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Negative Effects of Poor Sleep

  • Positively correlated with Wiggs & Stores, 1996; Zuckerman, Stevenson, & Bailey, 1987
    • SIB
    • Noncompliance
    • Aggression
    • Tantrums
    • Impulsivity
  • Family stress Kataria et al. 1987, Richman 1981

Co-occurring Sleep Disorder

  • ADHD: 25% - 50%
  • ASD: 50%-80%
  • Depression: up to 90%
  • Anxiety: up to 88%

Detecting Sleep Problems

  • Parents often do not discuss sleep problems with their pediatrician (Stein et al., 2001).
  • In one study involving 600 community-based pediatricians, less than 40% questioned adolescents directly (Owens, 2001).

Common Treatment

  • 80% of children diagnosed with sleep problems are prescribed medication.
  • Evidence suggests that pharmacology has positive short term effect but lacks any long term benefits (Ramchandani et al. 2000).
  • Additionally, a 48.9% of pediatricians surveyed suggest to parents that children will outgrow sleep problems (mindell et al. 1994).
  • Behavioral intervention is found to have positive short term effect without the long term decline.  

Behavioral Approach

  • Individualized:
    • Bed refusal
    • Sleep-onset delay
    • Night waking
    • Cosleeping

Operant Conditioning

  • “The term emphasizes the fact that the behavior operates upon the environment to generate consequences.” – Skinner

Respondent Behavior

  • Behavior consistently elicited by a reflexive or classically conditioned stimulus.

Stimulus > Reflex Behavior

Respondent Conditioning

  • A previously neutral stimulus comes to evoke a specific response by being repeatedly paired with another stimulus that evokes the response.

Sleep Architecture

  • The circadian cycle is marked by cycles of phases of rapid-eye-movement (REM) and non-REM sleep.
  • REM regularly precedes periods arousals.

  • Sleep cycles are under purely endogenous control for the first 3 – 6 months.


  • Screening tool such as BEARS (B = bedtime issues, E = Excessive daytime sleepiness, A = night awakenings, R = regularity and duration of sleep, S = snoring).
  • Increased detection of sleep problems from 4.1% to 16% (n = 195).  


  • Generally considered an inappropriate treatment.
    • Many parents cannot ignore bedtime crying.
    • Extinction burst (increase in severity and variability).

Sleep Hygiene

  • Cortez de Sousa et al. (2007):
    • Regular sleep pattern
    • Relaxation techniques
    • 15 min naps early in day but no naps later in the day.
    • No caffeine after 2pm.
  • Engeljardt et al., 2013: No TV in the bedroom and limit access to visual media during the day for children with Autism.  


  • France and Hudson (1990):
    • Introduced regularly scheduled story time before bed.
  • Adams and Rickert (1989):
    • 4 – 7, 20 minute, quiet activities before bedtime.
    • Also included a faded bedtime.  

Faded Bedtime

  • Delayed sleep onset:
    • Bedtime is set at average sleep onset + 30 minutes.
    • If child fell asleep within 15 minutes of bedtime, bedtime was made 30 minutes earlier the next night.
    • If the child did not fall asleep within 15 minutes of bedtime, bedtime was made 30 minutes later the following night.
    • Pizza and Fisher (1991) - If sleep onset does not occur within 15 minutes, remove from bed and keep awake for 1 hour.

Graduated Extinction/Progressive Waiting

  • Crying and leaving the bedroom

Schedule Competing Reinforcers Before Sleep

  • Interfering behaviors:
    • O’Reilly et al. (2004) conducted paired choice assessment and then schedule preferred activity before bedtime.
    • Jin et al. (2013) did the same based on parent interview.

Questionable Procedures

  • Bedtime Pass
  • Scheduled Waking


  • Basic information and sleep problem history.
  • Develop sleep goals.
  • ID specific sleep problems.
  • ID antecedents and consequences of problem behavior.
  • ID sleep schedule and sleep dependencies
  • ID interfering behaviors and their likely reinforcers Treatment options


•Stein MA, Mendelsohn J, Obermeyer WH, Amromin J, Benca R. Sleep and behavior problems in school-aged children. Pediatrics. 2001;107(4):E60. [PubMed]
•Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. BMJ 2000).
•Owens J A. The practice of pediatric sleep medicine: results of a community survey. Pediatrics 2001 108(3)
•Engelhardt, Mazurek and Sohl (2013). Media use and sleep among boys with autism spectrum disorder, ADHD or typical development. Pediatrics, 1081 – 1089.


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