Danielle Liso, PhD, BCBA Johns Hopkins University
What is sleep disorder? Problems related to sleep onset and maintenance Irregular sleep-wake patterns Long sleep latencies (how long it takes to fall asleep) Nightmares Night terrors Irregular sleep patterns Problems with sleep onset Generally poor sleep Early and night waking Poor sleep routines Shortened night sleep Alternations in sleep onset and wake times Night waking
What are the impacts of sleep disorders? Related to greater autistic symptomology during the day Greater parent stress Loss of sleep= less time attending to learning for child Loss of sleep=increase in challenging behavior for child Loss of sleep= less time being productive for parents, sibs Sleep disordered breathing associated with stereotypic behavior and social interaction problems
What do we know about autism and sleep? It has been reported that 44-83% of the ASD population has sleep disorder Appears at all IQ levels Younger children with ASD have more sleep problems than older children with ASD Due to better coping, more demand=better sleep, or do kids grow out of it? Children with ASD have more reported sleep problems in the following categories, as compared to typically-developing peers: Bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night wakings, parasomnias (problems transitioning between sleep phases), sleep disordered breathing Do not differ from TDP in daytime sleepiness
What causes sleep disorders in autism? Elevated or reduced levels of melatonin Hyper- and hypo-arousal (esp. overstimulation) Anxiety May not respond to environmental cues (time to sleep) May have weak sleep control (don t sleep well when it s hot or cold, not completely dark in bedroom, etc.) Jan & Freeman, 2004
What about comorbid conditions? Seizures: It has been hypothesized that children with autism often suffer from mild (petit mal) seizures; often times, these seizures take place at night may be the reason for many of the sleep disorders common in autism ADHD MR
Assessing sleep disorder Medical concerns that may influence sleep How many hours does the child sleep? How many times does the child wake each night? How long, on average, is the child awake? Why do you think the child wakes up? What is the child s temperament when he/she wakes?
Assessment, cont. Does the child nap? If so, how many and how long? Does the child sleep with any items? What is the bedroom environment like? What is the current bedtime routine? What motivates the child? What activities or items calm the child? What is the child s primary mode of communication?
Addressing sleep disorder behaviorally Positive bedtime routines Bedtime fading Bedtime fading with response cost Sleep restriction (chronotherapy) Scheduled awakenings Extinction Stimulus fading
Positive bedtime routines Engage in specific bedtime routines conductive to sleep Last 30 minutes before sleep Enjoyable Low demand no conflict or confusion Predictable order and timing of events the same; insert minor changes if becoming too restrictive NO TV (stimulating) Try to stick to routine even when child is sick
Bedtime fading (for difficulties falling asleep) Put your child to bed and leave the room If your child starts to cry, wait the agreed-upon time before entering time for bed then leave the room Wait another [5] minutes if necessary, then start again Extend time between visits by 2-3 minutes each subsequent night
Bedtime fading with response cost Remove your child from bed if he/she does not fall asleep within 15 minutes Keep child awake for 1 hour, the back to bed If your child is not asleep within 15 minutes, start again
Sleep restriction (chronotherapy) (for non-disruptive and disruptive wakening) Use the sleep diary to estimate the number of hours your child sleeps per night asleep time only Multiply the average number of hours by 0.9 to arrive at a figure representing 90% of the time your child sleeps Adjust your child s bedtime, or preferably, the time you wake your child in the morning, to approximate the new schedule If you find your child lying be bed awake, have him/her leave the bed and engage in a quiet activity until sleepy, then back to bed If night waking is eliminated or diminished for 1 week, readjust bedtime or waking time by 15 minutes Continue to adjust once per week until the desired schedule is reached
Scheduled awakenings (for disruptive wakening) Use sleep diary to determine the time our times your child typically awakens Wake your child up 30 minutes before his first typical waking time enough for him to open his eyes, then let him go back to sleep Repeat this plan each night until your child sleeps for a full 7 nights without waking, then skip one night If your child has awakenings, go back to every night Slowly reduce the number of nights per week with scheduled wakings until your child no longer wakes in the night
Extinction (for difficulties falling asleep or disruptive wakening) Non-graduated: Ignore all bedtime disruptions or night waking Graduated: Follow a systematic routine to put your child to bed If your child cries, initially ignore the behavior at a pre-set period of time (5 min) If your child is still crying, enter the room to resettle your child ( time for bed ), with as little attention as possible, then leave Continue pattern until child is asleep On each subsequent night, extend the time between visits by 2-3 minutes
Stimulus fading Gradually move the co-sleeper out of your bedroom OR Moving you out of your child s room On bed- touching, on bed-no touching, on floor next to bed, slowly move across room, at door, beyond door
leep Diary (Adapted from Durand 1998) hild: Person collecting data: Please collect the following information for one week. Each night, indicate (1) the initial time you put your child to bed, (2) he time your child actually fell asleep after being put to bed, (3) the time of each instance of waking, and (4) what your child did uring the waking and what you did to respond to your child. Also describe the length and nature of any naps that occurred hat day. Day Date Time put to bed Time fell asleep Time awoke Describe nighttime waking Describe any naps Sunday Monday Tuesday
Sleep Data Date Time bedtime routine started Time asleep Time awake (1) Time asleep (1) Time awake (2) Time asleep (2) Time awake (3) Time asleep (3) Time awake, next morning
Sleep Behavior Log (Durand 1998) Child: Please provide the following information for one week. For each bedtime, and for each nighttime waking, describe (1) what your child was doing and (2) what you did to respond to your child. Date Time Behavior at bedtime Person collecting data: What did you do to handle the problem? Behavior during awakenings What did you do to handle the problem?
Social story: Sleeping in my own room I like to sleep with Mom and Dad. Sleeping with Mom and Dad makes me feel safe. I know that when I close my eyes in Mom and Dad s room, I don t have to feel scared. But I have my own room. I keep all of my favorite things in my room. I have my toys and clothes in my room. My room is my own space, and I know everything that is in my room. I know a lot about the things in my room, so I know that I don t have to feel scared. When I feel scared about being in my own room, I can think of ways to make myself feel better. I can leave a light on or ask Mom or Dad to come check on me during the night. I know that I can sleep in my own room. It s my very own space, and I like that!
Melatonin The pineal gland in the brain secretes a hormone called melatonin in response to light-dark cycle Melatonin regulates body temperature, sleep cycle, hormone activity, and other circadian functions run by the body s internal biological clock At night, higher levels of melatonin are released to induce sleepiness; levels drop during early morning hours and throughout the day to promote alertness
Melatonin, cont. It has been hypothesized that children with ASD may manufacture either too much or too little melatonin Nightly melatonin supplementation may improve sleep patterns in up to 80% of children Should be given only once per day in small amounts, about ½ hour before normal bedtime body weight and diet are factors
Melatonin, cont. Melatonin supplements are known to lose their effect over time as the body accommodates to them When a low dose starts to lose its effect, STOP the melatonin for a short time, then restart, do NOT increase dosage restores sensitivity to the supplement Quick response rate (70-90%) but works better in conjunction with behavior therapy
Considerations for tackling sleep disorder Does my child only fall asleep under certain circumstances? Does my child need certain things in order to sleep? Can I make the bedtime routine more soothing by adding quiet music, stories, lotion, or massage? Do I make bedtime clear by stating, time for bed?
General tips for sleep disorder Maintain your bedtime routine Maintain sleep and wake times, even on weekends and holidays Encourage your child to be active throughout the day Encourage your child to exercise up to 4 hours before bedtime No vigorous physical activity in the hours before bedtime
General tips, cont. Your child s bed should be for sleeping only (and bedtime stories!) Be aware of the effects of foods, drinks, and meds, especially close to bedtime caffeine, upset stomach Milk and protein-rich foods may aide in sleep; high-fat foods may contribute to sleep disturbance
General tips, cont. Reduce surrounding noise, light, and other distractions, but be careful that these can be replicated outside of your home Avoid extreme temperature changes in the bedroom If your child has nighttime waking problems as well as bedtime problems, tackle the bedtime problems first
Thank you!