Behavioral Interventions for Sleep Disturbances. By Matthew Osborne, M.S., BCBA

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1 Behavioral Interventions for Sleep Disturbances By Matthew Osborne, M.S., BCBA

2 Kahoot! Access conference Wi-Fi Direct your phone s internet browser to: kahoot.it Enter game PIN

3 Disclosure I am NOT a sleep expert. This presentation is meant to summarize current behavioral interventions for sleep disturbances. This presentation is NOT meant to replace individualized consultation with a sleep expert.

4 Objectives 1. Describe some of the causes for sleep disturbances, 2. Described how to monitor sleep with a sleep log, and 3. Describe and provide examples of behavioral treatments for sleep disturbances. 4. Finally, a list of resources and references for the treatment of sleep disturbances will be provided at the end of the presentation.

5 Definition & Scope Applied Behavior Analysis Behavioral Interventions (Integrative) If you re not sleeping in bed, you re behaving (sleep interfering behavior) Pillow, bed, and night time routine control behavior

6 Definition & Scope First, rule out and treat medical/psychological diagnoses Sleep is behavior that can be learned and improved Insomnia (persistent): Difficulty initiating sleep Difficulty maintaining sleep (night and morning awakenings) Non-restorative sleep

7 Definition & Scope Medical or Psychological diagnoses: Epilepsy Sleep apnea / breathing disorders Restless leg syndrome (RLS) Hypersomnia / narcolepsy Night terrors Urinary or bowl incontinence Discomfort or pain (e.g., constipation, tooth ache, eczema, etc.) Gastrointestinal / acid reflux Upper-respiratory (e.g., cough, sore throat, runny nose, etc.) Psychiatric (e.g., anxiety, depression, ADHD) Medications

8 Understanding Sleep Age

9 Understanding Sleep Age Circadian rhythm (~24.2-hour clock)* Stages of sleep: good sleepers fall asleep within 3-5 min Non-REM 1. Light Sleep: drifting in and out and can be awakened easily 2. Stage 2 Sleep: eye movements stop; brain waves become slower 3. & 4. Deep Sleep: Slow wave sleep 5. REM Sleep: brain is active; muscles are atonic

10 Insomnia Prevalence Normal Population 9 50% ASD 50 80%! Sleep does NOT improve with age in majority of ASD population. Wait and see approach doesn t work with those diagnosed with ASD

Consequences of Disturbed Sleep Irritability and difficult temperament Daytime sleepiness Unintentional injuries Poor performance on IQ

11 Consequences of Disturbed Sleep Irritability and difficult temperament Daytime sleepiness Unintentional injuries Poor performance on IQ measures Increased risk of obesity Anxiety in adulthood Increased rates of: self-injury, aggression, non-compliance, tantrums and impulsivity

12 Secondary Effects of Disturbed Sleep Poor parental sleep quality and daytime functioning Family stress and tension Maternal malaise Marital discord

13 Co-morbid Diagnoses & Medications Diagnoses: ADHD, anxiety, depression, severe behavior (aggression, SIB, stereotypy) Treatment: Medication (e.g., Adderall, Ritalin, Vyvanse, Tenex, Abilify, Risperidone, Risperdal) Side effects: sleepiness, fatigue, GI issues, RLS, dry mouth Secondary effects: disturbed sleep, low quality sleep, daytime napping

14 Standard Treatments for Sleep Disturbances Pediatrician is usually first contact; yet survey of med schools reveal ~5-hours of training in sleep disturbances (~25% somewhat confident ) Wait and see. ; They ll grow out of it. Prescription sleep aids (e.g., Clonidine, Ambien, Lunesta, Sonata, Xanax, Trazadone); as many as 81% of children s visits to medical professionals. No FDA med to treat pediatric sleep disturbances Non-prescription sleep aids (melatonin, Benadryl)

15 Behavioral Interventions Data Collection Sleep Diaries (unstructured vs. structured) Sleep Behavior Log ( Interfering Behaviors ) Purpose: Baseline: How are they currently sleeping (before changing anything) Find patterns or relationships (Assessment and Function*) Monitoring effectiveness of interventions

16 Behavioral Interventions Data Collection

17 Behavioral Interventions Data Collection

18 Behavioral Interventions - Goals Reduce Interfering Behavior(s): If they re awake in bed, they re behaving Crying / calling out Playing with toys/electronics Curtain calls Stereotypy (with items, rocking, hand flapping, vocal, rumination, oral stim) Other Goal(s): behavioral quietude ; reduce sleep onset delay; reduce night awakenings

19 Behavioral Interventions Phenomena: Forbidden Zone (3-hrs before they went to bed the previous night) Bedtime schedule Reduce naps No caffeine (chocolate) within 4 hours of bedtime

20 Behavioral Interventions (cont.) No vigorous activity (e.g., wrestling, exercise, etc.) Eliminate screen time within min of bedtime Avoid excess liquids No warm showers or baths right before bed Cool room environment stimulates sleep (body temp is lowest right before bed)

21 Behavioral Interventions (cont.) Bedroom Environment: Cool temp. Reduce lighting Own bed (bunk beds) Reduce dependencies (e.g., music; parent sleeping on floor or in same bed) No electronics No toys No stim objects

22 Behavioral Interventions (cont.) Bedtime Routine (about 30-min to bedtime) Parent: Reduce / remove other responsibilities Consistent bedtime and order of events Putting on pajamas, brushing teeth, story-time, etc. Reduce activities/demands that might cause conflict No bargaining or negotiating Love and compassion (never yell) Exit room when sleepy, but not asleep (practice falling asleep alone)

23 Behavioral Interventions (cont.) Cry it out method Caution: Increase in severity and other types of problem behavior Random checks (Zero attention, just checking to make sure they re ok) Ferber method (fading time to respond to crying) Faded bedtime (problem with delayed sleep onset) Moving bedtime forward by ~ 1-hour Fading time back by 30-min if fell asleep w/in min

24 Behavioral Interventions (cont.) Chronotherapy (disrupted sleep cycle) Bedtime Pass Set number of passes per night Gives up pass when calling out or curtain calls Fade to one pass per night Time-based visiting (do not go in when crying, but during quietude) Morning Reinforcement (Sleep Fairy)

25 Behavioral Interventions (cont.) Leaving Room & Curtain Calls Negative attention is better than no attention Robotic (minimize language; use gestures) Statements; No questions ( Are you tired?, Are you ready for bed? ) Firm, but don t raise voice

26 General Strategies Start on a Friday Exercise 4-6 hours before bed Avoid sleep meds and caffeine Put your thoughts to bed Reduce liquids Void bowel / bladder before bed Get out of bed if not asleep w/in min (do something boring)

27 Resources BOOKS Sleep Better! by V. Mark Durand VIDEO Greg Hanley (

28 Resources (cont.) WEBSITES Phantom Sleep Resources ( Sleep Medicine ( The Sleep Well ( ASAT s Regulating Sleep ( AACAP s Facts for Families ( s/fff-guide/childrens-sleep-problems-034.aspx)

29 Resources (cont.) WEBSITES Bedtime Pass ( Autism Speaks Sleep (

30 Contact Matthew Osborne, M.S., BCBA

Falling asleep within minutes Staying asleep throughout the night

Falling asleep within minutes Staying asleep throughout the night (or fall back asleep with ease) Waking without much trouble Not feeling drowsy during the day Sleep problems = skill deficit Sleep is influenced