Danielle Liso, PhD, BCBA
Johns Hopkins University
What is sleep disorder?
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Problems related to
sleep onset and
maintenance
Irregular sleep-wake
patterns
Long sleep latencies
(how long it takes to
fall asleep)
Nightmares
Night terrors
Irregular sleep
patterns
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Problems with sleep
onset
Generally poor sleep
Early and night
waking
Poor sleep routines
Shortened night sleep
Alternations in sleep
onset and wake times
Night waking
What are the impacts of sleep
disorders?
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Related to greater autistic symptomology
during the day
Greater parent stress
Loss of sleep= less time attending to learning
for child
Loss of sleep=increase in challenging
behavior for child
Loss of sleep= less time being productive for
parents, sibs
Sleep disordered breathing associated with
stereotypic behavior and social interaction
problems
What do we know about autism
and sleep?
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It has been reported that 44-83% of the ASD
population has sleep disorder
Appears at all IQ levels
Younger children with ASD have more sleep
problems than older children with ASD
y Due to better coping, more demand=better sleep, or do
kids grow out of it?
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Children with ASD have more reported sleep
problems in the following categories, as compared to
typically-developing peers:
y Bedtime resistance, sleep onset delay, sleep duration,
sleep anxiety, night wakings, parasomnias (problems
transitioning between sleep phases), sleep disordered
breathing
y Do not differ from TDP in daytime sleepiness
What causes sleep disorders in
autism?
Elevated or reduced levels of melatonin
€ Hyper- and hypo-arousal (esp.
overstimulation)
€ Anxiety
€ May not respond to environmental cues
(time to sleep)
€ May have weak sleep control (don’t
sleep well when it’s hot or cold, not
completely dark in bedroom, etc.)
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Jan & Freeman, 2004
What about comorbid
conditions?
Seizures: It has been hypothesized that
children with autism often suffer from
mild (petit mal) seizures; often times,
these seizures take place at night– may
be the reason for many of the sleep
disorders common in autism
€ ADHD
€ MR
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Assessing sleep disorder
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Medical concerns that may influence sleep
How many hours does the child sleep?
How many times does the child wake each
night?
How long, on average, is the child awake?
Why do you think the child wakes up?
What is the child’s temperament when
he/she wakes?
Assessment, cont.
Does the child nap? If so, how many
and how long?
€ Does the child sleep with any items?
€ What is the bedroom environment like?
€ What is the current bedtime routine?
€ What motivates the child?
€ What activities or items calm the child?
€ What is the child’s primary mode of
communication?
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Addressing sleep disorder
behaviorally
Positive bedtime routines
€ Bedtime fading
€ Bedtime fading with response cost
€ Sleep restriction (chronotherapy)
€ Scheduled awakenings
€ Extinction
€ Stimulus fading
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Positive bedtime routines
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Engage in specific bedtime routines
conductive to sleep
Last 30 minutes before sleep
Enjoyable
Low demand– no conflict or confusion
Predictable– order and timing of events the
same; insert minor changes if becoming
too restrictive
NO TV (stimulating)
Try to stick to routine even when child is
sick
Bedtime fading (for difficulties
falling asleep)
Put your child to bed and leave the room
€ If your child starts to cry, wait the
agreed-upon time before entering
€ “time for bed” then leave the room
€ Wait another [5] minutes if necessary,
then start again
€ Extend time between visits by 2-3
minutes each subsequent night
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Bedtime fading with response
cost
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Remove your child from bed if he/she
does not fall asleep within 15 minutes
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Keep child awake for 1 hour, the back to
bed
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If your child is not asleep within 15
minutes, start again
Sleep restriction (chronotherapy)
(for non-disruptive and disruptive
wakening)
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Use the sleep diary to estimate the number of hours
your child sleeps per night– asleep time only
Multiply the average number of hours by 0.9 to arrive at
a figure representing 90% of the time your child sleeps
Adjust your child’s bedtime, or preferably, the time you
wake your child in the morning, to approximate the new
schedule
If you find your child lying be bed awake, have him/her
leave the bed and engage in a quiet activity until
sleepy, then back to bed
If night waking is eliminated or diminished for 1 week,
readjust bedtime or waking time by 15 minutes
Continue to adjust once per week until the desired
schedule is reached
Scheduled awakenings (for
disruptive wakening)
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Use sleep diary to determine the time our times
your child typically awakens
Wake your child up 30 minutes before his first
typical waking time– enough for him to open his
eyes, then let him go back to sleep
Repeat this plan each night until your child sleeps
for a full 7 nights without waking, then skip one
night
If your child has awakenings, go back to every
night
Slowly reduce the number of nights per week with
scheduled wakings until your child no longer
wakes in the night
Extinction (for difficulties falling
asleep or disruptive wakening)
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Non-graduated:
y Ignore all bedtime disruptions or night waking
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Graduated:
y Follow a systematic routine to put your child to
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bed
If your child cries, initially ignore the behavior at
a pre-set period of time (5 min)
If your child is still crying, enter the room to resettle your child (“time for bed”), with as little
attention as possible, then leave
Continue pattern until child is asleep
On each subsequent night, extend the time
between visits by 2-3 minutes
Stimulus fading
Gradually move the co-sleeper out of
your bedroom
€ OR
€ Moving you out of your child’s room
€ On bed- touching, on bed-no touching,
on floor next to bed, slowly move across
room, at door, beyond door
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Sleep Diary
________________________________________________________________
(Adapted from Durand 1998)
Child: _______________________________
Person collecting data: ___________________________
Please collect the following information for one week. Each night, indicate (1) the initial time you put your child to bed, (2)
the time your child actually fell asleep after being put to bed, (3) the time of each instance of waking, and (4) what your child did
during the waking and what you did to respond to your child. Also describe the length and nature of any naps that occurred
that day.
Day
Date
Sunday
Monday
Tuesday
Time put Time fell
to bed
asleep
Time
awoke
Describe nighttime waking
Describe any naps
Sleep Data
___________________________________________
Date
Time
bedtime
routine
started
Time
asleep
Time
awake
(1)
Time
asleep
(1)
Time
awake
(2)
Time
asleep
(2)
Time
awake
(3)
Time
asleep
(3)
Time
awake,
next
morning
Sleep Behavior Log
________________________________________________________________
(Durand 1998)
Child: ___________________________
Person collecting data: ______________________
Please provide the following information for one week.
For each bedtime, and for each nighttime waking, describe (1) what your child was doing and
(2) what you did to respond to your child.
Date
Time
Behavior at
bedtime
What did you
do to handle
the problem?
Behavior
during
awakenings
What did you
do to handle
the problem?
Social story: Sleeping in my
own room
I like to sleep with Mom and Dad.
Sleeping with Mom and Dad makes me feel safe.
I know that when I close my eyes in Mom and Dad’s room, I don’t have to
feel scared.
But I have my own room.
I keep all of my favorite things in my room.
I have my toys and clothes in my room.
My room is my own space, and I know everything that is in my room.
I know a lot about the things in my room, so I know that I don’t have to feel
scared.
When I feel scared about being in my own room, I can think of ways to
make myself feel better.
I can leave a light on or ask Mom or Dad to come check on me during the
night.
I know that I can sleep in my own room.
It’s my very own space, and I like that!
Melatonin
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The pineal gland in the brain secretes a
hormone called melatonin in response to
light-dark cycle
Melatonin regulates body temperature,
sleep cycle, hormone activity, and other
circadian functions run by the body’s
internal biological clock
At night, higher levels of melatonin are
released to induce sleepiness; levels drop
during early morning hours and throughout
the day to promote alertness
Melatonin, cont.
It has been hypothesized that children
with ASD may manufacture either too
much or too little melatonin
€ Nightly melatonin supplementation may
improve sleep patterns in up to 80% of
children
€ Should be given only once per day in
small amounts, about ½ hour before
normal bedtime– body weight and diet
are factors
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Melatonin, cont.
Melatonin supplements are known to
lose their effect over time as the body
accommodates to them
€ When a low dose starts to lose its effect,
STOP the melatonin for a short time,
then restart, do NOT increase dosage–
restores sensitivity to the supplement
€ Quick response rate (70-90%) but works
better in conjunction with behavior
therapy
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Considerations for tackling
sleep disorder
Does my child only fall asleep under
certain circumstances?
€ Does my child need certain things in
order to sleep?
€ Can I make the bedtime routine more
soothing by adding quiet music, stories,
lotion, or massage?
€ Do I make bedtime clear by stating,
“time for bed?”
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General tips for sleep disorder
Maintain your bedtime routine
€ Maintain sleep and wake times, even on
weekends and holidays
€ Encourage your child to be active
throughout the day
€ Encourage your child to exercise up to 4
hours before bedtime
€ No vigorous physical activity in the
hours before bedtime
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General tips, cont.
Your child’s bed should be for sleeping
only (and bedtime stories!)
€ Be aware of the effects of foods, drinks,
and meds, especially close to bedtime–
caffeine, upset stomach
€ Milk and protein-rich foods may aide in
sleep; high-fat foods may contribute to
sleep disturbance
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General tips, cont.
Reduce surrounding noise, light, and
other distractions, but be careful that
these can be replicated outside of your
home
€ Avoid extreme temperature changes in
the bedroom
€ If your child has nighttime waking
problems as well as bedtime problems,
tackle the bedtime problems first
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Thank you!