Beyond medication: a scoping review of non-pharmacological interventions for pediatric sleep disturbances in autism spectrum disorder

Introduction

Sleep disturbances are highly prevalent among children with autism spectrum disorder (ASD), with reported rates ranging from 50% to 80% (1,2). These sleep issues, including sleep-onset delay, bedtime resistance, frequent night wakings, and irregular sleep-wake cycles, significantly affect not only the child’s development but also family well-being and overall quality of life (3,4). Sleep problems in children with ASD are often linked to the exacerbation of core ASD symptoms, such as communication impairments, social difficulties, and sensory sensitivities (5,6). Addressing sleep difficulties is particularly crucial for children with ASD, as poor sleep can exacerbate these core symptoms, negatively impacting their functioning in various domains (5). While pharmacological treatments, such as melatonin supplementation and sedative medications, have been commonly used, they are often associated with side effects and fail to address the underlying factors contributing to sleep issues (7). This has led to increasing interest in non-pharmacological interventions, which offer safer and more sustainable solutions for managing sleep disturbances (8,9). Non-pharmacological approaches encompass a variety of strategies, including behavioral therapies, sensory-based interventions, physical activity, and environmental adjustments, each targeting different aspects of sleep disturbances experienced by children with ASD (5,9).

A scoping review was chosen for this study due to its primary objective of mapping the breadth of existing research on non-pharmacological sleep interventions for children with ASD. Unlike systematic reviews or meta-analyses, which focus on evaluating the effectiveness of specific interventions rigorously, a scoping review facilitates a comprehensive examination of the available literature, highlighting the variety of intervention strategies and sleep disturbances addressed. This approach is particularly valuable in a field characterized by considerable heterogeneity in study designs, intervention types, and outcome measures (10,11). Non-pharmacological interventions benefit children with ASD by addressing sleep disturbances that can exacerbate behavioral and cognitive challenges. These interventions help improve sleep quality, promote better sleep routines, reduce anxiety, and enhance overall well-being for both the child and their family (7,8). Previous reviews have examined non-pharmacological interventions for sleep disturbances in children with ASD, but these reviews often focus on narrower aspects of treatment or fail to integrate interventions across different domains of sleep disturbance (7,8). Additionally, existing reviews have not comprehensively mapped the types of sleep interventions or fully addressed the biological mechanisms underlying sleep disturbances in this population. Research on biological mechanisms, such as melatonin dysregulation and circadian rhythm disruptions, is vital to understanding the root causes of sleep difficulties in children with ASD (5). Addressing these mechanisms is crucial, as they provide a foundation for developing targeted and effective interventions. Thus, there is a need to systematically review and map the existing evidence on non-pharmacological sleep interventions for children with ASD, focusing on categorizing interventions by the types of sleep disturbances they address.

The primary objective of this scoping review is to map the existing literature on non-pharmacological sleep interventions for children with ASD. This review aims to categorize interventions by the types of sleep disturbances they address and assess their specific outcomes. By providing a comprehensive synthesis of the evidence, this review will highlight the need for individualized, multimodal intervention strategies to address the diverse sleep-related challenges faced by children with ASD. Furthermore, the review will lay the groundwork for future research, emphasizing the need for standardized protocols, long-term follow-up studies, and the exploration of effective combinations of interventions to achieve optimal outcomes. We present this article in accordance with the PRISMA-ScR reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-59/rc)

Methods

Study design

This scoping review followed the framework proposed by Arksey and O’Malley (11) and the PRISMA-ScR checklist (10) to map the breadth of non-pharmacological interventions for sleep disturbances in children with ASD. The methodology aimed to provide an overview of the types of interventions used, the specific sleep disturbances targeted, and key findings.

Search strategy

A comprehensive search strategy was employed across multiple databases, including Web of Science, Scopus, PubMed, ScienceDirect, COCHRANE Library, and OTseeker. Keywords and Medical Subject Headings (MeSH) terms related to “sleep disturbances”, “autism spectrum disorder”, and “non-pharmacological interventions” were used to retrieve relevant studies. In addition to published peer-reviewed articles, the review also included grey literature such as dissertations, unpublished studies, and conference proceedings. This broader search was necessary to mitigate the risk of publication bias, as it is well-known that published studies may not represent the full scope of evidence, particularly in emerging fields such as non-pharmacological interventions for ASD (12). The complete search strategy is detailed in (Table 1).

Study selection

The process of study selection was conducted by M.R.R.A.B., A.D., and Z.I.I.Z. in three phases: title screening, abstract screening, and full-text screening. Initially, all studies identified from the search were reviewed by M.R.R.A.B. and A.D. based on their titles. The studies that appeared relevant were further assessed through abstract screening. Any disagreements or discrepancies between the reviewers were resolved through discussions to reach a consensus. Following this, the full-text articles were reviewed to determine their eligibility. The final inclusion criteria for the studies were that they were published between 2014 and September 2024, written in English, involved children aged 2 to 18 years diagnosed with ASD, and focused on non-pharmacological interventions for sleep disturbances. The 2014 lower bound was selected to reflect a shift in research towards more comprehensive and diverse non-pharmacological approaches to managing sleep disturbances in children with ASD, including the integration of behavioral, sensory, physical activity, and environmental strategies, which became more prevalent after this period. The decision to exclude studies with comorbid conditions was to ensure the review focused on interventions for ASD-related sleep disturbances. While many children with ASD have comorbidities, these can affect sleep patterns and intervention outcomes, so excluding them helped isolate these effects on sleep. Studies that used pharmacological treatments, involved populations with comorbid conditions besides ASD, or focused on the development and validation of sleep measurement instruments were excluded. The final analysis did not include systematic reviews, meta-analyses, scoping reviews, or study protocols. After duplicates were removed using Mendeley, the remaining articles were screened according to the predefined inclusion and exclusion criteria. A third reviewer resolved any discrepancies in the eligibility assessment process. This rigorous screening process ensured that only relevant studies were included for data extraction and analysis.

Data extraction

All reviewers in this study performed data extraction. Key information extracted from the studies included author details, publication year, study design, sample size, and participant characteristics such as age and ASD diagnosis. Intervention details, including the type, frequency, and duration of the non-pharmacological interventions, were recorded, along with the settings in which they took place (e.g., home, school) (13). We also documented the primary and secondary outcomes related to sleep disturbances, such as sleep onset delay, night wakings, and sleep duration. Any limitations of the studies, as reported by the authors, were also noted. Discrepancies between the reviewers were resolved by Z.I.I.Z. and H.F.M.R., ensuring accuracy in the extracted data.

Data analysis

Data analysis followed a narrative synthesis approach due to the wide variability across studies in terms of design, sample size, and interventions (11). This was done by all the reviewers. The interventions were categorized into four main types: behavioural, sensory-based, physical activity-based, and multimodal interventions. The categorization of intervention strategies in this review is based on their core focus and mechanisms of action. Behavioral intervention aims to modify specific behaviors through reinforcement, rewards, and consequences (14,15). These strategies are used to encourage or discourage certain actions. Sensory-based strategies focus on regulating sensory inputs (e.g., sight, sound, touch) to influence emotional and behavioral responses, which is particularly helpful for individuals with sensory processing issues (7). Physical activity-based strategies utilize movement and exercise to promote physical and emotional well-being especially for sleep (16). Finally, the multimodal intervention combines behavioral interventions and environmental strategies, adjusting the surrounding environment, such as lighting or noise, to enhance comfort and support focus (8,9). This categorization allows for a clearer understanding of how each strategy influences outcomes for individuals with ASD, helping to identify the most effective interventions based on the diagnostic criteria. By organizing the strategies in this way, the review provides a structured analysis of their relevance and applicability. The analysis highlighted the effectiveness of each type of intervention while acknowledging the challenges of comparing studies with different methodologies. Due to the heterogeneity of the studies, a quantitative meta-analysis was not feasible, and the findings were summarized qualitatively to provide a broad understanding of the current evidence.

Results

A total of 1,533 studies were identified through database searches and manual reference checks. After removing duplicates, 972 records were screened based on titles and abstracts, leading to 60 studies assessed for eligibility. Of these, 37 studies were excluded for reasons such as unavailability of full text, irrelevant populations, or incorrect study designs. Ultimately, 23 studies were included in the final analysis. The study selection process is detailed in Figure 1.

Figure 1 Overview stages of study identification and selection based on the PRISMA 2020 flow diagram.

Study characteristics

The study characteristics of the reviewed papers, as stated and described in Table 2, displayed a wide range of methodologies, sample sizes, and intervention approaches. The majority of the studies were randomized controlled trials (RCTs) (n=9) (2,16,17,26-28,30,31,34), followed by single-case experimental designs (n=7) (14,19-21,23,24,32), pre/post studies (n=3) (15,18,22), and others, such as feasibility study (n=1) (25), retrospective case analysis (n=1) (33), randomized crossover design (n=1) (29), and semi experimental trial (n=1) (35). Sample sizes varied significantly, with some studies involving just one participant (14), while others included as many as 247 participants (28). The participants’ ages ranged from 2 to 18 years. The studies were conducted in various countries or regions, including Hong Kong (n=3), the United States (n=10), New Zealand (n=2), Switzerland (n=1), Canada (n=1), England (n=1), Australia (n=3), Northern Ireland (n=1), Iran (n=1), and China (n=1). The interventions used were categorized into different types: behavioral interventions (n=11) (2,14,15,18-20,23,26,28,30,31), sensory-based interventions (n=4) (21,25,27,29), physical activity (n=4) (16,22,24,35), and multimodal interventions (n=4) (17,32-34), which combine behavioral interventions with environmental strategies, and physical activity. These differences in interventions, along with the varied sample sizes and study durations, made it difficult to draw definitive conclusions about the most effective interventions.

Types of sleep disturbances

The analysis identified several common sleep disturbances among children with ASD. The most frequently reported disturbances were sleep-onset delay (65.2%) (2,14,15,17,19-24,26-29,32-34), bedtime resistance (56.5%) (17,26,28,30,35), night wakings (65.2%) (2,14,16,19,20,24,26,32,33,35), early awakenings (4.3%) (20), sleep duration issues (30.4%) (14,15,21,23,24,27,29,35) and parasomnias (4.3%) (28,33). These disturbances varied in severity and were often interrelated, with multiple sleep issues co-occurring in the same individuals (3,4,36).

Intervention categories

The reviewed papers of the sleep interventions are stated and described in Table 2. The interventions were categorized into behavioural interventions, sensory-based interventions, physical activity-based interventions, and environmental strategies. The behavioural interventions were the most common, with techniques like bedtime fading (14,19,23), and positive routine (14,23,32) being employed to address issues like sleep-onset delay and bedtime resistance. Sensory-based interventions, such as weighted blankets (21,27) and sound-to-sleep devices (29), target issues like sleep anxiety and sensory sensitivities. Physical activity interventions, including aerobic exercises (22) and aquatic therapy (24,25,35), focused on improving overall sleep duration and efficiency. Multimodal interventions that combine behavioral intervention and environmental strategies (17,32,33), and physical activity (34), were used to optimize the sleep environment and improve sleep quality.

Long-term effectiveness and sustained improvements

While many studies reported short-term improvements in sleep outcomes, only a few provided follow-up data to assess the lasting impact of the interventions (2,28,30). For instance, Malow et al. (2) conducted a RCT with a 12-month follow-up, and found that children who participated in an individualized sleep education program continued to show improvements in sleep onset latency and night wakings compared to the control group. Similarly, Papadopoulos et al. (30) observed that improvements in bedtime resistance and sleep onset delay were maintained 3 months post-intervention, suggesting some enduring effects. However, most studies lacked long-term follow-up, which limits our ability to assess whether these improvements persist beyond the intervention period.

Multimodal interventions

Several studies employed multimodal interventions, combining behavioural intervention, physical activity and environmental strategies to address sleep disturbances in children with ASD (17,32-34). For instance, McLay et al. (33) combined bedtime fading with sleep hygiene education, targeting both sleep behaviours and environmental factors. Similarly, Shen et al. (34) integrated aerobic exercise with structured bedtime routines, aiming to improve sleep duration and quality. In another study, Ip et al. (17) used sleep environmental settings alongside parent-mediated behavioural training, addressing both environmental and behavioural challenges. Additionally, Knight & Johnson (32) combined behavioural and environmental interventions in a parent-based sleep education program, which showed significant improvements in sleep quality.

Discussion

This review highlights the effectiveness of various non-pharmacological interventions for sleep disturbances in children with ASD, emphasizing the importance of individualized approaches. Behavioral interventions, such as bedtime fading and parent sleep education, are most commonly used in managing sleep-onset delay and bedtime resistance (17,19,20,23,26,30). These strategies help establish consistent sleep routines, which are crucial for children with ASD who struggle with behavioral rigidity (32,37). Sensory-based interventions, like weighted blankets and sound-to-sleep devices, target sleep anxiety and sensory sensitivities. Although results vary, they offer promising benefits, particularly in improving sleep duration and quality (18,21,29). These interventions highlight the importance of addressing the sensory needs of children with ASD to promote better sleep. Physical activity, including aerobic exercises and aquatic therapy, also shows positive effects by improving sleep efficiency and reducing sleep latency (16,22,34). Regular physical activity helps regulate circadian rhythms, leading to longer and more restful sleep (24). Finally, environmental strategies, such as modification and structured sleep routines, in combination with behavioral intervention, help optimize the sleep environment, reducing disruptions and improving overall sleep quality (17). These interventions emphasize the role of the environment in supporting better sleep patterns for children with ASD. The review suggests that a multimodal approach combining behavioral, physical, and environmental strategies is most effective in addressing the diverse sleep challenges in children with ASD (17,33).

This review provides a comprehensive mapping of non-pharmacological interventions, addressing a wide range of sleep disturbances in children with ASD. The inclusion of studies across behavioral, sensory, physical activity, and environmental domains ensures a holistic view of the existing interventions. Inclusion of gray literature and unpublished studies helped minimize publication bias, which is common in emerging fields such as non-pharmacological sleep interventions (12). The review also employed a scoping methodology, which is ideal for mapping out the breadth of interventions and identifying knowledge gaps in the literature (11). However, the review’s heterogeneity in study designs, sample sizes, and outcome measures limited the ability to draw definitive conclusions about the most effective interventions or combinations of strategies. Also, the lack of quality appraisal of included studies means that the strength of evidence supporting the various interventions is not fully assessed. This is particularly important given the variability in study methodologies (10). Many studies provided short-term follow-up, and the long-term sustainability of improvements in sleep outcomes remains unclear, which is a significant limitation in understanding the enduring impact of these interventions (30,33). The findings of this review align with previous studies that have explored non-pharmacological interventions for sleep disturbances in children with ASD. For example, a meta-analysis by Keogh et al. (8) emphasized the effectiveness of behavioral interventions in reducing sleep-onset delay, similar to the findings of this review. However, this review builds upon previous work by incorporating a broader range of interventions, including sensory and physical activity-based strategies, which were underexplored in past reviews. Compared to other systematic reviews in the field (7), which focused predominantly on behavioral interventions, this review highlights the potential of integrating multimodal approaches to address the diverse and often co-occurring sleep issues faced by children with ASD. Furthermore, unlike other reviews that have failed to map the biological mechanisms underlying sleep disturbances in ASD (5), this review provides a theoretical structure that includes the need for interventions targeting these mechanisms in conjunction with behavioral and environmental strategies. The effectiveness of behavioral interventions can be explained by their focus on establishing consistent sleep routines and reinforcing healthy sleep behaviors. Studies such as Luiselli et al. (23) have shown that techniques like bedtime fading allow for gradual adjustment to the sleep schedule, which is particularly effective for children with ASD, who often struggle with behavioral rigidity (19). Behavioral interventions also benefit from strong parent involvement (18,31), which has been shown to improve adherence in managing sleep problems (33,38). Sensory-based interventions (e.g., weighted blankets) are rooted in the Ayres Sensory Integration (ASI) framework, which posits that sensory input can help regulate the nervous system and promote relaxation (39). These interventions address the sensory sensitivities often seen in children with ASD, which may disrupt their ability to fall asleep or stay asleep (27,36). However, the mixed results observed in the studies reviewed could be attributed to individual differences in sensory processing among children with ASD, highlighting the need for personalized approaches (19,29). Physical activity-based interventions regulate circadian rhythms and promote sleep by reducing excess energy and enhancing sleep quality through increased physical exertion (40). Aerobic exercise, in particular, has been found to improve sleep efficiency by facilitating deep, restorative sleep (16,34,35). Environmental strategies, such as modification and structured routines, work by minimizing external disruptions and enhancing the overall sleep environment. As children with ASD are particularly sensitive to environmental factors, these interventions can help provide a calming atmosphere conducive to better sleep (30).

Clinicians should consider multimodal strategies for treating sleep disturbances in children with ASD. This means combining behavioral, sensory, physical activity, and environmental interventions to create personalized treatment plans based on the individual’s unique sleep challenges. Additionally, parent training remains crucial to ensure the consistent application of interventions and the long-term success of sleep interventions (14,31,33). Given the varied effectiveness of different interventions, clinicians should adopt a flexible approach that allows for adaptations based on a child’s specific needs and preferences. Future research should focus on standardizing intervention protocols to allow for better comparison across studies and the identification of best practices. Additionally, more research is needed on the long-term outcomes of non-pharmacological interventions, particularly on whether improvements in sleep quality are sustained over time. Research should also explore the biological mechanisms underlying sleep disturbances in children with ASD to inform the development of targeted interventions (5). While multimodal interventions combining behavioral, sensory, physical, and environmental strategies show promise for improving sleep outcomes in children with ASD, further research using advanced methodologies such as the Multiphase Optimization Strategy (MOST) or adaptive clinical trials could enhance the precision and flexibility of intervention protocols. MOST, an approach focused on optimizing intervention components in a phased manner (41), could allow for identifying the most effective combinations of treatments tailored to individual children.

Conclusions

This scoping review has mapped the range of non-pharmacological interventions available for managing sleep disturbances in children with ASD. The findings demonstrate that behavioral, sensory-based, physical activity, and multimodal interventions all have the potential to significantly improve sleep-related issues such as sleep-onset delay, bedtime resistance, and night wakings. Each type of intervention targets specific aspects of sleep disturbance, offering promising solutions for children with ASD.

The evidence supports the importance of adopting individualized, multimodal approaches to address the diverse sleep challenges these children face. By combining different strategies, it is possible to create more effective, personalized treatment plans that improve not only sleep quality but also overall well-being for both children and their families. Ultimately, the review highlights the critical need for clinicians to consider a variety of intervention strategies to best meet the unique needs of each child with ASD.

Acknowledgments

The authors would like to express their gratitude to MARA University of Technology for its support and contributions to this study.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-59/rc

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-59/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-59/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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