LEADERS
Lake Erie Autism Diagnostic Educational & Research Services
Sleep Issues
and
Children with Autism
Robert F. Gulick, MFA BCBA
Linda Hartken, MS BCBA
April 17, 2012
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 selfcalming 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 preestablished 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