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Summer 2001 Table of Contents
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Helping You and Your Child Get a Good Night's Sleep

By Craig Axelrod, Teacher Trainer, TSBVI, Texas Deafblind Outreach
A version of this article appeared in the April 1994 edition of P.S. News!!!

Editor's note: This article is based on information presented by Ray Condon at a workshop in July 1993.

"Oh those sleepless nights will break my heart in two." Truer words have ne'er been spoken, particularly by parents of children with disabilities. While anyone might find a night of restful sleep elusive, it can be a unique challenge for children with disabilities, and their families.

When looking for causes and solutions to a problem like this, parents and school staff should work together as a team. A team will be best able to develop an intervention plan that succeeds. The kinds of stimulation provided at school during the day influence a student's ability to sleep at night, and a sleepy student has difficulty learning. A child's sleep problem is everyone's problem.

What Is Sleep?

Identifying some common facts about sleep will help distinguish general characteristics that most people experience from problems unique to children with disabilities.

  1. The function of sleep is controversial. Some people believe sleep is an internally controlled period of non-responding, during a phase of the circadian cycle, that promotes energy conservation. Others think sleep is a restorative or balancing process that occurs after energy consumption. Everyone agrees that sleep is a state of consciousness.
  2. Sleep occurs in repeating 70 to 100 minute cycles of two states, REM and nonREM. In the REM state, when dreaming happens, the brain is active but the body is effectively paralyzed. In the nonREM state, muscles are relaxed but can move. This state (in 4 stages from drowsy to deep sleep) may serve a restorative function, and is most typically identified as sleep.
  3. Circadian cycles are repeating biological cycles approximately 25 hours long, in which sleep, waking, alertness, activity, rest, changes in body temperature, hormone release and many other body functions take place. This cycle is reset daily to the 24 hour clock by internal processes and external cues such as daylight and darkness, mealtimes, social structures, bedtime and especially time of waking. Daily routines are critical for resetting the biological clock, because external cues influence a body's internal processes. Chronically delayed sleep can lead to reversal of a person's daily schedule.
  4. Wakings and arousals, typically 3 to 7 per night, are normal for children and adults. They're most likely to happen at the end of a REM state and, among other things, enable us to change positions in bed. Usually we're unaware of them and resume sleeping within a few seconds. Problems can arise when a person has difficulty going back to sleep after an arousal.
  5. People require varying amounts of sleep and generally need less sleep with age. Fragmented or fitful sleep is more common after age 7, and especially for people over 45.
  6. Most children sleep deeply during the first and last few hours of night, and more lightly between those times.
  7. Sleep/wake cycles can be easily disrupted in people sensitive to change. Irregular sleep/wake patterns lead to significant alterations in a person's mood, energy level, sense of well being and ability to learn new information. A tired child may not act tired, but be irritable, inattentive, impulsive, aggressive, hyperactive or socially withdrawn. Behavioral indicators like these might suggest a sleep problem.
  8. Causes of disrupted sleep differ between people. An individual's sleep history can be looked at to help identify patterns of problems.

Sleep Problems of Children with Disabilities

Though much has been published about the sleep and sleep problems of adults and children, there's little information about sleep-related issues of children who are visually impaired or deafblind. A review of several studies, however, indicates that children with disabilities are more likely than those without disabilities to have sleep problems.

Our environment provides many cues that help us wake up, stay awake during the day and go to sleep at night. The communication difficulties often experienced by a child with multiple disabilities make understanding and appropriately responding to these cues more challenging. Other factors can also effect sleep. For example, the medication a child is taking may cause daytime drowsiness. A child with high or low muscle tone might be unable to independently change positions in bed, which is important for a good night's sleep. Some children with profound disabilities have difficulty intentionally regulating their levels of wakefulness and move through sleep, drowsiness, alertness and agitation, independent of environmental cues. Individuals who are totally blind experience a high incidence of sleep phase disorder (where days and nights are gradually reversed), in part because they don't receive the light cues that influence their circadian rhythms.

Some of the sleep concerns often identified by parents of children with deafblindness include night wakings, reversed schedules (sleeping in the day), whether or not to use medication, irregular and fragmented sleep, difficulty falling asleep, short durations of sleep, night wandering, extensive screaming or crying at night, and sleeping with parents.

Children may never outgrow their sleep problems, but many situations can be improved with intervention. It's important to see a sleep problem as symptomatic of one or more other problems, then identify and address those problems. Often there are no easy answers, but regular contact between the parents and professionals trying to resolve a persistent sleep disturbance helps everyone on the team stay energetic and optimistic. An outside consultant can contribute objectivity and perspective to a team's overall game plan. In some cases, this may be all that's needed to solve a child's sleep problem. When seeking assistance from the medical profession, it's difficult to find a person with both an understanding of sleep disorders and experience helping children who have multiple disabilities. A knowledgeable professional, with the interest and willingness to work as part of a team, can be a valuable resource. The American Academy of Sleep Medicine has information about sleep disorder clinics in Texas, and can be contacted at:

American Academy of Sleep Medicine
6301 Bandel Rd., Suite 101
Rochester, MN 55901
Phone: (507) 287-6006
Website: www.AASMnet.org

Pencil line drawing of boy in bed."Sleep is Boy"
by
Wendy Haynes
1975

Exploring Sleep Behaviors

Sleep disorders are behaviors, triggered and maintained for specific reasons. After the possible causes for a behavior have been identified, intervention strategies can be designed.

Sleep Hygiene

As mentioned earlier, sleep patterns are influenced by external conditions and events. Setting up and maintaining good "sleep hygiene" is the first step in addressing a child's sleep problem. Factors that will improve sleep include good health, exercise, a meaningful and consistent daily schedule, a balanced diet and appropriate amounts of food, a bedtime environment that encourages sleep, and a pleasant, relaxing sequence of activities in the hour before bedtime.

Collecting Information

In addition to establishing conditions that make sleep more likely, it's helpful to systematically collect information about a child's sleep behaviors. Doing this will help indicate tendencies and patterns that might not be seen if memory alone is relied upon. Clearer understanding of a sleep problem's causes will make successful intervention more likely. Since improvement and change can be slow, documentation also charts progress. In addition, this information will highlight the severity of a child's sleep problem. A child who is routinely awake at night, and sleeping during significant portions of most school days, is not learning very much. An intervention strategy coordinated between school and home will improve the quality of this student's education. A "Daily Sleep Diary," completed over a period of time, can help provide a picture of current and changing sleep behaviors.


Daily Sleep Diary

Name:___________________ Date:___________________

Planned Bedtime:__________ Actual Bedtime:__________

  cooperated resisted resisted strongly
Cooperation going to bed:      
Cooperation staying in bed:      

 

Night wakings:  begin  end  total time
#1      
#2      
#3      
#4      
#5      
#6      
    Total time slept (naps and night sleep):  

End of sleep - Wake-up time: _____________

Total amount of night sleep (minus night wakings): ________________

Child's mood upon final awakening: __________________________________________

Naps  begin  end  total time
#1      
#2      
#3      
#4      
#5      
#6      
    Total time slept (naps and night sleep):  

Comments and observations:_______________________________________________


Children generally sleep less as they become older, but each child's sleep requirements are unique. Knowing the total amount of time that your child sleeps in a day will have implications for intervention. For example, because naps taken during the day count toward the total number of sleep hours, eliminating daytime naps may help some children sleep better at night. Or, moving naps from 4:00 p.m. to 2:00 p.m. might improve sleep onset at bedtime.

The time a child is awakened is one variable that can be externally controlled and followed consistently. A routine weekday wake up time that changes over the weekend may make adjustment to Monday mornings more difficult.

A child's mood upon final awakening in the morning will be one measure of the previous night's quality of sleep.

Interpreting Information

Now that sleep information has been collected, the "ABC Record of Sleep Problems" can help pinpoint possible reasons for the problem behavior or behaviors. In some cases, an event occuring prior to a sleep problem could be causing the problem sleep behavior. Changing one or more preceding events may make the behavior less likely to occur. A child who roughhouses with siblings before going to bed (antecedent), then remains awake for several hours (behavior), might fall asleep more easily if activities before bedtime are less energetic. In other situations, reinforcing consequences may motivate a child to repeat a behavior. A child who is given a snack (consequence) after getting out of bed (behavior) might learn to get out of bed more frequently. Behaviors won't appear as often when their consequences are less rewarding, especially if effective, more appropriate alternative behaviors are taught.


ABC Record of Sleep Problems

Name:_____________________________ Date:___________________

Antecedents Behavior Consequences Reason
Describe what happened before the behavior occurred (what, who, where and when). Describe the behavior (include how it began, as well as its intensity, how long it lasted and how many times it occurred). Describe what happened after the behavior occurred (any change in the environment or reactions from people). Why did my child behave in this way? What did the behavior accomplish?
       

Intervention Techniques

Sleep problems have traditionally been addressed differently by the medical and behavioral communities. Recently though, these approaches have become more consolidated.

Behavioral Intervention

Information collected in the "Daily Sleep Diary" and "ABC Record of Sleep Problems," will help the team identify patterns of problems and possible interventions. Any program that's implemented must be individualized for each child's needs and circumstances. Several intervention plans are described below. Each has a different goal and procedure for addressing a particular sleep problem. A mix and match approach might be helpful. When teaching a child new behaviors, the positive attitude of parents, teachers and other team members is crucial for success. An intervention plan should be implemented at a pace that's comfortable for all participants.

1. Positive Bedtime Routine

Problem: Bedtime resistance

Goal: To teach a child bedtime cooperation

Procedure:

  1. Determine child's natural bedtime
  2. Develop a 20 minute fixed sequence of enjoyable, calming prebed activities (warm bath, lotion rub, story time in a rocking chair, etc.)
  3. Begin the sequence 20 minutes before child's natural bedtime
  4. Follow the sequence and praise child for completing each activity, including going to bed

Things to consider: Prebedtime routines will prepare a child physiologically and behaviorally for bed. Calming activities can be identified and learned at school, then practiced at home during the bedtime sequence and at other times.

2. Graduated Extinction

Problem: Bedtime resistance and night wakings

Goal: To gradually withdraw the consequences maintaining a problem behavior and help a child accept change calmly through "progressive learning."

Procedure:
  1. Implement good sleep hygiene practices
  2. Determine when child should go to bed
  3. Put child to bed; if tantrums persist after 1 to 2 minutes, provide neutral reassurance; repeat as often as necessary
  4. Over time, ignore tantrums for increasingly longer intervals, up to a maximum of 20 minutes
  5. Respond consistently within each episode

Things to consider: A calm child will return to sleep more easily than one who becomes upset.

3. Extinction

Problem: Bedtime resistance and night wakings

Goal: To totally withdraw the consequences that maintain a problem behavior through "planned ignoring"

Procedure:

  1. Implement good sleep hygiene practices
  2. Determine when child should go to bed
  3. Put child to bed and ignore tantrums
  4. If child gets out of bed, direct child to return with minimal attention or interaction
  5. Respond consistently in every episode

Things to consider: Extinction may work with some children, especially those who are younger, nonambulatory, and/or not "fighters." Other children might continue struggling, then become physiologically agitated and difficult to calm.

4. Scheduled Awakening

Problem: Night arousals and night wakings

Goal: To retrain a child who regularly wakes up spontaneously to awaken under new conditions

Procedure:

  1. Determine time(s) child routinely wakes up
  2. Awaken child 15 to 30 minutes earlier
  3. Follow a routine procedure with awakened child (hold, console, change diaper, etc.)
  4. Return sleepy child to bed

Things to consider: A child who associates waking up with reinforcing consequences (parents come, play, snack, etc.) is conditioned to be awakened by parents. After the initial retraining, time intervals between awakenings are gradually increased.

5. Bedtime Fading

Problem: Bedtime resistance and night arousals

Goal: To shift a child's natural bedtime to a more acceptable time and reduce night arousals

Procedure:

  1. Eliminate all daytime sleep (sleep restriction)
  2. Determine child's natural bedtime within 15 minutes
  3. Follow positive bedtime routine sequence. Begin the sequence 20 minutes before child's natural bedtime
  4. If child falls asleep within 15 minutes, begin the sequence 15 to 30 minutes earlier the following night
  5. If child does not fall asleep within 15 minutes, begin the sequence 15 to 30 minutes later the following night, then return to step 4 when child begins sleeping

Things to consider: External circumstances and habits can help build associations about going to sleep. It's important to continue increasing the percentage of successful bedtime experiences.

Whatever intervention strategy is attempted, it's important to negotiate a level of cooperation acceptable to both child and adult, then slowly increase expectations. Mutual support between adults is also essential for maintaining perspective, confidence and calm.

Medication and Chemical Intervention

If all other attempts at finding a solution through behavioral intervention have been unsuccessful, the use of medication may be appropriate as a final resort. Medication alone is of limited benefit. It might be a short term solution that provides temporary or intermittent relief from insomnia, or may be used in combination with a more permanent behavioral retraining approach that changes a persistent pattern. When administered over a long period of time, medication can sometimes actually be counterproductive to sleep. It may cause "rebound" insomnia, impede or impair the quality of a person's sleep, and/or produce adverse side effects. Tolerance to medication might also develop, making increased dosages necessary for achieving desired results. Before experimenting with medications or nutritional approaches such as vitamins and herbal remedies, consult with a neurologist, psychiatrist, or physician familiar with sleep disorders.

Conclusion

While learning to get a good night's sleep may be a slow, labor intensive process for you and your child, the results will be well worth the effort. Good luck, good night and sweet dreams!

References

Adams, L. A. & Rickert, V. I. (1989) Reducing bedtime tantrums: comparison between positive routines and graduated extinction. Pediatrics, 84, 756-761.

Durand, V. M. & Mindell, J. A. (1990) Behavioral treatment of multiple childhood sleep disorders. Behavior Modification, 14, 37-49.

Ferber, R. (1985) Solve Your Child's Sleep Problems. New York: Simon and Schuster.

Finnie, N. R. (1975) Handling the Young Cerebral Palsied Child at Home. 2nd Edition. New York: E. P. Dutton.

Nakagawa, H. Sack, R. L. & Lewy, A. J. (1992) Sleep propensity free-runs with the temperature, melatonin, and cortisol rhythms in a totally blind person. Sleep, 15(4), 330-336.

Palm, L., Blennow, G. & Wetteberg, L. (1991) Correction of non-24-hour sleep/wake cycle by melatonin in blind retarded boy. Annals of Neurology, 29(3), 336-339.

Piazza, C. C. & Fisher, W. (1991) A faded bedtime response cost protocol for treatment of multiple sleep problems in children. Journal of Behavioral Analysis, 24, 129-140.

Rickert, V. I. & Johnson, M. C. (1988) Reducing nocturnal awakening and crying episodes in infants and young children: A comparison between scheduled awakenings and systematic ignoring. Pediatrics, 81, 203-212.

Stores, G. (1992) Annotation: sleep studies in children with a mental handicap. Journal of Psychology and Psychiatry, 33,1303-1317.

Tzischinsky, O., Skene, D., Epstein, R. & Lavie, P. (1991) Circadian rhythms in 6-sulphatoxymelatonin and nocturnal sleep in blind children. Chronobiology International, 8(3), 168-175.


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