Spring 2010

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Q&A: Sleep Difficulties

With contributions from Jennifer Alfieri, Terri Kim, Steve Michalski, Shannon Morgan, Rachel Russell, and Linda Wright

Initial Question

I am working with a little girl, two years of age, who consistently does not sleep more than three to four hours at a time. Sleep has been an issue since birth and her mom is the only one who can get her to fall asleep. Her mom reports that the only way she will fall asleep is with movement or sitting in a very specific way on a La-Z-Boy chair. Even when implementing these conditions, it still takes at least one to two hours to get her to fall asleep, and it does not guarantee that she will stay asleep. Her parents try different things to get her to fall asleep, but have not been able to remain consistent with any one approach due to their own sleep deprivation. She is falling asleep between 10 p.m. and 12 a.m. and then waking up around 2 a.m. She may fall back asleep, but usually not until several hours have passed (e.g., today she woke up at 2 a.m. and then fell asleep again around 6 a.m. for another two hours.) If she does take a nap, it is usually for only an hour or so, mid-day. Therefore, she only gets about five to seven hours of sleep per day. Her parents are also investigating biomedical interventions and medications to help with sleep.

Response One

I found that a schedule definitely makes a difference. For one of my clients who had trouble getting to sleep and frequently woke up during the night, I created a visual schedule (from Boardmaker or real photos) which included: 1) put PJs on, 2) brush teeth, 3) read books, 4) go to bed, and 5) listen to music. The schedule was shown to him every night as the routine was implemented so he knew what was coming next. I was present to help his parents consistently implement the visual schedule and also to support them as they placed attention-seeking and avoidant behaviors on extinction. The "listen to music" step was implemented because his parents were unable to move around in the house after their son fell asleep (the slightest noise woke him up). An attic vent was left on throughout the night as well for white noise. It took about a month, but with consistency on the parents' part, they are now getting their son to sleep and he remains asleep.

Response Two

Here are a handful of ideas:

1. Increase her activity level during the day (trampoline, walks, playground, etc.).
2. Depending on the child's response, either increase or decrease the child's activity level in the hour leading up to bedtime.
3. Restrict naps during the day.
4. Evaluate the bedroom for environmental noises that could be waking her (a radiator that hasn't been vented lately, a newspaper hitting the front porch in the early morning).
5. Get a blackout shade for each bedroom window.
6. Use a consistent bedtime routine.
7. When she wakes, don't turn on lights, talk, etc. Keep everything neutral and silent.
8. Consider whether her dad can also help with putting her to sleep, not just assist her mom, but also to change the bedtime routine and build in some flexibility.

Do you think her parents would be open to letting her "cry herself to sleep" a couple nights? It's possible that within a short period of time, she might learn to fall asleep sooner.

Response Three

It sounds like this little girl's parents are concerned about her getting enough sleep (rightly so!) and therefore may be allowing her to sleep whenever possible. I would recommend that they begin "restricting" sleep by not allowing her to nap. Hopefully, this will increase the likelihood of her sleeping through the night. I have even had parents wake their children up a little earlier and keep them awake a little later in order to establish an appropriate sleep pattern. This procedure paired with systematically fading the current sleeping environment (moving the Lay-Z-Boy closer and closer to the child's bed, placing the chair cushions on the bed, etc.) to a more natural sleep environment should yield you some results. In general, new routines can be an effective way to break old patterns. I would make sure the new bedtime routine was standardized (e.g., brushing teeth, putting on PJs, reading a book, etc.) to help this child understand what the response criterion is each night.

Response Four

I highly recommend the book "Sleep Better," by Vincent Mark Durand. The book explains various techniques, including graduated extinction, bedtime fading, scheduled awakenings, sleep restriction, and other strategies. I would also recommend for the family to record baseline data on her sleep patterns to help you identify the most appropriate intervention method.

To purchase the book, Sleep Better: A Guide to Improving Sleep for Children with Special Needs, please visit our online store:
http://www.lovaas.com/store-product.php?category=Books&page=1&asin=1557663157

Response Five

I did my masters thesis on sleep disorders in children with autism and focused on looking at symptoms, treatments, and treatment effectiveness. What I found was that children with autism were most often waking up at night to engage in stereotypical behaviors with a self-stimulatory function (very different from typically-developing children who were waking for parental attention, to have access to toys or TV out of the room, to attain food or water, etc.) Children with autism were waking (or not initiating sleep) to engage in singing, humming, banging, tapping, laughing, stereotypical toy play, etc. Although they were content to stay in their rooms to engage in these behaviors, they were often very loud and disruptive to the rest of the family and were causing sleep deprivation for both themselves and their parents and siblings.

Using a parental survey, I found that very few children with autism were given behavioral treatments by their doctors and psychiatrists (while typically-developing children the same age were often prescribed behavioral treatments before medications were discussed). The children with autism were prescribed heavy duty sleep medications right away – the majority of which were not effective, and actually appeared to cause more negative side effects and sleep disruption for them (again, according to the parent survey).

Children with autism who were in behavioral treatment programs were more likely to have tried behavioral treatments and were more likely to have seen improvement in their sleeping patterns. The behavioral treatments that were successful for children with autism in my study are clearly described in the book "Sleep Better: A guide for sleeping for children with special needs." This book shows how to do a functional analysis of a child's sleep patterns (data sheet included) and then how to choose the appropriate intervention based on the data (all interventions are described very well.)

In addition, my study found that children with autism had shown the most overall improvement for the symptom "engaging in self-stimulatory behavior" by the use of melatonin in conjunction with behavioral strategies. Dr. Jim Jan from Children's hospital in Vancouver, British Columbia has published a few research articles about his hypothesis that children with autism are similar to children who are blind – in how they do not "see" the cues of light and dark from the environment, which regulate their internal melatonin levels, which regulate appropriate sleep patterns. Since melatonin levels regulate sleep in their bodies, they often sleep at the wrong times (naps), cannot initiate sleep (and therefore engage in inappropriate behaviors to amuse them in the night) and have frequent night-wakings when they do sleep. My thesis was in 2000, so this may be somewhat outdated in the literature by more recent studies, but if you are interested, you can read more about the research I used in the literature referenced below:

• Jan, J.E., Espezel, H & Appleton, R.E. (1994). The treatment of sleep disorders with melatonin. Developmental Medicine and Child Neurology,36, 97-107
• Jan, J.E., & Espezel, H. (1995). Melatonin treatment of chronic sleep disorders, (Letter to the Editor). Developmental Medicine and Child Neurology, 37, 279-281.
• Jan, J.E., Freeman, R.D., & Fast, D.K. (1999). Melatonin treatment of sleep-wake cycle disorders in children and adolescents. Developmental Medicine and Child Neurology, 41, 491-500.
• Lord, C. (1998). What is melatonin? Is it a useful treatment for sleep problems in autism? (Letter to the Editor). Journal of Autism and Developmental Disorders, 28 (4). p. 345-346.

Response Six

During my Master's program through SCSU, Dr. Kim Schulze provided us with a GREAT powerpoint presentation that focused on sleep. Here are a few notes from the presentation:

1. Establish a routine - Regular sleep times are an important feature of creating desirable sleep behavior. A sleep diary can be used to determine how much sleep a child usually gets. Using that information, a regular bedtime and wakeup time should be established and consistently followed.
   • Make the last 30 minutes before bedtime a regular routine. Include activities such as dressing for bed, washing, and reading.
   • Keep the order and timing consistent each night (e.g., brush teeth, wash up, change into pajamas, read for 15 to 20 minutes, hug and kiss, say, "ok, it's time to sleep. Goodnight.").
   • Don't include activities that might result in conflict (i.e. picking out clothes for school). Work these into a routine before bedtime.
   Parents of kids on the autism spectrum likely face unique challenges. For instance, establishing a routine can feed into rigidity, a common feature of autism. If the routine is not exactly followed, it can result in severe tantrums. When establishing a bedtime routine for a child with autism, variations should be worked into the schedule.
2. Diet and Exercise
   • Diet is important to sleep. In general, a well-balanced diet is related to good sleep. Certain vitamins may have positive effects on sleep. A medical doctor should be involved in any decisions about treating sleep problems via diet and vitamins.
   • Exercise can also have a positive effect on sleep. Establish a daily exercise regime (consult doctor). Encourage aerobic activity. Optimal time is 4-6 hrs before bedtime. Discourage vigorous activity right before bedtime!!
3. The Setting – the bed and bedroom should exert the proper form of stimulus control. Stimulus control refers to associating the bed and bedroom with sleep versus other activities.
   • As much as possible, the bed should be associated with sleep (not wrestling, jumping, playing, etc.).
   • Environmental factors such as light, temperature, and noise also need to be controlled when a child is going to bed (not too light or dark, hot or cold, loud or noisy, etc.).
4. Things to Avoid:
   • Avoid watching TV because it can interfere with sleep.
   • Avoid vigorous activity right before bedtime.
   • Avoid extending the time for bedtime - don't give in to requests for just one more story, or one more drink of water.
   • Avoid Caffeine-- Caffeine is a stimulant that can stay in the body up to 6 hours. In general, drinks and foods containing caffeine, including soft drinks and chocolate, should be avoided in the hours before bedtime.

Good sleep habits should be combined with behavioral interventions. Dr. Schulze discussed several sleep interventions that are discussed in detail in the book, "Sleep Better," which others have already recommended.

• Creating Measurable and Achievable IEP Goals for Children with Autism
• Tips for Airplane Travel
• Top 10 Early Preschool Games
• Celebrating Success

The names of all children in this newsletter have been changed in respect for family confidentiality.

Aladdin's Magic Carpet! Put the child on a towel or blanket and pull them across the floor.

Jump! Sing, "Jump" by Van Halen and jump when the song tells you to.

I'm Shocked! Fall completely over with surprise and shock that the child answered the question correctly.

Car Ride! Line your chairs up next to each other and go for a car ride. Put seat belts on. Check left and right for traffic, beep the horn, etc.

Monster Palm! Draw a monster on your palm. Use the other hand to hold the wrist of monster palm so it can't get you. However, we all know a monster palm is stronger. Elicit the child's help to get rid of monster palm.

Recent Postings: Early Play Activities Weakening the Evidence for ABA Therapy, Part 2 - A Dialogue Weakening the Evidence for ABA Therapy - Is it Our Fault?

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