Sleep Problems in Autistic Children

Overview of the Study

• Examined assessment-based interventions for sleep problems in 3 young children, including 2 with autism
• Sleep diaries along with infrared nighttime video were used in the child's bedroom
• These tracked measures of sleep onset, sleep-interfering behaviors, night waking, total sleep, parental presence, and medication administration each night.
• The Sleep Assessment and Treatment Tool was used through open-ended interviews to identify environmental factors contributing to sleep problems
• Individualized treatment packages were designed with parents based on the assessment results.
• Treatment packages involved adjusting sleep schedules based on norms and sleep phases.
• The packages also designed better sleep environments, eliminated sleep dependencies, and used function-based interventions that decreased sleep-interfering behaviors
• The function-based interventions disrupted the connection between interfering behavior and reinforcement
• A nonconcurrent multiple baseline design across subjects saw effective treatment for all 3 kids
• Parents reported satisfaction with the assessment, treatment, and behavior change via social acceptability measures

Context of Sleep Problems in Children

• Sleep problems are regularly experienced by families and practitioners in managing sleep problems of young children
• Difficulties include falling/staying asleep, noncompliance with routines, and problematic post-"goodnight" behaviors that interfere with sleep (e.g., crying, leaving the room, or playing).
• Such issues are frequently raised with pediatricians and are a common cause for prescribing medication to children.
• Sleep problems can negatively affect children and families
• Negative effects include child irritability, difficult temperament, daytime sleepiness, unintentional injuries, and diminished performance on IQ tests.
• Sleep problems are correlated with obesity risk and anxiety in adulthood
• Sleep issues correlate with self-injury, noncompliance, aggression, tantrums, and impulsivity
• Secondary effects include poor parental sleep quality, family stress/tension, maternal malaise, and marital discord
• By 3 to 6 months, most infants don't need parental care at night, yet 35%-50% of typical, and 67%-73% children with ASD, still have sleep problems
• While some believe kids outgrow sleep issues, they can persist without resolving
• Parents seek pediatricians, but pediatric residency programs only provide about 5 hours of sleep training
• Pediatricians suggest children will outgrow problems, without prescribing treatment.
• Treatments given are often pharmacological, especially for disabled children.
• A survey found over 50% of pediatricians prescribe medications and over 75% recommend nonprescription drugs for pediatric insomnia
• About 81% of visits for sleep problems result in medication prescriptions.
• Clear prescribing guidelines and long-term research on pharmacological interventions is lacking
• There is a need for effective treatments to address and prevent sleep problems in young children.
• Empirically supported pediatric sleep problem treatments encourage behavior-analytic strategies
• Behavioral assessment and treatment are limited for pediatric sleep problems compared to other behaviors like self-injury

Effective Behavioral Interventions

• Stimulus control and extinction were successful for decreasing night waking and improving sleep quality in infants
• An effective faded bedtime with response cost procedure increased appropriate sleep in intellectually disabled individuals
• Key components were to bid goodnight later than average sleep-onset time, fading the bedtime earlier if sleep onset occurred rapidly, no going to bed before the set time or sleeping past scheduled wake time, and a response cost involving 1 hr out of bed for sleep-onset delays of over 15 min
• Replicated effects in a home setting was replicated with a 2-year-old child
• Extinction and bedtime pass were key for sleep-interfering behaviors of six typically developing children
• The pass allowed a brief trip outside the room for parental attention
• These studies demonstrate the effectiveness of behavioral tactics for certain sleep problems.
• Caregiver ability to implement behavioral interventions has some limitations in home environments
• Home-based studies are needed with parents as primary interventionists.
• Reliance on parental reports of sleep and waking exist in the majority of behavioral studies
• Objective measurement systems should be in place with behavioral interventions that are being evaluated
• Social validity measures and parental involvement in the interventions should be evaluated more routinely
• Efficacious tactics, like faded bedtime with response cost, and the bedtime pass are available, but are not assessment based
• Individualized treatments, designed based on the factors that influence problem behavior, are recommended

Behavioral Approach to Sleep Problems

• Behavioral (vs. pharmacological) pediatric sleep problem treatment begins with the target behavior through a contingency
• Behavioral quietude is the measurable dimension that always precedes falling asleep
• Lying quietly and falling asleep are operant behaviors maintained by the reinforcing event of sleep
• Stimuli in the environment get discriminative properties that signal sleep availability
• Discriminative stimuli include dimly lit rooms, cool temperatures, pillows/blankets, stuffed animals, rocking, patting, or a parent's presence
• Environmental operations may establish sleep value and evoke behavior historically resulting in reinforcement
• Sleep deprivation value establishes, and increases the chances of behavioral quietude
• Supplements/drugs like melatonin or clonidine can establish sleep value
• Main point: A coherent contingency analysis of sleep problems is possible with behavioral quietude and falling asleep selected as the target responses
• Effective intervention is more probable when the controlling variables are also recognized for operants occurring after goodnight and interfering with behavioral quietude
• Common interfering behaviors include calling out/leaving the bed, crying for parents, eating, watching TV, playing with toys, or talking in bed.
• Reinforcers may vary and be either automatic or socially mediated (positive or negative)
• Crying out may be reinforced with milk or extended parental presence or, negatively reinforced when parents remove the crying child from the room who cries
• Assessing sleep problems involves pinpointing behavior reinforcers, establishing operations, and discriminative stimuli

Study Details

• The study addressed limitations in behavioral literature on pediatric sleep issues
• Used an assessment/treatment model for behavior analysts working with parents to resolve their children’s sleep issues
• The goal was to develop individual, comprehensive, and socially acceptable interventions to address sleep problems based on the assessment
• Efficacy and acceptability data are presented from three families
• Three children, ages 7-9, and their parents were selected via flyers at child-care centers/pediatricians' offices
• Problems persisted for years, causing stress in each of the three families, for their sleep
• Walter was a 7-year-old typically developing boy, experiencing delayed sleep onset
• He took toys, stuffed animals, or books to his bed when it was time for sleep and talked to himself or got out of bed to ask questions if he was unable to fall asleep
• Walter had been taken to an outpatient clinic for evaluation of obsessive and compulsive behavior, and his sleep patterns were unaffected
• Parental goals included reducing sleep-onset delay, eliminating sleep-interfering behavior, and achieving 10.5 hr of sleep - Andy was a 9-year-old diagnosed with ASD, and who experienced delayed sleep onset and night awakenings
• Parents reported difficulty settling Andy to bed due to body rocking, head shaking, and repetitive manipulation/screaming/tantrums.
• Parental goals included reducing sleep-onset delay, eliminating sleep-interfering behaviors, reducing night wakings, and eliminating medication.
• Lou was a 9 year-old boy with ASD, with difficulties falling asleep and waking up multiple times per night and early in the mornings
• If a parent didn't lie down with Lou, he would sing, turn on lights, or sleep in parents’ room
• Both parents reported poor sleep quality due to constant nighttime interactions with Lou.
• Parental sleep goals included reducing sleep-onset delay, eliminating interfering behaviors, reducing night/early wakings, achieving 10.25 hr sleep, and eliminating parental presence/medication/supplements
• The study took place in the children's homes, and their parents implemented all treatment components in the bedrooms

Measurement Systems for Study

• Parents recorded info each day about their child’s sleep
• (a) time they bid goodnight, (b) when child fell asleep, (c) of night awakenings and resumption of sleep (if any), (d) of morning awakening, and (e) of any naps
• Sleep diary also included open-ended questions on bedtime disruptions, interfering behaviors, and parental presence or cosleeping
• High-definition camcorder with infrared illumination was placed inconspicuously in each child’s room
• Parents instructed to turn on before bidding child goodnight and off in morning shortly after starting morning routine to compliment sleep diary info
• Observation limited to behavior that occurred in and around child's beds

Dependent Variables Measured

• Sleep-onset delay was measured via time elapsed from bidding goodnight to falling asleep
• Observed from bidding goodnight to falling asleep continuously via video to record sleep-onset delay duration
• Collectors turned on an assigned key when bidding goodnight to child and turned off when 10 min elapsed without signs of being awake
• Sleep-interfering behaviors included any behavior that occurred after the goodnight bid that would interfere with quietude (minutes spent vocalizing/out of bed/sitting or standing in bed/engaging in stereotypy)
• Behavior was recorded from the video and real-time data were collected
• Entire sleep duration using a paper and pencil time-sampling procedure with 30-min intervals was recorded

Results

• After applying individualized intervention, immediate decrease in sleep-onset variability and level was noted in Walter, and Andy
• Delayed treatment effect for Lou, but the length of delays was shorter at the end of treatment
• Decreases in level and variability of all 4 sleep interrupting behaviors observed for Andy, and Walter.
• Reduction in vocalization observed post treatment, for Lou, (limited baseline forms of interfering behavior)
• Night walking reduced post treatment according to the analysis, video also show more episodes of Andy night waking which was less easily detectable via the less sensitive measure used by the parents

Sleep

• For both Walter and Andy, there was a slight decrease in variability in the percentage of sleep and more stability following treatment
• Lou's percentage of sleep was highly variable in the baseline, after treatment it decreased with variability appearing to decrease, especially during the final 2 weeks of treatment
• Sleep goals met across more measures for each child.
• Percentages greater during treatment vs baseline. for each of the individual children
• Social acceptance questionnaire score 6.8 throughout, for all three families

Discussion

• Improvements in additional sleep measurements seen in all three children post implementing individualized behavioral strategies.
• Strategies applied immediately for Walter/Andy. Delayed strategy for Lou/
• Parents indicated a higher level of satisfaction post assessment changes, treatment packages, better improvements in their kids sleep post therapy
• The importance of detailed review of what factors influence sleep in all child, through a comprehensive treatment style is stressed.