Sleep Issues and

Children with Autism

Robert F. Gulick, MFA BCBA

Linda Hartken, MS BCBA

April 17, 2012

LEADERSLake Erie Autism Diagnostic Educational & Research Services

25% of adults have sleeping

problems

25% of kids have severe sleeping

problems

80% of kids with Autism

have difficulty sleeping

“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

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

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

Sleep Issues in Children with ASD

• Getting to sleep– Alone– In own bed

• Sleeping through the night

• Refusal to nap

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

What do Typical Kids Do?

• Bedtime routine– warm bath– story time– cuddle time– lighting– clothing

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

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

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

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

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.

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!

This can create an unending cycle of

fatigue and frustration for both parties.

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.

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

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”

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)

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

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

Behavioral Interventions

• Unmodified Extinction• Graduated Extinction• Extinction with Parent Presence• Positive Bedtime Routines

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

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

Graduated Extinction

• Advantages– Positive results within first week– Easier for parents to tolerate

• Disadvantages– Can shape up longer periods of crying

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

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)

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

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

Sleep Better by V. Mark Durand (1998)

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…

“H” is for Hell

?