Nicole DeRosa, Psy.D., BCBA-D, LBA The Family Behavior Analysis Program Department of Pediatrics Upstate Medical University firstname.lastname@example.org (315)-464-3950
Childhood sleep disturbances not only affect the child, but can disrupt the entire family. Often times it is thought that a child may outgrow sleep issues; however, this is not the case. Sleep issues are complex and are often influenced by many variables, including biological, cognitive, and physiological factors (Durand, 2008). Many may consider sleep issues to be too difficult or even impossible to treat given the lack of accessibility of medical and behavioral providers during the time when these challenging behaviors are present (i.e., at night). However, there is extensive evidence demonstrating that behavioral interventions can be effective for mediating sleep disturbances. Unlike other behavioral interventions that generally target intervention directly with the child, sleep interventions often times focus on the caregivers as they are the one’s responsible for implementing and following through on the plan developed with the BCBA, as well as for collecting information, or data, to help know if the intervention is successful. Practitioners who have a strong understanding of the various sleep disturbances and related factors can effectively work with families to help them identify strategies to assist with alleviating their child’s sleep disturbance symptoms.
What to know before you start
There are both biological and environmental reasons for sleep disturbances and understanding what is affecting your child is essential for effective intervention.
Having a discussion with your child’s pediatrician regarding the sleep concerns is an important step in order to rule out any medical complications. Behavioral interventions may not be effective is there is an underlying medical cause or correlate to the sleep disturbance.
Sleep professionals may prescribe medications as a short-term solution for adult sleep problems, but rarely making this recommendation for children. Despite this, medications are often recommended (both over-the-counter and prescription) to assist with sleep problems in children; however, this should not be a long term solution as prolonged use could lead to dependency and/or an increased tolerance for the medication (Durand, 2008).
There are various types of sleep disturbances (e.g., trouble falling asleep, night waking, nightmares, sleep terrors, apnea, and limb movement problems) and each may warrant a specific type of intervention. Thus, it’s important to identify your child’s specific sleep difficulty in order to understand how to best treat the concern.
Treatment for sleep disturbances can be intensive and time consuming (e.g., taking weeks to achieve desired outcomes), but the results are worth the effort.
Questions for the BCBA
I am not comfortable with trying that or that sounds great, but I’m not sure I’ll be able to follow through. Is there something else we can try?
Again, depending on the targeted sleep disturbance specific interventions are recommended. However, your BCBA should provide you with some options of different types of interventions, as well as work with you on making some modifications to assist in making the process as feasible as possible for the entire family.
How can we identify what specific type of sleep problem my child is having?
Your BCBA should ask you to do a couple of things to assist with identification of not only the type of sleep disturbance your child is experiencing, but also specific details that will assist with developing an effective intervention. For example, keeping track of a sleep log can assist with knowing how long it takes your child to fall asleep, how often and when your child is waking, and how long he is staying awake for during night waking episodes. Additionally, a behavior log can provide information on your child’s behavior at bedtime and upon waking during the night, which can assist with understanding how to best respond to the behavior.
Is there something different we should be doing for the bedtime routine?
One of the first things your BCBA should assess is the bedtime routine as this can be a simple first step with favorable outcomes. Sometimes making changes to your child’s sleep hygiene can be beneficial in resolving some, or all, sleep disturbance symptoms.
I’m feeling exhausted and I don’t know if I can keep this up, what can we do differently?
Sleep interventions can be challenging for everyone involved. Your BCBA should support you through this process and help you problem solve when problems arise. Additionally, your BCBA should develop an effective data collection system for you so that you can monitor even minute changes that may be occurring to help you in recognizing that although you may not have met your end goal yet, your hard work is paying off and improvements are being made. However, if in fact the intervention is not associated with improvements then your BCBA should work with you to make modifications.
Won’t changing up my child’s bedtime routine result in more challenging behavior?
It is true that individuals with autism may present with rigid patterns of behaviors or develop rituals. When these rituals are interrupted, this could result in marked distress for the child resulting in the occurrence of challenging behavior. This is an important consideration that your BCBA should not overlook. Gradual changes should be considered.
Materials you may want to have
This will depend on the intervention. Sometime additional materials may not be necessary while other times they will (e.g., bedtime pass).
Bedtime routine items: favorite blanket, books, etc.
Sleep and Behavior logs (should be provided by your BCBA).
Reinforcers, visual cues or schedules
Your BCBA may complete sleep questionnaires with you to gather information related to the specific type of sleep disturbance that is present.
You will be asked to collect data on certain variables, such as time you put your child to bed, time your child fell asleep, where your child fell asleep, what time and how often your child awoke during the night, how long did he stay awake, what did he do when he was awake?
If you have difficulty collecting this data be sure to speak with your BCBA about possible ways to modify the data collection procedures.
The BCBA should review your data to ensure that the intervention is being effective and/or to assist with making modifications in the intervention procedures.
What to expect
Implementing a sleep intervention may be challenging and frustrating. Be sure to openly communicate with your BCBA to ensure you maintain the proper support needed. Additionally, it is important that everyone in the household is on the same page regarding the intervention and following through with the plan.
Alleviating your child’s sleep disturbances may include making changes to daily routines while your child is awake (e.g., physical activity, nutrition, etc.).
Your child is likely going to resist any changes and you may see new problems emerge as your child learns that previous behaviors no longer work. This is not surprising and you should still follow through with the plan you developed with the BCBA.
If your child engages in challenging behavior (e.g., aggression) you should talk with your BCBA about how to safely handle these behaviors should they occur during implementation of the sleep intervention.
Your child’s safety is the number one concern. Therefore, if you feel as though something is not right you should be responsive to that and then discuss your concern with your BCBA as soon as possible to resolve the situation.
Not all sleep disturbances are curable, but rather managed. Thus, certain intervention procedures may need to remain in place long term in order to continue to be effective. However, the end goal should be a significantly better nights rest for everyone in the family. The intervention may seem intensive at first, but should be much more manageable across time.
Books and resources
Durand, V. M. (2008). When Children Don’t Sleep Well: Interventions for Pediatric Sleep Disorders Parent Workbook. New York: Oxford University Press, Inc. Ferber, R. (2006). Solve your child’s sleep problems (2nd ed.). New York: Fireside. Katz, T. & Malow, B. Solving sleep problems in children with Autism Spectrum Disorders: A guide for frazzled families. Bethesda: Woodbine House, 2014. Moon, R. ed. Sleep: What every parent needs to know. Elk Grove Village: American Academy of Pediatrics, 2013. Owens, J.A., & Mindell, J.A. (2005). Take charge of your child’s sleep: The all-in-one resource for solving sleep problems in kids and teens. New York: Marlow.