Interventions to Support Participation in Sleep for Autistic Children and Adolescents (2013–2021)

Full Systematic Review Question

This systematic review addressed the question “What are the interventions within the scope of occupational therapy to address participation in activities of daily living, instrumental activities of daily living, rest and sleep, work, education, play, leisure, social participation, and health management among autistic people under the age of 18?”

Current Theme Reported

The main themes of the studies included in this systematic review brief are the use of sleep education, exercise/movement, and technology-aided interventions.

Clinical Scenario

Autistic children and adolescents frequently experience a disruption in sleep occupations that are often attributed to differences in severity of social communication, behavior regulation, and sensory processing patterns (American Psychiatric Association, 2013; Carmassi et al., 2019; Johnson et al., 2018; Mazzone et al., 2018). Accordingly, previous systematic reviews have often focused on the efficacy of specific intervention approaches and contexts (e.g., peer-mediated interventions, parent training, early intervention, physical activity, sensory integration) to reduce symptom severity and skill deficits at the cost of considering if the outcome measures are performance based or align with the aims of the study (Lami et al., 2018; McConachie et al., 2015; Schaaf et al., 2021). Occupational therapy practitioners are well equipped to work collaboratively with autistic children and their families using multidimensional interventions; however, they need more information on the efficacy of interventions to promote participation in meaningful activities of daily life (American Occupational Therapy Association [AOTA], 2020). This systematic review brief presents the evidence on the efficacy of interventions to support sleep participation for autistic children and adolescents.

Summary of Key Findings

Ten articles were included in the review related to interventions that support participation in sleep. These 10 articles were divided into three categories (sleep education, exercise/movement, and technology-aided interventions) depending on the intervention approach (Table 1). The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Bottom Line for Occupational Therapy Practice

The intentional focus on participation in occupations often differentiates occupational therapy from other providers on a care team with autistic persons (AOTA, 2020). Whereas many service providers focus services on skill building with the intent to generalize, occupational therapy services start by considering function and participation in authentic contexts. Participation-focused interventions led to enhanced sleep participation in autistic children and adolescents.

Parent education in four studies improved sleep behavior, latency, and efficiency (Johnson et al., 2013; Loring et al., 2016; Malow et al., 2014; Papadopoulos et al., 2019). All studies used an individualized approach to develop sleep routines and coach behavior management strategies with parents. One study (Malow et al., 2014) showed equal effectiveness with group implementation. Three studies used low dosage of intervention, conducting two individual consultations with follow-up phone calls and the other with five training sessions. Considered together, these findings guide practitioners to engage parents in two to five individualized intervention planning sessions with telecommunication follow-up implementation support to enhance sleep participation for their autistic children.

Use of exercise/movement (e.g., bike riding, swimming, basketball) in three studies also yielded improved sleep efficiency, latency, and behavior (Brand et al., 2015; Lawson and Little, 2017; Tse et al., 2019). These studies do not provide clear intervention guidance for practitioners, as there was wide variability in type of exercise, session frequency (1–3/wk), total dosage (range 8–24), and context (e.g., clinic, school, community). The three studies included technology-aided interventions and provide little guidance for practitioners given the different technologies and sensory systems targeted. Though two of these studies showed improvements in sleep latency, efficiency, and duration, clear direction cannot be gained from use of a tactile input producing mattress nightly over 2 weeks (Frazier et al., 2017) versus a sound producing pillowcase nightly over 4 weeks. The third study (Gringras et al., 2014) using a weighted blanket over 2 weeks yielded inconsistent results. Additional evidence is needed to determine which intervention dosage and contextual factors of exercise/movement and technology-aided interventions are most effective in promoting sleep participation.