Falling asleep within minutes Staying asleep throughout the night

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Loreen Bruce
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2 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

3 Sleep problems = skill deficit Sleep is influenced by Past experience Present sleeping conditions Ancestral history (genetics) Cultural practice

4 Unintentional injuries (Koulouglioti et al., 2008) Difficult temperament (Richman, 1981) Obesity (Bell & Zimmerman, 2010; Magee & Hale, 2012) Poor school performance (Dewald et al., 2010) Noncompliance Aggression Self-injury (Wiggs & Stores; 1996)

5 Poor sleep quality (Meltzer & Mindell, 2007) Poor daytime functioning (Meltzer & Mindell, 2007) Maternal depression (Richman, 1981) Marital discord (Chavin & Tinson, 1980)

6 Prevalent 35-50% typically children (Johnson, 1991; Polimeni et al., 2005) 63-73% children with autism (Polimeni et al., 2005; Souders et al., 2009)

7 On their own Pediatrician Spanking Staying with parents 5 hr training (Mindell et al, 1994) Outgrow problems Persistent (Kataria et al., 1987; Zuckerman et al., 1987)

8 81 % of children s visits result in medication (Stojanovski, et al. 2007) No prescribing guidelines No drug approved by FDA Limited research on efficacy, tolerability and acceptability

9 Naturally secreted hormone (pineal gland) Rises just prior to sleep onset (when it gets dark) Yields statistically significant improvement in sleep (Guenole et al. 2011)

10 Efficacious (Kuhn & Elliott, 2003; Mindell, 1999;, Mindell et al., 2006) Lack of objective measure Not home-based Unacceptable strategy Not comprehensive Not based on individualized controlling variables

11 Through a general understanding of the common factors that influence good sleep and sleep problems Using an open-ended indirect assessment to identify the personal factors influencing the sleep problem SATT (Sleep Assessment and Treatment Tool) By encouraging parents to develop the intervention with us we support parents in their implementation of the assessmentbased treatment via phone calls and weekly visits

13 3 children Ages ranged from 7-9 years Home

14 Sleep diary Infrared nighttime video recording

15 History of sleep problems Sleep goals Specific sleep problems routine noncompliance, night awakenings etc Conditions under which problem behavior occur Interfering behaviors and possible reinforcers Sleep dependencies and sleep schedule Steps to guide a personalized intervention

16 2 hour training session using behavioral skills training Instruction Modeling Role-play Feedback

17 Nights Baseline Treatment Follow-up Diary Video 40 Walter 20 0 Sleep Onset Delay (min) Clonidine: 0.50 mg 0.25 mg 0.00 mg Andy 0 0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg 120 Parent Presence Time-based Visiting Lou

18 Nights 100 Baseline Treatment Follow-up Interfering Behavior (min) Clonidine: 0.50 mg 0.25 mg 0.00 mg 0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg Parent Presence Walter Andy 60 Time-based Visiting Lou

19 Sleep Onset Delay < 30 min Interfering Behavior < 2 min Night Waking = 0 min Percent of Goal Sleep > 90% Baseline Treatment Met Unmet Walter Sleep Goals Sleep Onset Delay < 15 min Interfering Behavior < 2 min Night Waking = 0 min Percent of Goal Sleep > 90% Disruptive Music = None Clonidine = None Andy Sleep Onset Delay < 15 min Interfering Behavior < 2 min Night Waking = 0 min Percent of Goal Sleep > 90% Parent Presence = None Melatonin and Benadryl = None * Lou Nights

Table 1 Questions Walter Andy Lou Average (Range) 1.Acceptability of assessment procedures 2. Acceptability of treatment 7 6 7 6.7 (6-7) 7 6 7 6.7 (6-7) 3.

20 Table 1 Questions Walter Andy Lou Average (Range) 1.Acceptability of assessment procedures 2. Acceptability of treatment (6-7) (6-7) 3. Improvement in sleep Consultation was helpful (6-7) Note: Likert scale: 1 to 7. 1 (not acceptable, not satisfied, not helpful), 7 (highly acceptable, highly satisfied, highly helpful)

21 Personalized Comprehensive Assessment-based

22 EO + SD Falling Asleep Sleep What alters the value of sleep as a reinforcer?

23 EO + SD Falling Asleep Sleep What signals that the reinforcer is available (and prepares the body to consume the reinforcer), and are those signals available when the child wakes up multiple times each night?

24 EO + SD Interfering behaviors Sr What other behaviors are occurring before and after the bid good night that are incompatible with falling asleep (i.e., that do not allow for behavioral quietude)?

25 EO + SD Interfering behaviors Sr What reinforcers are available for behaviors that are incompatible with falling asleep?

26 EO + SD Incompatible behaviors Sr What alters the value of these other reinforcers for behaviors that are incompatible with falling asleep?

27 EO + SD Incompatible behaviors Sr What signals that these other reinforcers are available?

28 What makes sleep valuable?

29 Recognize of age-appropriate sleep amounts

30 Age-Based Sleep Averages Age Total Sleep Night Sleep # Naps 2 11 hrs 30 min 9.5 hours 1 (2 hrs) 3 11 hrs 15 min 10 hours 1 (1hr15min) 4 11 hrs hours hrs 45 min 6 10 hrs 30 min 9 10 hrs 12 9 hrs 45 min 15 9 hrs 15 min 18 9 hrs Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

31 Cautions: child is expected to be in bed too long or too short of a time Implication: Select the right sleep total for child

32 Midday Dip in Alertness Forbidden Zone Alert Sleepy Nigh t Day Nigh t Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

33 Caution: Putting children to bed during the Forbidden Zone will increase the likelihood of nighttime routine noncompliance, sleep onset delays, & interfering behavior

34 We have a tendency to go to bed later and wake up later because of our 24.2 hr clock Artificial light and nighttime activity availability leads to a 25-hour clock

35 Copied from: National Institute of Health (NIH) Sleep and Sleep Disorder s Teacher s Guide

36 Implication: At the beginning of sleep treatment: set the start of the sleep routine slightly later than when the child fell asleep the previous night Then gradually transition sleep phase earlier if child falls asleep within 15 min move bedtime 15 min earlier next night until desired bedtime is achieved (Piazza et al., 1991)

37 Nighttime Routine Ambient Environment

38 Prior to bid goodnight: Activities progress from active to passive Arrange choices on picture schedule Baths earlier in routine Ambient light gets progressively dimmer Light snacks without caffeine After bid goodnight: Cooler temperature Indirect lighting only Non-undulating noise

39 Compliance with bedtime instructions

40 Tendency to not follow instructions or resist guidance to, for example, put on PJs, brush teeth, or get in bed. Solutions: Start routine just prior to natural sleep phase Promoting instruction following during the day Arrange big discrepancy in consequences for compliance vs. noncompliance to routine Avoid differential reinforcement with extinction

41 M % Precursors M % Compliance BL1 U = 11, p >.05 U = 0, p <.05 Individual Children U = 12, p >.05 U = 4.5, p <.05 Control Experimental Group BL2 Precursor = Responding effectively to one s name = stopping activity, Beaulieu looking et al., at teacher, saying, (2013, Yes, JABA) and waiting until teacher says something. Control Experimental

42 M % Precursors M % Compliance BL1 U = 11, p >.05 U = 0, p <.05 Individual Children U = 12, p >.05 U = 4.5, p <.05 Control Experimental Group BL2 Precursor = Responding effectively to one s name = stopping activity, looking at teacher, saying, Yes, and waiting until teacher says something. Compliance = completing an instruction within 6 s Control Experimental

43 M % Precursors M % Compliance BL1 BL2 U = 11, p >.05 U = 0, p <.05 Individual Children U = 12, p >.05 U = 4.5, p <.05 Control Experimental Control Experimental Group

44 M % Precursors M % Compliance BL1 BL2 U = 11, p >.05 U = 0, p <.05 Individual Children U = 12, p >.05 U = 4.5, p <.05 Control Experimental Control Experimental Group

45 What signals the availability of sleep? What helps to occasion sleep?

46 Transitioning from laying in bed to falling asleep depends on stimuli associated with falling asleep

48 Things that occasion sleep are not present when the child wakes up during the night = Night Awakenings. Things that occasion sleep are suddenly removed or inconsistently available = Sleep Onset Delay and possibly Interfering Behavior

49 Solutions: Occasion sleep with things that (a) don t require your presence, (b) can be there in the middle of the night, and (c ) are transportable (e.g., for vacations or nights at Grandparent s home) Examples: pillow, blanket, stuffed animal (with bed rails), sound machine on continuous

50 What are the likely reinforcers for interfering behavior? How to reduce interfering behavior?

51 IB = Behaviors that interfere with behavioral quietude necessary for falling asleep; the big three are: leaving bed (curtain calls) crying / calling out playing in bed or in bedroom this includes motor or vocal stereotypy (talking to oneself) Be sure to first properly consider what the likely reinforcers are for the interfering behavior Attention / Interaction Food/drink Access to TV or toys Escape/avoidance of dark or of bedroom Automatic reinforcers (those directly produced by the behavior)

52 Interfering Behavior Treatment Part 1: Provide the presumed reinforcer prior to bidding the child good night Part 2: After bid goodnight, eliminate access to presumed reinforcer following IB With socially mediated IB, options include: Extinction, Progressive Waiting, Time-Based Visiting, Quiet- Based Visiting, Quality Fading, or Bedtime Pass With automatically-reinforced IB, we use: Relocation of relevant materials Blocking

53 Time-Based Visiting: Visit your child at increasingly larger intervals after the bid good night and across nights (hopefully before IB occurs); during visit re-tuck them, bid good night, and leave. Day First visit Second visit Third visit Fourth visit Fifth visit Sixth visit Seventh visit 1 10 s 30 s 1 min 3 min 5 min 10 min 30 min 2 30 s 1 min 3 min 5 min 10 min 30 min 3 30 s 3 min 5 min 10 min 30 min 4 1 min 3 min 5 min 10 min 30 min 5 1 min 5 min 10 min 30 min 6 5 min 10 min 30 min 7 5 min 30 min

54 Bed Time Pass: Give your child a bed time pass to be used as needed after the bid good night to have one request granted. If # of IBs was high before you try this treatment, provide more than one bed time pass initially and then fade out the number each night.

55 Just prior to bed, the children were allowed to choose the treatment for each night Treatment- Correlated Stimuli Blue Card Green Card Treatments Bedtime pass Extinction Contingencies Reinforcement only if handed a pass No reinforcement (period) Red Card Time-based Visiting Reinforcement available according to time

56 3 2 Cumulative Selections (#) Bedtime Pass Extinction Time-based Visiting Gina Nights Sam

57 Table 1 Results of Social Acceptability Questionnaire Administered to Parents Gina Sam Ranking Mom Mom Dad 1 Bedtime Pass Time-based Visiting Bedtime Pass 2 Extinction Bedtime Pass Extinction 3 Time-based Visiting Extinction Time-based Visiting Note. 1 = most preferred strategy.

58 Table 1 Results of Social Acceptability Questionnaire Administered to Parents Gina Sam Ranking Mom Mom Dad 1 Bedtime Pass Time-based Visiting Bedtime Pass 2 Extinction Bedtime Pass Extinction 3 Time-based Visiting Extinction Time-based Visiting Note. 1 = most preferred strategy.

Adjust sleep schedule based on developmental norms and current sleep phases Arranging healthy sleep routine and sleep conducive environment Incorporate strategies to promote

59 Adjust sleep schedule based on developmental norms and current sleep phases Arranging healthy sleep routine and sleep conducive environment Incorporate strategies to promote instruct following Arrange healthy sleep dependencies that are constantly available throughout the night Disrupt contingencies between problem behavior and controlling variables

60 C. Sandy Jin Ph.D. BCBA-D Assistant Professor of Psychology Eastern Connecticut State University

Assessment and Treatment of Sleep Problems in Young Children:

National Autism Conference 2018 Penn State University Assessment and Treatment of Sleep Problems in Young Children: Designing Individualized, Function-based, and Consumer Friendly Interventions Through