Pharmacological or non-pharmacological therapies? The impact of different therapies on sleep in children with autism spectrum disorder: A systematic review and network meta-analysis

This systematic review and network meta-analysis evaluated the efficacy of various therapies on sleep disturbances in children with autism spectrum disorder. We analyzed 35 randomized controlled trials comparing five interventions: melatonin, parent-mediated sleep education, behavioral interventions, physical activity, and adjunctive therapies. Standardized mean differences and surface under the cumulative ranking curve values were calculated to rank efficacy. Physical activity demonstrated the largest effect size (standardized mean difference = 1.13, surface under the cumulative ranking curve = 98.1%), followed by melatonin (standardized mean difference = 0.57, surface under the cumulative ranking curve = 62.8%) and behavioral interventions (standardized mean difference = 0.49, surface under the cumulative ranking curve = 51.6%). Parent education and adjunctive therapies showed limited efficacy. Heterogeneity ( I ² = 67%) was addressed via sensitivity analyses. A stepped-care model is recommended, prioritizing daytime physical activity (30–45 min, 3–5 sessions/week) combined with telehealth parent education as first-line treatment, followed by prolonged-release melatonin and therapist-supported cognitive behavioral therapy for non-responders. Lay abstract Many children with autism spectrum disorder struggle with sleep problems like trouble falling asleep, waking up at night, or not sleeping enough. This study looked at different treatments to improve sleep in these children, including melatonin supplements, parent-led bedtime routines, exercise programs, and other therapies. The researchers reviewed 35 studies involving over 2700 children with autism spectrum disorder. They compared how well each treatment worked using a method called network meta-analysis, which ranks treatments based on their effectiveness. Exercise programs, such as swimming or martial arts, were the most effective at improving sleep. These activities helped children fall asleep faster and stay asleep longer. Melatonin supplements also worked well but had side effects like morning drowsiness. Behavioral strategies, like structured bedtime routines, showed moderate benefits, while therapies like weighted blankets or iron supplements had little impact. This study helps families and doctors choose the best treatments for sleep problems in children with autism spectrum disorder. Exercise is a safe, low-cost option that not only improves sleep but also enhances daytime behavior. The findings support starting with physical activity and parent coaching before trying medications like melatonin. Recognizing effective treatments can reduce stress for caregivers and improve quality of life for children with autism spectrum disorder.