Download - ABAI Sleep 2016 · 2016-05-27 · Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006 Copied from: National Institute of Health (NIH) Sleep and

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GregoryP.Hanley.Ph.D.,BCBA‐D

SleepProblemsofChildrenwithAutismPrevalent,Relevant,andTreatable

byBehaviorAnalysts

ABAIMay,2016

Formoreinformation(tutorial,etc.),goto:www.practicalfunctionalassessment.com

Learnmorebyreadingthesleepresearcharticlesauthoredbythesebehavioranalysts:

NevilleBlampiedRichardBootzinMarkDurandKarenFrancePatrickFrimanCarlMerleJohnsonCathleenPiazza

CommonSleepProblems

Delayedsleeponset(longlatencytofallasleep)‐Sleep‐interferingbehavior

‐crying,callingout,curtaincalls,playing,stereotypy,talkingtooneself,etc.

Nightawakenings/Earlyawakenings

Shortsleepduration

Phaseshifts(sleepingatwrongtimesthusconflictingwithdailyroutines)

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SleepProblemsofChildrenwithAutism

(1)Prevalent

(2)Donotabateovertime


(3)Probablyanchoringchildren’sdeficits(Interferewithskilldevelopment)


(4)Worsenmaternalmentalhealth(negativelyaffectfamilyfunctioning)

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(5)Probablynotcauseddirectlybytheuniqueneurobiologyofchildrenwithautism

(6)Bestunderstoodasalearningissue


(7)Worsenedbythemostcommontreatments


(8)Meaningfullyaddressedwithcomprehensive treatmentsthatinvolvechangestothevariablesintwocompetingcontingencies

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(9)Bestsolvedbyfirstunderstandingthechild‐specificvariablesoperatingontwocompetingbehaviors:

behavioralquietudevsinterferingbehavior


(10)Maybeaddressedbestbybehavioranalysts

Sleepproblemsareprevalent,especiallyforchildrenwithautism

10‐50%ofchildrenwithoutautism

50‐80%ofchildrenwithautism

Wiggs &Stores JIntellectDisabil Res 1996Richdale DevMedChildNeurol 1999Schreck &Mulick JAutismDevDisord 2000Couturieretal. JAmAcad ChildAdolesc Psychiatry 2005Malow etal. Sleep 2006Krakowiak etal. JSleepRes 2008Richdale &Schreck SleepMedRev 2009Souders etal. Sleep 2009Cortesi etal. SleepMedicine 2010

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Hodgeetal.,2014,ResinDevDis

%ofchildrentoreceiveCSHQscoreof41orabove

ASDgroup(%)TDgroup(%)




Allages(n=216) 82 50





Ages3–5(n=50) 84 72

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Ages3–5(n=50) 84 72

Ages6–9(n=118) 78 46





Ages3–5(n=50) 84 72

Ages6–9(n=118) 78 46

Ages10–17(n=48) 88 38

Sleepproblemsgenerallydonotresolveontheirown,especiallyforchildrenwithautism




Ages3–5(n=50) 84 72

Ages6–9(n=118) 78 46

Ages10–17(n=48) 88 38

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Whatisdifferentaboutchildrenwithautismandchildrenoftypicaldevelopmentwithregardstosleep?

Suspects: Sleeparchitecturee.g.,DurationandqualityofREMsleep

NeurotransmittersandrelatedbiochemicalpathwaysSerotoninlevelsEndogenousmelatoninlevels

ASMT(melatoninbiochemicalpathway)GABAGABAergicinterneurons

Clockgenese.g.,Per3,BMAL,CRY

Itisstillnotclearwhetherthereisanythingphysiologicallyuniqueaboutchildrenwithautismthatiscontributingtotheirsleepproblems

E.g.,DurationandqualityofREMsleep

REMsleep:Longsuspectedofbeingofshorterdurationandlowerqualityamongchildrenwithautism

Tanguay etal. JAutismChildSchizophr 1976Diomedi etal. BrainDev 1999Thirumalai etal. JChildNeurol 2002Buckleyetal. ArchPedatr Adolesc Med 2010


Malow etal.(Sleep,2006)

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Malow etal.(Sleep,2006)showednodifferenceinsleepstructure,includingqualityanddurationofREMsleepbetweenchildrenwithandwithoutautism

Importantconsiderations:

• OnlyMalow etal.restrictedtheirstudytochildrenwithnohistoryofpharmacologicalintervention

• Manydrugsgiventochildrenwithautismtofacilitatesleeponsetortoaddressirritability/problembehaviornegativelyaffectthedurationandqualityofREM

Itisstillnotclearwhetherthereisanythingphysiologicallyuniqueaboutchildrenwithautismthatiscontributingtotheirsleepproblems

Whatelseiscorrelatedwithsleepproblemsofchildrenwithautism?

Richdale DevMedChildNeurol 1999Schreck etal. ResinDevDis 2004Malow etal. PedNeurol 2006Malow etal. Sleep 2006Liuetal. ChildPsychiatry&HumDev 2006Krakowiak etal. JSleepRes 2008Richdale &Schreck SleepMedRev 2009Goldmanetal. DevNeuropsychology 2009Cortesi etal. SleepMedicine 2010Hollway &Aman ResinDevDis 2011Sikora etal. Pediatrics 2012DelaHaye etal. ResinAut SpecDis 2013

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CorrelatesofSleepProblemsforChildrenwithautism

Cognitiveimpairment/IQ: NoAutismSymptomSeverity

languageimpairment: Nosocialreciprocity: Yesritualistic/repetitivebeh.: Yes

stereotypy YesSevereproblembehavior: YesPooradaptiveskilldevelopment: YesComorbidconditions

ADHD Yesallergies: Yesasthma: YesGIproblems: Yesanxiety: Yesdepression: Yes

Health‐relatedqualityoflife: Yes

Example:

Limitedhoursofsleeping negativelycorrelatedwithratesofstereotypy

CorrelatesofSleepProblemsforChildrenwithautism

Cognitiveimpairment/IQ: NoAutismSymptomSeverity

languageimpairment: Nosocialreciprocity: Yesritualistic/repetitivebeh.: Yes

stereotypy YesSevereproblembehavior: YesPooradaptiveskilldevelopment: YesComorbidconditions

ADHD Yesallergies: Yesasthma: YesGIproblems: Yesanxiety: Yesdepression: Yes

Health‐relatedqualityoflife: Yes

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Screeningforthecorrelates

Reynolds&Malow Pediatr Clin NAm 2011

SeethisarticleforaScreeningChecklist:

Mayachievemoretraditionalobjectivesifyouresolvethesleepproblem

Improvecompliancewithinstructions

Decreasesevereproblembehavior

Gainstimuluscontroloverstereotypy

Decreasetrialstomastersocialandacademicskills

…

(thisisamostimportantareaofresearch)

Mayachievemoreextraordinaryobjectivesifyouresolvethesleepproblem

ImproveparentalsleepproblemsMiminize maternalstress,malaise,anddepressionEnhanceFamilyfunctioning/qualityoflife

Sadah etal. Dev.Psych. 2000Meltzer&Mindell JFamPsychol 2007Hoffmanetal. FocusonAutandOthDevDis 2008Meltzer ResinAutSpecDis 2011Hodgeetal. JAut &DevDis 2013

(thistooisanimportantareaofresearch)

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Mindelletal. Pediatrics 1994

Pediatriciansreceiveonlyabout5hoursoftrainingonsleepproblems

Owensetal. Pediatrics 2001

Inasurveyof626pediatriciansinNewEngland,only25% ratedthemselvesasconfidentintreatingpediatricsleepproblems.

Maybesomeotherhelpingprofessionalswilladdresstheproblem?

Stojanovski etal. JSleep&SleepDisRes 200781%ofchildren’svisitstopediatricians,psychiatrists,orfamilyphysiciansforsleepproblemsresultinaprescriptionforamedication

Owensetal. Pediatrics 2013Familiesofchildrenwithautismaretwiceaslikelytoreceiveprescriptiontoaddressinsomniaoftheirchildren

despitenoFDAapproval,nomedicationlabeledforpediatricinsomnia,no(orinconsistent)efficacysignalinliterature

Maybesomeotherhelpingprofessionalswilladdresstheproblem?

From:NationalAcademyofSciences,CommitteeonSleepMedicineandResearch,BoardonHealthSciencesPolicy(2006)

“Therehavebeennolarge‐scaletrialsexaminingthesafetyandefficacyofhypnoticsinchildrenandadolescents.Otherpharmacologicalclassesusedforinsomniaincludesedatinganti‐depressants,antihistamines,andantipsychotics,buttheirefficacyandsafetyfortreatinginsomniahavenotbeenthoroughlystudied.”

TreatmentOptions?

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Part1: PersonalizeSleepSchedule

Part2:RoutinizeNighttimeRoutine

Part3: OptimizeBedroomConditions

Part4: RegularizeSleepDependencies

Part5:MinimizeSleepInterferingBehavior

Freedomfromsleepproblemsispossibleandprobablewith:

Individualizedassessment

Individualizedandcomprehensivetreatment:Tolearnmore,gotowww.practicalfunctionalassessment.comFor:

Video‐tutorialWorkbookDownloadableassessmentHandoutforparentsPowerpointPeer‐reviewedarticle

Howdoweassessandtreatchildren’ssleepproblem?

• Withanopen‐endedinterviewstoidentifythepersonalfactorsinfluencingthesleepproblem– SATT:SleepAssessmentandTreatmentTool

• Throughageneralunderstandingofthecommonfactorsthatinfluencegoodsleepandsleepproblems

• Bydevelopingtreatmentswith parentsbasedonthecontrollingvariables

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Assumptions

• Behavioralquietude/Fallingasleeparethebehaviorsofinterest– Blampied andFrance,1993;Bootzin,1972

• Isinfluencedbypastandpresentexperiencesinone’ssleepingenvironment

– canbemotivated(ordemotivated)– canbecomereliantonenvironmentalcues– canbeaffectedbyotherreinforcersforotherbehaviorsavailableatnight

Lookingthroughthelensofacontingency

Conductacontingencyanalysis:

EO+SD BehavioralQuietude Sr

• Thatwhichisknown:

– Reinforcer (Sr)forbehavioralquietudeissleep


Conductcontingencyanalyses:

EO +SD BehavioralQuietude Sleep?

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Ingeneral,

childrenneedlesssleepastheygetolder.

Saidanotherway,

Sleepisvaluableforlesstimeaschildrengetolder

Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

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

Ingeneral,

Sleepismorevaluableanhourlaterthanthetimeachildfellasleeponthepriornight

Thevalueofsleepmaybeatitslowestatthefamily‐expectedbedtime

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Night NightDay

Alert

Sleepy

Forbidden Zone

Midday Dip in Alertness

Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006

Thevalueofsleepmaybeatitslowestatthefamily‐expectedbedtime

Lookingatbehavioralquietudethroughthelensofacontingency

AbolishingOperations +SD FallingAsleep Sleep

Whatdecreasesthevalueofsleepwhenachildisputtobed?

– Havingsleptwithin6hoursofbeingputtobed(e.g.,catnapsoncouch)– Havingslepttoomanyhoursthepreviousnight– Beingputtobedin“forbiddenzone”(2‐3)hourspriortonaturalsleepphase– Caffeinewithin6hoursofbeingputtobed– Exercise,hotbath,wrestlingwithparentrightbeforebedtime– Availabilityofotherreinforcers afterthebidgoodnight

• socialreinforcers likeparentalattention/interaction/affection• automaticreinforcers viaiPad,televisionormovies,internetbrowsing,etc.• automaticreinforcers viastereotypyorritualisticbehavior

– Overlywarm,bright,ornoisysleepcontext

Lookingatbehavioralquietudethroughthelensofacontingency

EO +SD BQ Sleep

Whatincreasesthevalueofsleepasareinforcer forBQ?

– Sleepingonthepreviousnightfororjustunderthenumberofhoursofsleepneededgivenage

– Beingputtobedatthesametimeorslightlylaterthanwhenonefellasleepthenightbefore(andgraduallyfadingbacktodesiredtime)

– Limitingdaytimehoursofsleep(nappingforlessthan20min)– Extendinghourssincelastslept(notnappingafter3pm)– Dimminglightspriortobedtime/Makingbedroomdarker– SchedulingaccesstoliteraryclassicslikeBeowulf– Gradualtransitionbetweendentobed(minimizerichtoleantransition)

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EO+SD BehavioralQuietude Sleep?

Thingsthatoccasionsleeparenotpresentwhenthechildwakesupduringthenight=NightAwakenings

Thingsthatoccasionsleeparesuddenlyremovedorinconsistentlyavailable=SleepOnsetDelayandpossiblysleepinterferingbehavior

TroublesomeSDsduetotheirinconsistentpresencewhenchildrenwakeupduringthenight:TV,radio,bottles,“fullbelly,”presenceofanotherperson,beingrockedorpatted,lights,fallenstuffedanimals

EO+SD BehavioralQuietude Sleep

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Occasionsleepwiththingsthat:don’trequireparentalpresence,canbetheretheentirenight,andaretransportable

(e.g.,forvacationsornightsatGrandparent’shome)

Suchas:pillow,blanket,stuffedanimal(withbedrails),soundmachineoncontinuous

Forquer &Johnson ChildandFamBeh Ther 2005

Eliminateorfade“bad”onesandreplacewith“good”ones

EO+SD BehavioralQuietude Sleep



EO +SD BehavioralQuietude Sleep? ?

?? ? ?


EO +SD Interferingbehaviors Sr‐ &Sr+

EO+SD Interferingbehaviors Sr‐ &Sr+

Behaviorsthatinterferewithbehavioralquietudenecessaryforfallingasleep

Commonforms:

leavingbed(curtaincalls)crying/callingout

playinginbedorinbedroom(thisincludesmotororvocalstereotypy)

talkingtooneself

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Considerpossiblereinforcer(s):

Attention,Interaction

Food,drink

AccesstoTVortoys

Escape/avoidanceofdarkorofbedroom

Automaticreinforcers

(thosedirectlyproducedbythebehavior)

Combinationofoneormore

EO+SD Interferingbehaviors Sr‐ &Sr+

Considerpossiblereinforcer(s):

Attention,Interaction

Food,drink

AccesstoTVortoys

Escape/avoidanceofdarkorofbedroom

Automaticreinforcers

(thosedirectlyproducedbythebehavior)

Combinationofoneormore

EO+ SD Interferingbehaviors Sr‐ &Sr+

1. Providethepresumedreinforcerpriortobiddingthechildgoodnight

2. RemoveSDsforreinforcers forinterferingbehavior

3. Afterbidgoodnight,disruptcontingencybetweeninterferingbehavioranditsreinforcement

e.g.,Time‐BasedVisiting,BedtimePass

EO+ SD Interferingbehaviors Sr‐ &Sr+1 2 3

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EO +SD BehavioralQuietude Sleep? ?

?? ?


EO +SD Interferingbehaviors Sr‐ &Sr+



EO+SD BehavioralQuietude Sleep1

EO+SD Interferingbehaviors Sr‐ &Sr+3 4 5

2

Establishvalueofsleepasreinforcer

Developstimuluscontroloverbehavioralquietudeinbedroom

Weakenvalueofreinforcers forSLIB

WeakenstimuluscontroloverSLIB

DisruptcontingencybetweenSLIBanditsreinforcement

1

2

4

3

5

BehavioralProcessAims

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Part5:MinimizeSleepInterferingBehavior(SLIB)

Establishvalueofsleepasreinforcer


WeakenstimuluscontroloverSLIB


Weakenvalueofreinforcers forSLIB

DisruptcontingencybetweenSLIBanditsreinforcement

NormalizedAims BehavioralProcessAims

1

2

4

2

3

5

Atypicalcaseexample

Ray

4‐year‐old‐boywithAutismandhyperactivity

Parentstriedmultiplemedicationsforsleepproblemsandphysicallyrestrainedhimtosleepeachnight

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Part1: PersonalizedSleepSchedule

Part2:RoutinizedNighttimeRoutine

Part3: OptimizedBedroomConditions

Part4: RegularizedSleepDependencies

Part5:MinimizedSleepInterferingBehavior

Part1: PersonalizedSleepSchedule

Part2:RoutinizedNighttimeRoutine

Part3: OptimizedBedroomConditions

Part4: RegularizedSleepDependencies

Part5:MinimizedSleepInterferingBehavior





Part5:MinimizeSleepInterferingBehavior

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SocialAcceptabilitySurvey(Parents)

Bedtime pass(DRA)

Extinction

Time‐basedVisiting(NCR)

Reinforcement only if handed a pass

No reinforcement (period)

Reinforcement available according to time

Contingencies

Whichismoreeffectiveandpreferredforaddressingsleepinterferingbehavior?

(Jin &Hanley,inprep.)

Treatments

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Bedtime pass

Blue Card

Green Card

RedCard

Extinction

Time‐basedVisiting

Reinforcement only if handed a pass

No reinforcement (period)

Reinforcement available according to time

Contingencies

Just prior to bed, the children were allowedto choose the treatment for each night

TreatmentsTreatment‐CorrelatedStimuli

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Formoreinformationgoto:www.practicalfunctionalassessment.com

Contactinfo.:GregoryP.Hanley,Ph.D.,BCBA‐D

PsychologyDepartmentWesternNewEnglandUniversity

1215WilbrahamRoadSpringfield,Massachusetts01119

[email protected]