Sleep Issues and Children with Autism

1. LEADERS Lake Erie Autism Diagnostic Educational & Research Services Sleep Issues and Children with Autism Robert F. Gulick, MFA BCBA Linda Hartken, MS BCBA April 17, 2012

2. 25% of adults have sleeping problems25% of kids have severe sleeping problems80% of kids with Autism have difficulty sleeping

3. “When children don’t sleep well, the parents end up having 2 full-time jobs in a 24 hour day.” V. Mark Durand, Sleep Better

4. Honesty and Helping the Child • All of us have issues • Add Autism to the mix=very difficult • You should receive compassion, honesty about what is best for your child, and patience from your BSC • Try to be honest about attachment issues with your child so the therapist knows where you are coming from emotionally • Slow and steady always wins • Sleep is a crucial contributor to a good day • It can wreak havoc on a home if all are not getting enough sleep

5. Effects of Sleep Deprivation • Decreased motivation to learn or participate in daily tasks • Decreased ability to concentrate • Boring and repetitive tasks increase agitation • Decreased ability to tolerate change • Decreased overall mood

6. Sleep Issues in Children with ASD • Getting to sleep • Alone • In own bed • Sleeping through the night • Refusal to nap

7. The Function of Sleep Non-Compliance • Attention • missing Mommy and/or Daddy • Tangible • missing out on toys, food, or other activities that cannot come to bed with you • Escape • fears • the dark • being alone • perceives being in bed as an aversive

8. What do Typical Kids Do? • Bedtime routine • warm bath • story time • cuddle time • lighting • clothing

9. What do Typical Kids Do? • Verbal rules • able to understand deferred contingencies • “If you go to sleep, then tomorrow we can…” • Learn to settle themselves down so that sleep can occur

10. What do ASD Kids Do? • Bedtime routine • can be effective • compliance problems can interfere • consistency!! • Verbal rules • generally do not have language to support the understanding of these deferred rewards

11. What do ASD Kids Do? • Often never learn to self-calm so that sleep can occur • Drop over in midst of toys or drift off while watching movie • Require someone to lie down with them and hold them • Medication • Need for sleep? • anecdotal evidence suggests that some ASD kids can get by on very little sleep

12. Parent Contingencies • Sleep Deprivation can be Debilitating • Affects work, relationships, parenting, mental health, and physical well being • Tried and failed traditional approaches • Desperation - “Whatever works” • Play til collapse • Sneak into bed • Car seat

13. Sleeping Through the Night • Most people awaken during the night • If you have not learned how to self-calm and get to sleep, you’re likely not going to be able to get “back to sleep” once awakened.

14. Sleeping Through the Night • If you have been “tricked” into your own bed, then awakening in the middle of the night can be: • frightening (“Where’s my Mommy?”) • angering (“Where’s my movie?”) • Requires most parents to repeat the bedtime ritual again • lie back down with them • give them access to movie, toys, food until they fall back asleep • or….back in the car we go!

15. This can create an unending cycle of fatigue and frustration for both parties.

16. Nap Refusal • Related directly to self-calming deficits seen in the ASD population • Also related to the possibility that ASD kids might not need as much sleep as neurotypical kids.

17. Nap Refusal • Napping at Preschool • Takes it to yet another level • the child’s existing self-calming deficits and reduced need for sleep are brought into a new environment • Novel distractions • Mom and Dad not present • Bedtime rituals missing

18. Nap Refusal • Result • Resistance, Tantrum or Aggression • Disruption of other students’ attempts at sleep • Inadvertent reinforcement of problem behaviors • opportunity for attention following misbehavior • opportunity for escape from the demand of napping following misbehavior • opportunity for “redirection” to preferred tangibles following misbehavior • All in the name of “QUIET”

19. What to do??? • Medications • Antihistamines (e.g., Benadryl) • Short-term improvements (quicker sleep onset) • Improvements are temporary (few sleep thru night) • Side effects (paradoxical arousal, hang-over) • Antihypertensives (Tenex, Clonidine) • Short-term improvements • 4-hour duration (re-dose) • Side effects (blood pressure)

20. What to do??? • Medications • Melatonin • Hormone produced naturally in body • Production is stimulated by onset of darkness • Appears to have dual effect • Sedating agent • Regulating sleep-wake cycle • Now synthesized for oral use • Over the counter availability

21. What to do??? • Medications • Melatonin • Limited research • Some have shown it to be effective • Anecdotal reports from parents • Long term effects? • Currently classified as a “supplement” • Not regulated by FDA • Not tested for composition or impurities • Need more efficacy studies before it will be routinely prescribed by physicians

22. Behavioral Interventions • Unmodified Extinction • Graduated Extinction • Extinction with Parent Presence • Positive Bedtime Routines

23. Unmodified Extinction • “Let her cry..” • Establish regular bedtime and bedtime routine • Place child in bed • Do not attend to the child until morning • Illness or danger are only exceptions • Produces rapid results • Worse of crying usually fades within 3 nights • Side effects and difficulties • Extinction burst and spontaneous recovery • Socially unacceptable and difficult to do

24. Graduated Extinction • Gradually reducing parental attention • Two versions • Parents wait for progressively longer periods of time before responding to their child • Parents respond immediately, but gradually decrease the amount of time they spend attending to the child

25. Graduated Extinction • Advantages • Positive results within first week • Easier for parents to tolerate • Disadvantages • Can shape up longer periods of crying

26. Extinction with Parent Presence • Parent sleeps in same room with child for 1 week while using unmodified extinction • Parental presence expected to reassure the child • Advantages • Rapid results and reduced parent anxiety • Disadvantages • Requires parents to change sleeping arrangements • Does not teach the child to fall asleep independent of parental presence

27. Positive Bedtime Routines • Teaching procedure • Teach appropriate pre-bedtime behaviors and sleep onset skills • Temporarily move bedtime later in the evening to more closely coincide with the child’s natural sleep onset time (increases probability of rapid sleep onset) • Institute a positive and enjoyable pre-bedtime routine that teaches the child to engage in relaxing activities (bath, story, cuddle time)

28. Positive Bedtime Routines • Each activity is followed by praise and encouragement signaling the transition to the next activity (building a chain) • Once the chain is established and the child is falling asleep quickly, the child’s bedtime is systematically moved earlier in the evening until reaching the pre-established bedtime goal

29. Positive Bedtime Routines • Advantages • Prevents long bouts of crying • Fewer bedtime struggles • Reduced parental anxiety • “Errorless “ procedure • Disadvantages • Time commitment • Parent resistance to changing bedtime to a later time

30. Sleep Better by V. Mark Durand (1998)

31. Take Away Points • Sleep is similar to dieting, in that medications may help, but the most effective results come from hard work. • There are several research-backed methods for addressing sleep issues with our kids. Contact a qualified behavior analyst to serve as your guide. • Need to address it now because you want to definitely avoid…

32. “H” is for Hell

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