Clinical Practice in Pediatric Psychology

Behavioral sleep education has shown promise in young children with autism spectrum disorder (ASD), but has received much less study in adolescents with ASD. We conducted a pilot study of a brief sleep intervention delivered to 18 adolescents, ages 11–18 years, and their parents. Adolescents had sleep onset delay, night wakings, or both. Actigraphy and parent and adolescent questionnaires were collected at baseline and 1 month after treatment. Sleep education, delivered in a 2-session format, was associated with improved sleep onset delay and sleep efficiency in adolescents with ASD as measured by actigraphy a month after the intervention. Parent and adolescent questionnaires also indicated improvements in other sleep parameters and sleep hygiene during that time period. Half of the sample was available for follow-up 3 months after completion of the study and, based on verbal parent and/or adolescent report, gains were maintained for those participants. Parents reported high satisfaction with the program and were able to implement recommendations discussed in the sessions at a high rate of understanding and comfort level. This brief behavioral sleep education program shows promising results in improving sleep hygiene and sleep onset latency for adolescents with ASD.

While many factors contribute to sleep difficulties in children with autism spectrum disorder (ASD), behavioral sleep education is often effective. However, providing families with the educational tools and the support they need to help their children sleep can be challenging given limited access to care. We piloted the use of a 5-week home sleep education program in 10 parents of children with ASD, ages 3–9 years. Parents read a sleep education manual (extracted from a book on sleep and ASD) and then implemented the suggested strategies with their children. The Children’s Sleep Habits Questionnaire, the Family Inventory of Sleep Habits, and actigraphy were completed prior to and after the intervention. Parents also completed a postintervention interview to assess understanding and comfort with implementation. Of 8 completers, 6 children showed improvement in sleep patterns, which included bedtime resistance, time to fall asleep, night wakings, and cosleeping. Actigraphy data showed improvements in sleep latency (time to fall asleep) for most of the children. Two children were able to discontinue supplemental melatonin. All parents reported good to excellent understanding of the manual and reported high comfort levels with implementation. Our pilot findings suggest that some parents can learn effective strategies for promoting sleep and teach them to their children with ASD without the guidance of a trained educator.

Sleep problems are common in families raising children with autism spectrum disorder (ASD). Clinicians often depend on parent reports of child sleep but minimal research exists to address the accuracy or biases in these reports. To isolate parent-report accuracy (from differences in sleep behaviors), the sleep of younger siblings were assessed within a 2-group design. The present study compared parent diary reports of infant sibling sleep to videosomnography and actigraphy. In the high-risk group, families had at least 1 child with ASD and a younger sibling (n = 33). The low-risk comparison group had no family history of ASD (n = 42). We confirmed comparable sleep behaviors between the groups and used paired t tests, two 1-sided tests (TOST), and Bland-Altman plots to assess parent-report accuracy. The parameters of sleep onset, nighttime sleep duration, awakenings, morning rise time, and daytime sleep duration were evaluated. Diary and videosomnography estimates were comparable for nighttime sleep duration, morning rise time, and awakenings for both groups. Diary and actigraph estimates were less comparable for both groups. Daytime sleep duration estimates had the largest discrepancy with both groups reporting (on average) 40 additional minutes of sleep when compared to actigraphy estimates. In the present study, families raising children with ASD were just as accurate as other families when reporting infant sleep behaviors. Our findings have direct clinical implications and support the use of parent nighttime sleep reports.

Children with neurodevelopmental disorders (NDD) are at increased risk for having sleep problems, including sleep-related breathing disorders such as obstructive sleep apnea (OSA). Because of their increased risk for OSA, children with NDD may require a polysomnogram (PSG, or sleep study). PSG involves a number of sensors that may be difficult for children with NDD to tolerate because of their difficulties with anxiety, behavioral regulation, communication, and increased sensitivity to environmental stimulation. When trying to help a child complete a PSG, sedation and restraint are not preferred ways to gain cooperation and compliance. Behavioral interventions using simulated medical procedures, exposure therapy, distraction, and counterconditioning can help children succeed with a variety of challenging medical procedures. This case series describes a behavioral intervention used to help 3 children with autism spectrum disorders learn to tolerate PSG without the use of sedation or restraint. All 3 participants successfully completed the behavioral desensitization sessions, as well as their PSG. The results are discussed in terms of their apparent utility, limitations of the case studies presented, need for empirical validation in future experimental studies, and recommendations for future practice and research.

Psychoeducational approaches to managing behavioral sleep problems in children with neurodisabilities are directed at the parent, increasing their knowledge and understanding of sleep and requiring them to change the way they manage sleep disturbance. Given parental engagement with and adherence to an intervention are critical to its success, it is important we understand parents’ experiences of participating in interventions of this nature. It is surprising therefore that, to date, research in this area is extremely limited. This article reports the findings from a qualitative study of 35 parents who had received a psychoeducational sleep management intervention (SMI) delivered through 1 of the following modes: a half-day workshop (n = 8); a 4-session group-delivered intervention (n = 15); or 1-to-1 work with a specialist sleep practitioner (n = 12). The study was part of a larger program of work evaluating SMIs for children with developmental disorders, autistic spectrum conditions, or both. Purposeful sampling was used to represent intervention outcome, child’s diagnosis, parents’ education, and partner involvement in the intervention. Focus groups and individual interviews were used to gather data. The data were subject to a thematic analysis in relation to (a) parents’ descriptions of the processes by which a SMI leads to improvements in their child’s sleep; (b) parents’ views of the factors which hinder the achievement of positive intervention outcomes; and (c) parents’ views on intervention intensity and mode of delivery. The implications of the findings in terms of the design, content, and delivery of such interventions are discussed.

The purpose of this study was to conduct a preliminary evaluation of a brief behavioral sleep protocol for enhancing standard behavioral treatment for child noncompliance among children with behavior problems. Data were drawn from an archival analysis of pediatric cases treated for noncompliance or disruptive behavior problems in an outpatient behavioral health clinic. A total of 50 cases (mean age = 7.6 years) were identified in which the brief behavioral sleep protocol was delivered prior to behavioral parent training, and weekly parent ratings of child sleep and compliance were collected. Repeated-measures analyses indicated a significant immediate improvement in both child sleep and compliance ratings following the brief behavioral sleep protocol and prior to initiating behavioral parent training. Analyses examining changes from pretreatment to the end of all treatment (including both sleep and behavioral parent training) indicated large improvements in parent ratings of child compliance, with an effect size much larger than typical effect sizes in the literature for behavioral parent training alone. Treatment effects did not significantly differ across 3 clinicians delivering the interventions. Results of this preliminary evaluation suggest that the addition of a brief behavioral sleep protocol at the beginning of standard behavioral treatment for child noncompliance can substantially improve treatment outcomes. Further evaluation using rigorous clinical trial methods and norm-referenced measures is needed, but this study suggests that addressing sleep problems may be an important component of optimal treatment for child behavior problems.

Although sleep problems in youth with neurodevelopmental conditions (NDC) tend to be more prevalent and severe than those of typically developing (TD) youth, their clinical presentations and needs are rarely compared in real-world settings. This study compared sleep patterns, diagnostic impressions, and treatment recommendations between a diverse outpatient sample of TD youth and those with NDC. Data were collected from electronic medical records for 327 consecutive patients (58.4% male; 52.6% White, age range = 0–20 years) presenting for an initial consultation at an outpatient sleep clinic in an urban children’s hospital. Of the sample, 45.3% had a preexisting NDC, with 7% diagnosed with autism spectrum disorder (ASD), 9.9% with Trisomy 21 or other genetic disorder, 26.8% with another developmental delay, and 16.5% with ADHD. Obstructive sleep apnea (OSA) was the most frequent diagnosis overall (64.5%). However, patients with Trisomy 21 or other genetic disorders were especially more likely than TD youth to receive an OSA diagnosis and to receive medical treatment recommendations or referrals, but less likely to receive behavioral recommendations. Although patients with ADHD presented with higher rates of OSA symptoms, patients with ADHD and/or ASD did not differ in any other ways from TD patients in their sleep patterns, diagnosis, or treatment recommendations. Findings underscore the range of sleep problems in TD youth and those with NDC. The breadth of services provided at pediatric sleep centers highlights the importance of referral to such centers when sleep problems are present, especially in children with NDC.

Pain and sleep exhibit a bidirectional relationship, leading to questions about how to prioritize treatment targets. This article illustrates the efficacy of a sleep intervention on functional outcomes for an adolescent with disrupted sleep patterns, chronic migraines, and a complex psychological and social history. Baseline data indicated that the patient’s sleep duration was well below recommendations for adolescents. Migraine headache, as well as fatigue secondary to sleep issues, resulted in missing 1–2 days of school per week. Ferritin evaluation and history of sleep irregularity warranted iron supplementation and actigraphy. Actigraphy data confirmed delayed sleep wake phase disorder (DSWPD), and chronotherapy was initiated. After the initial active chronotherapy phase, the patient maintained a regular sleep schedule and school attendance improved. Preexisting mental health issues remained, but symptoms were described as more manageable. After approximately 5 weeks in the maintenance phase of chronotherapy, drift to increased sleep onset latency was observed. Additional actigraphy data were collected during the maintenance phase, which supported an ongoing need for follow-up through the clinic, including use of other behavioral sleep interventions. This case study illustrates the efficacy of a sleep intervention (chronotherapy) on improving sleep regularity and daily functioning for an adolescent with DSWPD and chronic migraine pain. It also highlights the difficulty implementing this intervention over time, warranting the need for routine follow-up. Future research should focus on how to prioritize treatment targets in patients with comorbid pain conditions and sleep disruptions.

Sleep issues in children with allergic diseases may be a result of illness-related factors (e.g., itching, wheezing) and/or poor sleep habits due to disrupted routines and parental permissiveness. However, the ability of parents to attend a multisession sleep intervention may be limited. Thus, we examined the validity of a one-time sleep health group intervention for parents of children with allergic diseases. Ninety-three parents of children who were admitted to a 2-week intensive day hospital treatment program completed measures of child sleep habits (Children’s Report of Sleep Patterns), parent sleep habits (Sleep Hygiene Inventory), parent sleep quality (Pittsburgh Sleep Quality Index), and parental insomnia symptoms (Insomnia Severity Index) before the group intervention and 1-month after program discharge; 54 parents attended the sleep health group. Sleep habits and sleep quality improved for both parents and children at the 1-month follow-up. However, improvements were seen regardless of group attendance. Potential reasons for the lack of difference between those who did and did not participate in group are presented, and implications of this study for pediatric psychologist in practice are discussed.

Insomnia is highly prevalent in the adolescent population and frequently occurs in the context of other medical or mental health concerns. Efficacy of cognitive–behavioral therapy for insomnia (CBT-I) has been determined in adults with comorbid conditions. However, there are limited data applying CBT-I to adolescents with comorbid conditions. Therefore, the purpose of this study was to (a) develop and refine a 4-session CBT-I intervention for adolescents with co-occurring medical and mental health conditions, and (b) evaluate feasibility and acceptability of applying the intervention to adolescents and their parents. Forty participants (ages 11 to 18 years) were recruited from 2 pediatric specialty clinics representing a range of physical and psychiatric comorbidities (e.g., depression, chronic pain, anxiety). Adolescents and parents attended 4 treatment sessions of CBT-I delivered individually or conjointly to adolescent and parent. Daily sleep diaries were completed during the treatment period. Preliminary findings demonstrated a high level of feasibility and acceptability of treatment. Compliance with treatment visits was high, with 34 of the 40 families (85%) completing all 4 sessions. Youth and parents were highly engaged in therapy sessions as rated by treating therapists. On the Treatment Evaluation Inventory, parents’ and teens’ mean scores indicated high treatment acceptability (M = 38.8, SD = 5.2; M = 36.8, SD = 4.6, respectively). The preliminary data suggest that CBT-I is feasible to implement to treat insomnia in adolescents with co-occurring health and mental health conditions. Future studies are needed to evaluate intervention efficacy on sleep and functional outcomes in youth.

Findings from Type 2 diabetes research has indicated that sleep is both a predictor of onset and a correlate of disease progression. However, the role that sleep plays in glucose regulation and daytime functioning in youth with Type 1 diabetes mellitus (T1DM) has not been systematically investigated. Nonetheless, preliminary findings have supported that various sleep parameters are strongly correlated to health-related and neurobehavioral outcomes in youth with T1DM. This suggests that improving sleep might reduce morbidity. A critical step in developing evidence-based guidelines regarding sleep in diabetes management is to first determine that sleep modification in natural settings is possible (i.e., instructing youth to have a healthy sleep opportunity leads to more total sleep time) and that an increased sleep duration impacts disease and psychosocial outcomes in these youth. This article describes the background, design, and feasibility of an ongoing randomized clinical trial that aims to examine if increasing sleep relative to youth’s own sleep routines affects glucose control and daytime functioning.

Delayed sleep onset and problematic night wakings are common during the infant and toddler years. Such sleep disturbances typically develop as the result of learned associations with specific cues needed for sleep initiation and/or maintenance that are not consistently available at bedtime or immediately available to the child after night wakings (e.g., rocking, feeding, being held). Effective empirically supported behavioral treatments for these common sleep problems exist. Despite the research evidence supporting the effectiveness of these behavioral treatments, widespread dissemination of unsubstantiated concerns about the appropriateness and theorized negative impact of behavioral sleep treatments persists. Some researchers have even raised concerns about the ethics of health providers providing behavioral sleep treatments, particularly extinction-based treatments. As a result, providers of pediatric behavioral sleep services routinely encounter parents who raise concerns about the use of extinction-based behavioral treatments. Unwarranted parental concerns may prevent some families from seeking services that could lead to positive health outcomes. This article discusses important ethical considerations for pediatric psychologists who provide behavioral sleep medicine services. Recommendations for evidence-based clinical practice are made considering American Psychological Association Ethical Principles of Psychologists and Code of Conduct, American Academy of Pediatrics guidelines for safe sleep practices, and current research on behavioral sleep treatment outcomes.