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

Interventions for Interventions for Sleeping Problems in Sleeping Problems in Children with Autism Children with Autism Spectrum DisordersSpectrum Disorders

By Corine van StaalduinenBy Corine van Staalduinen

OverviewOverview About meAbout me GoalsGoals Why is this topic important?Why is this topic important? Common sleeping problems in Common sleeping problems in

children with ASDchildren with ASD Possible causes of sleeping problemsPossible causes of sleeping problems Types of interventionsTypes of interventions Practical applicationPractical application What’s next?What’s next?

About MeAbout Me Early family influences.Early family influences. Undergraduate degree in Psychology Undergraduate degree in Psychology

at Brock University, Ontario.at Brock University, Ontario. Started as a behaviour interventionist Started as a behaviour interventionist

in summer of 2005.in summer of 2005. M. Ed in Special Education with M. Ed in Special Education with

concentration in autism and concentration in autism and developmental disabilities at UBC.developmental disabilities at UBC.

GoalsGoals1.1. To increase knowledge and skills related to To increase knowledge and skills related to

providing interventions to young children providing interventions to young children with autism spectrum disorderswith autism spectrum disorders

2.2. To increase knowledge and skills in the area To increase knowledge and skills in the area of functional behaviour assessment and of functional behaviour assessment and positive behaviour supportpositive behaviour support

3.3. To increase knowledge of the principles of To increase knowledge of the principles of applied behaviour analysisapplied behaviour analysis

Why is this topic important?Why is this topic important?

Prevalence rates of 41-86% for sleeping problems Prevalence rates of 41-86% for sleeping problems in children with ASD have been reported in children with ASD have been reported (Goodlin-Jones, (Goodlin-Jones, Tangs, Liu, & Anders, 2008; Liu, Hubbard, Fabes, & Adam, 2006; Richdale & Prior, 1995; Wiggs & Tangs, Liu, & Anders, 2008; Liu, Hubbard, Fabes, & Adam, 2006; Richdale & Prior, 1995; Wiggs & Stores, 2004).Stores, 2004).

Sleeping problems predicted more intense Sleeping problems predicted more intense symptoms of autismsymptoms of autism (Schreck, Mulick, & Smith 2004).(Schreck, Mulick, & Smith 2004).

Sleep problems in children with ASD are a Sleep problems in children with ASD are a significant predictor of maternal stresssignificant predictor of maternal stress (Hoffman et al., (Hoffman et al., 2008).2008).

Why is this topic important?Why is this topic important? Parents of children with ASD report Parents of children with ASD report

higher rates of sleep problems for higher rates of sleep problems for themselves than parents of typically themselves than parents of typically developing childrendeveloping children (Lopez-Wagner, Hoffman, (Lopez-Wagner, Hoffman, Sweeney, & Hodge, 2008).Sweeney, & Hodge, 2008).

More severe sleeping problems in More severe sleeping problems in children with ASD was related to children with ASD was related to higher rates of sleep problems in their higher rates of sleep problems in their parentsparents (Lopez-Wagner et al., 2008).(Lopez-Wagner et al., 2008).

Parents of children with ASD wake up Parents of children with ASD wake up earlier and sleep fewer hours per night earlier and sleep fewer hours per night than parents of typically developing than parents of typically developing childrenchildren (Meltzer, 2008).(Meltzer, 2008).

Common Sleeping Problems in Children with Common Sleeping Problems in Children with ASDASD

Bedtime resistanceBedtime resistance Insomnia Insomnia Parasomnias (interruption of Parasomnias (interruption of

sleep after falling asleep, e.g. sleep after falling asleep, e.g. nightmares)nightmares)

Sleep breathing disorders (e.g. Sleep breathing disorders (e.g. sleep apnea).sleep apnea).

Morning rise problems Morning rise problems Daytime sleepiness Daytime sleepiness (Liu et al., 2006)(Liu et al., 2006)

Night-waking Night-waking (Hoffman et al., 2005).(Hoffman et al., 2005).

Shorter sleep duration Shorter sleep duration (Giannotti, (Giannotti, Cortesi, Cerquiglini, & Bernabei, 2006).Cortesi, Cerquiglini, & Bernabei, 2006).

Unwillingness to fall asleep in Unwillingness to fall asleep in own bed own bed (Williams, Sears, & Allard, 2004).(Williams, Sears, & Allard, 2004).

Rapid eye movement (REM) Rapid eye movement (REM) dysfunctiondysfunction (Schreck, 2001). (Schreck, 2001).

Possible Causes of Sleeping ProblemsPossible Causes of Sleeping Problems

Sleeping problems in children with ASD are not related to Sleeping problems in children with ASD are not related to intellectual functioningintellectual functioning (Richdale, 1999).(Richdale, 1999).

Poor sleep hygienePoor sleep hygiene (Malow et al., 2009).(Malow et al., 2009).

Daytime, evening, and bedtime habits that influence sleep.Daytime, evening, and bedtime habits that influence sleep. E.g. low level of exercise during the day, consuming foods E.g. low level of exercise during the day, consuming foods

or drinks containing caffeine after dinner, not having a or drinks containing caffeine after dinner, not having a regular bedtime routine, etc.regular bedtime routine, etc.

Medication useMedication use (Liu et al., 2006).(Liu et al., 2006).

HypersensitivityHypersensitivity (Liu et al., 2006).(Liu et al., 2006).

Comorbid epilepsy, ADHD, asthma, allergies, gastrointestinal Comorbid epilepsy, ADHD, asthma, allergies, gastrointestinal problemsproblems (Liu et al., 2006).(Liu et al., 2006).

Melatonin regulation may be abnormalMelatonin regulation may be abnormal (Richdale, 1999).(Richdale, 1999).

Anxiety/FearAnxiety/Fear (Richdale, 1999).(Richdale, 1999).

Types of Sleep InterventionsTypes of Sleep Interventions

MelatoninMelatonin Light therapyLight therapy ChronotherapyChronotherapy Behavioural interventionsBehavioural interventions

MelatoninMelatonin

Melatonin is a hormone produced by the pineal gland that causes Melatonin is a hormone produced by the pineal gland that causes drowsiness.drowsiness.

Melatonin levels rapidly increase in the evening, peak in the middle Melatonin levels rapidly increase in the evening, peak in the middle of the night and decreases during the second half of the night.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 Melatonin is not considered a drug, so it is not regulated by the FDA.FDA.

No side effects have been reported in children with ASD.No side effects have been reported in children with ASD.

In a randomized, double-blind, placebo-controlled crossover trial of In a randomized, double-blind, placebo-controlled crossover trial of melatonin with 7 children with ASD and sleep problems, melatonin melatonin with 7 children with ASD and sleep problems, melatonin significantly reduced sleep latency, number of night wakings and significantly reduced sleep latency, number of night wakings and increased total sleep time increased total sleep time (Garstang & Wallis, 2006).(Garstang & Wallis, 2006).

Two other studies obtained similar resultsTwo other studies obtained similar results (Giannotti et al., 2006; Wasdell et al., (Giannotti et al., 2006; Wasdell et al., 2008)2008)

Light TherapyLight Therapy

Bright light suppresses the secretion of Bright light suppresses the secretion of melatonin, thereby decreasing drowsiness melatonin, thereby decreasing drowsiness (individuals should be exposed to bright light in (individuals should be exposed to bright light in the morning and afternoon, not in the evening) the morning and afternoon, not in the evening) (Richdale, 1999).(Richdale, 1999).

No studies have been conducted to assess the No studies have been conducted to assess the effectiveness of light therapy in reducing sleep effectiveness of light therapy in reducing sleep problems in children with ASD.problems in children with ASD.

ChronotherapyChronotherapy Chronotherapy involves systematically delaying bedtime Chronotherapy involves systematically delaying bedtime

on successive nights until the individual is falling asleep on successive nights until the individual is falling asleep at an appropriate time.at an appropriate time.

Capitalizes on circadian drift (human circadian cycles Capitalizes on circadian drift (human circadian cycles last 25 hours; when time cues are absent we tend to fall last 25 hours; when time cues are absent we tend to fall asleep an hour later every day).asleep an hour later every day).

It is actually easier to change sleep onset from 2 a.m. to It is actually easier to change sleep onset from 2 a.m. to 10 p.m. by gradually increasing bedtime than by making 10 p.m. by gradually increasing bedtime than by making bedtime earlier. bedtime earlier.

Irregular sleep onset times, night and early wakings and Irregular sleep onset times, night and early wakings and short sleep times were successfully treated with short sleep times were successfully treated with chronotherapy in an 8-year old girl with autism and chronotherapy in an 8-year old girl with autism and mental retardation mental retardation (Piazza, Hagopian, Hughes, & Fisher, 1998).(Piazza, Hagopian, Hughes, & Fisher, 1998).

Behavioural InterventionsBehavioural Interventions

Almost all of the studies using behavioural Almost all of the studies using behavioural interventions include establishing a bedtime interventions include establishing a bedtime routine.routine.

A bedtime routine should consist of specific A bedtime routine should consist of specific activities conducive to sleep.activities conducive to sleep.

For example, taking a bath, brushing teeth, For example, taking a bath, brushing teeth, changing into pajamas, read bedtime story, turn off changing into pajamas, read bedtime story, turn off the light and go to sleep.the light and go to sleep.

There are no studies examining the effectiveness of There are no studies examining the effectiveness of this component by itself this component by itself (Schreck, 2001).(Schreck, 2001).


Non-graduated extinctionNon-graduated extinction (Schreck, 2001).(Schreck, 2001).

Parents ignore all crying and screaming at bedtime Parents ignore all crying and screaming at bedtime and during the night. They keep the bedroom door and during the night. They keep the bedroom door closed and do not respond.closed and do not respond.

Behavioural InterventionsBehavioural Interventions Graduated extinction Graduated extinction (Schreck, 2001).(Schreck, 2001).

If the child engages in problem behaviour at bedtime, the If the child engages in problem behaviour at bedtime, the parents ignore it for a pre-set time period (e.g. 5 minutes). 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 If the child continues to cry, the parents re-settle the child with as little attention as possible and leaves the room again.with as little attention as possible and leaves the room again.

Continue this procedure until the child falls asleep.Continue this procedure until the child falls asleep. Used because parents feel uncomfortable letting their child Used because parents feel uncomfortable letting their child

tantrum for long periods of time.tantrum for long periods of time.

Based on specific criteria for different classifications of Based on specific criteria for different classifications of evidence-based treatment effectiveness, extinction evidence-based treatment effectiveness, extinction (graduated and non-graduated) was deemed a (graduated and non-graduated) was deemed a possibly efficacious ABA intervention for sleep possibly efficacious ABA intervention for sleep problems by Schreck in 2001. problems by Schreck in 2001.


Stimulus fadingStimulus fading (Schreck, 2001).(Schreck, 2001).

Used to eliminate co-sleeping.Used to eliminate co-sleeping. Involves gradually and systematically moving a co-Involves gradually and systematically moving a co-

sleeper (usually a parent) farther away from the child’s sleeper (usually a parent) farther away from the child’s bed.bed.

On the first night, the parent sleeps on a bed or On the first night, the parent sleeps on a bed or mattress beside the child’s bed.mattress beside the child’s bed.

On subsequent nights, the parent is moved farther from On subsequent nights, the parent is moved farther from the child’s bed until he or she is out of the child’s room.the child’s bed until he or she is out of the child’s room.

One study showed effectiveness of stimulus One study showed effectiveness of stimulus fading in eliminating co-sleeping and reducing fading in eliminating co-sleeping and reducing night wakings in a 5 year old boy with autism night wakings in a 5 year old boy with autism (Howlin, 1984, as cited in Schreck, 2001).(Howlin, 1984, as cited in Schreck, 2001).

Behavioural InterventionsBehavioural Interventions Faded bedtime with and without response cost Faded bedtime with and without response cost

(Piazza, Hagopian, Hughes, & Fisher, 1998).(Piazza, Hagopian, Hughes, & Fisher, 1998).

1)1) Take baseline data to calculate average sleep onset Take baseline data to calculate average sleep onset timetime

2)2) Set initial treatment bedtime a half hour laterSet initial treatment bedtime a half hour later

3)3) If child falls asleep within 15 minutes, set bedtime for If child falls asleep within 15 minutes, set bedtime for next night a half hour earliernext night a half hour earlier

4)4) If child does not fall asleep within 15 minutes, remove If child does not fall asleep within 15 minutes, remove from for 1 hour (response cost) and set bedtime for from for 1 hour (response cost) and set bedtime for next night a half hour later OR do not remove child next night a half hour later OR do not remove child from bed (no response cost) but move bedtime half an from bed (no response cost) but move bedtime half an hour later the subsequent night hour later the subsequent night (Schreck, 2001).(Schreck, 2001).

5)5) Gradually adjust bedtime until child is falling asleep at Gradually adjust bedtime until child is falling asleep at appropriate bedtimeappropriate bedtime


Faded bedtime with and without response costFaded bedtime with and without response cost At least 3 studies have shown the effectiveness of At least 3 studies have shown the effectiveness of

faded bedtime without response cost in reducing faded bedtime without response cost in reducing

sleeping problems in children with ASDsleeping problems in children with ASD (Christodulu & (Christodulu & Durand, 2004; Durand & Christodulu, 2004; Piazza & Fisher, 1991, as cited in Durand, 2004; Durand & Christodulu, 2004; Piazza & Fisher, 1991, as cited in Schreck, 2001)Schreck, 2001)

One study demonstrated that faded bedtime with One study demonstrated that faded bedtime with response cost was more effective than without response cost was more effective than without response costresponse cost (Piazza, Fisher, & Sherer, 1997, as cited in Schreck, 2001). (Piazza, Fisher, & Sherer, 1997, as cited in Schreck, 2001).


Social Stories Social Stories (Gray, 1995, as cited in Moore, 2004).(Gray, 1995, as cited in Moore, 2004).

Carol Gray developed social stories to help children with Carol Gray developed social stories to help children with ASD understand social behaviours and teach them how to ASD understand social behaviours and teach them how to behave in specific situations.behave in specific situations.

Social stories should be short (20-150 words)Social stories should be short (20-150 words) Explain subtle social cues and socially acceptable behaviourExplain subtle social cues and socially acceptable behaviour Emphasis on perspective of child and perspective of othersEmphasis on perspective of child and perspective of others Includes descriptive sentences, directive sentences, Includes descriptive sentences, directive sentences,

perspective sentences and control sentences.perspective sentences and control sentences. For every directive or control sentences there should be 2-5 For every directive or control sentences there should be 2-5

descriptive or perspective sentences.descriptive or perspective sentences. Children’s language comprehension should be taken into Children’s language comprehension should be taken into

account.account.


Social Stories Social Stories Co-sleeping and night-wakings were successfully Co-sleeping and night-wakings were successfully

eliminated with a social story, graduated extinction and eliminated with a social story, graduated extinction and reinforcement in a 4-year old boy with ASD. Delayed reinforcement in a 4-year old boy with ASD. Delayed sleep latency was reduced from 1-2 hours to 30 minutes. sleep latency was reduced from 1-2 hours to 30 minutes.

Graduated extinction was only loosely followed by his Graduated extinction was only loosely followed by his mother so it is likely that the social story had some mother so it is likely that the social story had some positive effects on the child’s sleeping behaviour positive effects on the child’s sleeping behaviour (Moore, (Moore, 2004).2004).

Practical Application of Behavioural Practical Application of Behavioural InterventionIntervention

George (pseudonym) is a 5 year old boy with George (pseudonym) is a 5 year old boy with autismautism

Mother is Japanese, father is CanadianMother is Japanese, father is Canadian

Mother is a flight attendant – frequently away at Mother is a flight attendant – frequently away at nightnight

Has a younger brother (2 years old)Has a younger brother (2 years old)

Live in one bedroom apartmentLive in one bedroom apartment

Practical Application continuedPractical Application continued

Has a different bedtime routine and sleeping arrangements Has a different bedtime routine and sleeping arrangements when mom is home compared to when she is awaywhen mom is home compared to when she is away

When mom is not home there is a strict bedtime routine: When mom is not home there is a strict bedtime routine: Both kids in bath at 6 PM (6:30 on weekends)Both kids in bath at 6 PM (6:30 on weekends) Teeth brushed in tub and G. is given melatonin dropsTeeth brushed in tub and G. is given melatonin drops G. gets out first, is dressed in pajamas and helps get his G. gets out first, is dressed in pajamas and helps get his

younger brother dressed. younger brother dressed. Younger brother sleeps on a mattress on the floor and G. lies 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.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 Dad cannot leave the room all night or G. will wake up. There

are no problem behaviours during bedtime routine, but he are no problem behaviours during bedtime routine, but he wakes up frequently at night and needs to be rocked back to wakes up frequently at night and needs to be rocked back to sleep. Wakes up very early (between 3:30 and 5:30) and sleep. Wakes up very early (between 3:30 and 5:30) and doesn’t go back to sleep.doesn’t go back to sleep.

Practical Application continuedPractical Application continued

When mom is homeWhen mom is home Both kids in bath between 6:30-7 PM on weekdays and 7-8 PM Both kids in bath between 6:30-7 PM on weekdays and 7-8 PM

on weekends.on weekends. Brush teeth in bath OR afterBrush teeth in bath OR after Melatonin drops after bathMelatonin drops after bath Kids get out at the same timeKids get out at the same time Dressed in pajamasDressed in pajamas G. engages in frequent crying and screaming after bath timeG. engages in frequent crying and screaming after bath time Mom, G. and younger brother sleep on mattress in living room Mom, G. and younger brother sleep on mattress in living room

while dad sleeps in bedroom.while dad sleeps in bedroom. G. is rocked to sleep across mom’s waist.G. is rocked to sleep across mom’s waist. Wakes up when younger brother cries or when mom gets up to Wakes up when younger brother cries or when mom gets up to

go to bathroom. However, goes back to sleep quickly (doesn’t 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.need to be rocked back to sleep). Wakes up around 6:30-7 AM.

Practical Application ContinuedPractical Application Continued

Ideal sleeping arrangements are defined Ideal sleeping arrangements are defined differently by mom and daddifferently by mom and dad

Dad would like to sleep in the bedroom with mom Dad would like to sleep in the bedroom with mom and have kids sleep in bunk bed in a room that is and have kids sleep in bunk bed in a room that is currently a very small office. He’d like to be able currently a very small office. He’d like to be able to read a bedtime story to G.to read a bedtime story to G.

Mom would like everybody to sleep in the Mom would like everybody to sleep in the bedroom, with mom and dad on the bed and the bedroom, with mom and dad on the bed and the kids on a mattress on the floor.kids on a mattress on the floor.

Functional Assessment InterviewFunctional Assessment Interview

G. only slept by himself for a few weeks when he G. only slept by himself for a few weeks when he was approximately 2 years old. At the time they was approximately 2 years old. At the time they used non-graduated extinction (ignoring crying, used non-graduated extinction (ignoring crying, but checking on him every 10 minutes).but checking on him every 10 minutes).

After a trip to Japan, where he was allowed to After a trip to Japan, where he was allowed to sleep with his parents, he again started crying sleep with his parents, he again started crying when put to bed by himself at home.when put to bed by himself at home.

Mom was too traumatized from previous Mom was too traumatized from previous experience to want to try again.experience to want to try again.

Functional Assessment InterviewFunctional Assessment Interview

Problem behaviours that parents expect to see if Problem behaviours that parents expect to see if they leave the bedroom are:they leave the bedroom are:

Leaving bedroomLeaving bedroom WhiningWhining CryingCrying ScreamingScreaming Self-injury (hitting head with open hand or fist)Self-injury (hitting head with open hand or fist) VomitingVomiting They expect behaviour to escalate the longer They expect behaviour to escalate the longer

they refuse to rock him to sleepthey refuse to rock him to sleep

Functional Assessment ObservationFunctional Assessment Observation

I wanted to observe bedtime routine both when mom I wanted to observe bedtime routine both when mom was home and when she was not home to see if there was home and when she was not home to see if there were any differences in behaviours.were any differences in behaviours.

We planned to videotape each scenario so that my We planned to videotape each scenario so that my presence would not change George’s behaviour.presence would not change George’s behaviour.

I instructed the parents to put George to bed and to I instructed the parents to put George to bed and to leave the bedroom a few times to see if George would leave the bedroom a few times to see if George would actually engage in problem behaviour when they left.actually engage in problem behaviour when they left.

If problem behaviour was mild they would leave 3 If problem behaviour was mild they would leave 3 times, then rock him to sleep as they normally would.times, then rock him to sleep as they normally would.

If problem behaviour was severe, they could If problem behaviour was severe, they could immediately rock him to sleep as they normally would.immediately rock him to sleep as they normally would.

Functional Assessment ObservationFunctional Assessment Observation

First videotaping was scheduled on a night when both First videotaping was scheduled on a night when both mom and George’s younger brother would be away.mom and George’s younger brother would be away.

Dad put G. to bed and left the room. G. screamed and Dad put G. to bed and left the room. G. screamed and cried for a few seconds, got out of bed (occasionally cried for a few seconds, got out of bed (occasionally whimpering) and went to the living room after a few whimpering) and went to the living room after a few minutes. Dad put him back in bed and G. stayed in minutes. Dad put him back in bed and G. stayed in bed and fell asleep within 10 minutes.bed and fell asleep within 10 minutes.

G. continued to fall asleep independently over the G. continued to fall asleep independently over the next few nights when mom was away.next few nights when mom was away.

No intervention needed for falling asleep. However, he No intervention needed for falling asleep. However, he still wakes up easily (dad eventually does need to go still wakes up easily (dad eventually does need to go to sleep in same bed) and wakes up early.to sleep in same bed) and wakes up early.

Temporary Behavioural Intervention Temporary Behavioural Intervention PlanPlan

Dad wanted this behaviour to continue when mom came Dad wanted this behaviour to continue when mom came home.home.

We hypothesized George’s behaviour would be more We hypothesized George’s behaviour would be more challenging when mom was home, because his daytime challenging when mom was home, because his daytime behaviour is more challenging when mom is home (her behaviour is more challenging when mom is home (her attention is very reinforcing to him).attention is very reinforcing to him).

We also expected that mom might not be able to handle his We also expected that mom might not be able to handle his challenging behaviour and would quickly give in.challenging behaviour and would quickly give in.

We decided to ask mom to take George’s younger brother We decided to ask mom to take George’s younger brother down to the apartment building lobby for about 15 minutes in down to the apartment building lobby for about 15 minutes in the evening until G. fell asleep.the evening until G. fell asleep.

Once falling asleep independently was more firmly Once falling asleep independently was more firmly established they would start putting G. to bed together.established they would start putting G. to bed together.

Temporary InterventionTemporary Intervention

When mom came home she had a jetlag and When mom came home she had a jetlag and wanted to go to sleep early so she decided not to wanted to go to sleep early so she decided not to leave the apartment. leave the apartment.

They put George to bed and he immediately came They put George to bed and he immediately came out. out.

Dad immediately decided that this was not the Dad immediately decided that this was not the time to use extinction, because mom was too tired time to use extinction, because mom was too tired to deal with problem behaviour.to deal with problem behaviour.

If they had used extinction for half an hour and If they had used extinction for half an hour and given up after that, it would only teach him that he given up after that, it would only teach him that he needs to engage in problem behaviour for half an needs to engage in problem behaviour for half an hour and then he would get what he wants.hour and then he would get what he wants.

Summary StatementSummary Statement From the functional assessment interview From the functional assessment interview

and functional assessment observation, I and functional assessment observation, I developed the following hypothesis:developed the following hypothesis:

Setting Setting EventEvent

AntecedentAntecedent Problem Problem BehaviourBehaviour

Maintaining Maintaining ConsequencConsequencee

Mom leaving Mom leaving frequentlyfrequently

Not feeling Not feeling tiredtired

Mom leaving Mom leaving bedroombedroom

Leaving bed/ Leaving bed/ roomroom

WhiningWhining

CryingCrying

ScreamingScreaming

(Self-injury, (Self-injury, vomiting?)vomiting?)

Attention – Attention – Mom rocks Mom rocks him to sleep him to sleep and stays in and stays in bed with himbed with him

Positive Behaviour Support PlanPositive Behaviour Support Plan

PBS plan is a long-term plan with two phasesPBS plan is a long-term plan with two phases During phase 1, George will continue to fall asleep independently During phase 1, George will continue to fall asleep independently

when his mom is not home. Dad values this behaviour.when his mom is not home. Dad values this behaviour. Dad will start to gradually delay bedtime by 10 minutes each Dad will start to gradually delay bedtime by 10 minutes each

day, until he is going to sleep at a more age-appropriate time day, until he is going to sleep at a more age-appropriate time (approximately 8 PM). (approximately 8 PM).

When George wakes up at night, dad will no longer rock him 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 back to sleep. He will ignore G until he goes back to sleep by himself.himself.

However, George will continue to sleep with his mom and However, George will continue to sleep with his mom and younger brother when his mom is home. Mom values sleeping in younger brother when his mom is home. Mom values sleeping in the same room with her kids.the same room with her kids.

Mom will structure bedtime routine (bath, brush teeth, pajamas, Mom will structure bedtime routine (bath, brush teeth, pajamas, etc.) the same way as dad to eliminate crying/screaming during etc.) the same way as dad to eliminate crying/screaming during bedtime routine.bedtime routine.

Positive Behaviour Support Plan Positive Behaviour Support Plan ContinuedContinued

During phase 2, sleeping arrangements will During phase 2, sleeping arrangements will change. Dad will clean out the small office space change. Dad will clean out the small office space and purchase a bed for George.and purchase a bed for George.

George will sleep in this new small bedroom. George will sleep in this new small bedroom. Mom and dad will sleep in the big bedroom and Mom and dad will sleep in the big bedroom and the younger brother will sleep on a mattress on the younger brother will sleep on a mattress on the floor in the big bedroom.the floor in the big bedroom.

Both mom and dad made compromises on Both mom and dad made compromises on sleeping arrangements.sleeping arrangements.


Setting event strategiesSetting event strategies Set bedtime at 8 PMSet bedtime at 8 PM No nappingNo napping Cannot change the fact that mom leaves frequentlyCannot change the fact that mom leaves frequently

Antecedent strategiesAntecedent strategies Structured bedtime routineStructured bedtime routine Will start including bedtime story in routineWill start including bedtime story in routine Read social story about how big boys sleep by themselvesRead social story about how big boys sleep by themselves

Teaching StrategiesTeaching Strategies Teach appropriate behaviour through “Sleeping by myself” Teach appropriate behaviour through “Sleeping by myself”

social storysocial story Teach calming strategies during behaviour intervention Teach calming strategies during behaviour intervention

sessions (taking deep breath, squeezing hands, closing eyes).sessions (taking deep breath, squeezing hands, closing eyes).


Consequence Strategies (graduated extinction)Consequence Strategies (graduated extinction) If G. does not engage in problem behaviour, his parents will If G. does not engage in problem behaviour, his parents will

check on him every 10 minutes until he falls asleep and check on him every 10 minutes until he falls asleep and provide whispered praise for staying in bed. If he does not provide whispered praise for staying in bed. If he does not disturb them at night, they will praise him in the morning disturb them at night, they will praise him in the morning and provide his favourite breakfast.and provide his favourite breakfast.

If G. whines, cries, or screams, they will ignore the behaviour If G. whines, cries, or screams, they will ignore the behaviour and keep bedroom door closed. They will check on him every and keep bedroom door closed. They will check on him every 10 minutes, providing as little attention as possible.10 minutes, providing as little attention as possible.

If G. leaves bedroom, they will tell him “it’s bedtime” and put If G. leaves bedroom, they will tell him “it’s bedtime” and put him back to bed without additional comments or eye contact him back to bed without additional comments or eye contact and repeat this procedure as many times as necessary.and repeat this procedure as many times as necessary.

If G. vomits or engages in destructive or other dangerous If G. vomits or engages in destructive or other dangerous behaviour, they will stop the procedure.behaviour, they will stop the procedure.

What’s next?What’s next?

I will take EPSE 593 (Design and Analysis of I will take EPSE 593 (Design and Analysis of Research with Small Samples and Single Research with Small Samples and Single Subjects) in September.Subjects) in September.

I plan on taking the BCBA exam in March 2010.I plan on taking the BCBA exam in March 2010. Start my own behaviour consulting company.Start my own behaviour consulting company.

ReferencesReferences

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Christodulu, K. V. & Durand, V. M. (2004). Reducing bedtime disturbance and night waking using Christodulu, K. V. & Durand, V. M. (2004). Reducing bedtime disturbance and night waking using positive bedtime routines and sleep restriction. positive bedtime routines and sleep restriction. Focus on Autism and Other Developmental Focus on Autism and Other Developmental Disabilities, 19Disabilities, 19, 130-139., 130-139.

Durand, V. M., & Christodulu, K. V. (2004). Description of a sleep-restriction program to reduce Durand, V. M., & Christodulu, K. V. (2004). Description of a sleep-restriction program to reduce bedtime disturbances and night waking. bedtime disturbances and night waking. Journal of Positive Behavior Interventions, 6Journal of Positive Behavior Interventions, 6, 83-91., 83-91.

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