I am a home program coordinator who works with a six-year old child diagnosed with autism. The parents are concerned because their child struggles at bedtime and will often wake up in the middle of the night to come into their room. The parents want their child to stay asleep and have tried everything to get him to stay in bed all night. What can I suggest they do to treat their child's sleep behavior?
Answered by Lauren Schnell, BCBA, Children’s Specialized Hospital
Sleep disturbances in children with autism are a common concern for many parents. It has been estimated that approximately 25% of typical children between the ages of one and four struggle with nighttime wakings (Lozoff, Wolf, & Davis, 1985). For children with special needs, the number increases dramatically with upwards of 80% experiencing some type of sleep problems (Lamberg, 1994). Of those who frequently wake at night, the majority end up sleeping in their parent’s bed, and the sleep problems often persist over time.
The good news is there are a variety of behavior analytic approaches found to be effective in addressing sleep disturbances in children with autism. An underlying premise of these approaches is that poor sleep patterns are learned, and, as such, can be unlearned.
Prior to implementing a behavioral sleep program, it is important to first rule out any medical reasons for the sleep disturbance, such as physical discomfort related to an illness. Discussions with a pediatrician should help to determine if the sleep issues may be associated with an underlying medical issue and if further testing or evaluation is warranted.
If the sleep issues are thought to be behavioral, the first step is to complete a sleep log to determine the extent of the problem and potential environmental factors that may be adversely affecting the child’s sleep. A sleep log outlines the time the individual is put into bed, the actual time he/she falls asleep, frequency of night wakings, and the duration of those awakenings. Additional information may be collected on any other behaviors which are observed during bedtime, such as tantrums during the bedtime routine or disruptive behavior during the night. Baseline data collection should continue until a consistent pattern of sleep (or lack thereof) or challenging behavior is apparent. This information can later be used to assess the effectiveness of the sleep intervention.
Some questions which may be helpful for parents in completing the sleep log are:
• What time does the child go to bed?
• What does the child do leading up to bedtime?
• What else is going on in the home while the child is in bed which could be influencing his/her sleep?
• What activities does the child engage in prior to falling asleep?
• What time does the child awaken during the night as well as in the morning?
• Does the child take naps during the day?
Based upon the results of the baseline data collected in the sleep log, a number of interventions may be considered. Below are several practical strategies which may be helpful to improve the sleep behavior of the child with autism.
A bedtime routine can be helpful for the child, as it creates predictability in the sequence of activities leading up to bedtime. A written or visual schedule may be helpful in ensuring the routine is consistently followed. The schedule should outline activities preceding bedtime; for example, brushing teeth, changing into pajamas, saying goodnight to loved ones, and reading a bedtime story. The routine should begin at least 30-60 minutes prior to bed time. It is also recommended that parents eliminate all foods and drinks containing caffeine at least six hours prior to bed, and avoid rigorous activities during the later evening hours.
Initially, the child may need a high rate of positive reinforcement for following the routine. Eventually, the parent may consider providing the child with positive reinforcement the following morning if he/she successfully follows the nighttime activity schedule and remains in bed throughout the night. Such reinforcement might include earning access to a favorite breakfast cereal, a toy, or getting a sticker to put on a special chart upon waking (Mindell & Durand, 1993).
The manipulation of bedtime routines does not always result in successful treatment of sleep disturbances, necessitating further intervention. The choice of procedure largely depends upon when the sleep disturbances occur. In situations where the child has difficulty falling asleep or wakes multiple times throughout the night, an escape extinction procedure may be used. Escape extinction is a commonly used intervention which involves preventing or removing access to the reinforcement which has previously maintained the behavior. During this procedure, the parent implements the nightly sleep routine culminating in placing the child in bed and leaving the room. Each time the child wakes up and attempts to leave the room, the parent redirects the child back to bed with minimal discussion and interaction. This procedure should be repeated until the child stays in his/her own bed and falls asleep (Rickert & Johnson, 1988; France, Blampied, & Wilkinson, 1991).
When implementing escape extinction protocols, it is essential to ensure the child is kept safe from harm. For example, if the child engages in severe problem behavior such as self-injury, or disruptions such as climbing on furniture, a modified extinction program may be implemented. This involves the parent staying in the room to monitor the child’s safety with minimal interaction. In addition, the parent may consider using a video monitoring system so the child can be monitored from a different room to ensure his or her safety.
Graduated Escape Extinction
When an escape extinction procedure cannot be used, the parent may implement a graduated extinction intervention. This treatment procedure should be used when the child has difficulty falling asleep, wakes frequently during the night, and engages in nighttime tantrum behavior. Similar to the escape extinction procedure, a graduated procedure begins by putting the child to bed and leaving the room (Durand, 1998). When crying or tantrum behavior occurs, the parent will wait a designated amount of time before going back into the child's bedroom. The latency of this response will systematically increase until the child falls back to sleep before the parent enters (Durand & Mindell, 1990).
Bedtime Fading with Response Cost
Another option is a faded bedtime with response cost (Piazza & Fisher, 1991) procedure. This involves first determining the actual time that the child falls asleep once placed in bed (as noted in the sleep log) and adding an additional 30 minutes to the child’s subsequent bedtime. For example, if the child is put into bed at 8:00pm and falls asleep at 8:30pm, the assigned bedtime would now be moved to 9:00pm. Once the time is set, it is important that the child be kept awake until 9:00pm to increase the likelihood that he/she will be tired at the appointed bedtime. If the child falls asleep within 15 minutes of being placed in bed, then the bedtime should be faded back by reducing the time by 30 minutes the next night (9:00pm bedtime goes down to 8:30 pm). If the child does not fall asleep within 15 minutes of being placed in bed, then he/she will be brought out of the bed for approximately 15 minutes. During that time, the child will not be encouraged to fall asleep nor should he/she be engaged in any excitable activity. The purpose is to increase the motivation to sleep. At the end of the 15 minute interval, the child will be placed back into bed. This procedure will be repeated until the child falls asleep. The bedtime would then be set for 30 minutes later on the following night (increased from 9:00pm to 9:30pm). This cycle should be repeated until the child falls asleep at the time designated by the parents.
If a child has difficulty remaining asleep and wakes throughout the night, a procedure known as scheduled awakenings may be helpful. Using the data from the sleep log, the parent identifies the most typical night waking times and awakens the child approximately 30 minutes prior to that time by gently touching or softly speaking to the child. Once the child is awake, the parent would allow him/her to fall back asleep. The plan is repeated each night until the child successfully sleeps through the night for 5-7 consecutive days. Once this criterion has been met, one night of awakenings can be skipped per week until the child is no longer waking during the night (Rickert & Johnson, 1988).
The Bedtime Pass
Oftentimes, a child may resist going to sleep, and call out or leave their bedroom to seek their parents. One intervention that may be beneficial in treating these behaviors, is use of a bedtime pass. Parents may want to provide their child with a pass that can be exchanged for leaving the bedroom for a brief amount of time. The bedtime pass may be a small index card with the child’s name written on the top. Departures from the bedroom should be short in duration and serve a specific purpose, such as, getting a drink, going to the bathroom, or giving the parent a hug. Once the pass has been used, the child must surrender it to the parent, until the next bedtime. Depending on the frequency of calling out or leaving the room (as identified during the baseline sleep log) the child may be provided with additional passes. If the child engages in problem sleep behavior after the passes have been exchanged, the parent should use the escape extinction procedure discussed above.
Sleep disturbances are a common issue that many families of children with disabilities face. Because sleep interventions often involve sleep disruptions for those implementing the plan, the plan should be reviewed with the parents to ensure the likelihood that they can and will implement it. Often, plans will need to be modified to fit into a parent’s work and family lifestyle. As with any treatment, it is important that all members of the family remain consistent when applying a new intervention. Even siblings play an important role in treating sleep disturbances, as they can serve as models for appropriate sleep behavior by following a nighttime schedule and remaining in their bed throughout the night. With the use of research-based interventions, along with a great deal of patience and persistence, sleep disturbances can be put to rest for many families of children with autism.
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