Falling asleep within minutes Staying asleep throughout the night - PowerPoint PPT Presentation

 Falling asleep within minutes  Staying asleep throughout the night  (or fall back asleep with ease)  Waking without much trouble  Not feeling drowsy during the day

 Sleep problems = skill deficit  Sleep is influenced by  Past experience  Present sleeping conditions  Ancestral history (genetics)  Cultural practice

 Unintentional injuries (Koulouglioti et al., 2008)  Difficult temperament (Richman, 1981)  Obesity (Bell & Zimmerman, 2010; Magee & Hale, 2012)  Poor school performance (Dewald et al., 2010)  Noncompliance  Aggression  Self-injury (Wiggs & Stores; 1996)

 Poor sleep quality (Meltzer & Mindell, 2007)  Poor daytime functioning (Meltzer & Mindell, 2007)  Maternal depression (Richman, 1981)  Marital discord (Chavin & Tinson, 1980)

Prevalent 63-73% 35-50% children with autism typically children (Polimeni et al., 2005; Souders et al., 2009) (Johnson, 1991; Polimeni et al., 2005)

• Spanking On their own • Staying with parents Pediatrician • 5 hr training (Mindell et al, 1994) • Outgrow problems • Persistent (Kataria et al., 1987; Zuckerman et al., 1987)

 81 % of children’s visits result in medication (Stojanovski, et al. 2007) ▪ No prescribing guidelines ▪ No drug approved by FDA ▪ Limited research on efficacy, tolerability and acceptability

• Naturally secreted hormone (pineal gland) • Rises just prior to sleep onset (when it gets dark) • Yields statistically significant improvement in sleep (Guenole et al. 2011)

 Efficacious (Kuhn & Elliott, 2003; Mindell, 1999;, Mindell et al., 2006) ▪ Lack of objective measure ▪ Not home-based ▪ Unacceptable strategy ▪ Not comprehensive ▪ Not based on individualized controlling variables

 Through a general understanding of the common factors that influence good sleep and sleep problems  Using an open-ended indirect assessment to identify the personal factors influencing the sleep problem  SATT (Sleep Assessment and Treatment Tool)  By encouraging parents to develop the intervention with us  we support parents in their implementation of the assessment- based treatment via phone calls and weekly visits

 3 children  Ages ranged from 7-9 years  Home

 Sleep diary  Infrared nighttime video recording

 History of sleep problems  Sleep goals  Specific sleep problems  routine noncompliance, night awakenings etc…  Conditions under which problem behavior occur  Interfering behaviors and possible reinforcers  Sleep dependencies and sleep schedule  Steps to guide a personalized intervention

 2 hour training session using behavioral skills training  Instruction  Modeling  Role-play  Feedback

120 Baseline Treatment Follow-up 100 Diary 80 Video 60 Walter 40 20 0 0.00 mg 0.25 mg Clonidine: 0.50 mg 120 Sleep Onset Delay (min) 100 80 60 40 Andy 20 0 0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg 120 Parent Presence 100 Time-based Visiting 80 60 40 Lou 20 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Nights

100 Baseline Treatment Follow-up 80 60 40 20 Walter 0 0.00 mg Clonidine: 0.50 mg 0.25 mg 100 Interfering Behavior (min) 80 60 40 20 Andy 0 0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg 100 Parent Presence 80 Time-based Visiting 60 40 20 Lou 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Nights

Treatment Baseline Sleep Onset Delay < 30 min Interfering Behavior < 2 min Met Night Waking = 0 min Unmet Walter Percent of Goal Sleep > 90% Sleep Onset Delay < 15 min Sleep Goals Interfering Behavior < 2 min Night Waking = 0 min Percent of Goal Sleep > 90% Disruptive Music = None Andy Clonidine = None * Sleep Onset Delay < 15 min Interfering Behavior < 2 min Night Waking = 0 min Percent of Goal Sleep > 90% Parent Presence = None Lou Melatonin and Benadryl = None 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 Nights

Table 1 Average Questions Walter Andy Lou (Range) 1.Acceptability of 7 6 7 6.7 (6-7) assessment procedures 2. Acceptability of 7 6 7 6.7 (6-7) treatment 3. Improvement in sleep 7 7 7 7 4. Consultation was helpful 7 6 7 6.7 (6-7) Note: Likert scale: 1 to 7. 1 (not acceptable, not satisfied, not helpful), 7 (highly acceptable, highly satisfied, highly helpful)

Personalized Comprehensive Assessment-based

EO + SD  Falling Asleep  Sleep  What alters the value of sleep as a reinforcer?

EO + SD  Falling Asleep  Sleep  What signals that the reinforcer is available (and prepares the body to “consume” the reinforcer), and are those signals available when the child wakes up multiple times each night?

EO + SD  Interfering behaviors  Sr  What other behaviors are occurring before and after the bid good night that are incompatible with falling asleep (i.e., that do not allow for behavioral quietude)?

EO + SD  Interfering behaviors  Sr  What reinforcers are available for behaviors that are incompatible with falling asleep?

EO + SD  Incompatible behaviors  Sr  What alters the value of these other reinforcers for behaviors that are incompatible with falling asleep?

EO + SD  Incompatible behaviors  Sr  What signals that these other reinforcers are available?

What makes sleep valuable?

 Recognize of age-appropriate sleep amounts

Age-Based Sleep Averages Age Total Sleep Night Sleep # Naps 2 11 hrs 30 min 9.5 hours 1 (2 hrs) 3 11 hrs 15 min 10 hours 1 (1hr15min) 4 11 hrs 10 -11 hours 0-1 5 10 hrs 45 min 6 10 hrs 30 min 9 10 hrs 12 9 hrs 45 min 15 9 hrs 15 min 18 9 hrs Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

Cautions:  child is expected to be in bed too long or too short of a time Implication: Select the right sleep total for child

Midday Dip in Alertness Forbidden Zone Alert Sleepy Nigh Day Nigh t t Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

 Caution: Putting children to bed during the Forbidden Zone will increase the likelihood of nighttime routine noncompliance , sleep onset delays, & interfering behavior

 We have a tendency to go to bed later and wake up later because of our 24.2 hr clock  Artificial light and nighttime activity availability leads to a 25-hour clock

Copied from: National Institute of Health (NIH) Sleep and Sleep Disorder’s Teacher’s Guide

 Implication: At the beginning of sleep treatment: set the start of the sleep routine slightly later than when the child fell asleep the previous night Then gradually transition sleep phase earlier if child falls asleep within 15 min move bedtime 15 min earlier next night until desired bedtime is achieved (Piazza et al., 1991)

Nighttime Routine Ambient Environment

 Prior to bid goodnight:  Activities progress from active to passive ▪ Arrange choices on picture schedule  Baths earlier in routine  Ambient light gets progressively dimmer  Light snacks without caffeine  After bid goodnight:  Cooler temperature  Indirect lighting only  Non-undulating noise

 Compliance with bedtime instructions

Tendency to not follow instructions or resist guidance to, for example, put on PJs, brush teeth, or get in bed. Solutions:  Start routine just prior to natural sleep phase  Promoting instruction following during the day  Arrange big discrepancy in consequences for compliance vs. noncompliance to routine  Avoid differential reinforcement with extinction

BL1 BL2 100 Precursor = Responding U = 11, p > .05 U = 0, p < .05 M % Precursors 80 effectively to one’s name = Individual Children Beaulieu et al., 60 stopping activity, looking at (2013, JABA ) teacher, saying, “Yes,” and 40 waiting until teacher says 20 something. 0 100 U = 12, p > .05 U = 4.5, p < .05 M % Compliance 80 60 40 20 0 Control Experimental Control Experimental Group

BL1 BL2 100 Precursor = Responding U = 11, p > .05 U = 0, p < .05 M % Precursors 80 effectively to one’s name = Individual Children 60 stopping activity, looking at teacher, saying, “Yes,” and 40 waiting until teacher says 20 something. 0 100 U = 12, p > .05 U = 4.5, p < .05 M % Compliance 80 60 Compliance = completing an instruction within 6 s 40 20 0 Control Experimental Control Experimental Group

BL1 BL2 100 U = 11, p > .05 U = 0, p < .05 M % Precursors 80 Individual Children 60 40 20 0 100 U = 12, p > .05 U = 4.5, p < .05 M % Compliance 80 60 40 20 0 Control Experimental Control Experimental Group

BL1 BL2 100 U = 11, p > .05 U = 0, p < .05 M % Precursors 80 Individual Children 60 40 20 0 100 U = 12, p > .05 U = 4.5, p < .05 M % Compliance 80 60 40 20 0 Control Experimental Control Experimental Group

What signals the availability of sleep? What helps to occasion sleep?

 Transitioning from laying in bed to falling asleep depends on stimuli associated with falling asleep