wake times (TST/TWT), and sleep efficiency (SE) at pre/post/1‐month follow‐up. Parents also completed the Aberrant Behavior Checklist [irritability, lethargy, stereotypy, hyperactivity, inappropriate speech (e.g., excessive/repetitive, loud self‐talk)] at pre/post/1‐month. Fifteen children completed all sessions. Average integrity scores were high [90%‐delivery/receipt, 87.5%‐enactment]. Parents found CBT‐CI helpful, age‐appropriate, and autism‐friendly. Paired samples t‐tests (family‐wise error controlled) found CBT‐CI improved child sleep (objective SOL‐18 min, TWT‐ 34 min, SE‐5%; subjective SOL‐29 min, TST‐63 min, TWT‐45 min, SE‐8%), and decreased irritability, lethargy, stereotypy, and hyperactivity. At 1‐month, objective TST improved, inappropriate speech decreased, but hyperactivity was no longer decreased. Other gains were maintained. Parent sleep (objective SOL‐12 min, TST‐35 min, TWT‐21 min, SE‐4%; subjective SOL‐11 min, TWT‐ 31min, SE‐11%) and fatigue also improved. At 1‐month, gains were maintained. This pilot shows CBT‐CI is a feasible treatment that holds promise for improving child and parent sleep and functioning and suggests a randomized controlled trial in school‐aged children with autism is worth conducting. Autism Res 2020, 13: 167–176. © 2019 International Society for Autism Research, Wiley Periodicals, Inc.Lay SummaryInsomnia is common in autism and associated with challenging behaviors and poor parent sleep and stress. Cognitive behavioral treatment for childhood insomnia (CBT‐CI) has not been tested in school‐aged children with autism. This pilot study shows therapists, parents, and children were able to use CBT‐CI to improve child and parent sleep, child behavior, and parent fatigue. Parents found CBT‐CI helpful, age‐appropriate, and autism‐friendly. CBT‐CI holds promise for treating insomnia in school‐aged children with autism and deserves further testing.

Telehealth cognitive behavioral therapy for insomnia in children with autism spectrum disorder: A pilot examining feasibility, satisfaction, and preliminary findings

“…The weekly timeline was as follows: 1–2: baseline, 3–10: treatment, 11–12: post-treatment, and 25–26: follow-up. Session content was selected from seven modules (similar to the in-person version of the treatment previously reported) (McCrae et al, 2020), and the administration order was tailored to prioritize each child/family’s most pressing sleep concerns based on the clinical interview. All children received all seven modules.…”

“…These challenges are greater for rural children with ASD, who have less access to autism specialists, are of older age at diagnosis, have decreased care access, and need disproportionately higher emergency room visits than children from urban or suburban areas (Carbone et al, 2010; Mandell et al, 2007; Zhang et al, 2017). In line with these statistics, in a recent pilot study (McCrae et al, 2020), 58% of interested families were unable to participate due to travel burden. Furthermore, when asked for feedback regarding how CBT-CI could be improved, >50% of parents suggested offering remote treatment.…”

“…These behavioral treatments (largely based on learning principles) improve sleep in very young children (Johnson et al, 2013; Malow et al, 2012, 2014) and lead to greater improvement relative to controls (Paine & Gradisar, 2011). However, a recent work (McCrae et al, 2020) suggests that a CBT-CI may hold greater promise than traditional behavioral-only techniques for treating insomnia and its consequences in school-aged children with ASD. Behavioral treatment alone does not address factors that significantly interfere with sleep but do not present until school age (i.e.…”

“…For example, a systematic review and meta-analysis by Åslund et al (2018) found that CBT-CI-based methods produced significant differences in total sleep time (TST) and sleep onset latency (SOL) in school-aged children and adolescents, consistent with what has been reported in adults following treatment with CBT-CI. A recent pilot study (McCrae et al, 2020) of in-person eight-session CBT-CI in school-aged youth with ASD showed that the intervention was feasible (15 out of 17 children with ASD completed all sessions), and preliminary results suggested promising efficacy. CBT-CI led to moderate to large improvements in child subjective sleep (SOL, total wake time (TWT), TST, and sleep efficiency (SE)), objective sleep (SOL, TWT, and SE), bedtime/wake time regulation, and daytime behavior.…”

“…This pilot study used a single-arm design to test the feasibility of telehealth delivery of an adapted CBT-CI protocol in school-aged children with ASD and comorbid insomnia and their parent(s). Based on a single-arm pilot of traditional, in-person delivery of CBT-CI in this population (McCrae et al, 2020), we hypothesized that participants would complete at least seven sessions on average; that treatment integrity scores would be at least 90% for delivery (by therapist), receipt (participant understanding), and enactment (home practice); and that the majority (80+%) of parents would indicate that the treatment was helpful, age-appropriate, reasonable, and autism-friendly. We also hypothesized that telehealth delivery would not differ from in-person delivery (Ashburner et al, 2016) on treatment integrity scores and treatment satisfaction indicators.…”