Sevan Celikian: Hi everyone. Welcome to the LeafWing Center podcast here. We’d like to discuss any and all matters relating to autism and applied behavior analysis. My name is Sevan Celikian, a behavior analyst at the LeafWing Center, and with me today I have my awesome colleagues and fellow behavior analysts.
Manjit Sidhu: Hello everyone and welcome to LeafWing’s podcast. My name is Manjit Sidhu and I am a BCBA with the LeafWing Center. And with me here, I have my colleagues.
Manjit Sidhu: Hi everyone and welcome to LeafWing’s podcast. My name is Manjit Sidhu. I’m a BCBA with the LeafWing Center and today I’m here with my colleagues.
Sevan Celikian: Hi everyone. My name is Sevan Celikian at the LeafWing Center. I’m a BCBA at the LeafWing Center.
Rei Reyes: Hey everyone. My name is Rei Reyes and I’m BCBA here at LeafWing Center.
John Lubbers: Greetings everybody. This is John Lubbers. I’m also a BCBA with the LeafWing Center and thank you for joining us today.
Manjit Sidhu: Today we’ll be talking about sleeping difficulties amongst children with ASD. I’m sure in many years of practice we’ve all had where parents have come up to us and said, you know what, my kid’s got sleeping difficulties and these can be anywhere from falling asleep to staying asleep, noncompliance with nighttime routines or issues that occur after the parents say good night, such as crying, leaving the bedroom, playing in bed. So those kinds of things. So that’s what we’ll be talking about today.
John Lubbers: Yeah, this is a really great topic. Manjit like you said, we do get this question fairly often or this comment, it may not even necessarily be in the form of a question because I think sometimes our families don’t even really understand that it can be addressed behaviorally and they think of it more as maybe a medical or a pharmacological thing. But I mean there’s some interesting statistics with respect to the prevalence of sleeping problems in neuro-typical kids and the prevalence of sleeping problems in children or individuals with autism spectrum disorders. So I think that really is important for us to talk about from the perspective of treating and meeting our client’s needs.
Sevan Celikian: Up to 83% in fact, 83% of children with autism spectrum disorder deal with some sort of sleep disturbances, unwanted co-sleeping, prolonged sleep onset delay night wakings early morning wakings and so on. So yeah, that number, it’s definitely significant.
John Lubbers: So let’s talk about that a little bit more in depth. So, 83% of individuals, children with autism spectrum disorder might have some form of a sleeping problem. And then maybe, what did we say 20 to 25% of even neuro-typical kids have some sort of sleeping challenge or problem when we’re talking about sleeping problems, what are the things we’re talking about Manjit? You did lay them out for us, but can we go over them again just so I have it straight in my head?
Manjit Sidhu: So the onset of sleep between when they go to bed to when they actually fall asleep.
John Lubbers: So when we’re talking about that, we’re talking about like, okay, everybody’s bedtime is say 8:00 PM and a child is put to bed at 8:00 PM but parents are commenting or asking us for help because their child doesn’t fall asleep till 11:00 PM
Manjit Sidhu: Right, right. Yeah, exactly.
John Lubbers: What other concerns?
Manjit Sidhu: There’s night awakenings, so waking up throughout the night and sometimes it can be for long periods of time.
John Lubbers: Got it. Okay. Obviously that’s a no brainer. That’s pretty clear that if an individual or a child’s waking up three, four times a night, it’s interrupting the whole family’s sleep and it can affect the whole family of course. And as well as theirs. Okay. What else?
Manjit Sidhu: And then we have interfering behaviors. So when they do wake up in the middle of the night, calling out, leaving their bed, crying out for the parents, going onto their iPad or video games, watching TV, playing in bed, that sort of thing, talking to themselves.
John Lubbers: Got it. Okay. And I remember something that is probably pretty common and may not be a problem for all parents based on their family practices. Some families may be fine with this, others may be a little bit more concerned with it. But the idea of co-sleeping, what is that?
Sevan Celikian: So co-sleeping is when a child and parents or caregiver are sleeping together and there’s at least two types of sensory interactions taking place like touch or sound or eyesight. So a lot of families place value on co-sleeping and in some cases they prefer to do it and they enjoy it and that’s great. But reactive co-sleeping as some researchers have pointed out, that’s done more as a response to challenging behaviors where they use co-sleeping to cope with sleep disturbances. So that’s the type of co-sleeping that we’ll probably place a little more emphasis on.
John Lubbers: Got it. Got it. And just so I get my brain around this, we’re talking about a parent that has one bedroom or one bed and then a child that has a separate bedroom or bed and then that interruption or the change of the child from sleeping in either their bedroom or their bed over into the parent or parents bed or bedroom. Right. That’s what co-sleeping is.
Sevan Celikian: Yes. Or when a parent enters the child’s bed and, and co sleeps with them as, as a reaction. Right.
Sevan Celikian: Great point. I didn’t even think about that one. The last one, which is kind of interesting, is waking up too early. Right. And that’s essentially, I guess that would be a very relative type of thing. If the family plan or schedule is to wake up at 7:00 AM but the child is waking up at four or 10:00 AM but the child’s waking up at six or seven, you know that discrepancy between when the family plan and practices verse when the individual is waking up can be where the problem lies. So okay, so those are the things we’re talking about with respect to sleep problems. We know the prevalency. Now how should we tackle this guys is is there an assessment that we should look at? What should be our first step here?
Sevan Celikian: We can dive right into one of the studies that we came across and kind of explore what the researchers did as part of their assessment and as part of their intervention plan.
John Lubbers: Got it.
Rei Reyes: They did use it’s called the sleep assessment and treatment tool or SATT. It was developed by Gregory Hanley, I believe back in 2005 so it’s an open ended functional assessment interview designed to identify specific sleep problems and other environmental variables that contribute to sleep problems observed. It looks into something like the history of the sleep problems, figuring out sleep goals. That’s actually a good figuring out sleep goals because sometimes I think from the studies that we look, some parents are not really aware about the what is developmentally appropriate in terms of how much sleep my child can should get every night and the thing that’s actually something that must be considered when developing a sleep plan.
John Lubbers: That’s a good point, Rei. As professionals, we should kind of take that into consideration. The individuals that we’re working with, a three year old has very different sleep needs than a 12 year old does. And then of course we have teenagers and adults and then elderly and they all have different sleep needs. So we should, when we start to kind of approach this from an assessment treatment perspective, we should start to look into the developmental needs. So I think that’s a very good point.
Manjit Sidhu: And not getting enough sleep is definitely positively correlated with behavior problems.
John Lubbers: And attentional problems too Manjit. That’s a great point. I forgot about that. When we’re working with our kids, if we’re teaching them skills and we’re teaching them things and we’re having difficulty with attention and staying on task, you know, we might want to explore this idea of how do they sleep? Did they get good sleep and is that part of the explanation?
Manjit Sidhu: Right.
Sevan Celikian: Absolutely. So to all the professionals out there, the sleep assessment treatment tool or the SATT developed by Hanley in 2005 is an excellent functional assessment tool. It’s basically provides for a structured interview and it captures a lot of information about a child’s sleep problem and history on their sleep goals. Like Ray pointed out, identifying specific sleep interfering behaviors, and it even has a menu, I’ll call it, towards the end, where where parents and practitioners can kind of choose and custom tailor an intervention based on the results of the sat. So definitely a tool worth considering and worth using for the professionals out there.
Sevan Celikian: Yeah, I agree on that Sevan. I think in also, it’s just for, our listener out there, our professional, this, listen to this. It’s a 5-6 page assessment, pretty comprehensive at glance and it asks questions like once in bed, does your child have difficulty staying in bed or once asleep, does your child wake in the middle of the night? Yes. No, on average, how many times? How many nights per week? So it kind of gives a good assessment of sleeping behavior.
Sevan Celikian: Absolutely. So in the studies that we reviewed and the literature that we reviewed, we found that the SATT was a commonly used assessment tool to gather more information about about sleep problems. Definitely useful .
John Lubbers: What about a sleep diary? I think you’re going there Sevan, what about that?
Sevan Celikian: Yeah, so that was another tool used in the literature that we reviewed and this was more geared towards parents. So parents were the data collectors in this method. So basically a sleep diary, it’s exactly what it sounds like. Parents recorded the times that they bid good night, the number of naps the child had during the day, the duration of those naps. How many night wakings occurred, how long those night night wakings lasted for if there was any co-sleeping involved. So really a lot of useful information, especially for baseline purposes and to help guide the intervention and to kind of narrow down the results a little bit.
John Lubbers: And guys when we’re talking about a sleep diary, we’re not necessarily compared to the, in contrast to this SATT by Hanley, we’re talking about something that, it’s not a formal already pre-created pre constructed tool, but it’s maybe something that you as a professional would develop for your particular client, your family and their needs. And in like Sevan outlined, it would include things like, okay, what is your sleep routine? What time do you go to bed? What time do you wake up? And all the questions that were detailed, it could be done in a word document or on a piece of paper or similar to a notebook that you, a school home notebook that you would send home, one of those composition books that could be given to your family and they could just have an entry for every day with the questions. And so it’s really a way of starting to accumulate the information that we as professionals need to be able to start looking at this from the behavior analytic problem perspective.
Sevan Celikian: Definitely. Thanks John. So we have the SATT which we came across commonly used measurement tool. We have the sleep diaries that we did, we just discussed that we came across also very useful tool. And for the purposes of the research studies that we reviewed, there was also infrared nighttime video that was used and this was to capture raw data. So these were cameras that were set up in discrete locations and children’s bedrooms and they continuously recorded child’s nighttime behaviors.
Rei Reyes: So they took like a certain percentage of the nights that they are collecting data around 30% and basically use that data for iOS so that the parents are indeed collecting accurate data.
John Lubbers: Okay. So did they describe why they didn’t collect like some solid period of time like okay, we’re going to collect two weeks worth of data. Did they describe why they did a sampling and they collected that? Was it just a purely a matter of like a research practicality thing where they couldn’t necessarily get all that data or was it an issue of this is what we need? Or did they even talk about that at all in the articles? I don’t recall.
Sevan Celikian: I think it depended on the availability of the camcorder and the number of errors and setting up the equipment. Ma there were some nights where parents might’ve forgotten to turn it on. So the, those all kind of played a role.
John Lubbers: Okay. And anybody who’s ever done a research study knows the practical parts of research that happen. All right. So we have a couple of good assessments out there that we can use. What about, should we talk a little bit about now intervention strategies or should we talk about the particular studies and the participants that were in there?
Sevan Celikian: Yeah, I think at the very least, John, it’s definitely worth mentioning the studies that were referring to before we get any further. So we’re actually referring to two different studies that we came across. So the first study was published in the journal of applied behavior analysis in spring 2013 titled An Individualized And Comprehensive Approach To Treating Sleep Problems In Young Children. This study was conducted by C Sandy Jean, Gregory Handley, and Lauren blue out of the Western new England university. So that particular study focused on three participants, all male aged seven to nine years old. Two of them had autism spectrum disorder. So that’s the first study that we referred to, which we’ll probably go into in more depth. The second study is called the effectiveness of function-based interventions to sleep to treat sleep problems, including unwanted co-sleeping and children with autism. That was carried out by Laurie McClay, Karen France, Jacqueline Knight, bland, peed and hasty, and that was published in 2018 out of the University of Canterbury in New Zealand.
John Lubbers: It was the journal of behavior interventions?
Sevan Celikian: I believe so.
John Lubbers: Yeah. In 2018 okay. Yeah, I really liked that study. Both studies were nice in the sense that they’d addressed pretty directly what were encountering during as professionals. The problem in both studies kind of offered a little bit different to us as professionals. Of course. Again, I think you’ve mentioned this in one, but I think the, gene study was from 2013 right, and the Maclay study is from 2018 so a five year gap between the two studies and then you said the participants or the kids in the gene study were ages seven to nine and then in the Maclay was two to five if I remember.
Sevan Celikian: Right, and there was seven participants in that study all of whom had an autism diagnosis. Excellent.
Sevan Celikian: Excellent. Okay, fantastic. Now should we talk a little bit about the interventions globally? Should we talk about the particulars in the study? What do you guys think is the next direction we want to take for our listeners?
Sevan Celikian: Maybe an overview of the participants and the type of sleep problems and goals that they were looking at? We already covered the measurement tools, which were similar across both studies. The SATT, the sleep diaries, the nighttime infrared recording.
John Lubbers: That’s a great way to go.
Sevan Celikian: Awesome. So in the gene study, which had three participants, there were similar sleep problems across all of the participants. So those included nighttime awakenings, sleep interfering behaviors, and also early morning waking or, well, I mentioned that already, the nighttime awakenings and I think I’m missing one.
Rei Reyes: The DS sleep onset delay.
Manjit Sidhu: I remember that two of them were on medication as well for sleep.
Sevan Celikian: Yes, yes, that’s right. I think there was melatonin, Benadryl, and maybe one of them was taking Clondine as well.
Manjit Sidhu: Yeah. Yes.
Sevan Celikian: Okay guys. So we covered the gene article there in terms of participants and problem behaviors. What sort of thing did we see in the Maclay article? What did they add to the table in terms of participants and problem behaviors?
Rei Reyes: Okay. For the Maclay study, the participants are from seven families from New Zealand. All children have a formal diagnosis of ASD. The ages range from two to five years old. There were five boys, two girls. The children were non-vocal or communicating using a maximum of two to three word utterances. And engage in parent reported unwanted co-sleeping along with any other kind of behavioral sleep disturbances like prolonged sleep, onset delay, frequent or prolonged night wakings and or early morning wakings. In terms of medication, two of the seven kids continued taking three milligrams of melatonin throughout the study. One out of seven started using trime met cuisine during intervention.
John Lubbers: Got it. Okay. Again, just to point out, for our listener, the gene study was more the seven to nine year olds and then McClay is the younger kids, the two to five, right?
Rei Reyes: Yes.
John Lubbers: Okay. And then in gene it was three boys. In Maclay, it was a little bit of a mixture. Maybe four boys and three girls or something.
Rei Reyes: One boy and one female. One girl. Their siblings still sleeping in the sun. They shared a room.
John Lubbers: Same household. Okay. Same household. Good. Okay, so global. Should we talk a little bit about the global general interventions that are in this world of sleep problems?
Rei Reyes: Well, we’ll start with how things are being done. More often than not our families who will resort to consulting with their doctor or pediatrician to address this sleep problem. And unfortunately, the studies have mentioned that not all doctors are really versed in this area addressing sleep disorders among the younger individuals and the typical course of treatment is, well they say they will outgrow it, which they won’t and if they are actually given something, it is a prescription medication in about 50% of the time which is pretty high already 50% it was also mentioned that in 75% of the time the children are recommended to have over the counter sleep aids. So that’s where the mindset of folks are and that’s why we kind of want to break out of that mindset and get into an ABA base sleep intervention and that’s why we’re here.
John Lubbers: Excellent. Yeah I think that’s important. We probably know as professionals, but in case we don’t to point out that there is a behavioral intervention for our kids with sleeping problems for our kids on the spectrum there are assessment tools, there are a function or evidence based practices and that medication is not always the the first course or the right course for treatment with respect to our children that we’re working with. So it’s very good points. Right? Thank you.
Sevan Celikian: Yes, definitely. And what’s great about the two studies that we came across is they both use the assessment methods, functional behavior assessments to identify functions of the problem behavior, which in many cases was social attention and also to custom tailor treatment packages for each child. So maybe we can go through some of the different interventions that were used across both studies and kind of dive into that a little bit.
Sevan Celikian: Can we talk a little bit more guys? I think this is kind of important if we to just touch base a little bit more. Sevan you pointed out that they looked at the functions, the hypothesized functional of the behavior and overwhelmingly the hypothesized function for the behavior derived from the assessments was attention sometimes access or tangible and then sometimes it was escape. Right?
Sevan Celikian: Right.
John Lubbers: Do you recall at all? I don’t recall now. I’m looking at this right now, the information, I don’t recall if there was any automatic or sensory reinforcement.
Manjit Sidhu: There wasn’t the gene study.
John Lubbers: How prevalent was that Manjit? Do you remember what? Of the three, was it one, two or three or do you now recall top of your head?
Manjit Sidhu: One for sure. It could have been two.
John Lubbers: Okay. Interesting. All right. Did they talk a little bit about that or do you recall what they said with respect to that?
Manjit Sidhu: They did talk about it in terms of one of the biggest, I believe was waking up in the middle of the night and engaging in self-talking.
John Lubbers: Interesting. Yeah. I guess where my curiosity is, what does a sleep problem that serves an automatic or sensory function look like? You know, what is that? I’d have to really kind of scratch my head and think about that. But you provided a great example of one there, which is a child waking up and engaging in self stimulatory, hand flapping or self talk.
Manjit Sidhu: Exactly. Yes. So just looking at it right now, playing with clothing, curtains, rocking their body back and forth, shaking their head, jumping or running around the room.
John Lubbers: Hmm. Interesting. And this was one particular participant in this.
Rei Reyes: I remember this for the gene study, they have one specific child that did engage in those kinds of behavior and none in the Maclay study.
John Lubbers: McLay right. Yeah. And those are the younger ones. Again, the two year olds, the five-year-olds and the Maclay.
Manjit Sidhu: And for this particular participant in the gene study, they were very lengthy night wakings because of the self-stimulatory.
John Lubbers: Very interesting. Okay. So we talked a little bit about functions and the another important thing to mention with functions is that most of the studies found that the behavior served multiple functions. So in addition to attention, attention I think was a function for almost all of the participants across both studies. It’s sometimes found escape, occasionally found access or one of those two. And then the example that Manjit you just brought to our attention, there was one particular participant that had an automatic or self stimulatory function. What about interventions guys? What do we like globally? What are we talking about with respect to interventions kind of things do we do?
Rei Reyes: For the sleep onset delay, the intervention is fairly similar. So basically again just to review, sleep onset delay is sending, kissing your child goodnight at seven o’clock but they don’t really sleep until 10 so a common theme for this intervention is making sure that the child is motivated, more motivated sleep. Right? So what they do is they move the play around with the time, the time that the child is actually sent to bed. So for that example that I just mentioned, they’ll send bid the child good night at 10 o’clock because the child is more likely to fall asleep within minutes after 10 o’clock.
Sevan Celikian: It’s closer to their actual sleep.
Rei Reyes: The actual sleep time, and then from there to it back, they keep shaping back. They keep moving back until the sleep time goal is met. From what we’ve gathered, this really works addressing sleep onset delay.
Sevan Celikian: It’s not very difficult to implement either.
Rei Reyes: Yeah. It’s really changing the time alone How many kids are these? 10 kids. So for sleep onset delay, this alone fixes it. It addresses that, which makes sense.
John Lubbers: So what are we talking about behavior analytically there guys, we’re talking about two processes.
Sevan Celikian: Establishing operations a little bit.
John Lubbers: Yeah, the motivating operations and creating a maybe a little bit of a situation, I don’t want to say deprivation, I don’t know. But that’s really the technical term.
Sevan Celikian: Establishing the value of sleep. They’re increasing the value of sleep. Naps can sometimes decrease the value of sleep.
John Lubbers: It can be abolishing. Yeah, they can definitely decrease. Yes. absolutely.
Rei Reyes: So it’s really one of those things that we’ve got to talk to our families about as professionals. Like, look, I understand that you’re putting priority on naps. However, if the naps are becoming like problematic at nighttime, you notice the sleep time, then we really need to address it. And that’s one thing that, at least for me, I hit that wall sometimes with families, like letting go of that nap in the afternoon just so they can have better sleep at night.
John Lubbers: That is tough and if you look at it, I mean we can go a little deep on this, but if you look at this from the perspective sometimes of the parent, sometimes that afternoon nap can be negative reinforcement for their behavior of letting the individual, the child sleep. It’s when they cook.
Manjit Sidhu: When you get your chores done.
John Lubbers: Yeah, yeah. Pay bills, make phone calls, all that kind of stuff. So it’s tough sometimes for us as professionals to get a parent to maybe suffer a little bit in the short term to gain in the longterm. It’s challenging.
Rei Reyes: Yeah, we gotta make sure what they really want, like you can’t have both and it has to be a compromise somewhere to some gains.
John Lubbers: That’s the speaking to the, to the aspect of social validity, right? We’re talking about social validity then. Is this important to you? We talked a little bit, I want to kind of just also pointed out, you talked about shaping guys. It was one of the things where they started to start it with the sleep onset problem where they started with bedtime was eight o’clock but real sleep time was 10 o’clock so then we’re going to go closer to 10 and then move it back closer to eight. Did they describe any more details about how they thought that would would work ideally?
Rei Reyes: Each child had a different role contingencies for how they move back but primarily along the lines of if the child fell asleep within X amount of minutes, they move back the time.
Sevan Celikian: About 15-30 minutes.
Rei Reyes: 15 to 30 minutes until, I guess from what we’ve read, it was done pretty much straightforwardly.
Sevan Celikian: Reinforcing approximations.
Rei Reyes: Approximations and works. That alone is a very powerful intervention. Just that alone is to make that huge difference for at least sleep onset delay.
John Lubbers: Yeah, it’s modifying the environment to change behavior, and so that’s a really good example. For us and behavior analysis, we love those kinds of things because they’re not more naturalistic. They’re not too intrusive. They’re usually higher in social validity, usually higher and treatment acceptance and those types of things that are important to us. So yeah, those antecedent interventions are great. What about other antecedent interventions as well? There’s some other things that we would want to kind of point out from the global perspective.
Sevan Celikian: Yeah, great use of non-contingent reinforcement. The researchers came across this issue with most of the participants is after being bid good night, the participants were seeking parent attention, asking questions, calling out and also trying to get access to tangibles, toys, tablets, things like that. So in both studies, a period of time was set up before bedtime in which rich social interaction would occur between the parents and the kids during this time because would have open access to conversation with their parents, asking, answering questions, access to books, some, some different toys, maybe some electronics. And then once good night was bid, all of these were withheld. And the purpose behind this was to lower the motivation for engaging in sleep interfering behaviors, especially the, the tangible function, the social attention function ones while they’re in bed with, with the idea being that they’d be satiated with that rich attentional schedule before bed. So there was no deprivation there. So we’re kind of talking about satiation now instead of that probation.
Manjit Sidhu: And that method would work great also with automatic reinforcement there. Let them run around their room, let them engage in flapping or rocking your body. Once they’ve engaged, like they have 30 minutes to do all that and then it’s like, okay, it’s bedtime now, that helps decrease the value of the automatic reinforcement as well.
John Lubbers: Got it. these attentional function behaviors with respect to sleep onset non-contingent reinforcement in a planned time in the evening before bed close to bedtime where the child was just absorbed in attention and whatever they wanted from the parents was effective. What about like a, here’s another sort of interesting sort of behavior analytic approach. I’d kind of, always get a smile out of these great things, but what about the grow clock guys? That was something that was brought up in McClay study. What does that, what, how do they use that?
Manjit Sidhu: So it’s a digital clock with the large screen, which indicates a sun, meaning that it’s time to wake up or stars and the moon, which indicates it’s time to sleep. It’s to basically discriminate between nighttime and morning by visually looking at it.
John Lubbers: I was just gonna say Sevan, that it makes laugh, it makes me giggle that exists and that it’s out there. I love it. I mean I think it’s great that we have, or somebody has invented a clock that indicates nighttime and daytime for our individuals, including kids that need something to facilitate stimulus discrimination and SDs and S Deltas. I think it’s amazing.
Sevan Celikian: Exactly. And the FBA outcomes, especially in the Maclay study indicated that most of the children in this study, they had that difficulty discriminating sleep time from, from wake times. So the grow clock function as a I know this is a little premature now, but now since we’re on the topic right now, did we have any discussion in the articles of how that functioned? discriminative stimulus for either sleep or waking up.
John Lubbers: I know this is a little premature now, but now since we’re on the topic right now, did we have any discussion in the articles of how that functioned? Did that start to take on discriminative stimulus properties with some of the participants?
Rei Reyes: I don’t think it was brought up. We were just talking about this. Did it work?
Sevan Celikian: Well in the Maclay study, the intervention was implemented as a package, so treatment effect was recorded and measured. They didn’t have a staggered approach where one intervention at a time. So it’s kind of difficult to differentiate which specific component had the most profound effects but use it with some of the participants.
John Lubbers: That would be interesting at some point down the line as study to replicate this a little bit but really replicate the intervention components to see what happens. A component analysis to do that. That would be really cool. Okay, so we had that positive reinforcement. What do we have any like what about like extinction and and consequence based interventions. Anything with respect to that?
Sevan Celikian: Yeah, extinction was used, they called it planned ignoring, so like a modified form of extinction and it was a followup to the gradual fading of parental presence. So maybe we should talk about that component first because that’s what they use in the Maclay study and especially if co-sleeping or access to parent attention was a reinforcing variable. A time-based parental visit schedule was implemented. So the parents would openly make themselves available regardless of behavior and time increment. I think it was every one minute, five minutes, 10 minutes, and then progressively those time intervals were thinned out so they were further apart. And that also in a way was functioning as non-contingent reinforcement. So it kind of removed the motivation for the kids to leave their beds and try to co-sleep. During that time, the parents were instructed to keep neutral facial expressions, minimize eye contact, and gently guide their child back to bed with minimal intention if they were out of bed during those visits.
John Lubbers: So this is the planned ignoring phase and the extinction phase at the component package, right?
Sevan Celikian: Yeah. Yeah.
John Lubbers: Okay. All right. So during planned ignoring, just redirect them when. Clarify for me guys, I don’t recall this specifically from this study, but when there were little intervals of attention provided, was that during the sleep, what should have been sleep time or was that before?
Sevan Celikian: I think it was right after the bid good night. In Maclay study, the parent would either visit or they would sit in the chair like next to the child’s bed and then they would gradually further themselves and distance. So there’s two things going on there. There’s a parent visit schedule that was utilized and then there was also an actual like fading of the presence.
John Lubbers: Yes. Yeah. So really interesting so that fading of that reinforcement schedule by pulling themselves out was also, and it sounds like they did it pretty systematically was also a part of the packet. So again, this is really based on sound behavior analysis principles and evidence based practices. So that’s really great to see.
Sevan Celikian: Yeah, it definitely was, there was a lot of emphasis placed on establishing and maintaining a consistent sleep environment. So all of the researchers here, they were really focused on establishing conditions where the same conditions in which the child falls asleep and the same condition should still be present if the child’s wakes up. For example, if a child wakes up in the middle of the night, we don’t want to have on iPad within arms reach. So to that end, the researchers set up a pre-bedtime cleanup routine and this accomplished a few different things. It made items inaccessible during sleep time so as to prevent distraction. So right before the bid, good night, the kids were asked to put their toys away. I think it was in like a designated bag or a box. So not only did that make some of these items inaccessible during sleep, it also functioned as discriminative stimulus indicate that, okay, it’s sleep time now these things are being put away and they’re not going be available even if I wake up in the middle of the night. So that was kind of an interesting environment for modification. Pretty easy to implement as well. It’s not a very taxing intervention.
Manjit Sidhu: There was a participant in the gene study who used to fall asleep listening to music, and then the parents would go in and turn off the music, take off the headphones. So when he woke up in the middle of the night, he didn’t know how to go back to sleep because the music wasn’t there. So how you mentioned earlier Sevan about the consistent environment, that’s very important. So I think they in that intervention, they, correct me if I’m wrong, but I wanna say they started playing white noise. As soon as the parents left the room, it was turned on right before they left and then it was turned off when the participant woke up in the morning, so it was playing throughout the night.
John Lubbers: There was also a participant in the Maclay study, and this was a 4 year 5 month old girl that participated in this study that would listen to mom, whisper her to sleep and they replaced that with ocean sounds, ocean waves sounds so that you could hear that it’s kind of a white noise kind of thing, and so it’s a little bit of a differential reinforcement of an alternative or appropriate behavior or maybe even a more logistically possible behavior rather than mom or dad whispering and singing our kids to sleep every night. That’s a little bit more manageable. You can turn the radio on.
Sevan Celikian: Social stories were used, especially in the Maclay study, and that’s just a great behavioral analytic tool that we use with a lot of it from behaviors. So they were individualized. They included photographs and texts depicting the steps required or expected from the kiddos surrounding bedtime routine and other expectations around sleep, like sleeping independently. And that also pointed out any rewards or reinforcers that they would receive for good sleeping or following through with their sleep goals. So that was a tool that was used.
John Lubbers: So some of the principles involved in social stories are like modeling, right? So for us professionals, we would want to look at this from the perspective of what makes modeling most successful? Well, if we watch ourselves do something, it’s usually the most successful. However, sometimes that’s not possible. Conversely, or alternatively, sometimes if we see somebody that is highly motivating and what we’re talking about here is if a, we have a younger child who’s really into wonder woman or captain America and they see wonder woman or captain America emulating those types of things or the Bernstein bears or whatever it is that is motivating or interesting, the wiggles or whatever, we can utilize those, that interest, that motivation and those modeling principles to really maximize the effectiveness of the social stories.
Sevan Celikian: Definitely. So that covers, I want to say all the different interventions are most for both studies.
Rei Reyes: For both studies, they did have some parent training for the families and just so they can have an idea, expectations from them when they do implement the intervention. Remember, that’s very important because since these are parent implemented interventions.
Sevan Celikian: Great reminder. They were all implemented by the parents.
Rei Reyes: There was ongoing communication as well between the family and their researchers throughout the intervention, which for us it equates to continual parent training throughout the process.
John Lubbers: I think just a comment too about the quality of the studies. Both studies included information statements or data on inner observer agreement. So the independent variable was measured treatment integrity, the dependent variable was measured so they were all methodologically adequate or or highly sound. Even given the difficulties of measuring sort of a, I don’t want to say a covert behavior, but it’s an overt behavior but it’s a semi difficult to measure over behavior because it’s happening in somebody’s home or a clinic at night kind of thing.
Sevan Celikian: Also to add to some of the measures that you mentioned, John treatment acceptability was also measured in the Maclay study and the researchers found that out of everyone who completed the intervention, the parents overall reported the interventions to be acceptable, effective and clear to understand. However they did perceive the interventions to require a lot of effort and time so that’s not too surprising. But yes, on the positive note, they were behind the interventions in terms of the clarity and the ease of implementation and the effectiveness.
John Lubbers: Yeah, that should be some, no surprise to any of our behavior analysts, professionals out there. Most of our things do require a lot of effort and energy to put in to do it and certainly up front and that’s usually a tradeoff like we mentioned earlier, is you have to kind of put any energy up front to be able to reap the benefit down the line. Sometimes that’s easier to convey and each family and each parent is different and their circumstances change from moment to moment. At one particular time in their lives, they may have a lot of additional family stress. There may be grandparents that are ill, there may be additional work stress, somebody may have a big deadline or what have you. And so a parent may or may not really be able to concentrate on these types of things and of course we know that as professionals that we have to choose the most appropriate time in addition to these things that require so much effort.
Sevan Celikian: So true.
John Lubbers: So what should we talk about next guys? Should we talk about the general summaries of the interventions? What kind of, we didn’t calculate effect sizes, but most everybody benefited from it. A couple of kids dropped out. Maybe we should kind of go over that information and where should we go? What should we leave our professionalism with takeaways after that?
Sevan Celikian: So overall the results were positive across the board. There was some really significant improvement we can provide. Maybe just a couple of examples cause there’s a lot of different participants to get through. Let’s point one out from the gene study. So one of the participants, Walter, he was a seven year old typically developing boy. He was experiencing delayed sleep onset. He would talk to himself, get out of bed, walk around treatment package. Some of the interventions we mentioned earlier were were put together in a package for him. His bedtime was pushed forward by one hour. He was allowed access to all of his preferred items and activities for at least 20 minutes before getting ready for bed. His sleep onset delay decreased from 55 minutes down to about 22 minutes. His sleep interfering behaviors decreased to near zero levels and they were maintained in the followup conditions across all forms.
John Lubbers: Sleep interfering was the walking around and talking.
Sevan Celikian: Talking to himself, walking around, sitting up in bed, engaging in stereotypy and also night waking also decreased from baseline about 12 minutes down to four minutes and then zero during followup, so some really positive results with that particular participant. Here’s another example, and the nine year old boy with ASD, this was from the gene study as well. Experienced delay, sleep onset and extended night awakenings. Stereotypy, including body rocking, head shaking, repeated manipulation of items, occasional screaming tantrums. My package was put together for him as well. Bedtime move forward an hour and a half at the start of treatment. That’s the established the value of sleep. The parents allowed and to engage in stereotypy for 30 minutes before his bedtime routine in order to decrease the value of stereotypy during the time that he’s in bed asleep time.
Sevan Celikian: After midnight was bid, all of these activities and items were restricted. The parents would gently interrupt stereotypy and guide them back to bed. Minimal attention, neutral facial expression and his SATT results indicated he had a sleep dependency on music. So, and these parents would turn on a CD player Manjit I think you brought this example earlier and they played music for about 45 minutes when they bid him good night. So the researchers asked the parents to eliminate the music in order to keep a consistent environment throughout the night with the logic being that since the stimulation of music was not present throughout the entire night, brief night wakings episodes, they were turning into full, full awakenings. So I think they replaced the music with white noise for that one. So his sleep onset delay decreased from about 16 minutes down to eight minutes. So that’s a 50% decrease right there. His sleep interfering behaviors decreased to near zero levels during treatment and night waking decreased from a baseline of 26 minutes down to 22 minutes. However, most of those 22 minutes were were quiet wakefulness, so his eyes would be open but you would still be in bed. Got it. So that’s just a couple of examples of of some of the positive results from the gene study.
John Lubbers: Being the objective professionals that we are, which probably should look at a couple of the situations where things didn’t work out ideally or where parents dropped out. So we can look at that from our perspective of professionals and see if we can anticipate any problems there. I remembered there were and we talked a little bit about this earlier, but it might be worth us kind of discussing it again. There were a couple parents that dropped out, correct?
Sevan Celikian: Yeah. In the Maclay study, there were two if I remember correctly.
John Lubbers: That was mostly guys because of the intervention difficulty in particular was it the planned ignoring that was difficult for these parents to implement.
Sevan Celikian: There might’ve been other personal factors that led them to drop out as well.
Rei Reyes: It was mentioned by the authors that there were some personal factors that may have been in effect around that time. There were in the study but the authors said they had mentioned that from the data that they have collected so far for with those two families it looks like they were having difficulties as well during implementation of the intervention
John Lubbers: Planned ignoring. Yeah. I think that speaks maybe just reading between the lines in this study and I know we probably shouldn’t do that but I’ll just take the liberty to do that here is probably, there were some things like I was saying earlier about maybe there was additional work stress or family stress, there was ill family members or financial stress or something that made the starting and the implementation of this treatment package non-ideal. So again, making the point of and take the takeaway message of this is probably something that we should really take into consideration like we always do when we start a treatment package.
Rei Reyes: Yeah. And especially, we have to consider the ages of our participants the front of Maclay studies there, their kids were much younger than gen studies. It may be harder for these parents to kind of like really stick by, stick to their guns, you know, while their two year old is having a fit at 3:00 AM, I mean any parent will have a hard time with that. So, you know, I,
Sevan Celikian: And of course I can see that. Yeah, that makes sense. That’s very, really logical. Yeah. So what should we do guys now, shall we show, we kind of summarize everything for our professionals in show we give some takeaways and some direction or what do you think? Is there something else that we want to really explore or expose our listeners to?
Sevan Celikian: Yeah, that sounds like a plan, John and I also wanted to point out, I love how the researchers, especially the gene study pointed this out and I’ll read this quote, behavioral as opposed to pharmacological treatment of pediatric sleep problems begins with a look at the target behavior through the lens of a contingency. They go on to say, we are interested in the behavior of lying quietly in bed and falling asleep. Procedurally, we focus on developing a period of behavioral quietude or lying quietly in bed because that is a measurable dimension that always proceeds the target behavior of falling asleep. They also go on to say that discriminative stimuli that often occasion falling asleep include dimly lit rooms, cool temperatures, particular pillows, blankets, stuffed animals rocking or the mere presence of a parent. I thought it was great how the researchers really took on a behavior analytic approach. They operationally defines all of the target behaviors and and the problem behaviors and they really looked at it through a lens of contingencies and through a lens of identifying functions for these behaviors. So I thought that was great for for us behavior analysts.
John Lubbers: Yeah, it really speaks to us that in the sense that we’re looking at it in terms of were identifying it, we’re operationally defining it, we’re looking at the antecedent conditions, we’re looking at the functions that the behavior serves and we’re developing an intervention or a composite intervention that has multiple components to it that address those antecedents and those behavioral functions. And then like we mentioned earlier, parent training is a big component here. Like it is with everything with potty training, with feeding, with behavior intervention, with teaching skills, all these types of things. Parent trainings are an important component here for our families. So we really need to kind of not forget that that’s an important part of what we offer to our family.
Sevan Celikian: Definitely. And for the professionals out there and, and myself as a professional, I do plan to start using sleep diaries for parents to record and to track information about their child’s sleeping behaviors. And we also encourage the use of the SATT as well. It’s a really useful functional assessment tool that captures a lot of information to help guide sleep based interventions. So I myself as a professional plan to integrate that more into my practice.
John Lubbers: My takeaways from this guys and tell me if you have any additional ones for our listeners, but my takeaways are starting very global, very high level perspective, is that to just confirm a little bit that sleep problems can be addressed behavior analytically and with behavioral interventions and it can be successful too that there is one formal structured assessment tool, semi-structured tool and that’s the SATT by Hanley and then there’s also the lesser structured tool which is the sleep diary. So there’s ways to assess. There are evidence based practices for intervention. So we have those types of things and those are based on, you know, positive reinforcement, planned ignoring, altering the motivation, motivating variables and motivating operations and with respect to deprivation and satiation and those things are well established in our literature. And also that necessarily if we were having a client or somebody that has a problem with sleep that in a family brings it to us as a concern that you can kind of have a discussion with them, that there are alternatives to a medical treatment approach. Not saying that that’s wrong or bad or you can’t do it. Just saying that, when we want to really best support our families out there that we can bring to their attention that there may be some things that we can be offered that are non medicinal non-pharmacological nonmedical based and they might be behavioral intervention. So those, those were some big takeaways that I would offer. Am I missing anything guys?
Manjit Sidhu: No, I think you’ve covered it all, John.
John Lubbers: Okay. So I guess maybe we should thank our listeners for listening to our podcast today. As always, if you have requests, questions, comments, or anything for future podcast or about this podcast, please visit us on the website and make some comments or request some additional information or make suggestions. We’d be really happy to hear from you because this really is a podcast for you, for the listener. Even though it does help us considerably as professionals, we hope it helps you the same. It is ultimately for you. So we’re providing this sort of as a service to kind of get behavior analysis disseminated in media formats, (i.e. podcasts) that’s easy for us when you’re on the train or in an airplane or in a commute or wherever you are and you need to kind of expose yourself to some treatment, behavior analytic or behavior behavior analytic approaches. You can always access this kind of stuff through podcasts. So please do reach out to us and otherwise, thank you very much and we wish you good luck with everything.
Sevan Celikian: Thank you all. We hope you found this helpful. Thank you.
Manjit Sidhu: Thank you for listening.
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