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5/27/2016
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GregoryP.Hanley.Ph.D.,BCBA‐D
SleepProblemsofChildrenwithAutismPrevalent,Relevant,andTreatable
byBehaviorAnalysts
ABAIMay,2016
Formoreinformation(tutorial,etc.),goto:www.practicalfunctionalassessment.com
Learnmorebyreadingthesleepresearcharticlesauthoredbythesebehavioranalysts:
NevilleBlampiedRichardBootzinMarkDurandKarenFrancePatrickFrimanCarlMerleJohnsonCathleenPiazza
CommonSleepProblems
Delayedsleeponset(longlatencytofallasleep)‐Sleep‐interferingbehavior
‐crying,callingout,curtaincalls,playing,stereotypy,talkingtooneself,etc.
Nightawakenings/Earlyawakenings
Shortsleepduration
Phaseshifts(sleepingatwrongtimesthusconflictingwithdailyroutines)
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SleepProblemsofChildrenwithAutism
(1)Prevalent
(2)Donotabateovertime
SleepProblemsofChildrenwithAutism
(3)Probablyanchoringchildren’sdeficits(Interferewithskilldevelopment)
SleepProblemsofChildrenwithAutism
(4)Worsenmaternalmentalhealth(negativelyaffectfamilyfunctioning)
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SleepProblemsofChildrenwithAutism
(5)Probablynotcauseddirectlybytheuniqueneurobiologyofchildrenwithautism
(6)Bestunderstoodasalearningissue
SleepProblemsofChildrenwithAutism
(7)Worsenedbythemostcommontreatments
SleepProblemsofChildrenwithAutism
(8)Meaningfullyaddressedwithcomprehensive treatmentsthatinvolvechangestothevariablesintwocompetingcontingencies
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SleepProblemsofChildrenwithAutism
(9)Bestsolvedbyfirstunderstandingthechild‐specificvariablesoperatingontwocompetingbehaviors:
behavioralquietudevsinterferingbehavior
SleepProblemsofChildrenwithAutism
(10)Maybeaddressedbestbybehavioranalysts
Sleepproblemsareprevalent,especiallyforchildrenwithautism
10‐50%ofchildrenwithoutautism
50‐80%ofchildrenwithautism
Wiggs &Stores JIntellectDisabil Res 1996Richdale DevMedChildNeurol 1999Schreck &Mulick JAutismDevDisord 2000Couturieretal. JAmAcad ChildAdolesc Psychiatry 2005Malow etal. Sleep 2006Krakowiak etal. JSleepRes 2008Richdale &Schreck SleepMedRev 2009Souders etal. Sleep 2009Cortesi etal. SleepMedicine 2010
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Hodgeetal.,2014,ResinDevDis
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Hodgeetal.,2014,ResinDevDis
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Allages(n=216) 82 50
Hodgeetal.,2014,ResinDevDis
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Allages(n=216) 82 50
Ages3–5(n=50) 84 72
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Hodgeetal.,2014,ResinDevDis
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Allages(n=216) 82 50
Ages3–5(n=50) 84 72
Ages6–9(n=118) 78 46
Hodgeetal.,2014,ResinDevDis
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Allages(n=216) 82 50
Ages3–5(n=50) 84 72
Ages6–9(n=118) 78 46
Ages10–17(n=48) 88 38
Sleepproblemsgenerallydonotresolveontheirown,especiallyforchildrenwithautism
%ofchildrentoreceiveCSHQscoreof41orabove
ASDgroup(%)TDgroup(%)
Allages(n=216) 82 50
Ages3–5(n=50) 84 72
Ages6–9(n=118) 78 46
Ages10–17(n=48) 88 38
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Whatisdifferentaboutchildrenwithautismandchildrenoftypicaldevelopmentwithregardstosleep?
Suspects: Sleeparchitecturee.g.,DurationandqualityofREMsleep
NeurotransmittersandrelatedbiochemicalpathwaysSerotoninlevelsEndogenousmelatoninlevels
ASMT(melatoninbiochemicalpathway)GABAGABAergicinterneurons
Clockgenese.g.,Per3,BMAL,CRY
Itisstillnotclearwhetherthereisanythingphysiologicallyuniqueaboutchildrenwithautismthatiscontributingtotheirsleepproblems
E.g.,DurationandqualityofREMsleep
REMsleep:Longsuspectedofbeingofshorterdurationandlowerqualityamongchildrenwithautism
Tanguay etal. JAutismChildSchizophr 1976Diomedi etal. BrainDev 1999Thirumalai etal. JChildNeurol 2002Buckleyetal. ArchPedatr Adolesc Med 2010
E.g.,DurationandqualityofREMsleep
Malow etal.(Sleep,2006)
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E.g.,DurationandqualityofREMsleep
Malow etal.(Sleep,2006)showednodifferenceinsleepstructure,includingqualityanddurationofREMsleepbetweenchildrenwithandwithoutautism
Importantconsiderations:
• OnlyMalow etal.restrictedtheirstudytochildrenwithnohistoryofpharmacologicalintervention
• Manydrugsgiventochildrenwithautismtofacilitatesleeponsetortoaddressirritability/problembehaviornegativelyaffectthedurationandqualityofREM
Itisstillnotclearwhetherthereisanythingphysiologicallyuniqueaboutchildrenwithautismthatiscontributingtotheirsleepproblems
Whatelseiscorrelatedwithsleepproblemsofchildrenwithautism?
Richdale DevMedChildNeurol 1999Schreck etal. ResinDevDis 2004Malow etal. PedNeurol 2006Malow etal. Sleep 2006Liuetal. ChildPsychiatry&HumDev 2006Krakowiak etal. JSleepRes 2008Richdale &Schreck SleepMedRev 2009Goldmanetal. DevNeuropsychology 2009Cortesi etal. SleepMedicine 2010Hollway &Aman ResinDevDis 2011Sikora etal. Pediatrics 2012DelaHaye etal. ResinAut SpecDis 2013
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CorrelatesofSleepProblemsforChildrenwithautism
Cognitiveimpairment/IQ: NoAutismSymptomSeverity
languageimpairment: Nosocialreciprocity: Yesritualistic/repetitivebeh.: Yes
stereotypy YesSevereproblembehavior: YesPooradaptiveskilldevelopment: YesComorbidconditions
ADHD Yesallergies: Yesasthma: YesGIproblems: Yesanxiety: Yesdepression: Yes
Health‐relatedqualityoflife: Yes
Example:
Limitedhoursofsleeping negativelycorrelatedwithratesofstereotypy
CorrelatesofSleepProblemsforChildrenwithautism
Cognitiveimpairment/IQ: NoAutismSymptomSeverity
languageimpairment: Nosocialreciprocity: Yesritualistic/repetitivebeh.: Yes
stereotypy YesSevereproblembehavior: YesPooradaptiveskilldevelopment: YesComorbidconditions
ADHD Yesallergies: Yesasthma: YesGIproblems: Yesanxiety: Yesdepression: Yes
Health‐relatedqualityoflife: Yes
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Screeningforthecorrelates
Reynolds&Malow Pediatr Clin NAm 2011
SeethisarticleforaScreeningChecklist:
Mayachievemoretraditionalobjectivesifyouresolvethesleepproblem
Improvecompliancewithinstructions
Decreasesevereproblembehavior
Gainstimuluscontroloverstereotypy
Decreasetrialstomastersocialandacademicskills
…
(thisisamostimportantareaofresearch)
Mayachievemoreextraordinaryobjectivesifyouresolvethesleepproblem
ImproveparentalsleepproblemsMiminize maternalstress,malaise,anddepressionEnhanceFamilyfunctioning/qualityoflife
Sadah etal. Dev.Psych. 2000Meltzer&Mindell JFamPsychol 2007Hoffmanetal. FocusonAutandOthDevDis 2008Meltzer ResinAutSpecDis 2011Hodgeetal. JAut &DevDis 2013
(thistooisanimportantareaofresearch)
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Mindelletal. Pediatrics 1994
Pediatriciansreceiveonlyabout5hoursoftrainingonsleepproblems
Owensetal. Pediatrics 2001
Inasurveyof626pediatriciansinNewEngland,only25% ratedthemselvesasconfidentintreatingpediatricsleepproblems.
Maybesomeotherhelpingprofessionalswilladdresstheproblem?
Stojanovski etal. JSleep&SleepDisRes 200781%ofchildren’svisitstopediatricians,psychiatrists,orfamilyphysiciansforsleepproblemsresultinaprescriptionforamedication
Owensetal. Pediatrics 2013Familiesofchildrenwithautismaretwiceaslikelytoreceiveprescriptiontoaddressinsomniaoftheirchildren
despitenoFDAapproval,nomedicationlabeledforpediatricinsomnia,no(orinconsistent)efficacysignalinliterature
Maybesomeotherhelpingprofessionalswilladdresstheproblem?
From:NationalAcademyofSciences,CommitteeonSleepMedicineandResearch,BoardonHealthSciencesPolicy(2006)
“Therehavebeennolarge‐scaletrialsexaminingthesafetyandefficacyofhypnoticsinchildrenandadolescents.Otherpharmacologicalclassesusedforinsomniaincludesedatinganti‐depressants,antihistamines,andantipsychotics,buttheirefficacyandsafetyfortreatinginsomniahavenotbeenthoroughlystudied.”
TreatmentOptions?
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Part1: PersonalizeSleepSchedule
Part2:RoutinizeNighttimeRoutine
Part3: OptimizeBedroomConditions
Part4: RegularizeSleepDependencies
Part5:MinimizeSleepInterferingBehavior
Freedomfromsleepproblemsispossibleandprobablewith:
Individualizedassessment
Individualizedandcomprehensivetreatment:Tolearnmore,gotowww.practicalfunctionalassessment.comFor:
Video‐tutorialWorkbookDownloadableassessmentHandoutforparentsPowerpointPeer‐reviewedarticle
Howdoweassessandtreatchildren’ssleepproblem?
• Withanopen‐endedinterviewstoidentifythepersonalfactorsinfluencingthesleepproblem– SATT:SleepAssessmentandTreatmentTool
• Throughageneralunderstandingofthecommonfactorsthatinfluencegoodsleepandsleepproblems
• Bydevelopingtreatmentswith parentsbasedonthecontrollingvariables
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Assumptions
• Behavioralquietude/Fallingasleeparethebehaviorsofinterest– Blampied andFrance,1993;Bootzin,1972
• Isinfluencedbypastandpresentexperiencesinone’ssleepingenvironment
– canbemotivated(ordemotivated)– canbecomereliantonenvironmentalcues– canbeaffectedbyotherreinforcersforotherbehaviorsavailableatnight
Lookingthroughthelensofacontingency
Conductacontingencyanalysis:
EO+SD BehavioralQuietude Sr
• Thatwhichisknown:
– Reinforcer (Sr)forbehavioralquietudeissleep
Lookingthroughthelensofacontingency
Conductcontingencyanalyses:
EO +SD BehavioralQuietude Sleep?
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Ingeneral,
childrenneedlesssleepastheygetolder.
Saidanotherway,
Sleepisvaluableforlesstimeaschildrengetolder
Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006
Copied from: National Institute of Health (NIH) Sleep and Sleep Disorder’s Teacher’s Guide
Ingeneral,
Sleepismorevaluableanhourlaterthanthetimeachildfellasleeponthepriornight
Thevalueofsleepmaybeatitslowestatthefamily‐expectedbedtime
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Night NightDay
Alert
Sleepy
Forbidden Zone
Midday Dip in Alertness
Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006
Thevalueofsleepmaybeatitslowestatthefamily‐expectedbedtime
Lookingatbehavioralquietudethroughthelensofacontingency
AbolishingOperations +SD FallingAsleep Sleep
Whatdecreasesthevalueofsleepwhenachildisputtobed?
– Havingsleptwithin6hoursofbeingputtobed(e.g.,catnapsoncouch)– Havingslepttoomanyhoursthepreviousnight– Beingputtobedin“forbiddenzone”(2‐3)hourspriortonaturalsleepphase– Caffeinewithin6hoursofbeingputtobed– Exercise,hotbath,wrestlingwithparentrightbeforebedtime– Availabilityofotherreinforcers afterthebidgoodnight
• socialreinforcers likeparentalattention/interaction/affection• automaticreinforcers viaiPad,televisionormovies,internetbrowsing,etc.• automaticreinforcers viastereotypyorritualisticbehavior
– Overlywarm,bright,ornoisysleepcontext
Lookingatbehavioralquietudethroughthelensofacontingency
EO +SD BQ Sleep
Whatincreasesthevalueofsleepasareinforcer forBQ?
– Sleepingonthepreviousnightfororjustunderthenumberofhoursofsleepneededgivenage
– Beingputtobedatthesametimeorslightlylaterthanwhenonefellasleepthenightbefore(andgraduallyfadingbacktodesiredtime)
– Limitingdaytimehoursofsleep(nappingforlessthan20min)– Extendinghourssincelastslept(notnappingafter3pm)– Dimminglightspriortobedtime/Makingbedroomdarker– SchedulingaccesstoliteraryclassicslikeBeowulf– Gradualtransitionbetweendentobed(minimizerichtoleantransition)
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EO+SD BehavioralQuietude Sleep?
Thingsthatoccasionsleeparenotpresentwhenthechildwakesupduringthenight=NightAwakenings
Thingsthatoccasionsleeparesuddenlyremovedorinconsistentlyavailable=SleepOnsetDelayandpossiblysleepinterferingbehavior
TroublesomeSDsduetotheirinconsistentpresencewhenchildrenwakeupduringthenight:TV,radio,bottles,“fullbelly,”presenceofanotherperson,beingrockedorpatted,lights,fallenstuffedanimals
EO+SD BehavioralQuietude Sleep
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Occasionsleepwiththingsthat:don’trequireparentalpresence,canbetheretheentirenight,andaretransportable
(e.g.,forvacationsornightsatGrandparent’shome)
Suchas:pillow,blanket,stuffedanimal(withbedrails),soundmachineoncontinuous
Forquer &Johnson ChildandFamBeh Ther 2005
Eliminateorfade“bad”onesandreplacewith“good”ones
EO+SD BehavioralQuietude Sleep
Lookingthroughthelensofacontingency
Conductcontingencyanalyses:
EO +SD BehavioralQuietude Sleep? ?
?? ? ?
Conductcontingencyanalyses:
EO +SD Interferingbehaviors Sr‐ &Sr+
EO+SD Interferingbehaviors Sr‐ &Sr+
Behaviorsthatinterferewithbehavioralquietudenecessaryforfallingasleep
Commonforms:
leavingbed(curtaincalls)crying/callingout
playinginbedorinbedroom(thisincludesmotororvocalstereotypy)
talkingtooneself
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Considerpossiblereinforcer(s):
Attention,Interaction
Food,drink
AccesstoTVortoys
Escape/avoidanceofdarkorofbedroom
Automaticreinforcers
(thosedirectlyproducedbythebehavior)
Combinationofoneormore
EO+SD Interferingbehaviors Sr‐ &Sr+
Considerpossiblereinforcer(s):
Attention,Interaction
Food,drink
AccesstoTVortoys
Escape/avoidanceofdarkorofbedroom
Automaticreinforcers
(thosedirectlyproducedbythebehavior)
Combinationofoneormore
EO+ SD Interferingbehaviors Sr‐ &Sr+
1. Providethepresumedreinforcerpriortobiddingthechildgoodnight
2. RemoveSDsforreinforcers forinterferingbehavior
3. Afterbidgoodnight,disruptcontingencybetweeninterferingbehavioranditsreinforcement
e.g.,Time‐BasedVisiting,BedtimePass
EO+ SD Interferingbehaviors Sr‐ &Sr+1 2 3
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Lookingthroughthelensofacontingency
EO +SD BehavioralQuietude Sleep? ?
?? ?
Conductcontingencyanalyses:
EO +SD Interferingbehaviors Sr‐ &Sr+
Lookingthroughthelensofacontingency
Conductcontingencyanalyses:
EO+SD BehavioralQuietude Sleep1
EO+SD Interferingbehaviors Sr‐ &Sr+3 4 5
2
Establishvalueofsleepasreinforcer
Developstimuluscontroloverbehavioralquietudeinbedroom
Weakenvalueofreinforcers forSLIB
WeakenstimuluscontroloverSLIB
DisruptcontingencybetweenSLIBanditsreinforcement
1
2
4
3
5
BehavioralProcessAims
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Part1: PersonalizeSleepSchedule
Part2:RoutinizeNighttimeRoutine
Part3: OptimizeBedroomConditions
Part4: RegularizeSleepDependencies
Part5:MinimizeSleepInterferingBehavior(SLIB)
Establishvalueofsleepasreinforcer
Developstimuluscontroloverbehavioralquietudeinbedroom
WeakenstimuluscontroloverSLIB
Developstimuluscontroloverbehavioralquietudeinbedroom
Weakenvalueofreinforcers forSLIB
DisruptcontingencybetweenSLIBanditsreinforcement
NormalizedAims BehavioralProcessAims
1
2
4
2
3
5
Atypicalcaseexample
Ray
4‐year‐old‐boywithAutismandhyperactivity
Parentstriedmultiplemedicationsforsleepproblemsandphysicallyrestrainedhimtosleepeachnight
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Part1: PersonalizedSleepSchedule
Part2:RoutinizedNighttimeRoutine
Part3: OptimizedBedroomConditions
Part4: RegularizedSleepDependencies
Part5:MinimizedSleepInterferingBehavior
Part1: PersonalizedSleepSchedule
Part2:RoutinizedNighttimeRoutine
Part3: OptimizedBedroomConditions
Part4: RegularizedSleepDependencies
Part5:MinimizedSleepInterferingBehavior
Part1: PersonalizeSleepSchedule
Part2:RoutinizeNighttimeRoutine
Part3: OptimizeBedroomConditions
Part4: RegularizeSleepDependencies
Part5:MinimizeSleepInterferingBehavior
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SocialAcceptabilitySurvey(Parents)
Bedtime pass(DRA)
Extinction
Time‐basedVisiting(NCR)
Reinforcement only if handed a pass
No reinforcement (period)
Reinforcement available according to time
Contingencies
Whichismoreeffectiveandpreferredforaddressingsleepinterferingbehavior?
(Jin &Hanley,inprep.)
Treatments
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Bedtime pass
Blue Card
Green Card
RedCard
Extinction
Time‐basedVisiting
Reinforcement only if handed a pass
No reinforcement (period)
Reinforcement available according to time
Contingencies
Just prior to bed, the children were allowedto choose the treatment for each night
TreatmentsTreatment‐CorrelatedStimuli
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Formoreinformationgoto:www.practicalfunctionalassessment.com
Contactinfo.:GregoryP.Hanley,Ph.D.,BCBA‐D
PsychologyDepartmentWesternNewEnglandUniversity
1215WilbrahamRoadSpringfield,Massachusetts01119