| Sıra | DOSYA ADI | Format | Bağlantı |
|---|---|---|---|
| 01. | Optimizing Melatonin Compliance Interfering | pptx | Sunumu İndir |
Transkript
Gregory P. Hanley. Ph.D., BCBA-D. Understanding and Treating Sleep Problemsof Children with Autism DataFinch November, 2014
Important assumption of Behavior Analysis: Sleep problems are viewed as skill deficits which can be addressedby teaching relevant skills
Important assumption of Behavior Analysis: Autism is not a life sentenceof poor sleepand tired days
Good Sleepfalling asleep quicklystaying asleep through the nightrising without much trouble each morningnot feeling drowsy during the day
Why is Good Sleep Important?Good sleep is restorative; without it, children are:more irritablemore easily fatiguedmore likely to suffer from unintentional injuryless likely to follow instructionsless likely to learn academic conceptsmore likely to engage in problem behavior(meltdowns, self-injury, aggression, stereotypy)
Without good sleep, people with autism may be more likely to engage in stereotypyJackDays5 10 15 200246810121416Number of Hours Slept each NightMean Baseline Session Rate of Stereotypy r = -.484, p < .05
Why is Good Sleep Important?Persistent sleep problems in childhood are also associated with:childhood and adult obesityadolescent behavioral and emotional problemsanxiety in adulthoodsleep problems through adulthood
Why is Good Sleep Important?Children’s sleep problems can lead to:Maternal malaise and depressionParental sleep problemsErosion of the parent’s relationship with each other and with their children
Sleep problems are prevalent:35 - 50% of young children 63 - 73% of children diagnosed with autism Sleep problems are persistent—they do not typically remit with time How Prevalent are Sleep Problems?
Clash between our ancestral history (encoded in our genes) and existing cultural practiceswe are built to sleep in a particular contextbutwe are expected to sleep in a very different context Why So Prevalent?
Parents are likely to consult with pediatriciansdespite only 5 hr of training on averageTreatment Options?
81% of children’s visits to pediatricians, psychiatrists, or family physicians for sleep problems result in a prescription for a medication despite no FDA approval, no medication labeled for pediatric insomnia, no (or inconsistent) efficacy signal in literatureTreatment Options?
Nights5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80TimeIdeal sleep zoneAsleepNap 07:00 pm09:00 pm11:00 pm01:00 am03:00 am05:00 am07:00 am09:00 am11:00 am AliceBaselineGoal wake time (08:00 am)Goal bid goodnight time (09:00 pm)Behavioral InterventionMelatonin: 3 mgClonidine: 0.1 mgHydroxyzine: 4 ml0 mg0 mg0 ml
Behavioral solutions are recommended 22% of time (Stojanovski et al., 2007)but the solutions are relatively weak antecedent-oriented approaches (e.g., positive routines prior to bed)or not “behavioral” at all (candles and lotion)Treatment Options?
Common Sleep ProblemsNighttime routine noncomplianceSleep-interfering behaviorDelayed sleep onset Night awakeningsEarly awakenings
Assumptions Regarding Sleep• Behavioral quietude /Falling asleep are the behaviors of interest• Can be influenced by past and present events in one’s sleeping environment – can be motivated (or demotivated)– can become reliant on environmental cues– can be affected by other reinforcers for other behaviors available at night
Looking at falling asleep….through the lens of a contingency• Conduct a contingency analysis: EO + SD R Sr• That which is known: – Reinforcer (Sr) for falling asleep is sleeping• That which is unknown: – Everything else!
Looking at sleep….through the lens of a contingencyEO + SD Falling Asleep Sleep– What alters the value of sleep as a reinforcer?
Looking at sleep….through the lens of a contingencyEO + SD Falling Asleep Sleep– What signals that the reinforcer is available (and prepares the body to “consume” the reinforcer), and are those signals available when the child wakes up multiple times each night?
Looking at sleep….through the lens of a contingencyEO + SD Interfering behaviors Sr– What other behaviors are occurring before and after the bid good night that are incompatible with falling asleep (i.e., that do not allow for behavioral quietude)?
Looking at sleep….through the lens of a contingencyEO + SD Interfering behaviors Sr– What reinforcers are available for behaviors that are incompatible with falling asleep?
Looking at sleep….through the lens of a contingencyEO + SD Incompatible behaviors Sr– What alters the value of these other reinforcers for behaviors that are incompatible with falling asleep?
Looking at sleep….through the lens of a contingencyEO + SD Incompatible behaviors Sr– What signals that these other reinforcers are available?
How do we assess and treatchildren’s sleep problem?• Through a general understanding of the common factors that influence good sleep and sleep problems• Using an open-ended indirect assessment to identify the personal factors influencing the sleep problem– SATT (Sleep Assessment and Treatment Tool)• By encouraging parents to develop the intervention with us – we support parents in their implementation of the assessment-based treatment via phone calls and weekly visits.
A typical case exampleRay4-year-old-boy with AutismHyperactiveParents tried multiple medications for sleep problems
020406080100120140160180Sleep Onset Delay (min)Baseline TreatmentVideoDiaryClonidine 0.10 mg Appropriate Range of Sleep Onset DelayIllness Melatonin 1-3 mg020406080100120Interfering Behavior (min)Illness Clonidine 0.10 mg Melatonin 1-3 mg050100150200250300350400Illness Clonidine 0.10 mg Melatonin 1-3 mgNight/Early Waking (min)5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10002468101214Total Sleep (hr)NightsGoal Range of SleepNapsIllness Clonidine 0.10 mg Melatonin 1-3 mgRay
020406080100120140160180Sleep Onset Delay (min)Baseline TreatmentVideoDiaryClonidine 0.10 mg Appropriate Range of Sleep Onset DelayIllness Melatonin 1-3 mg020406080100120Interfering Behavior (min)Illness Clonidine 0.10 mg Melatonin 1-3 mg050100150200250300350400Illness Clonidine 0.10 mg Melatonin 1-3 mgNight/Early Waking (min)5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10002468101214Total Sleep (hr)NightsGoal Range of SleepNapsIllness Clonidine 0.10 mg Melatonin 1-3 mgRay
020406080100120140160180Sleep Onset Delay (min)Baseline TreatmentVideoDiaryClonidine 0.10 mg Appropriate Range of Sleep Onset DelayIllness Melatonin 1-3 mg020406080100120Interfering Behavior (min)Illness Clonidine 0.10 mg Melatonin 1-3 mg050100150200250300350400Illness Clonidine 0.10 mg Melatonin 1-3 mgNight/Early Waking (min)5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10002468101214Total Sleep (hr)NightsGoal Range of SleepNapsIllness Clonidine 0.10 mg Melatonin 1-3 mgRay
020406080100120140160180Sleep Onset Delay (min)Baseline TreatmentVideoDiaryClonidine 0.10 mg Appropriate Range of Sleep Onset DelayIllness Melatonin 1-3 mg020406080100120Interfering Behavior (min)Illness Clonidine 0.10 mg Melatonin 1-3 mg050100150200250300350400Illness Clonidine 0.10 mg Melatonin 1-3 mgNight/Early Waking (min)5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10002468101214Total Sleep (hr)NightsGoal Range of SleepNapsIllness Clonidine 0.10 mg Melatonin 1-3 mgRay
020406080100120140160180Sleep Onset Delay (min)Baseline TreatmentVideoDiaryClonidine 0.10 mg Appropriate Range of Sleep Onset DelayIllness Melatonin 1-3 mg020406080100120Interfering Behavior (min)Illness Clonidine 0.10 mg Melatonin 1-3 mg050100150200250300350400Illness Clonidine 0.10 mg Melatonin 1-3 mgNight/Early Waking (min)5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 10002468101214Total Sleep (hr)NightsGoal Range of SleepNapsIllness Clonidine 0.10 mg Melatonin 1-3 mgRay
Social Acceptability Survey (Parents)Table 1Questions Walter Andy LouAverage(Range)1.Acceptability of assessment procedures7 6 7 6.7 (6-7)2. Acceptability of treatment7 6 7 6.7 (6-7)3. Improvement in sleep 7 7 7 74. Consultation was helpful 7 6 7 6.7 (6-7)Note: Likert scale: 1 to 7. 1 (not acceptable, not satisfied, not helpful), 7 (highly acceptable, highly satisfied, highly helpful)
Step 1: Develop Ideal Sleep ScheduleStep 2: Routinize Nighttime Routine Step 3: Optimize Bedroom ConditionsStep 4: Regularize Sleep DependenciesStep 5: Address Sleep Interfering Behavior
Step 1: Develop Optimal Sleep Schedule• Recognize of age-appropriate sleep amounts• Recognize importance of current sleep phase and “forbidden zones”• Recognize universal tendency to go to bed later and wake up later
Age Total Sleep Night Sleep # Naps2 11 hrs 30 min 9.5 hours 1 (2 hrs)3 11 hrs 15 min 10 hours 1 (1hr15min)4 11 hrs 10 -11 hours 0-1 5 10 hrs 45 min6 10 hrs 30 min9 10 hrs 12 9 hrs 45 min15 9 hrs 15 min18 9 hrsAdapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006Age-Based Sleep Averages:
Sleep SchedulingCautions:Difficulty falling asleep, staying asleep, or complying with nighttime routines may occur if child is expected to be in bed too longDifficulty waking up or day time tiredness may be related to child being in bed for too short of a timeImplication: Select the right sleep total for child
When should the bedtime be scheduled?Night NightDayAlertSleepyAdapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006
Night NightDayAlertSleepyForbidden ZoneMidday Dip in AlertnessAdapted from: Solve Your Child's Sleep Problems, Richard Ferber, Simon & Schuster, 2006When should the bedtime be scheduled?
CautionPutting children to bed during the Forbidden Zone will increase the likelihood of nighttime routine noncompliance, sleep onset delaysand sleep interfering behaviorWhen should the bedtime be scheduled?
We have a tendency to go to bed later and wake up later because of our 24.2 hr clockArtificial light and nighttime activity availability leads to a 25-hour clockWhen should the bedtime be scheduled?
Copied from: National Institute of Health (NIH) Sleep and Sleep Disorder’s Teacher’s Guide
At the beginning of sleep treatment:set the start of the sleep routine slightly later than when the child fell asleep the previous night Then gradually transition sleep phase earlier if child falls asleep within 15 min move bedtime 15 min earlier next night until desired bedtime is achieved (Piazza et al., 1991)When should the bedtime be scheduled?
Extreme Sleep Phase Shift?ConsiderationTry chronotherapy if sleep phase is more than 4 hours past desirable sleep time: Move sleep and awake times forward by 1 to 2 hours each night (larger leaps can be made with older children)
Step 2:Routinize Nighttime RoutineDevelop a nighttime routine that occasions “behavioral quietude”Try to implement it consistently across nights
Step 2:Routinize Nighttime RoutineSome emphases prior to bid goodnightActivities progress from active to passive Arrange choices on picture scheduleMake gradual changes in fun factor avoid rich to barren context transitionExercise/baths earlier in routineAmbient light gets progressively dimmerLight snacks without caffeine
Step 3: Optimize Bedroom ConditionsCooler temperatureIndirect lighting onlyNon-undulating noiseBest toys/preferred activities not visible
Nighttime Noncompliance ConsiderationsTendency to not follow instructions or resist guidance to, for example, put on PJs, brush teeth, or get in bedSolutions:• Start routine just prior to natural sleep phase• Promote instruction following during the day– See steps on handout (e.g., name game, follow through, etc.)
Control Experimental020406080100Control ExperimentalM % Compliance U = 12, p > .05 U = 4.5, p < .05020406080100 BL2BL1M % Precursors U = 11, p > .05 U = 0, p < .05Individual ChildrenGroupPrecursor = Responding effectively to one’s name = stopping activity, looking at teacher, saying, “Yes,” and waiting until teacher says something. Beaulieu et al., (2013, JABA)
Control Experimental020406080100Control ExperimentalM % Compliance U = 12, p > .05 U = 4.5, p < .05020406080100 BL2BL1M % Precursors U = 11, p > .05 U = 0, p < .05Individual ChildrenGroupPrecursor = Responding effectively to one’s name = stopping activity, looking at teacher, saying, “Yes,” and waiting until teacher says something. Compliance = completing an instruction within 6 s
Control Experimental020406080100Control ExperimentalM % Compliance U = 12, p > .05 U = 4.5, p < .05020406080100 BL2BL1M % Precursors U = 11, p > .05 U = 0, p < .05Individual ChildrenGroup
Control Experimental020406080100Control ExperimentalM % Compliance U = 12, p > .05 U = 4.5, p < .05020406080100 BL2BL1M % Precursors U = 11, p > .05 U = 0, p < .05Individual ChildrenGroup
Nighttime Noncompliance ConsiderationsTendency to not follow instructions or resist guidance to, for example, put on PJs, brush teeth, or get in bedSolutions:• Start routine just prior to natural sleep phase• Promote instruction following during the day– See steps on handout• Arrange big discrepancy in consequences for compliance vs. noncompliance to routine– Avoid DRA with extinction
Step 4:Optimize Sleep DependenciesTransitioning from behavioral quietude to sleep depends on stimuli associated with falling asleep
Stimuli that set the occasion for sleep must be there through the night because children wake up often during the night
Optimizing Sleep DependenciesTransitioning from behavioral quietude to sleep depends on stimuli associated with falling asleepProblems:Things that occasion sleep are not present when the child wakes up during the night = Night AwakeningsThings that occasion sleep are suddenly removed or inconsistently available = Sleep Onset Delay and possibly sleep interfering BehaviorExamples: TV, radio, books, bottles, “full belly,” presence of another person, being rocked or patted, lights, fallen stuffed animal or blanket
Optimizing Sleep DependenciesOccasion sleep with things that don’t require your presence, can be there in the middle of the night, and are transportable (e.g., for vacations or nights at Grandparent’s home)
Optimizing Sleep DependenciesGood dependencies:pillow, blanket, stuffed animal (with bed rails), pacifier, sound machine on continuousEliminate or fade “bad” ones and replace with “good” dependencies
Step 5: AddressSleep Interfering BehaviorSLIB = Behaviors that interfere with behavioral quietude necessary for falling asleepThe big four are:leaving bed (curtain calls)crying / calling outplaying in bed or in bedroom(this includes motor or vocal stereotypy)talking to oneself
Step 5: Address (SLIB)Be sure to first properly consider what the likely reinforcers are for the interfering behaviorAttention / InteractionFood/drinkAccess to TV or toysEscape/avoidance of dark or of bedroomAutomatic reinforcers (those directly produced by the behavior)
Part 1Provide the presumed reinforcer prior to bidding the child good nightAddressing SLIB
Part 2After bid goodnight, eliminate access to presumed reinforcer following IBWith socially mediated IB, options include:Extinction, Progressive Waiting, Time-Based Visiting, Quiet-Based Visiting, Quality Fading, or Bedtime PassWith automatically-reinforced SLIB, we use:Relocation of relevant materialsBlocking Addressing SLIB
Addressing SLIBTime-Based VisitingVisit your child at increasingly larger intervals after the bid good night and across nights (hopefully before IB occurs); during visit re-tuck them, bid good night, and leave.Day First visitSecond visitThird visitFourthvisitFifth visitSixthvisitSeventh visit1 10 s 30 s 1 min 3 min 5 min 10 min 30 min2 30 s 1 min 3 min 5 min 10 min 30 min3 30 s 3 min 5 min 10 min 30 min4 1 min 3 min 5 min 10 min 30 min5 1 min 5 min 10 min 30 min6 5 min 10 min 30 min7 5 min 30 min
Bed Time PassGive your child a bed time pass to be used as needed after the bid good nightto have one request granted.If # of IBs was high before you try this treatment, provide more than one bed time pass initially and then fade out the number each night. Addressing SLIB
Results of Social Acceptability QuestionnaireAdministered to Parents who Implemented Three Strategies for Addressing Sleep Interfering BehaviorGina SamRanking Mom Mom Dad1 Bedtime Pass Time-based Visiting Bedtime Pass2 Extinction Bedtime Pass Extinction3 Time-based Visiting Extinction Time-based VisitingMost Preferred
Bedtime passBlue CardGreen CardRedCardExtinctionTime-basedVisitingReinforcement only if handed a passNo reinforcement (period)Reinforcement available according to timeContingenciesJust prior to bed, the children were allowedto choose the treatment for each nightTreatmentsTreatment-CorrelatedStimuli
1 2 3Cumulative Child Selections (#)0123Bedtime PassExtinctionTime-based VisitingGinaNights5 10 15 20 250510152025Sam
Eliminating Interfering BehaviorMy new favorite: The Combo+Time-Based Visiting and the Bed Time Pass with dueling outcomes+Hand in pass for something now or hold onto pass and hand in at breakfast for something better
Addressing Night AwakeningsShould be resolved with appropriate sleep schedule and healthy sleep dependenciesIf not, address issues related to temperature, food, light, noise, incontinence, nighttime reinforcersIf not, we actively teach child to know when it is okay to get up for the dayusually with moon/sun clocks
Key Considerations for Good Sleepingsleep schedulenighttime routines sleep contexts sleep dependencies reinforcers for sleep interfering behavior
ImplicationsChronic medication use is not the solution for sleep problems exhibited by children with autism(or for your sleep problems)
For you to consider…Start on FridayExerciseAvoid caffeineReflect on the day and tomorrow before you are in bedand
For you to consider…Address sleep onset delay by:1. Making your bedtime 1 hr. later than usual, 2. Getting out of bed if not asleep within 10-15 min, and sitting in chair & read a literary classic for 15 min or until drowsy,3. Gradually adjusting sleep and wake times to desired times.Address difficulties getting out of bed in morning with:4. Sleep Cycle App
Step 1: Develop Ideal Sleep Schedule Step 2: Routinize Nighttime Routine Step 3: Optimize Bedroom Conditions Step 4: Regularize Sleep Dependencies Step 5: Address Sleep Interfering BehaviorFreedom from sleep problems is possible and probable with:Individualized assessmentIndividualized and comprehensive treatment:
Thank you.Good luck with all that you do for all who you teach and provide careContact info.:Gregory P. Hanley, Ph.D., BCBA-DPsychology DepartmentWestern New England University1215 Wilbraham RoadSpringfield, Massachusetts 01119ghanley@wne.edu
Optimizing Melatonin Compliance Interfering
Yıl : 2020
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