Umbrella Review and Meta-Analysis: The Efficacy of Nonpharmacological Interventions for Sleep Disturbances in Children and Adolescents

Objective: We conducted an umbrella review of systematic reviews (SRs), with or without meta-analysis (MA), of randomized controlled trials (RCTs) assessing nonpharmacological sleep interventions for children and adolescents across various clinical populations.

Method: We searched multiple electronic databases up to January 24, 2024. Meta-analyzable data from RCTs in the retrieved SRs/MAs were pooled using Metaumbrella. Primary outcomes were subjective/objective child sleep parameters. Additional outcomes included child health/functioning and parental sleep/health. The quality of the MAs/SRs was assessed with Assessment of Multiple Systematic Reviews (AMSTAR-2), and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results: We included 93 SRs/MAs covering 393 RCTs, with 25 (17%, 39%, and 30%: high, moderate, and low quality) providing data for quantitative synthesis. Behavioral interventions, usually multicomponent including parent training, psychoeducation, and/or specific sleep therapy/strategies, showed beneficial effects on night waking, sleep duration, overall sleep disturbance, mood/depression, and maternal sleep quality (standardized mean difference [SMD] = 0.10-0.80) in participants with sleep problems without a formal sleep disorder diagnosis. For those with a formal diagnosis (mainly insomnia), benefits were found for night waking, sleep efficiency (subjective/actigraphically measured), and sleep onset latency (mean SMD = 0.49-0.97). Those with attention-deficit/hyperactivity disorder (ADHD) improved in bedtime resistance, night waking, parasomnias, sleep anxiety, ADHD symptoms, sleep disturbance, and quality of life (mean SMD = 0.18-0.49). For those with autism, sleep disturbance improved (mean SMD = 0.70). However, all findings were of low to very low certainty of evidence.

Conclusion: Among nonpharmacological interventions for sleep difficulties in youth, only behavioral interventions are supported by meta-analytic evidence, yet with small-to-moderate effect sizes and limited certainty of evidence.

Study preregistration information: The efficacy and tolerability of nonpharmacological interventions for sleep problems in children and adolescents: protocol for an umbrella review of systematic reviews and meta-analyses of randomised controlled trials. https://osf.io; j9qna/.