Using Behavior Analysis to Treat Sleep Problems in Individuals with Autism
Common sleep-related issues
Caregivers are often concerned that their child did not get restful sleep during the night. Some of the common sleep problems reported are:
- Not being able to fall asleep at a regular time
- Waking up in the middle of night and remaining awake for an extended period of time during the night
- Bedtime resistance, which typically involves calling out from, or leaving one's bedroom after bedtime
Results of sleep disturbances
Sleep disturbances may cause problem behaviors, such as self-injury, noncompliance, aggression, tantrums, and impulsivity, which are commonly exhibited by individuals who have developmental disabilities (Wiggs & Stores, 1996; Zuckerman, Stevenson, & Bailey, 1987). As a result, caregivers are often negatively affected and may also experience poor sleep quality and daytime functioning (Meltzer & Mindell, 2007).
Treating sleep disturbances
Usually, when caregivers ask pediatricians about sleep-related issues, they are prescribed medications to treat them (Stojanovski, Rasu, Balkrishnan, and Nahata, 2007).
On the other hand, behavior analytic strategies have been shown to be effective in treating pediatric sleep problems (Kuhn & Elliot, 2003; Mindell, et al, 2006). Some of the successful interventions in behavior analytic literature include:
1. Stimulus control procedure
A routine bedtime procedure that involves bedtime stories, sleep music near the bed, a certain blanket etc. can be used on a regular basis (France & Hudson, 1990). These routines may help the child to associate these activities and items with sleep time.
After bidding good night to the child, parents should not attend to him or her, unless absolutely necessary (France & Hudson, 1990). When the child stops getting parent's attention after they bid goodnight to him or her, the child is likely to gradually stop seeking their attention during bedtime.
3. Faded bedtime
This procedure involves bidding the child goodnight about 30 minutes past the average sleep-onset time and fading the time earlier on the next night, if the child was able to sleep within 15 min of bedtime (Piazza &Fisher, 1991).
4. Function-based intervention
These interventions decrease behaviors that interfere with sleep by disrupting the contingencies between the interfering behavior and its likely reinforcer(s) (Jin, Hanley & Beaulieu, 2013). Behavior analyst provides training to parents about what they should do following each problem behavior during bedtime, based on the function of those behaviors.
5. Bedtime pass with extinction
Sometimes more than one treatment strategy can be used at the same time to make the interventions more effective for the individuals. Freeman (2006) used bedtime pass, a small notecard exchangeable for one trip out of the bedroom after bedtime, with an extinction procedure. For the extinction procedure, the parents were trained to ignore calling out after the bedtime pass was used. They were also trained not to provide attention to resistance to bedtime and return the child to his room without comment.
A successful treatment plan for sleep related issues involves support from families and an intensive training of caregivers. Keeping in mind the family's general bedtime routines helps to determine which procedure they are most likely to be able to maintain consistently, over a period of time. Behavior analysts should use a questionnaire to determine a family's readiness to begin the treatment, as well as, limitations due to personal circumstance. Usually, treatment of sleep problems is an individualized and comprehensive approach and includes more than one treatment strategy (Jin, Hanley & Beaulieu, 2013).
Freeman, K. A. (2006). Treating bedtime resistance with the bedtime pass: A systematic replication and component analysis with 3-year-olds. Journal of Applied Behavior Analysis, 39, 423–428. doi: 10.1901/jaba.2006.34-05
Jin, C.S., Hanley, G.P., & Beaulieu, L. (2013). An Individualized And Comprehensive Approach To Treating Sleep Problems In Young Children. Journal of Applied Behavior Analysis 46, 161-180
Kuhn, B. R., & Elliott, A. J. (2003). Treatment efficacy in behavioral pediatric sleep medicine. Journal of Psychoso- matic Research, 54, 587–597. doi: 10.1016/S0022- 3999(03)00061-8
Meltzer, L. J., & Mindell, J. A. (2007). Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: A pilot study. Journal of Family Psychology, 21, 67–73. doi: 10.1037/0893- 3126.96.36.199
Park, S., Cho, S., Cho, I., Kim, B., Kim, J., Shin, M., et al. (2012). Sleep problems and their correlates and comorbid psychopathology of children with autism spectrum disorders. Research in Autism Spectrum Disorders, 6 , 1068–1072. doi:10.1016/j.rasd.2012.02.004.
Stojanovski, S. D., Rasu, R. S., Balkrishnan, R., & Nahata, M. C. (2007). Trends in medication prescribing for pediatric sleep difficulties in US outpatient settings. Sleep: Journal of Sleep and Sleep Disorders Research, 30, 1013–1017. Retrieved from http://www. journalsleep.org/
Wiggs, L., & Stores, G. (1996). Severe sleep disturbance and daytime challenging behaviour in children with severe learning disabilities. Journal of Intellectual Disability Research, 40, 518–528. doi: 10.1046/j.1365-2788. 1996.799799.x
Zuckerman, B., Stevenson, J., & Bailey, V. (1987). Sleep problems in early childhood: Continuities, predictive factors, and behavioral correlates. Pediatrics, 80, 664. Retrieved from http://pediatrics.aappublications.org/