Pharmacological management for insomnia in children and adolescents with autism and attention deficit and hyperactivity disorder

Introduction: Insomnia is common in children and adolescents with autism spectrum disorder (ASD) and/or attention deficit and hyperactivity disorder (ADHD), with significant implications for quality of life and prognosis. Although non-pharmacological interventions represent the first-line approach, they are not always effective. Therefore, it is important to determine when a pharmacological treatment can be indicated and which compound to prefer based on evidence of efficacy and safety. Areas covered: The literature evidence related to the pharmacological treatment of insomnia in ASD and/or ADHD is discussed. We present data on drugs and supplements used and considerations about the choice of starting a pharmacological therapy, suggesting clinical advice that may guide clinicians. Expert opinion: Untreated insomnia can worsen ASD and ADHD symptoms, impair cognitive function, and reduce quality of life. Targeted interventions are essential. Behavioral strategies, with or without melatonin, are recommended after evaluating comorbidities and medications. Off-label treatments for children with ASD include antihistamines, alpha-adrenergics, trazodone, antidepressants, antipsychotics, anticonvulsants, and hypnotics. For ADHD, options include iron supplementation for restlessness and low ferritin levels, and alpha2-adrenergics like guanfacine and clonidine for their sedative effects.