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Gregory P. Hanley Ph.D., BCBA-D
Unveiling the Mysteries of Sleep Disorders in Children with Autism
Public LectureUniversity of Auckland / ABA awareness Week
October 2016
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Learn more by reading the sleep research articlesauthored by these behavior analysts:
Neville Blampied
Richard Bootzin
Mark Durand
Karen France
Patrick Friman
Carl Merle Johnson
Cathleen Piazza
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Common Sleep Problems
Delayed sleep onset (long latency to fall asleep)
-Sleep-interfering behavior
-crying, calling out, curtain calls, playing, stereotypy, talking to oneself, etc.
Night awakenings / Early awakenings
Short sleep duration
Phase shifts (sleeping at wrong times thus conflicting with daily routines)
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Sleep Problems of Children with Autism
(1) Prevalent
(2) Do not abate over time
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Sleep Problems of Children with Autism
(3) Probably anchoring children’s deficits
(Interfere with skill development)
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Sleep Problems of Children with Autism
(4) Worsen maternal mental health
(negatively affect family functioning)
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Sleep Problems of Children with Autism
(5) Probably not caused directly by the unique neurobiology of children with autism
(6) Best understood as a learning issue
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Sleep Problems of Children with Autism
(7) Worsened by the most common treatments
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Sleep Problems of Children with Autism
(8) Meaningfully addressed with comprehensive treatments
that involve changes to the variables in two competing contingencies
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Sleep Problems of Children with Autism
(9) Best solved by first understanding the child-specific variables operating on two competing behaviors:
behavioral quietude
vs
interfering behavior
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Sleep Problems of Children with Autism
(10) May be addressed best by behavior analysts
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Sleep problems are prevalent, especially for children with autism
10-50% of children without autism
50-80% of children with autism
Wiggs & Stores J Intellect Disabil Res 1996Richdale Dev Med Child Neurol 1999Schreck & Mulick J Autism Dev Disord 2000Couturier et al. J Am Acad Child Adolesc Psychiatry 2005Malow et al. Sleep 2006Krakowiak et al. J Sleep Res 2008Richdale & Schreck Sleep Med Rev 2009Souders et al. Sleep 2009Cortesi et al. Sleep Medicine 2010
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Hodge et al., 2014, Res in Dev Dis
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
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Hodge et al., 2014, Res in Dev Dis
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
All ages (n = 216) 82 50
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Hodge et al., 2014, Res in Dev Dis
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
All ages (n = 216) 82 50
Ages 3–5 (n = 50) 84 72
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Hodge et al., 2014, Res in Dev Dis
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
All ages (n = 216) 82 50
Ages 3–5 (n = 50) 84 72
Ages 6–9 (n = 118) 78 46
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Hodge et al., 2014, Res in Dev Dis
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
All ages (n = 216) 82 50
Ages 3–5 (n = 50) 84 72
Ages 6–9 (n = 118) 78 46
Ages 10–17 (n = 48) 88 38
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Sleep problems generally do not resolve on their own, especially for children with autism
% of children to receive CSHQ score of 41 or above
ASD group (%) TD group (%)
All ages (n = 216) 82 50
Ages 3–5 (n = 50) 84 72
Ages 6–9 (n = 118) 78 46
Ages 10–17 (n = 48) 88 38
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What is different about children with autism and children of typical development with regards to sleep?
Suspects: Sleep architecturee.g., Duration and quality of REM sleep
Neurotransmitters and related biochemical pathwaysSerotonin levelsEndogenous melatonin levels
ASMT (melatonin biochemical pathway)GABAGABAergic interneurons
Clock genes e.g., Per 3, BMAL, CRY
It is still not clear whether there is anything physiologically unique about children with autism that is contributing to their sleep problems
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E.g., Duration and quality of REM sleep
REM sleep: Long suspected of being of shorter duration and lower quality among children with autism
Tanguay et al. J Autism Child Schizophr 1976
Diomedi et al. Brain Dev 1999Thirumalai et al. J Child Neurol 2002Buckley et al. Arch Pedatr Adolesc Med 2010
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E.g., Duration and quality of REM sleep
Malow et al. (Sleep, 2006)
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E.g., Duration and quality of REM sleep
Malow et al. (Sleep, 2006) showed no difference in sleep structure, including quality and duration of REM sleep between children with and without autism
Important considerations:
• Only Malow et al. restricted their study to children with no history of pharmacological intervention
• Many drugs given to children with autism to facilitate sleep onset or to address irritability/problem behavior negatively affect the duration and quality of REM
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What else is correlated with sleep problemsof children with autism?
Richdale Dev Med Child Neurol 1999Schreck et al. Res in Dev Dis 2004Malow et al. Ped Neurol 2006Malow et al. Sleep 2006Liu et al. Child Psychiatry & Hum Dev 2006Krakowiak et al. J Sleep Res 2008Richdale & Schreck Sleep Med Rev 2009Goldman et al. Dev Neuropsychology 2009Cortesi et al. Sleep Medicine 2010Hollway & Aman Res in Dev Dis 2011Sikora et al. Pediatrics 2012DelaHaye et al. Res in Aut Spec Dis 2013
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Correlates of Sleep Problemsfor Children with autism
Cognitive impairment/IQ: NoAutism Symptom Severity
language impairment: Nosocial reciprocity: Yesritualistic/repetitive beh.: Yes
stereotypy YesSevere problem behavior: YesPoor adaptive skill development: YesComorbid conditions
ADHD Yesallergies: Yesasthma: YesGI problems: Yesanxiety: Yesdepression: Yes
Health-related quality of life: Yes
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Example:
Limited hours of sleeping negatively correlated with rates of stereotypy
Jack
Days
5 10 15 20
0
2
4
6
8
10
12
14
16
Number of Hours Slept each Night
Mean Baseline Session Rate of Stereotypy
r = -.484, p < .05
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Correlates of Sleep Problemsfor Children with autism
Cognitive impairment/IQ: NoAutism Symptom Severity
language impairment: Nosocial reciprocity: Yesritualistic/repetitive beh.: Yes
stereotypy YesSevere problem behavior: YesPoor adaptive skill development: YesComorbid conditions
ADHD Yesallergies: Yesasthma: YesGI problems: Yesanxiety: Yesdepression: Yes
Health-related quality of life: Yes
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Screening for the correlates
Reynolds & Malow Pediatr Clin N Am 2011
See this articlefor a Screening Checklist:
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May achieve more traditional objectivesif you resolve the sleep problem
Improve compliance with instructions
Decrease severe problem behavior
Gain stimulus control over stereotypy
Decrease trials to master social and academic skills
…
(this is a most important area of research)
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May achieve more extraordinary objectives if you resolve the sleep problem
Improve parental sleep problems
Miminize maternal stress, malaise, and depression
Enhance family functioning/quality of life
Sadah et al. Dev. Psych. 2000
Meltzer & Mindell J Fam Psychol 2007
Hoffman et al. Focus on Aut and Oth Dev Dis 2008
Meltzer Res in Aut Spec Dis 2011
Hodge et al. J Aut & Dev Dis 2013
(this too is an important area of research)
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Mindell et al. Pediatrics 1994
Pediatricians receive only about 5 hours of training on sleep problems
Owens et al. Pediatrics 2001
In a survey of 626 pediatricians in New England, only 25% rated themselves as confident in treating pediatric sleep problems.
Maybe some other helping professionals will address the problem?
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Stojanovski et al. J Sleep & Sleep Dis Res 2007
81% of children’s visits to pediatricians, psychiatrists, or family physicians for sleep problems result in a prescription for a medication
Owens et al. Pediatrics 2013
Families of children with autism are twice as likely to receive prescription to address insomnia of their children
despite no FDA approval,
no medication labeled for pediatric insomnia,
no (or inconsistent) efficacy signal in literature
Maybe some other helping professionals will address the problem?
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From: National Academy of Sciences, Committee on Sleep Medicine and Research, Board on Health Sciences Policy (2006)
“There have been no large-scale trials examining the safety and efficacy of hypnotics in children and adolescents. Other pharmacological classes used for insomnia include sedating anti-depressants, antihistamines, and antipsychotics, but their efficacy and safety for treating insomnia have not been thoroughly studied.”
Treatment Options?
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Nights
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Tim
e
Ideal sleep zone
AsleepNap
07:00 pm
09:00 pm
11:00 pm
01:00 am
03:00 am
05:00 am
07:00 am
09:00 am
11:00 am Alice
Baseline
Goal wake time (08:00 am)
Goal bid goodnight time (09:00 pm)
Behavioral InterventionMelatonin: 3 mg
Clonidine: 0.1 mg
Hydroxyzine: 4 ml
0 mg
0 mg
0 ml
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Part 1: Personalize Sleep Schedule
Part 2: Routinize Nighttime Routine
Part 3: Optimize Bedroom Conditions
Part 4: Regularize Sleep Dependencies
Part 5: Minimize Sleep Interfering Behavior
Freedom from sleep problems is possible and probable with:
Individualized assessment
Individualized and comprehensive treatment:
To learn more, go towww.practicalfunctionalassessment.comFor:
Video-tutorialWorkbookDownloadable assessmentHandout for parentsPowerpointPeer-reviewed article
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How do we assess and treatchildren’s sleep problem?
• With an open-ended interviews to identify the personal factors influencing the sleep problem– SATT: Sleep Assessment and Treatment Tool
• Through a conceptually systematic understanding of the common factors that influence good sleep and sleep problems
• By developing treatments with parents based on the controlling variables
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Assumptions
• Behavioral quietude /Falling asleep are the behaviors of interest – Blampied and France, 1993; Bootzin, 1972
• Is influenced by past and present experiences in one’s sleeping environment
– can be motivated (or demotivated)
– can become reliant on environmental cues
– can be affected by other reinforcers for other behaviors available at night
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Looking through the lens of a contingency
Conduct a contingency analysis:
EO + SD Behavioral Quietude Sr
• That which is known:
– Reinforcer (Sr) for behavioral quietude is sleep
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Looking through the lens of a contingency
Conduct contingency analyses:
EO + SD Behavioral Quietude Sleep?
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In general,
children need less sleep as they get older.
Said another way,
Sleep is valuable for less time as children get older
Adapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006
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Copied from: National Institute of Health (NIH) Sleep and Sleep Disorder’s Teacher’s Guide
In general,
Sleep is more valuable an hour later than the time a child fell asleep on the prior night
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The value of sleep may be at its lowestat the family-expected bedtime
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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
The value of sleep may be at its lowestat the family-expected bedtime
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Looking at behavioral quietude through the lens of a contingency
Abolishing Operations + SD Falling Asleep Sleep
What decreases the value of sleep when a child is put to bed?
– Having slept within 6 hours of being put to bed (e.g., cat naps on couch)
– Having slept too many hours the previous night
– Being put to bed in “forbidden zone” (2-3) hours prior to natural sleep phase
– Caffeine within 6 hours of being put to bed
– Exercise, hot bath, wrestling with parent right before bedtime
– Availability of other reinforcers after the bid goodnight
• social reinforcers like parental attention/interaction/affection
• automatic reinforcers via iPad, television or movies, internet browsing, etc.
• automatic reinforcers via stereotypy or ritualistic behavior
– Overly warm, bright, or noisy sleep context
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Looking at behavioral quietude through the lens of a contingency
EO + SD BQ Sleep
What increases the value of sleep as a reinforcer for BQ?
– Sleeping on the previous night for or just under the number of hours of sleep needed given age
– Being put to bed at the same time or slightly later than when one fell asleep the night before (and gradually fading back to desired time)
– Limiting daytime hours of sleep (napping for less than 20 min)
– Extending hours since last slept (not napping after 3pm)
– Dimming lights prior to bedtime / Making bedroom darker
– Scheduling access to literary classics like Beowulf
– Gradual transition between den to bed (minimize rich to lean transition)
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Extreme Sleep Phase Shift?
Try chronotherapy if sleep phase is more than 4 hours past desirable sleep time:
Move sleep and awake times forward by 1 to 2 hours each night (larger leaps can be made with older children)
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Goal
*
10 20 30 40
Self ReportAccelerometer
12 AM
6 PM
12 AM
6 AM
12 PM
Programmed sleep
6 AM
Programmed wake
Days
Tim
e
Baseline Chronotherapy Post-Chrono
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EO + SD Behavioral Quietude Sleep
Is the nighttime routine somewhat consistent and appropriate?
Are are the sleep dependencies appropriate?
?
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Routinize Nighttime Routine
Some emphases prior to bid goodnight
Activities progress from active to passive Make gradual changes in fun factor--avoid rich to barren context transition
Exercise/baths earlier in routine
Ambient light gets progressively dimmer
Light snacks without caffeine
• Arrange big discrepancy in consequences for compliance vs. noncompliance to routine (avoid DRA with extinction)
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Things that occasion sleep are not present when the child wakes up during the night = Night Awakenings
Things that occasion sleep are suddenly removed or inconsistently available = Sleep Onset Delay and possibly sleep interfering behavior
Troublesome SDs due to their inconsistent presence when children wake up during the night: TV, radio, bottles, “full belly,” presence of another person, being rocked or patted, lights, fallen stuffed animals
EO + SD Behavioral Quietude Sleep
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Occasion sleep with things that:
don’t require parental presence,
can be there the entire night, and
are transportable
(e.g., for vacations or nights at Grandparent’s home)
Such as:
pillow, blanket, stuffed animal (with bed rails),
sound machine on continuous
Forquer & Johnson Child and Fam Beh Ther 2005
Eliminate or fade “bad” ones and replace with “good” ones
EO + SD Behavioral Quietude Sleep
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Looking through the lens of a contingency
Conduct contingency analyses:
EO + SD Behavioral Quietude Sleep
?? ? ?
Conduct contingency analyses:
EO + SD Interfering behaviors Sr- & Sr+
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EO + SD Interfering behaviors Sr- & Sr+
Behaviors that interfere with behavioral quietude necessary for falling asleep
Common forms:
leaving bed (curtain calls)
crying / calling out
playing in bed or in bedroom
(this includes motor or vocal stereotypy)
talking to oneself
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Consider possible reinforcer(s):
Attention, Interaction
Food, drink
Access to TV or toys
Escape/avoidance of dark or of bedroom
Automatic reinforcers
(those directly produced by the behavior)
Combination of one or more
EO + SD Interfering behaviors Sr- & Sr+
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Consider possible reinforcer(s):
Attention, Interaction
Food, drink
Access to TV or toys
Escape/avoidance of dark or of bedroom
Automatic reinforcers
(those directly produced by the behavior)
Combination of one or more
EO + SD Interfering behaviors Sr- & Sr+
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1. Provide the presumed reinforcer prior to bidding the child good night
2. Remove SDs for reinforcers for interfering behavior
3. After bid goodnight, disrupt contingency between interfering behavior and its reinforcement
e.g., Time-Based Visiting, Bedtime Pass
EO + SD Interfering behaviors Sr- & Sr+1 2 3
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Establish value of sleep as reinforcer
Develop stimulus control over behavioral quietude in bedroom
Weaken value of reinforcers for SLIB
Weaken stimulus control over SLIB
Disrupt contingency between SLIB and its reinforcement
Behavioral Process Aims
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Part 1: Personalize Sleep Schedule
Part 2: Routinize Nighttime Routine
Part 3: Optimize Bedroom Conditions
Part 4: Regularize Sleep Dependencies
Part 5: Minimize Sleep Interfering Behavior(SLIB)
Establish value of sleep as reinforcer
Develop stimulus control over behavioral quietude in bedroom
Weaken stimulus control over SLIB
Develop stimulus control over behavioral quietude in bedroom
Weaken value of reinforcers for SLIB
Disrupt contingency between SLIB and its reinforcement
Normalized Aims Behavioral Process Aims
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A typical case example
Ray
4-year-old-boy with Autism and hyperactivity
Parents tried multiple medications for sleep problems and physically restrained him to sleep each night
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0
20
40
60
80
100
120
140
160
180
Sle
ep O
nse
t D
elay
(m
in)
Baseline Treatment
Video
Diary
Clonidine 0.10 mg
Appropriate Range of
Sleep Onset DelayIllness
Melatonin 1-3 mg
0
20
40
60
80
100
120
Inte
rfer
ing
Beh
avio
r (m
in)
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
0
50
100
150
200
250
300
350
400
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
Nig
ht/
Ear
ly W
akin
g (
min
)
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
0
2
4
6
8
10
12
14
To
tal
Sle
ep (
hr)
Nights
Goal Range
of SleepNaps
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
Ray
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0
20
40
60
80
100
120
140
160
180
Sle
ep O
nse
t D
elay
(m
in)
Baseline Treatment
Video
Diary
Clonidine 0.10 mg
Appropriate Range of
Sleep Onset DelayIllness
Melatonin 1-3 mg
0
20
40
60
80
100
120
Inte
rfer
ing
Beh
avio
r (m
in)
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
0
50
100
150
200
250
300
350
400
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
Nig
ht/
Ear
ly W
akin
g (
min
)
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
0
2
4
6
8
10
12
14
To
tal
Sle
ep (
hr)
Nights
Goal Range
of SleepNaps
Illness
Clonidine 0.10 mg
Melatonin 1-3 mg
Ray
Part 1: Personalized Sleep ScheduleFaded bedtime: 11pm-9am -- 9pm-7am
Part 2: Routinized Nighttime RoutinePillow, blanket only available during sleepNo caffeine w/in 6 hrs of bedSnuggle time with dimly lit movie on small screen
outside of bed
Part 3: Optimized Bedroom ConditionsMade room colder
Part 4: Regularized Sleep DependenciesWhite noise machineNo parental presence in bed
Part 5: Minimized Sleep Interfering BehaviorTime-based exiting
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Part 1: Personalize Sleep Schedule
Part 2: Routinize Nighttime Routine
Part 3: Optimize Bedroom Conditions
Part 4: Regularize Sleep Dependencies
Part 5: Minimize Sleep Interfering Behavior
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5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Melatonin and Benadryl = None
Parent Presence = None
Percent of Goal Sleep > 90%
Night Waking = 0 min
Interfering Behavior < 2 min
Sleep Onset Delay < 15 min
Clonidine = None
Disruptive Music = None
Percent of Goal Sleep > 90%
Night Waking = 0 min
Interfering Behavior < 2 min
Sleep Onset Delay < 15 min
Andy
Lou
Nights
Percent of Goal Sleep > 90%
Night Waking = 0 min
Interfering Behavior < 2 min
Sleep Onset Delay < 30 min
Walter
TreatmentBaseline
*
Met
Unmet
Sle
ep G
oal
s
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Social Acceptability Survey (Parents)
Table 1
Questions Walter Andy LouAverage
(Range)
1.Acceptability of
assessment procedures7 6 7 6.7 (6-7)
2. Acceptability of
treatment7 6 7 6.7 (6-7)
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)
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Bedtime pass(DRA)
Extinction
Time-basedVisiting(NCR)
Reinforcement only if handed a pass
No reinforcement (period)
Reinforcement available according to time
Contingencies
Which is more effective and preferredfor addressing sleep interfering behavior?
(Jin & Hanley, in prep.)
Treatments
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Results of Social Acceptability Questionnaire Administered to Parents
Gina Sam Alice
Mom Mom Dad Mom
Bedtime Pass Time-based Visiting Bedtime Pass Extinction
Extinction Bedtime Pass Extinction Bedtime Pass
Time-based Visiting Extinction Time-based Visiting Time-based Visiting
Note. 1 = most preferred strategy.
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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-Correlated
Stimuli
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5 10 15 20 25
0
5
10
15
20
0
5
10
15
20
Cu
mu
lati
ve
Nu
mb
er o
f S
elec
tio
ns
0
5
10
15
20
Bedtime Pass
Extinction
Time-based Visiting
Gina
Sam
Alice
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For you to consider…
Start on FridayExercise
Avoid medicating to sleepAvoid caffeine
Reflect on the day and tomorrow before you are in bed
and
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Address sleep onset delay by:
• Making your bedtime 1 hr. later than usual,
• Getting out of bed if not asleep within 10-15 min, and sitting in chair & read a literary classic for 15 min or until drowsy,
• Gradually adjusting sleep and wake times to desired times.
To address difficulties getting out of bed in morning
• Use Sleep Cycle app as morning alarm
For you to consider…
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For more information go to:www.practicalfunctionalassessment.com
Questions?
Contact info.:Gregory P. Hanley, Ph.D., BCBA-D
Psychology DepartmentWestern New England University
1215 Wilbraham RoadSpringfield, Massachusetts 01119