Is it Bedtime Yet?
By: Elizabeth Zeppernick, M.Ed., BCBA, LBA
Sleep related problems are seen in both children who are typically developing and those with developmental disabilities. Sleep problems occur at a higher rate in children with neurodevelopmental disabilities such as autism spectrum disorder (Kotagal & Broomal, 2012). There are profound consequences when children sleep poorly and this includes impaired daytime functioning (O’Brien, 2013), stress on caregivers (Meltzer & Mindell, 2007), health risks (Colton & Altevogt, 2006), and the presentation of day time challenging behavior (Eshbaugh et al., 2004). Sleep interventions designed with the principles of Applied Behavior Analysis have the potential to improve learning, health, and quality of life for both the child and parents.
In the article, Applied Behavior Analysis Measurement, Assessment , and Treatment of Sleep and Sleep-Related Problems, (2020) James K. Luiselli outlines some common sleep concerns-
Delayed Sleep-Onset: This is when a child is put to bed but doesn’t fall asleep within a reasonable amount of time.
Night Waking: The child falls asleep at bedtime but wakes, sometimes many times during the night.
Early-Morning Waking: The child wakes up and remains awake before getting a complete night’s sleep.
Bedtime Resistance: When prompted to bed, the child exhibits behaviors such as screaming, crying, tantrums and both environmental and physical aggression.
Sleep Dependency: The child is not able to fall asleep without accessing certain activities or items.
Unwanted Co-Sleeping: Children who regularly sleep in their parent’s bed contrary to the parent’s preference.
Heightening the stress and complexity related to treatment of these concerns, sometimes children demonstrate several of these sleep problems at once! Sleep disturbance is based on a multitude of factors which can be environmental, behavioral, neurodevelopmental and biological (Mindell et al., 2006). This makes the accurate assessment of factors that contribute to sleep problems, particularly crucial. Measurement methods have traditionally included sleep questionnaires and sleep diaries but it must be said that these can be subjective and vulnerable to biases so the results should be verified by direct observation. When possible, direct measurement should be used where real-time data is being collected by clinicians, researchers and care providers. Direct measurement can include video recording, motion detectors, and wearable sensor devices.
In his article, Luiselli summarized several studies which outline examples of effective interventions to address sleep-related problems. Some of these strategies are outlined below:
Faded Bedtime: The clinician determines the average time a child falls to sleep and then sets a bed time that is 30 minutes later. Each night the bedtime is adjusted either 30 minutes before or after the time it took the child to fall asleep the night before.
Faded Bedtime with Response Cost: A Response Cost can be added which, in a study by Piazza and Fisher (1991) meant that if the child didn’t fall asleep within 15 minutes of their scheduled bedtime, they were kept awake and out of their bedroom for 60 minutes before repeating the faded bedtime routine.
Control the Attention: If seeking caregiver attention is a contributing factor, the parent can initiate consistent bedtime routines, followed by a consistent bedtime and then the parent can return to the child’s bedroom at fixed intervals to give attention until the child falls asleep (O’Reilly et al. 2004).
Free Trip: Another similar strategy is to withhold attention by ignoring bedtime resistance after a child is put to bed. Friman et al. (1999) created an intervention that included a card which could be traded for one “free trip” out of their bedroom or to request a visit from the parent. Further attempts for attention were ignored.
Excuse Me Drill: The Excuse Me Drill (Kuhn et al. 2019) is when a child is put to bed after consistent routines, and the parent excuses themselves for only a few seconds before coming back to praise behaviors that are seen as positive (quiet, staying in bed, etc.) before excusing themselves again. The duration of the “Excuse me” trips out of the bedroom are gradually increased until the child is asleep. In this strategy, disruptive behavior is also ignored.
The interventions outlined above are only a sampling of ABA treatments for sleep problems. Thoughtful and effective interventions are particularly key given the approaches require significant dependence on the parents as in person supervision and support from a clinician is not always readily available late at night, during sleeping hours and early in the morning. For this reason, whichever care package or multi package approach is used, it is crucial that the approach is seen as practical and reasonable in the eyes of the caregivers.
Sources:
Colton, H. R, & Altevogt, V. M. (Eds.) (2006). Sleep disorders and sleep deprivation: An unmet health problem. National Academics Press. https://www.nap.edu/catalog/11617/sleep-disorders-and-sleep-deprivation-an-unmet-public-health-problem
Eshbaugh, B., Martin, W., Cunningham, K., & Luiselli, J.K. (2004). Evaluation of a bedtime medication regimen on daytime sleep and challenging behaviors of an adult with intellectual disabilities. Mental Health Aspects of Developmental Disabilities, 7, 21-25.
Friman, P. C., Hoff, K. E., Schnoes, C., Freeman, K. A., Woods, D. W., & Blum, N. (1999). The bedtime pass: An approach to bedtime crying and leaving the room. Archives of Pediatric and Adolescent Medicine, 153(10), 1027--1029. https://doi.org/10.1001/archpedi.153.10.1027.
Kotagal, S., & Broomall, E. (2012). Sleep in children with autism spectrum disorder. Pediatric Neurology, 47(4), 242-251. https://doi.org/10.1016/j.pediatrneurol.2012.05.007.
Kuhn, B. R., LaBrot, Z. C., Ford, R., & BRoane, B. M. (2019). Promoting independent sleep onset in young children: Examination of the Excuse Me Drill. Behavioral Sleep Medicine. https://doi.org/10.1080/15402002.2019.1674852.
Luiselli, J. K. (2020). Applied behavior analysis measurement, assessment, and treatment of sleep and sleep-related problems. Journal of Applied Behavior Analysis. 2020; 1-14. https://onlinelibrary.wiley.com/doi/10.1002/jaba.774
Meltzer, L. J., & Mindell, J. A. (2007). Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: A pilot study. Journal of Family Psychology, 21(1), 67-73. https://doi.apa.org/doiLanding?doi=10.1037%2F0893-3200.21.1.67.
Mindell, J. A., Kuhn, B., Lewin, D. S., Meltzer, L. J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29(10), 1263-1276. PMID: 17068979.
O’Brien, L. M. (2013). Neurocognitive implications. In A. R. Wolfson & H. Montgomery-Downs (Eds.), The Oxford handbook of infant, child, and adolescent sleep: Development and behavior (pp. 414-428). Oxford University Press.
O’Reilly, M. F., Lancioni, G. E., & Sigafoos, J. (2004). Using paired-choice assessment to identify variable maintaining sleep problems in a child with severe disabilities. Journal of Applied Behavior Analysis, 37(2), 209-212. https://doi.org/10.1901/jaba.2004.37-209.
Piazza, C. C., & Fisher, W. (1991). A faded bedtime with response cost protocol for treatment of multiple sleep problems in children. Journal of Applied Behavior Analysis, 24(1), 129-140. https://doi.org/10.1901/jaba.1991.24-129.
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