Sleep is an essential restorative process for every child’s body and brain. Sleep has been shown to promote growth of one’s muscles, bones, and skin, help protect the heart, combat germs, sickness, and injuries, and impact one’s weight. Further, research has shown that sleep helps individuals remember what they learn, increases children’s attention span and concentration, and boosts learning, including children’s ability to solve problems and think of new ideas (Souders et al., 2009).
Rebecca Schulman, PsyD, BCBA-D
Unfortunately, many children experience sleep problems, which affect their functioning academically, socially, and behaviorally. In fact, 10-50% of typically developing young children and 50-80% of youth with developmental disabilities have sleep problems (Abel, Kim, Kellerman, & Brodhead, 2017; Jin, Hanley, & Beaulieu, 2013). Children with autism spectrum disorder are at a higher risk for sleep problems and have been identified as one of the highest priority populations for sleep research (Souders et al., 2009; Abel et al., 2017). The underlying cause of sleep impairments may include behavioral factors, medical factors, biological factors, or an interaction of multiple factors (Krakowiak, Goodlin-Jones, Hertz-Picciotto, Croen, & Hansen, 2008).
Sleep problems not only cause frustration and discord among caregivers, but are also associated with higher levels of severe daytime problem behavior (e.g., tantrums, aggression, and self-injury), stereotypy, and noncompliance (Abel et al., 2017; Goldman et al., 2011; Jin et al., 2013; Krakowiak et al., 2008). Sleep problems may also interfere with learning, attention span, emotion regulation, and social interactions (Goldman et al., 2011; Souders et al., 2009). Additionally, persistent sleep problems in childhood are associated with childhood and adult obesity, adolescent behavioral and emotional problems, anxiety in adulthood, and sleep problems through adulthood (Jin et al., 2013).
However, the good news is that sleep problems can be considered a skill deficit and most children can learn to be better sleepers with the use of behavior therapy. To date, there is no FDA approval for any pediatric sleep medication, there is no medication labeled for pediatric insomnia, and research does not show evidence of consistent efficacy for pharmacological interventions. Although medication may help children fall asleep quicker, it often leads to a greater amount of night awakenings. Therefore, behavior therapy is a more effective, long-term solution for sleep problems.
The first step to addressing sleep problems is assessing the specific sleep difficulties experienced by a child and identifying goals for the child’s sleep. “Good sleep” is often characterized by falling asleep quickly, staying asleep throughout the night, waking up without much trouble each morning, and not feeling drowsy during the day. Common sleep problems in children with autism include delayed sleep onset, which can include sleep-interfering behavior (e.g., crying, calling out, playing, stereotypy, talking to oneself, etc.), night or early awakenings, short sleep duration, and phase shifts (i.e., sleeping at wrong times, thus conflicting with daily routines) (Jin et al., 2013; Krakowiak, et al., 2008). Children’s sleep problems are typically assessed using an open-ended interview and sleep questionnaires to identify the personal factors influencing sleep problems. This information is then combined with general information about common factors that influence good sleep and sleep problems in order to develop treatments in collaboration with parents based on the controlling variables. A child’s sleep behavior may be affected by the value of sleep for that individual at any given time, environmental cues, and the degree to which behaviors other than sleeping are reinforced at night.
Individualized and comprehensive treatment consists of five steps: 1) Develop an ideal sleep schedule, 2) Create a structured nighttime routine, 3) Optimize bedroom conditions, 4) Develop regular sleep dependencies, and 5) Address sleep interfering behavior (Abel et al., 2017; Jin et al., 2013). When creating a sleep schedule, it is essential to consider age-appropriate sleep amounts and recent sleep history. It is important that parents do not try to put their children to bed too early, as this can increase the likelihood of nighttime routine noncompliance, sleep onset delays, and sleep-interfering behavior. During the initial stages of sleep treatment, parents should put their children to bed approximately one hour later than when they typically fall asleep to ensure that they are sufficiently tired when going into bed. If the child falls asleep within 15 minutes, the child’s bedtime should be moved 15 minutes earlier the following night. This progression should continue until the desired bedtime is achieved (Abel et al., 2017; Piazza & Fisher, 1991). As part of a child’s bedtime routine, activities should progress from more active to more passive (e.g., bath time should be earlier in the routine, so as not to alter the descent of the child’s core body temperature, while reading books should be later in the routine). Further, ambient light should get progressively dimmer to assist with the release of endogenous melatonin (Jin et al., 2013).
Additionally, there are several environmental conditions that can assist a child in falling asleep, including cooler temperature, indirect lighting only, white noise, and ensuring that preferred toys/activities are not visible (Abel et al., 2017; Jin et al., 2013). It is also crucial to help children develop sleep dependencies on things that are routinely and easily present throughout the night. Therefore, it is essential that children do not become dependent on their caregivers or other items/activities to fall asleep that would not be present in the middle of the night so that they are more likely to successfully fall asleep on their own. There must also be a clear discrepancy between what is available during the day versus at night to ensure good sleep.
In order to address nighttime noncompliance, parents should begin the bedtime routine just prior to their child’s natural sleep phase, as well as promote compliance during the day. Additionally, children may be given the opportunity to earn additional reinforcement for compliance (e.g., compliance results in getting to stay up longer, reading a longer book or more books, having an extra snack, additional stickers or tokens, etc.). Finally, it is helpful to assess the specific function, or purpose, of the interfering behavior (e.g., access to attention or preferred items, escape/avoidance of the dark or the bedroom) and then create interventions based on the specific function of the behavior (Jin et al., 2013).
Addressing children’s sleep problems may seem daunting. However, sleep difficulties typically persist without treatment. A thorough assessment and consistent use of behavioral strategies can greatly improve children with autism’s ability to fall asleep and stay asleep. Isn’t it time that everyone got a good night’s sleep and experience its benefits?
For more information, contact Dr. Schulman at rschulman@behaviortherapyassociates.com.
References
Abel, E., Kim, S.Y., Kellerman, A.M., & Brodhead, M.T. (2017). Recommendations for identifying sleep problems and treatment resources for children with autism spectrum disorder. Behavior Analytic Practice, 10(3), 261-269.
Goldman, S.E., McGrew, S., Johnson, K.P., Richdale, A.L., Clemons, T., & Malow, B.A. (2011). Sleep is associated with problem behaviors in children and adolescents with Autism Spectrum Disorders. Research in Autism Spectrum Disorders, 5(3), 1223-1229.
Jin, C. S., Hanley, G. P., & Beaulieu, L. (2013). An individualized and comprehensive approach to treating sleep problems in young children. Journal of Applied Behavior Analysis, 46, 161-180.
Krakowiak, P., Goodlin-Jones, B., Hertz-Picciotto, I., Croen, L.A., & Hansen, R.L. (2008). Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: A population-based study. Journal of Sleep Research, 17(2), 197-206.
Piazza, C.C., & Fisher, W.W. (1991). Bedtime fading in the treatment of pediatric insomnia. Journal of Behavior Therapy and Experimental Psychiatry, 22(1), 53-56.
Souders, M.C., Mason, T.B.A., Valladares, O., Bucan, M., Levy, S.E., Mandell, D.S., Weaver, T.E., Pinto-Martin, J. (2009). Sleep behaviors and sleep quality in children with Autism Spectrum Disorders. Sleep, 32(12), 1566-1578.
