Behavioural approaches to sleeplessness

1
Behavioural approaches to sleeplessness

• Luci Wiggs
• Department of Psychology, Oxford Brookes
  University

2

What types of sleep disturbance are reported in
children with ASD?

• Physiological sleep abnormalitieseg. REM sleep
  melatonin profile
• Sleep disorders
• eg. REM sleep behaviour disorder
• sleep/wake cycle disorders
• Sleep problemseg. getting to sleep, waking in
  night, early waking, irregular sleep, short
  duration sleep

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Sleeplessness in children with ASD

• Parent reported sleeplessness rate about 66
  (range 49-89)
• (Richdale 2001 Wiggs Stores 2004)
• High rates in children intellectual
  disabilities
• (Hoshino et al 1984 Patzold et al 1998)
• Objective confirmation of sleeplessness
  contradictory

4
Objective sleep patterns of sleepless ASD
children

• 8 with sleep problems/ 8 with no problems
  (4-12 yrs). Wake up time earlier. No other
  differences.
• (Hering et al 1999)
• 38 sleepless/ 24 non-sleepless (5-16 yrs). No
  differences but BOTH groups worse than normal
  values
• (Wiggs Stores 2004)
• 10 individuals (15-25 yrs). 5 reported to have a
  problem 8 with objective sleep disturbance
• (Oyane Bjorvatn 2005)

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Effects of sleep disruption

• Family/carer stress
• Physical
• ? Growth
• ? Immune system
• ? Death!
• Motor skills
• ? Hand eye coordination
• ? Reaction time
• Cognition
• ? Memory
• ? Attention
• ? Divergent thinking

• Performance
• ? Work/school
• ? Accidents
• Mood and behaviour
• ? Fatigue/overactivity
• ? Irritability/Aggression
• ? Anxiety/Depression
• ? Hallucinations

(Pilcher Huffcutt 1996 Guilleminault Pelayo
2000)
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Effects of sleep extension?

• In typically developing children, increasing
  sleep by as little as 40 minutes led to
  significant effects on next day cognitive
  functioning (attention, memory, reaction time)
• (Sadeh et al 2003)

7
Risk factors for sleep disorders

• Physical factors
• Psychiatric/behavioural problems
• Impaired learning/communication
• Parent/family/carer mental state/behaviours

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Approaches to management of sleeplessness

• Hypnotics
• Ramchandani, Wiggs, Webb Stores (2000) Owens,
  Rosen Mindell (2003)
• Melatonin
• Stores (2003) Turk (2003)
• Behavioural management
• Richdale Wiggs (2005)

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Principles of behavioural management

• Behaviour can be encouraged by linking it with
  things that come before it (cueing)
• Behaviour is likely to recur if the consequences
  of the behaviour were rewarding (positive
  reinforcement)
• Behaviour can be reduced by removing rewards
  (negative reinforcement)
• Rewards/reinforcers are defined by their effects
  on behaviour
• Consistency!

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Behavioural sleep medicine

• Preferred by families
• No hang-over effects
• Lack of negative side-effects
• Empowering parents/carers
• Used in conjunction with other techniques 
• But.can be demanding

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Chambless Hollon (1998) criteria for assessing
evidence for psychological interventions

• Well established
• At least 2 parallel group experiments or large
  series of single-case experiments
• And by at least 2 investigators
• Probably efficacious
• At least 2 experiments with waiting list control
  group
• Or criteria for well-established met by one
  investigator
• Promising
• 1 well controlled study and another less rigorous
• 2 well-controlled studies by the same
  investigator
• 2 well-controlled studies with small samples

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Status of behavioural techniques for treatment of
child sleeplessness Chambless Hollon (1998) J
Consult Clin Psychol

• Well established
• Extinction
• Checking
• Preventive approaches
• Probably efficacious
• Scheduled waking
• Promising
• Extinction with parental presence
• Positive routines/faded bedtime
• Kuhn Elliott (2003)

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Status of behavioural techniques for treatment
of child sleeplessness in children with
developmental disorders Chambless Hollon
(1998) J Consult Clin Psychol

• Well established
• Probably efficacious
• Extinction
• Graduated extinction
• Promising
• and only if one includes heterogeneous samples
• (Richdale and Wiggs 2005)

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What help is being received?

• Treatment received by a limited number of
  families
• 47 with severe learning disability (n124)
• 54 with autistic spectrum disorders (n61)
• (Wiggs Stores 1996 2000)
• Had coped for years already
• Did not want child on medication
• Thought treatment unlikely to be helpful
• Previous unfavourable treatment experiences
• (Wiggs Stores 1996 Quine 1992 Bartlett et
  al 1985)

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Sleep disorders underlying sleeplessness (n44)
(Wiggs Stores 2004)
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Behavioural sleeplessness in children with ASD

• Behavioural sleeplessness disorders common in
  children with ASD (Wiggs Stores 2004)
• Limited intervention reports
• 7 case reports, 14 children, 3-12 years
• 1 multiple baseline study, 6 children 3-7 years
  (Weiskop et al 2005)

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There is a need for research evaluating
behavioural interventions in children with ASD
(not just an extrapolation of results from
studies of children with developmental
disorders) because children with ASD have

• particular social communication difficulties
• resistance to change
• high levels of anxiety
• high levels of challenging behaviour
• possible melatonin abnormalities

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A randomised controlled trial of
behaviouralintervention for sleeplessness in
childrenwith autism spectrum disordersLuci
Wiggs1,2 Gregory Stores2Department of
Psychology, Oxford Brookes University1Department
of Psychiatry, Oxford University2

• Aims To see if behavioural intervention for
• sleeplessness..
• improves reported objective child sleep
  patterns
• is associated with improvements in child
  behaviour and maternal mental state

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Subjects

• Screening questionnaire sent to parents of
  children with ASD aged 5-16 recruited through an
  Autism Education Support Service
• Parent report of frequent (gt 3 times
  week)        reluctance to go to bed      
  fear of going to bed       problems (for parent
  or child) settling gt 1 hour        night
  waking       insisting on co-sleeping      
  early waking (before 5am)

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Assessments

• Composite Sleep Index Score (via sleep diary)

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Composite Sleep Index Score (012)

• Settling frequency
• Settling duration
• Nightwaking frequency
• Nightwaking duration
• Early waking frequency
• Co-sleeping frequency

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Assessments

• Composite Sleep Index Score (via sleep diary)
• 5 nights of actigraphy (Ambulatory Monitoring
  Inc)

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(No Transcript)
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Actigraphy sleep variables

• Minutes taken to fall asleep
• Time falls asleep
• Final waking time in morning
• Total sleep duration

• Minutes of wake
• Number of wakes
• Sleep efficiency ()

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Assessments

• Composite Sleep Index Score (via sleep diary)
• 5 nights of actigraphy (Ambulatory Monitoring
  Inc)
• Parental evaluation of treatment
• Children
• Developmental Behaviour Checklist (DBC) (parent
  and teacher) (Einfeld Tonge 2000)
• Mothers
• General Health Questionnaire (GHQ) (Goldberg
  1991)

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Screening visit/Baseline assessments (n43)
Treatment group (n20)
Control group (n19)
6 weeks support/intervention
Repeat assessments
6 weeks support/intervention
Repeat assessments
6 months post-treatment postal follow-up
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Intervention Outline

• Appropriate bed time (linked with sleep onset)
• Appropriately timed bedtime routine
• Extinction/stimulus fading/checking
• Positive reinforcement

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Results Participants

• Treatment group (n20)
• 17 males
• mean age 8.6 (sd 4.7)
• range 4.5 - 15.75
• Diagnoses
• Autism 10
• ASD 4
• Asperger 6
• Schooling
• Mainstream 6
• Ed. Unit 6
• Special 8

• Control group (n19)
• 19 males
• mean age 7.5 (sd 3.2)
• range 4.7 - 14.5
• Diagnoses
• Autism 10
• ASD 3
• Asperger 3
• Schooling
• Mainstream 7
• Ed. Unit 5
• Special 7

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Results Mean Composite Sleep Index scores
pre/post treatment

p?0.001
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Results Responders and Non-Responders

• Response defined as
• 50 post treatment reduction in CSI
• Responders 33
• Non-responders 6

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Parents evaluation of change in childs sleep (
of responses)
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Parents evaluation of satisfaction with childs
sleep ( of responses)
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Results Mothers Mean GHQ scores pre/post
treatment
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Results Childrens Mean DBC scores pre/post
treatment
Plt0.05
Plt0.01
Plt0.05
Plt0.05
Plt0.05
Plt0.05
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Results Mean actigraphy scores pre/post
treatment
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Summary

• Behavioural treatment improved overt
  parent-reported sleeplessness problems and
  aspects of parent-reported child behaviour
• Treatment viewed positively by parents
• Maternal mental state, childrens reported
  behaviour at school and objective sleep patterns
  unaffected by behavioural intervention

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Conclusions

• Behavioural interventions for sleeplessness are
  possible with children with ASD (and have
  benefits for the children?)
• The mechanism underlying any associated benefits
  for child does not appear to be improved sleep
  quality/quantity
• The origins of the objective sleep disturbance
  needs explaining. Does it need treating? How?!