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Friedman26Luiselli2C2008.pdf

Volume 32 Number 4 July 2008 548-555

© 2008 Sage Publications 10.1177/0145445507312187

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Behavior Modification

Excessive Daytime Sleep hosted atBehavioral Assessment and http://online.sagepub.com

Intervention in a Child With Autism Abby Friedman James K. Luiselli May Institute, Randolph, Massachusetts

Some children with autism have excessive daytime sleep but intervention research for this problem has not been conducted. The present study evaluated procedures with a 13 year old boy who had autism and slept for prolonged periods during the day. Classroom staff at a specialized school implemented procedures with the boy according to an ABAB experimental design. Interven- tion eliminated daytime sleep through a 6-month follow-up assessment. The study adds to the literature concerning sleep problems in children with autism and extends intervention to excessive daytime sleep.

Keywords: excessive daytime sleep; autism; sleep problems; behavioral intervention

Some children with autism have sleep problems such as difficulty initiating and maintaining sleep, early morning awakening, bedtime tantrums, and night terror (Hoffman, Sweeney, Gilliam, & Lopez-Wagner, 2006; Richdale, 2001; Williams, Sears, & Allard, 2004). In fact, research suggests that children who have autism are more likely to experience sleep problems than age-equivalent, typically developing peers (Hoffman et al., 2006). Although nighttime sleep problems have been the focus of intervention, some children with autism have excessive daytime sleep. For example, based on data acquired from a sleep problem and patterns questionnaire, Liu, Hubbard, Fabes, and Adams (2006) found that 31% of 167 children with autism (2 to18 years old) slept for prolonged periods during the day. Similarly, Alik, Larsson, and Smedje (2006) designed a sleep questionnaire and sleep diary with 32

Authors’ Note: This study was conducted at the May Institute for Child Development, Randolph, MA. The authors acknowledge the skilled participation of the classroom staff. Abby Friedman currently is affiliated with Southwest Behavioral Health, Phoenix, Arizona. Address correspondence to James K. Luiselli, May Institute, 41 Pacella Park Drive, Randolph, MA 02368; e-mail: [email protected].

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children diagnosed with Asperger’s syndrome and high functioning autism (8 to 12 years old). The results showed that 37.5% of the children had excessive daytime sleep.

Hypersomnia is a condition of excessive daytime sleep that occurs in 31% of the adult population because of a medical affliction such as sleep apnea or narcolepsy (Roth & Roehrs, 1996). Occasional episodes of exces- sive daytime sleep not considered to be hypersomnia also may result from sleep deprivation or consuming caffeine, alcohol, and certain medications (Chokroverty, 1999). Among people who have developmental disabilities, specific disorders such as Kleine-Levin syndrome and Prader-Willi syndrome are associated with primary and secondary (intermittent) hypersomnia (Harris & Allen, 1996; Thorpy, 1990). In the case of a child with autism who sleeps excessively during the day, there will be fewer learning oppor- tunities and social interactions essential for skill development. The require- ment of keeping a child awake also creates difficulties for practitioners and parents. Another complication from excessive daytime sleep is possible dis- ruption of nocturnal sleep patterns (e.g., sleep-wake cycle disturbance) that in turn, can create problems during waking hours (Eshbaugh, Martin, Cunningham, & Luiselli, 2004).

Behavioral intervention has been effective in treating nighttime sleep problems of children with autism by eliminating the conditions maintaining the problems and teaching alternative (compensatory) skills (Schreck, 2001). However to our knowledge, research has not been conducted on excessive daytime sleep. In the present study, we evaluated procedures with a child who had autism and often slept during the day at school. The study included a functional behavioral assessment, a multicomponent intervention plan com- prised of antecedent and consequence procedures, and a 6-month follow-up evaluation.

Method

Participant and Setting

Robert was a 13-year-old boy diagnosed with Autistic Disorder (American Psychiatric Association, 2000). His verbal communication skills were limited to one- to two-word sentences and physical gestures, primarily to request objects and activities. Robert attended a specialized school for children with developmental disabilities 6 hours each weekday. His classroom at the school was comprised of a teacher, two teacher assistants, and five other students. Robert required frequent direction and support from classroom staff during

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550 Behavior Modification

instructional activities. His individualized educational program emphasized communication, learning readiness, and play (leisure) skills.

Robert’s classroom teacher reported that he frequently tried to sleep dur- ing the day and frequently fell asleep despite efforts to keep him awake. Parent information indicated that Robert slept soundly during the evening at home and occasionally napped during the day. Informal evaluations by the family’s primary care physician ruled out medical causes for Robert’s daytime sleep. He was not prescribed medication and was in good health.

Measurement

Sleeping was defined as Robert closing his eyes for at least 10 consecu- tive seconds, with his head down, while he was in a sitting or supine posi- tion. An episode of sleep ended when he lifted his head and kept his eyes open for at least 30 consecutive seconds. One member of the classroom staff was responsible for recording sleep duration during assigned periods in the day by activating and stopping a hand-held stopwatch each time Robert had a sleep episode. The dependent measure in the study was the cumulative number of minutes Robert slept each day.

Functional Behavioral Assessment

Two informant questionnaires, behavioral observations, and a recording checklist were used to determine functional influences on Robert’s daytime sleep.

Motivation Assessment Scale (MAS)

The MAS (Durand & Crimmins, 1988) is a 16-item Likert-type scale that ranges from 1 (never) to 6 (always). Four functions are assessed (social attention, access to tangible, escape from demand, automatic reinforce- ment) by having an informant record a rating to questions such as, “Does this behavior occur when you are talking to other people in the room?” Ratings are summarized to yield a total score suggestive of behavior func- tion. The resulting hypothesis from the MAS was that Robert’s daytime sleep was maintained primarily by automatic reinforcement.

Functional Analysis Screening Tool (FAST)

The FAST is an 18-item scale based on dichotomous scoring (yes/no) for questions such as, “The behavior usually occurs when the person is being ignored or when preferred items have been taken away.” Behavior function

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Friedman, Luiselli / Excessive Daytime Sleep 551

is inferred by calculating a summary score for four likely maintaining variables (social attention, access to tangibles, escape, and automatic rein- forcement from either sensory stimulation or pain attenuation). The resulting hypothesis from the FAST was that Robert’s daytime sleep was maintained primarily by automatic reinforcement.

Recording Checklist

Classroom staff completed an antecedent-behavior-consequence record- ing checklist (Bijou, Peterson, & Ault, 1968) for each sleep episode that was documented. They recorded the time of the sleep episode, where it occurred in the classroom, and the ongoing activity. Staff also described their interac- tion with Robert following a sleep episode. The checklist information sug- gested that Robert slept most frequently during break times, during leisure activities when there was reduced staff supervision, and when he was not engaged in purposeful instruction. Typically, the consequence immediately following sleep was ignoring or not attending to Robert until he was awake. Similar to the MAS and FAST results, we hypothesized that Robert’s daytime sleep was maintained primarily by automatic reinforcement, but also may have functioned to avoid or escape nonpreferred interactions.

Procedures and Experimental Design

Baseline and intervention procedures were evaluated in an ABAB rever- sal design. The senior author coordinated measurement and intervention procedures with the classroom staff during case review meetings and sched- uled observations.

Baseline

The conditions during baseline were the same as those in effect before the study. There was no intervention targeting Robert’s daytime sleep and as noted, classroom staff usually allowed him to wake up on his own. During the initial baseline phase, classroom staff began recording sleep duration and completed the functional behavioral assessment.

Intervention

Several procedures were combined with the objective of eliminating antecedent and consequence events that appeared to set the occasion for and reinforce Robert’s daytime sleep.

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552 Behavior Modification

Stimulus Change

The functional behavioral assessment suggested that Robert often slept on a soft floor mat or a large bean bag chair that were in one area of the classroom. To eliminate sleep-associated stimuli, the mat and chair were removed.

Response Interruption and Redirection

When Robert put his head down or appeared sleepy (closing his eyes), a staff person guided him to an area of the classroom containing highly stim- ulating objects and preferred activities. We selected the objects and activi- ties based on staff opinions about what Robert found pleasurable. He was allowed to play in the area with staff supervision, receiving prompts as nec- essary to keep him engaged with play. The play activity lasted 5 to 10 min- utes before staff directed Robert to his next scheduled instructional session.

Positive Reinforcement

Staff members were instructed to increase their positive interactions with Robert by praising him and giving a pat on the back for behaviors other than sleeping (differential reinforcement of alternative behavior). These positive consequences were implemented during instructional ses- sions with Robert and naturally occurring events in the day (e.g., snack, lunch, walking in the school corridors).

Follow-up

Staff continued to implement intervention procedures after the study concluded. At a 6-month follow-up assessment, daytime sleep was recorded each day for 1 week.

Results

Figure 1 shows the cumulative time (minutes) Robert slept each day. During the initial baseline phase, average sleep per day was 46 minutes. Daytime sleep did not occur when intervention was introduced, increased to an average of 22 minutes per day during the reversal (return to baseline) phase, and was absent when intervention was implemented again. At the 6- month follow-up, Robert continued to be awake all day.

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Friedman, Luiselli / Excessive Daytime Sleep 553

Figure 1 Cumulative Duration (Minutes) of Daytime Sleep

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Discussion

This study documented an effective intervention that eliminated exces- sive daytime sleep in a child with autism. It should be emphasized that the study was initiated after ruling out medical causes for Robert’s sleep prob- lem. Although a formal sleep evaluation was not conducted, parents reported that he slept soundly in the evening, was in good health, and had no apparent physical concerns that might account for daytime sleep. Accordingly, our interpretation was that Robert would sleep during the day if he was not actively engaged with staff, did not have access to stimulating activities, and was allowed to sleep without interruption. Before the study, classroom staff appeared to have tolerated Robert’s sleep episodes, focus- ing their attention on other students who had more challenging behavior. One objective of intervention was to provide them with easily implemented procedures that were preventive and also eliminated sleep maintaining con- sequences. Intervention was immediately effective and as revealed by the follow-up assessment, produced long lasting effects.

The reversal design evaluation showed that without intervention, day- time sleep remained a problem. Note that Robert stopped sleeping on the

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554 Behavior Modification

first day of both intervention phases. This finding may have resulted because intervention included removing stimuli associated with daytime sleep and interrupting and redirecting Robert when he appeared sleepy. Because intervention was comprised of several procedures, it is not possi- ble to judge conclusively how each one contributed to outcome. An alter- native strategy would have been introducing procedures one at a time instead of the entire intervention package. Another option would have been gradually withdrawing procedures to determine if effects maintained with fewer intervention components.

The study did not include an assessment of interobserver agreement or procedural fidelity. Scheduled observations by the senior author confirmed that classroom staff implemented measurement and intervention procedures as instructed but more formal assessment would have strengthened our findings. When questioned, staff reported that they found intervention to be acceptable and were pleased with how quickly Robert responded. Staff sat- isfaction may explain the continuation of intervention following conclusion of the study.

Our findings support procedures that have been used to treat nighttime sleep problems of children with autism (Schreck, 2001). Notably, the study is the first intervention evaluation for excessive daytime sleep in this clini- cal population. Because excessive daytime sleep is not uncommon in children who have autism (Alik et al., 2006; Liu et al., 2006), practitioners and parents will benefit from further evaluation of procedures that success- fully overcome this problem.

References

Allik, H., Larsson, J., & Smedje, H. (2006). Insomnia in school-age children with Asperger syndrome or high-functioning autism. BMC Psychiatry, 6, 6-18.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disor- ders (4th ed., text rev.). Washington, DC: Author.

Bijou, S. W., Peterson, R. F., & Ault, M. H. (1968). A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. Journal of Applied Behavior Analysis, 1, 175-191.

Chokroverty, S. (Ed.). (1999). Sleep disorders medicine: Basic science, technical considera- tions, and clinical aspects. Boston, MA: Butterworth-Heinemann.

Durand, V. M., & Crimmins, D. B. (1988). Identifying the variables maintaining self-injurious behavior. Journal of Autism and Developmental Disorders, 18, 99-117.

Eshbaugh, B. A., Martin, W., Cunningham, K., & Luiselli, J. K. (2004). Evaluation of a bed- time medication regimen on daytime sleep and challenging behavior of an adult with intel- lectual disabilities. Mental Health Aspects of Developmental Disabilities, 7, 21-25.

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Friedman, Luiselli / Excessive Daytime Sleep 555

Harris, J. C., & Allen, R. P. (1996). Is excessive daytime sleepiness characteristic of Prader- Willi syndrome: The effects of weight change. Archives of Pediatrics and Adolescent Medicine, 150, 120-128.

Hoffman, C. D., Sweeney, D. P., Gilliam, J. E., & Lopez-Wagner, M. C. (2006). Sleep problems in children with autism and in typically developing children. Focus on Autism and Other Developmental Disabilities, 21, 146-152.

Liu, X., Hubbard, J. A., Fabes, R. A., & Adam, J. B. (2006). Sleep disturbances and correlates of children with autism spectrum disorders. Child Psychiatry and Human Development, 37, 179-191.

Richdale, A. L. (2001). Sleep in children with autism and Asperger syndrome. In G. Stores & L. Wiggs (Eds.). Sleep disturbances in children and adolescents with disorders of devel- opment (pp. 181-191). London: Mac Keith Press.

Roth, T., & Roehrs, T. A. (1996). Etiologies and sequelae of excessive daytime sleepiness. Clinical Therapeutics, 18, 562-576.

Schreck, K. (2001). Behavioral treatments for sleep problems in autism: Empirically supported or just universally accepted? Behavioral Interventions, 4, 265-278.

Thorpy, M. J. (Ed.). (1990). Handbook of sleep disorders. New York: Marcel Dekker Inc. Williams, P. G., Sears, L. L., & Allard, A. (2004). Sleep problems in children with autism.

Journal of Sleep Research, 13, 265-268.

Abby Friedman, PhD, is program coordinator at Southwest Behavioral Health and adjunct faculty at Phoenix College in Arizona. Her interests include applied behavior analysis, behavior therapy, and behavioral consultation.

James K. Luiselli, EdD, ABPP, BCBA, is senior vice president of applied research, clinical training, and peer review at May Institute in Massachusetts. He also is director of the insti- tute’s predoctoral internship program in clinical psychology. His interests include applied behavior analysis, systems intervention, and the integration of research and clinical practice.

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