1. By Corine van Staalduinen
Interventions for Sleeping Problems in Children with Autism Spectrum Disorders
By Corine van Staalduinen

2. Overview About me Goals Why is this topic important?
Common sleeping problems in children with ASD
Possible causes of sleeping problems
Types of interventions
Practical application
What’s next?

3. About Me Early family influences.
Undergraduate degree in Psychology at Brock University, Ontario.
Started as a behaviour interventionist in summer of 2005.
M. Ed in Special Education with concentration in autism and developmental disabilities at UBC.

4. Goals
To increase knowledge and skills related to providing interventions to young children with autism spectrum disorders
To increase knowledge and skills in the area of functional behaviour assessment and positive behaviour support
To increase knowledge of the principles of applied behaviour analysis

5. Why is this topic important?
Prevalence rates of 41-86% for sleeping problems in children with ASD have been reported (Goodlin-Jones, Tangs, Liu, & Anders, 2008; Liu, Hubbard, Fabes, & Adam, 2006; Richdale & Prior, 1995; Wiggs & Stores, 2004).
Sleeping problems predicted more intense symptoms of autism (Schreck, Mulick, & Smith 2004).
Sleep problems in children with ASD are a significant predictor of maternal stress (Hoffman et al., 2008).

6. Why is this topic important?
Parents of children with ASD report higher rates of sleep problems for themselves than parents of typically developing children (Lopez-Wagner, Hoffman, Sweeney, & Hodge, 2008).
More severe sleeping problems in children with ASD was related to higher rates of sleep problems in their parents (Lopez-Wagner et al., 2008).
Parents of children with ASD wake up earlier and sleep fewer hours per night than parents of typically developing children (Meltzer, 2008).

7. Common Sleeping Problems in Children with ASD
Bedtime resistance
Insomnia
Parasomnias (interruption of sleep after falling asleep, e.g. nightmares)
Sleep breathing disorders (e.g. sleep apnea).
Morning rise problems
Daytime sleepiness (Liu et al., 2006)
Night-waking (Hoffman et al., 2005).
Shorter sleep duration (Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006).
Unwillingness to fall asleep in own bed (Williams, Sears, & Allard, 2004).
Rapid eye movement (REM) dysfunction (Schreck, 2001).

8. Possible Causes of Sleeping Problems
Sleeping problems in children with ASD are not related to intellectual functioning (Richdale, 1999).
Poor sleep hygiene (Malow et al., 2009).
Daytime, evening, and bedtime habits that influence sleep.
E.g. low level of exercise during the day, consuming foods or drinks containing caffeine after dinner, not having a regular bedtime routine, etc.
Medication use (Liu et al., 2006).
Hypersensitivity (Liu et al., 2006).
Comorbid epilepsy, ADHD, asthma, allergies, gastrointestinal problems (Liu et al., 2006).
Melatonin regulation may be abnormal (Richdale, 1999).
Anxiety/Fear (Richdale, 1999).
Similar to the light-dark cycle, humans likely use social cues to adjust their circadian rhythms. Children with social-communication deficits may find it difficult to use those cues to adjust their rhythms.
Increased levels of melatonin are supposed to induce sleepiness.

9. Types of Sleep Interventions
Melatonin
Light therapy
Chronotherapy
Behavioural interventions

10. Melatonin
Melatonin is a hormone produced by the pineal gland that causes drowsiness.
Melatonin levels rapidly increase in the evening, peak in the middle of the night and decreases during the second half of the night.
Melatonin is not considered a drug, so it is not regulated by the FDA.
No side effects have been reported in children with ASD.
In a randomized, double-blind, placebo-controlled crossover trial of melatonin with 7 children with ASD and sleep problems, melatonin significantly reduced sleep latency, number of night wakings and increased total sleep time (Garstang & Wallis, 2006).
Two other studies obtained similar results (Giannotti et al., 2006; Wasdell et al., 2008)
In the first study, the children’s sleep problems had previously failed to be alleviated by behavioural management techniques.
One had 16 children with autism and was also randomized, double-blind, placebo-controlled crossover
The other had 25 children with autism, but there was no placebo control group and melatonin was combined with behavioural techniques, making it difficult to assess the effect of melatonin on sleep. All children improved with melatonin treatment. Sleep problems returned in 16 out of 25 children when melatonin was discontinued but re-administration of melatonin was effective again. Treatment gains were maintained at 12 and 24-month follow-ups.

11. Light Therapy
Bright light suppresses the secretion of melatonin, thereby decreasing drowsiness (individuals should be exposed to bright light in the morning and afternoon, not in the evening) (Richdale, 1999).
No studies have been conducted to assess the effectiveness of light therapy in reducing sleep problems in children with ASD.

12. Chronotherapy
Chronotherapy involves systematically delaying bedtime on successive nights until the individual is falling asleep at an appropriate time.
Capitalizes on circadian drift (human circadian cycles last 25 hours; when time cues are absent we tend to fall asleep an hour later every day).
It is actually easier to change sleep onset from 2 a.m. to 10 p.m. by gradually increasing bedtime than by making bedtime earlier.
Irregular sleep onset times, night and early wakings and short sleep times were successfully treated with chronotherapy in an 8-year old girl with autism and mental retardation (Piazza, Hagopian, Hughes, & Fisher, 1998).
There are some obvious disadvantages to chronotherapy though; it is labour intensive and requires around the clock monitoring. It would be very disruptive to a family’s daily schedule and is not possible to do if the child has to go to school during the day.

13. Behavioural Interventions
Almost all of the studies using behavioural interventions include establishing a bedtime routine.
A bedtime routine should consist of specific activities conducive to sleep.
For example, taking a bath, brushing teeth, changing into pajamas, read bedtime story, turn off the light and go to sleep.
There are no studies examining the effectiveness of this component by itself (Schreck, 2001).

14. Behavioural Interventions
Non-graduated extinction (Schreck, 2001).
Parents ignore all crying and screaming at bedtime and during the night. They keep the bedroom door closed and do not respond.

15. Behavioural Interventions
Graduated extinction (Schreck, 2001).
If the child engages in problem behaviour at bedtime, the parents ignore it for a pre-set time period (e.g. 5 minutes).
If the child continues to cry, the parents re-settle the child with as little attention as possible and leaves the room again.
Continue this procedure until the child falls asleep.
Used because parents feel uncomfortable letting their child tantrum for long periods of time.
Based on specific criteria for different classifications of evidence-based treatment effectiveness, extinction (graduated and non-graduated) was deemed a possibly efficacious ABA intervention for sleep problems by Schreck in 2001.
Although additional studies examining the effectiveness of extinction have been conducted since 2001, none of them compare the extinction to other treatments and therefore extinction would still be considered a possibly efficacious intervention rather than a probably efficacious or well-established intervention.

16. Behavioural Interventions
Stimulus fading (Schreck, 2001).
Used to eliminate co-sleeping.
Involves gradually and systematically moving a co-sleeper (usually a parent) farther away from the child’s bed.
On the first night, the parent sleeps on a bed or mattress beside the child’s bed.
On subsequent nights, the parent is moved farther from the child’s bed until he or she is out of the child’s room.
One study showed effectiveness of stimulus fading in eliminating co-sleeping and reducing night wakings in a 5 year old boy with autism (Howlin, 1984, as cited in Schreck, 2001).

17. Behavioural Interventions
Faded bedtime with and without response cost (Piazza, Hagopian, Hughes, & Fisher, 1998).
Take baseline data to calculate average sleep onset time
Set initial treatment bedtime a half hour later
If child falls asleep within 15 minutes, set bedtime for next night a half hour earlier
If child does not fall asleep within 15 minutes, remove from for 1 hour (response cost) and set bedtime for next night a half hour later OR do not remove child from bed (no response cost) but move bedtime half an hour later the subsequent night (Schreck, 2001).
Gradually adjust bedtime until child is falling asleep at appropriate bedtime

18. Behavioural Interventions
Faded bedtime with and without response cost
At least 3 studies have shown the effectiveness of faded bedtime without response cost in reducing sleeping problems in children with ASD (Christodulu & Durand, 2004; Durand & Christodulu, 2004; Piazza & Fisher, 1991, as cited in Schreck, 2001)
One study demonstrated that faded bedtime with response cost was more effective than without response cost (Piazza, Fisher, & Sherer, 1997, as cited in Schreck, 2001).

19. Behavioural Interventions
Social Stories (Gray, 1995, as cited in Moore, 2004).
Carol Gray developed social stories to help children with ASD understand social behaviours and teach them how to behave in specific situations.
Social stories should be short ( words)
Explain subtle social cues and socially acceptable behaviour
Emphasis on perspective of child and perspective of others
Includes descriptive sentences, directive sentences, perspective sentences and control sentences.
For every directive or control sentences there should be 2-5 descriptive or perspective sentences.
Children’s language comprehension should be taken into account.

20. Behavioural Interventions
Social Stories
Co-sleeping and night-wakings were successfully eliminated with a social story, graduated extinction and reinforcement in a 4-year old boy with ASD. Delayed sleep latency was reduced from 1-2 hours to 30 minutes.
Graduated extinction was only loosely followed by his mother so it is likely that the social story had some positive effects on the child’s sleeping behaviour (Moore, 2004).

21. Practical Application of Behavioural Intervention
George (pseudonym) is a 5 year old boy with autism
Mother is Japanese, father is Canadian
Mother is a flight attendant – frequently away at night
Has a younger brother (2 years old)
Live in one bedroom apartment

22. Practical Application continued
Has a different bedtime routine and sleeping arrangements when mom is home compared to when she is away
When mom is not home there is a strict bedtime routine:
Both kids in bath at 6 PM (6:30 on weekends)
Teeth brushed in tub and G. is given melatonin drops
G. gets out first, is dressed in pajamas and helps get his younger brother dressed.
Younger brother sleeps on a mattress on the floor and G. lies across dad’s waist and is rocked to sleep in about 10 minutes.
Dad cannot leave the room all night or G. will wake up. There are no problem behaviours during bedtime routine, but he wakes up frequently at night and needs to be rocked back to sleep. Wakes up very early (between 3:30 and 5:30) and doesn’t go back to sleep.

23. Practical Application continued
When mom is home
Both kids in bath between 6:30-7 PM on weekdays and 7-8 PM on weekends.
Brush teeth in bath OR after
Melatonin drops after bath
Kids get out at the same time
Dressed in pajamas
G. engages in frequent crying and screaming after bath time
Mom, G. and younger brother sleep on mattress in living room while dad sleeps in bedroom.
G. is rocked to sleep across mom’s waist.
Wakes up when younger brother cries or when mom gets up to go to bathroom. However, goes back to sleep quickly (doesn’t need to be rocked back to sleep). Wakes up around 6:30-7 AM.

24. Practical Application Continued
Ideal sleeping arrangements are defined differently by mom and dad
Dad would like to sleep in the bedroom with mom and have kids sleep in bunk bed in a room that is currently a very small office. He’d like to be able to read a bedtime story to G.
Mom would like everybody to sleep in the bedroom, with mom and dad on the bed and the kids on a mattress on the floor.

25. Functional Assessment Interview
G. only slept by himself for a few weeks when he was approximately 2 years old. At the time they used non-graduated extinction (ignoring crying, but checking on him every 10 minutes).
After a trip to Japan, where he was allowed to sleep with his parents, he again started crying when put to bed by himself at home.
Mom was too traumatized from previous experience to want to try again.

26. Functional Assessment Interview
Problem behaviours that parents expect to see if they leave the bedroom are:
Leaving bedroom
Whining
Crying
Screaming
Self-injury (hitting head with open hand or fist)
Vomiting
They expect behaviour to escalate the longer they refuse to rock him to sleep

27. Functional Assessment Observation
I wanted to observe bedtime routine both when mom was home and when she was not home to see if there were any differences in behaviours.
We planned to videotape each scenario so that my presence would not change George’s behaviour.
I instructed the parents to put George to bed and to leave the bedroom a few times to see if George would actually engage in problem behaviour when they left.
If problem behaviour was mild they would leave 3 times, then rock him to sleep as they normally would.
If problem behaviour was severe, they could immediately rock him to sleep as they normally would.

28. Functional Assessment Observation
First videotaping was scheduled on a night when both mom and George’s younger brother would be away.
Dad put G. to bed and left the room. G. screamed and cried for a few seconds, got out of bed (occasionally whimpering) and went to the living room after a few minutes. Dad put him back in bed and G. stayed in bed and fell asleep within 10 minutes.
G. continued to fall asleep independently over the next few nights when mom was away.
No intervention needed for falling asleep. However, he still wakes up easily (dad eventually does need to go to sleep in same bed) and wakes up early.

29. Temporary Behavioural Intervention Plan
Dad wanted this behaviour to continue when mom came home.
We hypothesized George’s behaviour would be more challenging when mom was home, because his daytime behaviour is more challenging when mom is home (her attention is very reinforcing to him).
We also expected that mom might not be able to handle his challenging behaviour and would quickly give in.
We decided to ask mom to take George’s younger brother down to the apartment building lobby for about 15 minutes in the evening until G. fell asleep.
Once falling asleep independently was more firmly established they would start putting G. to bed together.

30. Temporary Intervention
When mom came home she had a jetlag and wanted to go to sleep early so she decided not to leave the apartment.
They put George to bed and he immediately came out.
Dad immediately decided that this was not the time to use extinction, because mom was too tired to deal with problem behaviour.
If they had used extinction for half an hour and given up after that, it would only teach him that he needs to engage in problem behaviour for half an hour and then he would get what he wants.

31. Summary Statement
From the functional assessment interview and functional assessment observation, I developed the following hypothesis:
Setting Event
Antecedent
Problem Behaviour
Maintaining Consequence
Mom leaving frequently
Not feeling tired
Mom leaving bedroom
Leaving bed/ room
Whining
Crying
Screaming
(Self-injury, vomiting?)
Attention – Mom rocks him to sleep and stays in bed with him

32. Positive Behaviour Support Plan
PBS plan is a long-term plan with two phases
During phase 1, George will continue to fall asleep independently when his mom is not home. Dad values this behaviour.
Dad will start to gradually delay bedtime by 10 minutes each day, until he is going to sleep at a more age-appropriate time (approximately 8 PM).
When George wakes up at night, dad will no longer rock him back to sleep. He will ignore G until he goes back to sleep by himself.
However, George will continue to sleep with his mom and younger brother when his mom is home. Mom values sleeping in the same room with her kids.
Mom will structure bedtime routine (bath, brush teeth, pajamas, etc.) the same way as dad to eliminate crying/screaming during bedtime routine.

33. Positive Behaviour Support Plan Continued
During phase 2, sleeping arrangements will change. Dad will clean out the small office space and purchase a bed for George.
George will sleep in this new small bedroom. Mom and dad will sleep in the big bedroom and the younger brother will sleep on a mattress on the floor in the big bedroom.
Both mom and dad made compromises on sleeping arrangements.

34. Positive Behaviour Support Plan Continued
Setting event strategies
Set bedtime at 8 PM
No napping
Cannot change the fact that mom leaves frequently
Antecedent strategies
Structured bedtime routine
Will start including bedtime story in routine
Read social story about how big boys sleep by themselves
Teaching Strategies
Teach appropriate behaviour through “Sleeping by myself” social story
Teach calming strategies during behaviour intervention sessions (taking deep breath, squeezing hands, closing eyes).

35. Positive Behaviour Support Plan Continued
Consequence Strategies (graduated extinction)
If G. does not engage in problem behaviour, his parents will check on him every 10 minutes until he falls asleep and provide whispered praise for staying in bed. If he does not disturb them at night, they will praise him in the morning and provide his favourite breakfast.
If G. whines, cries, or screams, they will ignore the behaviour and keep bedroom door closed. They will check on him every 10 minutes, providing as little attention as possible.
If G. leaves bedroom, they will tell him “it’s bedtime” and put him back to bed without additional comments or eye contact and repeat this procedure as many times as necessary.
If G. vomits or engages in destructive or other dangerous behaviour, they will stop the procedure.

36. What’s next?
I will take EPSE 593 (Design and Analysis of Research with Small Samples and Single Subjects) in September.
I plan on taking the BCBA exam in March 2010.
Start my own behaviour consulting company.

37. References
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