Sleep Problems and Autism
Dr. Helena Lydon
2nd International Conference on Autism Spectrum Disorders
12.06.2013
Sleep Problems and Autism
• Autism is characterised by impairments including
social interaction, communication deficits, and
restricted, repetitive behaviours.
• Secondary Behavioural difficulties often
coexist: tantrums, tactile hypersensitivity, selfinjury, destructive behaviour, cognitive
impairment, and sleep problems.
• Parental surveys indicate a 50-80% prevalence
of sleep problems in children with ADS (Richdale
& Schreck, 2009; Polimeni, Richdale & Francis,
2005).
Age and Sleep Problems
• While evidence exits for some improvements
with age, older children still exhibited sleep
problems
• Honomichl et al. (2002) found that parents of
older children report more sleep problems
• Doo and Wing (2006) reported that the onset of
Pervasive Developmental Disorder signs
before age 2 years was predictive of significant
sleep problems.
Types of Sleep problems
• Sleep Problems
–
–
–
–
–
–
Sleep Onset and Maintenance
Early Morning Awakenings
Unwillingness to fall asleep in own bed
Restless sleep
Nightmares/ night terrors
Excessive daytime sleepiness
Effects of Poor Sleep
• Sleep problems have been found to adversely
affect :
– Cognitive functioning (Taylor, Schreck, & Mulick, 2012)
– Daytime/adaptive behaviour (Taylor, Schreck, & Mulick, 2012)
– Increases aggression & irritability (Malow et al., 2006)
• Children’s sleep Problems can lead to:
– Maternal malaise and depression
– Parental sleep problems
– Parental relationships with each other and with their
children.
Cause of Sleep Disturbances in
children with autism
• The exact cause(s) of sleep problems is not yet
known, however, many researchers have put
forward a variety of factors
–
–
–
–
–
Serotonin and Melatonin
Sensory
Social and Communication difficulties
Anxiety
Environmental Factors
Treatments for sleep problems
•
•
•
•
•
Social Stories (Moore, 2004)
Light therapy
Chronotherapy (Piazza et al., 1998)
Medication
Behavioural Interventions
Behavioural Treatments of Sleep
Problems
• Behavioural Interventions have been shown to
be effective in treating daytime behavioural
difficulties in children with autism
• In addition Behavioural Interventions have been
shown to be effective in treating sleep problems.
• It is evident from parental reports that
behavioural interventions are viewed as
preferable to medication (Richdale, 1999).
Assessment of Sleep Problems
• Falling asleep is the target behaviour.
• Influenced by ancestral history and our
present culture.
• Influenced by past and present events in
one’s sleep environment.
– Motivated (or demotivated)
– Reliance on environmental cues
Assessment Tools
• Children’s Sleep Habit Questionnaire
(Owens, 2000)
http://www.gse.uci.edu/childcare/pdf/questionnaire_interview/Childrens
%20Sleep%20Habits%20Questionnaire.pdf
• Sleep Assessment and Treatment Tool (SATT)
(Hanley, 2005)
http://www.ontaba.org/pdf/conference_2011/sleep_asses
sment_and_treatment_tool.pdf
• Sleep Diary
Sleep Diary
Keys to success
• It is recommended that this programme be
implemented when the families/staff are
able to fulfil all the requirements to
facilitate the introduction of the
programme.
• E.g. Holiday periods
Getting the motivation for Sleep
• Recognition of age-appropriate day and night sleep amounts
The Forbidden Zone
•Recognise your child's current sleep phase and capitalise on sleep
pressure when beginning to treat any sleep problem
Adpated from: Solve Your Child’s Sleep Problems, Richard Ferber, Simon & Schuster, 2006
Bedtime Routines
• Children with autism can have unusual
and problematic sleep routines
• Regularizing bedtime routines can lead to
improved sleep
• Develop a bedtime routine that is as
pleasant, relaxed, and as consistent as
possible.
• Consider a picture schedule depicting the
night time routine.
Bedtime Routine
• It is recommended that a bedtime routine be
established and carried out nightly the half hour
before bedtime. It is important to practice the
routine consistently for 3 weeks for the routine to
become associated with sleep.
• Encourage calm activities before bedtime.
Cease exciting activities about an hour before
bedtime. Avoid (a) watching TV during this time,
(b) any activities which may cause conflict, and
(c) extending the time for the bedtime routine.
Behavioural Treatments of Sleep
Problems
• Extinction (Williams, 1959)
– sleep onset problems maintained by parental
attention.
– and effective treatment for sleep onset and
maintenance difficulties
– One obstacles is that parents frequently find it
difficult to ignore the cries of a child for an
extended period of time
• Graduated extinction (Rolider and Van Houten, 1984)
– decrease in the child’s crying
– Also found to be effective at reducing night waking
• Faded Bedtime Procedure with response
cost (Piazza and Fisher, 1991).
– effective at reducing sleep onset latency and night
waking.
• Piazza et al. (1997) conducted a comparison
faded bedtime with response cost and bedtime
scheduling.
– Bedtime scheduling produced minimal improvements
– Faded Bedtime with response cost was more
successful at reducing sleep problems
• Scheduled Awakening/ Sleep Restriction
(Durand, 1998; Durand & Mindell, 1999)
– Have successfully reduced night waking
– Durand and Christodulu (2003) eliminated bedtime
disturbances and reduced nighttime awakenings
– Christodulu and Durand (2004) combined bedtime
routine and sleep restriction to successfully eliminate
bedtime disturbances and reduce night awakenings in
children
– This intervention does not rely on the withdrawal of
parental attention
– Used in conjunction with fading
Case Study 1
Age:
Diagnosis:
18 years 8 months
Autism
Moderate to Severe Learning Disability
Query Tourette Syndrome
Sleep Problem: Sleep Maintenance
Early morning awakenings
Sleep Problem
•
The child typically wakes early in the morning between 4:00am and 5:00am. When
he wakes he typically engages in shouting, banging his chest, pull his stomach,
which can disrupt and wake other service users. Occasionally stays in bed and falls
back to sleep. However, on other occasions gets up and he wants to wet clothes. He
does this by placing his clothes in the bath, following this typically becomes vocal.
The behaviour of putting clothes in the sink or bath, and splashing in the toilet can
occur during the day.
•
Staff report that the early morning awakening used to occur approximately once per
week, but now occur 4-5 times per week. If the child wakes at 4am he is awake for
the day. Staff encourage him to return to bed. They place fresh sheets on the bed and
put the covers back on him. Staff report that tucking him in sometimes helps.
•
Staff report that if child is re-directed back to his room, and he does not return to bed
he can defecate on the floor. This behaviour has been observed on three occasions
in the last 6 months. Staff also report that he does experience sexual arousal and
query whether if he masturbated if he wakes and for this reason he may be taking off
his clothes and the bed linen.
Hours of Sleep
Number of Hours
10
8
6
4
2
01
/0
2
03 /2 0
/0 12
2
05 /2 0
/0 12
2
07 /2 0
/0 12
2
09 /2 0
/0 12
2
11 /2 0
/0 12
2
13 /2 0
/0 12
2
15 /2 0
/0 12
2
17 /2 0
/0 12
2
19 /2 0
/0 12
2
21 /2 0
/0 12
2
23 /2 0
/0 12
2
25 /2 0
/0 12
2
27 /2 0
/0 12
2/
20
12
0
Days
of wakes
Waking
TimeTime
Ross
8
7
Time (am)
6
5
4
3
2
1
0
1
3
5
7
9
11
13
15
Days
17
19
21
23
25
27
Present Sleep Schedule
• Typically goes to bed 10:3011:00.
• He falls asleep within
20minutes.
• Wakes in the morning anytime
between 5:00am and 7:30 am.
• Sleep duration varies from 5 -8
hrs.
Present Bedtime Routine
• Supper
• Watches TV
• Massage hands and feet
• brushes teeth,
• Lies in bed,
• Lights off/door closed
• Sleep (Normally goes to sleep,
might on occasion shout a few
times for 10-15 minutes).
Behavioural Treatment Package
• Environmental Accommodations
–
–
–
–
Visual timer
Laundry basket
Sleeping blanket
Social story
• Sleep Restriction
• Faded awakenings
• Reactive Strategy
– Procedure for night time awakenings
• Skills Teaching
ENVIRONMENTAL ACCOMODATIONS
• A visual timer. The clock has two settings night and day and change
colour to indicate that it is time to sleep or time to get up.
• A laundry basket placed in bedroom.
• A sleeping blanket/bag will be available in bedroom if he removes
his sheet due to it being wet.
• A Social Stories to provide information about expectations about
appropriate behaviour. To inform him of appropriate behaviour at
night and if he wakes early. The social story will address key
aspects of appropriate behaviours such when to stay in bed and
when to get up. It will also address if his clothes are wet that he can
put them in a laundry basket and return to bed.
DIRECT INTERVENTION
Sleep Restriction:
• Child to be woken 15-30 minutes before the time he
would spontaneously awaken.
E.g. Wakes regularly between 5:00am and 7:30am.
Therefore, will be awoken at 4:45am and shown that his
visual clock shows it is time to get up.
Fading
• A time fading procedure will also be used to gradually
change the time the child gets up at.
E.g. Following two successive nights at 4:45 awakenings
the time will gradually be adjusted to fade awakening to
his target awakening time of 7:00am.
SKILLS TEACHING
• Child to be taught that if his sheets are wet that
he places them in a laundry basket, and
changes his clothes and returns to bed.
• Also Child should be taught to stay in bed until
his visual clock indicates that it is time to get
up. To ensure this it may be important to identify
an activity that the child can engage in such as
listening to music on headphones. Alternatively
preferred items and/or activities will be put in
place to enable the child to self occupy if he
wakes early.
REACTIVE STRATIGIES
Procedure for night-time awakenings or early
morning awakenings
• If the child wakes at night remind him that it is
necessary to wait until the clock changes colour.
As the child has a history of escalating his
behaviour in response to being asked to return
to his room, staff are to reset the clock to change
to “time to get up” after 5 minutes. If the child
return to the bed for these 5 minutes staff should
praise child for getting up when the clock
changed.
Results
Hours of Sleep
Baseline
10
Intervention
Hours
8
6
4
2
H
H
H
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Time 1stDays
woke
Baseline
Intervention
Time in Hours
10
8
6
4
2
H
H
H
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
Days
H = Nights at Home
Case Study 2
Age:
Diagnosis:
5 years 9 months
Autism
Moderate Learning Disability
Sleep Problem: Sleep Onset
Difficulties getting up in the morning
Behavioural Treatment Package
• Environmental Changes
–
–
–
–
–
–
–
Visual Timer
Night Light
Door closed
Toys to be stored away
Bedtime Routine
Door to be left open until he has fallen asleep
Staff to sit inside the door (their back facing the bed)
• Faded Bedtime
• Reactive Strategy
– Procedure for Night time awakenings
– revised
• Wake-Up procedure
Intervention 1
Intervention 2
Environmental Changes
•
•
•
•
Visual Timer
Bedtime routine
A night light should be placed in the child’s room
The bedroom door should be closed at night after
bedtime
• Door to remain open until after he has fallen asleep
• Staff to sit inside the door with their back to the bed
• Access to toys and or activities within the bedroom
should be limited. Toys and/or activities will be put in a
chest or box and stored out of reach at night time.
Faded Bedtime
•
Child was put to bed 30 minutes later than he typically falls asleep.
– Current bedtime = 11:00pm,
– New Bedtime = 11:30pm.
– Bedtime routine to be completed in the half hour before bedtime.
• Child to sleep 10 to 11 hours.
Note: As child is going to bed at 11:30, allow the child to sleep for 10-11 hours.
e.g. The first two nights allow the child to sleep until 10:30am. If the child wakes
earlier than this time document the waking time and follow wake up
procedure
•
The criteria set for fading bedtime: if child falls asleep within 15 minutes of
going to bed for two consecutive nights, then bedtime can be moved
forward a half hour the following night.
•
It is important to stick to bedtime and waking times – as oversleeping one
day may lead to difficulty going to bed that night.
Night Time awakening
• If child gets up from his bed , staff should take
child back to bed immediately without making
eye contact, cuddling, talking to or ‘telling him
off’.
• Only words to be spoken are “Its bedtime”
• It is recommended that he is not allowed to run
about the house. To avoid this staff should stay
at his door until he has settled and fallen asleep.
• Remover soother if he wakes in at night.
• Do not sit on the bed
• Do not read extra stories
Wake-Up Procedure
A visual timer was used to teach the child when it is time to sleep and when it is
time to get up.
A picture based story was used to teach the child what each colour symbolises
and what happens when the clock is ringing and what happens when it is
not ringing. Example:
Blue = going to bed
Blue and stars = stay in bed/ bedroom
Yellow = time to get up
•
•
•
It is recommended that the story have key phrases such as “time for bed”,
“its sleep time” and its “time to get up”. Staff should refer to these at the
relevant stages.
In the morning when the child is being woken, the sound of clock should be
brought to his attention and he should be reminded its time to get up.
Small changes in the environment might help him to wake in a positive
mood, such as drawing the curtains a small portion at a time, or playing
preferred music at a low level.
Results
Bedtime
Intervention 1
12:00
Intervention 2
Time
Baseline
10:48
09:36
08:24
1
4
7
10
13 16
19 22
25 28
31 34
37 40
43 46
49 52
55 58 61
64
43
49
55
64
Days
Duration in Minutes
Duration to Sleep
150
Intervention 1
Intervention 2
Baseline
100
50
0
1
4
7
10
13
16
19
22
25
28
31
34
Days
37
40
46
52
58
61
Thank you.
Questions or Queries?