Functional assessment and treatment of sleeping problems with developmentally disabled children: six case studies

The Lighter Touch: Less-Restriction in Sequentially Implemented Behavioral Sleep Interventions for Children with Rare Genetic Neurodevelopmental Conditions

PURPOSE

The prevalence of sleep difficulties among children with rare genetic neurodevelopmental conditions (RGNC) is high. Behavioral interventions are commonly used in the treatment of sleep difficulties in children with neurodevelopmental conditions such as autism, however, research is scarce in children with RGNC. The range of co-occurring complexities within this population, means there is a need for research to not only determine the effectiveness of behavioral sleep interventions, but also which components might be the least restrictive (i.e., intensive/aversive) and minimally sufficient.

METHODS

This study used a single-case multiple baseline design to investigate the effectiveness and acceptability of behavioral sleep interventions, indicated within a Functional Behavior formulation in eight children with RGNC (M = 7.3 years). Intervention components were sequentially administered across up to three phases, based on the principle of less restriction (from least to relatively more intensive) to determine what might be minimally sufficient.

RESULTS

Results showed an improvement in sleep onset latency, night wakings, early morning waking and unwanted bed-sharing for 7/7, 6/7, 3/3 and 3/3 children respectively. Improvement was observed for most participants following the less restrictive phases of intervention (circadian modifications, antecedent modifications and positive reinforcement), however, more restrictive, albeit modified, extinction procedures were still implemented for five participants. Improvements were maintained at follow-up and interventions were deemed acceptable to parents.

CONCLUSIONS

Less restrictive function-based behavioral strategies are an effective, and in some cases sufficient, contribution to a sequence of interventions for a range of sleep difficulties. They should be implemented first, before more restrictive strategies.

Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia

Pediatric insomnia is common, impacting up to a third of typically-developing, healthy children, and over 80% of children with neurodevelopmental disorders or chronic medical conditions. Previous reviews of behavioral interventions for pediatric insomnia have had a limited focus on a single age group, a specific population, and/or only randomized controlled trials. Furthermore, few reviews have considered non-sleep outcomes of both children and their parents. This scoping review provides a broader context, including studies regardless of research design or population, along with sleep and non-sleep study outcomes. Clear gaps in the literature were identified, highlighting the need for additional research in different populations, including school-age children and adolescents, racial/ethnic groups around the world, as well as youth with medical or psychiatric disorders. In addition, more research is needed on different features of treatment, including the delivery mode, involvement of all family members, non-sleep outcomes, and long-term follow-up.

Sleeping without Prescription: Management of Sleep Disorders in Children with Autism with Non-Pharmacological Interventions and Over-the-Counter Treatments

Autism Spectrum Disorders (ASD) are lifelong neurodevelopmental conditions characterized by abnormal social interaction, communication, and behavior. Sleep disturbances represent a common comorbidity in children and adolescents with ASD, with prevalence ranging from 50 to 80%. It has been proved that sleep disruption worsens the symptoms of autism and results in challenging behaviors. Improving sleep should therefore be a primary therapeutic goal. Treatment options range from lifestyle modifications to pharmacological therapy. Several reviews have been written on pharmacological treatments, but very few on the beneficial effects of non-pharmacological interventions, over-the-counter drugs, and nutritional supplements. This study consists of a narrative review of the literature, presenting the available evidence on the following treatments: sleep education, behavioral interventions, complementary and alternative medicine (special mattresses and blankets, massage, aromatherapy, yoga, physical activity), and commonly used over-the-counter medications and supplements (antihistamines, melatonin, tryptophan, carnosine, iron, vitamins, and herbal remedies). For some treatments—such as melatonin and behavioral interventions—effectiveness in ASD is well established in the literature, while other interventions appear of benefit in clinical practice, even if specific studies in children and adolescents with ASD are lacking. Conversely, other treatments only seem to show anecdotal evidence supporting their use.

Behavioral Treatment of Sleep Problems in a Child with a Visual Impairment

In this study, treatment focused on parenting practices for a 4½-year-old girl with a visual impairment caused by Leber's congenital amaurosis and problems initiating and maintaining sleep. The sleep problem was effectively treated with a graduated extinction procedure.

A systematic review to explore the feasibility of a behavioural sleep intervention for insomnia in children with neurodevelopmental disorders: A transdiagnostic approach

Children with neurodevelopmental disorders (NDD) are at high risk for sleep problems, especially insomnia. It is currently not known whether behavioural sleep interventions developed for typically developing (TD) children are effective for children with NDD, and if interventions need to be modified for each diagnostic group. The aim of this systematic review was to identify and evaluate commonalities, trends in outcomes, and the methodological quality of parent-delivered behavioural sleep interventions for children with NDD, specifically Attention-Deficit/Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Cerebral Palsy, and Fetal Alcohol Spectrum Disorder. Nine databases were searched. A total of 40 studies met eligibility criteria. The majority of studies were conducted with ASD and ADHD populations. Common sleep problems were evident across the NDD populations. The most frequently reported included bedtime resistance, night-waking, early morning awakening, and co-sleeping. The most common interventions used were implementation of healthy sleep practices, reinforcement, graduated extinction, and faded bedtime. All studies reported at least one behavioural treatment component as effective. Commonalities across NDD populations, as well as the TD population, for both sleep problems reported and behavioural interventions implemented, suggest the feasibility of developing a transdiagnostic behavioural sleep intervention suitable for children with a range of NDD.

The effect of supported physical activity on parental-reported sleep qualities and pain severity in children with medical complexity

PURPOSE

To study the impact of a 5-week supported physical activity (PA) intervention on parental report of sleep qualities, sleep duration, and pain severity in children with medical complexity (CMC).

METHODS

Twenty-nine CMC participated in 180 minutes of daily supported PA on weekdays over 5 weeks. A pre- and post-test design was used to collect sleep qualities (Children's Sleep Habits Questionnaire) and pain severity (Faces Pain Scale- Revised) as reported by parents. Using a repeated measures design, weekly sleep diaries captured sleep duration.

RESULTS

Children with medical complexity experienced no adverse effects, including pain, with the supported PA intervention. Significant improvements in sleep problems, sleep duration, and pain severity (P< 0.05) were demonstrated.

CONCLUSION

Short-term supported PA did not interfere with sleep or pain in CMC, and in fact, seems to have enhanced parental report of sleep qualities, sleep duration, and pain severity. Supported PA appears safe for CMC and healthcare professionals should explore methods to expand opportunities for supported PA participation.

Non-pharmacological management of problematic sleeping in children with developmental disabilities

AIM

Sleep is important for underlying neural plasticity, and children with developmental disabilities suffer behavioural, emotional, cognitive, and sensory-motor issues that affect their wake and sleep states. Problematic sleeping can be hypothesized to have adverse effects on both of these areas in children with developmental disabilities. With this review, we aim to provide a benchmark in managing problematic sleeping in children with developmental disabilities.

METHOD

A literature search was conducted and data on the study descriptives, patient characteristics, study design, study-related factors, criteria applied to operationalize sleep and developmental disability, and sleep 'management' were collected. Each management strategy was tabulated and analysed.

RESULTS

We identified 90 studies involving 1460 children with developmental disabilities, of whom 61.6% were male. The highest proportion of studies, almost half, were in children with syndromes (44.4%), followed by studies in children with intellectual disabilities (18.9%). Non-pharmacological sleep management was primarily aimed at improving sleep quality (86.7%), followed by sleep-wake schedules and, to a certain extent, sleep regularity (42.2%). About 56.7% of the studies reported more than one approach. Studies mostly focused on disorders of initiating and maintaining sleep through a diversity of strategies and relied heavily on subjective measures to identify and monitor problematic sleeping. Sleep management approaches were primarily delivered at the level of the individual in the home setting. The number of management approaches per study was unrelated to the number of sleep problems discussed.

INTERPRETATION

Modifying sleep management strategies to meet the specific needs of children with developmental disabilities is encouraged, and studies that look beyond sleep quality or sleep quantity are required. It is also advocated that modifications to sleep hygiene, sleep regularity, and sleep ecology in a population with developmental disabilities are rigorously investigated. Finally, daytime somnolence should not be overlooked when aiming to optimize sleep in children with developmental disabilities across the ages and stages of their lives. There were several limitations in the research findings of problematic sleep in children with developmental disabilities. In general, the sleep problems and the developmental disabilities investigated were multicomponent in nature. It is likely that management approaches impacted those problems on multiple levels or through diverse 'therapeutic' pathways. There is a need for randomized controlled trials and more objective measures that quantify improved sleep or wake states.

Principles of medicating children with neurodevelopmental and sleep disorders--a review

Conflict between the demands of the environment in which a child lives and the child's intrinsic sleep signature, produces stress-behaviour difficulties in the child. Distorted development, especially distorted brain development, often leads to distorted intrinsic sleep signatures. The sleep-behaviour outcome, arising from the conflict between each child's sleep signature and the environmental niche in which they live, can be modified by medications, on the one hand, and taking the role of kin, peer and social networks seriously. Medications alter the intrinsic sleep signature of the child and the stress response. Non-medical interventions address the demands and constraints of the child's environmental niche. When the main medication strategy to address distorted sleep involves brain stimulation, those children that do not respond will often need a reversal of medication priorities; an inhibitory strategy as a short to medium term support, sleep regulation being primary for longer term management, and stimulatory strategies used sparingly, if at all. We are often dealing with vulnerable populations, not all of which are reliable or accurate sources of information. Features of a presentation alerting the clinician to non-medication factors contributing to the failure of treatment are discussed.

Epidemiology and management of insomnia in children with autistic spectrum disorders

Insomnia is the predominant sleep concern in children with autistic spectrum disorder (ASD), and its nature is most likely multifactorial, with neurochemical (abnormalities in serotonergic transmission or melatonin levels), psychiatric (anxiety), and behavioral (poor sleep habits) etiological factors involved. Children with ASD experience sleep problems similar to those of typically developing children, although the prevalence is markedly higher, occurring in 44-83% of school-aged children with ASD. Caregivers usually report that insomnia is the most frequent sleep disorder, described as disorders of initiating and maintaining sleep, restless sleep, bedtime resistance, co-sleeping, alterations of sleep hygiene, and early awakenings in the morning. Many actigraphic studies have added information on sleep disorders, confirming the questionnaire findings in the majority of cases. There are relatively few polysomnographic data for ASD, compared with questionnaire studies, and most of these studies reported a reduction in total sleep time and more undifferentiated sleep in the youngest patients. These findings were associated with several sleep microstructure alterations during rapid eye movement (REM) sleep, and with non-REM (NREM) sleep microstructure changes that appeared to be related to cognitive impairment rather than to the autistic core. Moreover, few data about other less frequent sleep disorders, such as periodic limb movements disorder and obstructive sleep apnea syndrome, bruxism, and the influence of epilepsy and EEG abnormalities, are available. Both pharmacologic and behavioral interventions have been suggested for the treatment of sleep problems in autistic children. The most common types of behavioral interventions are complete extinction (removing reinforcement to reduce a behavior) and various forms of graduated extinction. Melatonin has shown promising results in the treatment of insomnia in children with ASD. Although controlled studies are limited, there are more data demonstrating the safety and effectiveness of melatonin in ASD than for other sedative/hypnotic drugs. Finally, a dual treatment for insomnia in ASDs with melatonin and behavioral techniques has been suggested. A recent study using a combination of genetic and functional experimental techniques reported evidence that low melatonin concentration caused by a primary deficit in acetylserotonin methyltransferase activity is a risk factor for ASD. Sleep problems usually start at the same age as developmental regression, suggesting a higher vulnerability at this period of life. Further studies, beginning at younger ages, are necessary to better investigate these aspects and the role of melatonin in insomnia in children with ASD.

Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders

Children diagnosed with autism or autism spectrum disorders (ASD) are more likely than other children to exhibit behaviors characteristic of a feeding or sleeping disorder. Parents of children with these disorders may be extremely concerned about the health and safety of their child. Sleeping and feeding problems can cause a great deal of stress to parents and other family members. Behavioral assessment and treatment procedures have been developed to address behavior problems related to sleeping and feeding disorders. This article reviews the literature about assessment and treatment, and provides recommendations regarding services to family members of individuals diagnosed with ASD and feeding or sleeping disorders.

Sleep problems in children with neurological disorders

This review describes the complex and often reciprocal relationship between sleep problems, neurological disorders and/or intellectual disability in children. The causes of Intellectual disability (ID) discussed in this review include those conditions present from or around the time of birth, although it also considers traumatic brain injuries occurring later in development. This review discusses the patterns of sleep difficulty associated with specific disorders and summarizes the assessment and interventions, both behavioural and pharmacological, applicable to children. Many neurological disorders such as epilepsy, narcolepsy and neurorespiratory disorders vary considerably in terms of the degree of co-morbid problems and can present with a spectrum of effects on underlying cognitive or behavioural substrates including sleep function. These conditions are discussed as they provide useful insights into how disordered sleep can impact on cognitive development and behaviour. The review draws both on the literature in these areas and the extensive clinical experience of the authors.

Sleep problems in children with an intellectual disability: parental perceptions of sleep problems, and views of treatment effectiveness

BACKGROUND

Sleep problems are common in children with an intellectual disability (ID), often lasting for many years. Many parents do not perceive their child to have a sleep problem, do not believe treatment is possible and do not seek treatment. This paper examined prevalence and duration of sleep problems in children with an ID and considered parental perceptions of sleep problems and views towards treatment.

METHOD

The paper reports on two studies (n = 149 and 243 respectively) of children between 3 and 18 years, with a range of disabilities. Parents in each study completed a questionnaire about their child's sleep problems, and the type and effectiveness of any treatment used to address their child's sleep problems.

RESULTS

Prevalence rates ranged between 25.5% and 36.2% for sleep problems with an average duration of between 6 and 9 years. Around half of parents had sought treatment for their child's sleep problem in Study 1, while 76% had done so in Study 2. Parental ratings regarding treatment effectiveness were higher in Study 1 than in Study 2. Contrary to expectations, behavioural treatment was not rated as significantly more effective than other treatments in either study.

CONCLUSIONS

While sleep problems are common and chronic in children with an ID, parents may not recognize a sleep problem as present, often do not seek treatment for their child's sleep problems, and treatment advice and effectiveness is very variable. Thus, further research and parent and professional education regarding the identification and treatment of sleep problems in these children is required.

Nonpharmacologic treatments for pediatric sleeplessness

Because of the high prevalence of sleep problems in children and adolescents, as well as the profound negative impact that pediatric sleeplessness has on daytime functioning, pediatric practitioners must be aware not only of the causes of sleeplessness but also how to treat sleep problems effectively with nonpharmacologic interventions. This article provided an overview of common pediatric disorders that present as pediatric sleeplessness and are effectively treated by behavioral interventions. Although more studies on behavioral interventions for pediatric sleeplessness are needed, behavioral approaches have been shown to be effective in addressing concerns related to bedtime problems, night wakings, insufficient sleep, insomnia, and DSPS. Behavioral interventions are effectively used for children with special needs, including developmental disabilities, ADHD, and mood disorders.

Sleep problems in children and young adults with developmental disabilities: home-based functional assessment and treatment

Sleep problems such as settling problems, frequent night waking, and early waking are prevalent as well as persistent with children and young adults with developmental disabilities who live at home. In this study, results of pretreatment functional assessment suggested that parental attention may have shaped and maintained the sleep problems with four participants. Effectiveness of extinction of parental attention, that is planned ignoring, was assessed on number of minutes of nighttime disruptive behaviors. Treatment resulted in a normalized sleep pattern in all cases and effects were maintained across time.

Treatment of sleep problems in a 5-year-old boy with autism using behavioural principles

This article presents a case study which is part of a larger project on sleep problems in children with autism. The successful treatment of sleep problems (night settling, night waking, and co-sleeping) in a boy of 5 years 4 months with autism is described. The intervention was based on behavioural principles and involved the parents attending an individually-run parent training programme. The programme consisted of an interview, three weekly training sessions and a review session. The parents learned how to use a bedtime routine, reinforcement, effective instructions, partner support strategies and extinction procedures. Once the techniques were implemented, the child learned how to settle himself to bed and how to sleep alone for the entire night. For this child, the results of the sleep programme were clinically significant as measured by a scale of goal achievement, and were maintained at a 3 month and a 12 month follow-up.

Behavioural treatments for sleep problems in children and adolescents with physical illness, psychological problems or intellectual disabilities

Young people with physical, psychological or intellectual disabilities or disorders are reported to have more frequent and persistent problems with sleep than their peers without <<<<special needs>>>>. Sleep disorders affecting the quantity or quality of sleep have effects on a child's daytime functioning and the functioning of their families. Many children with special needs have learning and behaviour problems and their parents (particularly mothers) have increased levels of stress and poorer mental health. This relationship between sleep disorders and learning, and behaviour and family functioning makes it particularly important that children with special needs receive appropriate intervention for their sleep disorders. This may be one way of mitigating these other problems. This review considers the case reports and experimental trials which have used behavioural treatments for sleep problems in children and adolescents with special needs. Behavioural treatments for sleep-wake cycle disorders, sleeplessness, parasomnias and excessive sleepiness are reported. These preliminary reports do suggest that behavioural approaches can be rapidly successful for treating sleep problems, even where the sleep problems are long-standing, severe and associated with physical, psychological or intellectual problems. The parent and the clinician should not be deterred from treating the sleep problem in isolation using behavioural treatments. Methodological issues, however, highlight the importance of further and better research. Not all children responded to the behavioural interventions and some needed re-implementation of therapy to maintain improvements; the use of heterogeneous groups make the findings and choice of treatment for individuals difficult to interpret. Finally, there are few studies overall, and the majority are case studies rather than controlled studies using multiple baseline designs or randomization and a control group. Careful studies are required in order to establish the relative efficacy of the behavioural techniques and their suitability with homogeneous subgroups of children with special needs.