JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2013, 46, 161–180 NUMBER 1 (SPRING 2013)

AN INDIVIDUALIZED AND COMPREHENSIVE APPROACH TO

TREATING SLEEP PROBLEMS IN YOUNG CHILDREN
C. SANDY JIN, GREGORY P. HANLEY, AND LAUREN BEAULIEU
WESTERN NEW ENGLAND UNIVERSITY

We evaluated the effects of assessment-based interventions on the treatment of sleep problems in 3

young children, 2 of whom had been diagnosed with autism. We used sleep diaries and infrared
nighttime video in the child’s bedroom to obtain measures of sleep onset, sleep-interfering
behaviors, night waking, total sleep, parental presence, and medication administration each night.
We then identified environmental factors that contributed to sleep problems using an open-ended
interview called the Sleep Assessment and Treatment Tool. Individualized treatment packages were
designed with the children’s parents based on the idiosyncratic results of the assessment. Treatment
packages included adjustment of the sleep schedule based on developmental norms and current
sleep phases, design of a sleep-conducive environment, elimination of inappropriate sleep
dependencies, and function-based interventions to decrease sleep-interfering behaviors by
disrupting the contingency between the interfering behavior and its likely reinforcement. A
nonconcurrent multiple baseline design across subjects revealed that treatment was effective for all 3
children. In addition, social acceptability measures showed that the parents were satisfied with the
assessment process, the treatment, and the amount of behavior change.
Key words: assessment, autism, children, functional assessment, sleep problems, sleep treatment

Families and practitioners regularly experience IQ measures (Gruber et al., 2010), risk of obesity
difficulty managing sleep problems of young (Bell & Zimmerman, 2010), and anxiety in
children. Problems with falling or staying asleep, adulthood (Gregory et al., 2005) are all positively
noncompliance with nighttime routines, and correlated with sleep problems. Sleep problems
problem behaviors that occur after the bid are also positively correlated with other behavior
goodnight and interfere with sleep onset (e.g., problems that are commonly addressed by
crying, leaving the bedroom, and playing in bed) behavior analysts, such as self-injury, noncompli-
are common child-rearing difficulties for parents, ance, aggression, tantrums, and impulsivity
frequently complained about to pediatricians, (Wiggs & Stores, 1996; Zuckerman, Stevenson,
and a common reason for prescribing psychotro- & Bailey, 1987). Equally troublesome are the
pic medication to young children (Minde, 1998; concomitant secondary effects on other family
Mindell, Moline, Zendell, Brown, & Fry, 1994). members, including poor parental sleep quality
A growing body of evidence suggests that sleep and daytime functioning (Meltzer & Mindell,
problems can negatively affect children and their 2007), family stress and tension (Kataria,
families. Child irritability and difficult tempera- Swanson, & Trevathan, 1987; Richman, 1981),
ment (Richman, 1981; Wiggs & Stores, 1996), maternal malaise (Richman, 1981), and marital
daytime sleepiness (Liu, Liu, Owens, & Kaplan, discord (Chavin & Tinson, 1980).
2005), unintentional injuries (Koulouglioti, By approximately 3 to 6 months of age, most
Cole, & Kitzman, 2008), poor performance on infants do not require routine parental care to be
able to sleep through the night (T. Moore &
Lauren Beaulieu is now at Regis College. Ucko, 1957), yet sleep problems remain preva-
Address correspondence to Gregory P. Hanley, Psychology lent, affecting 35% to 50% of typically develop-
Department, Western New England Unversity, 1215 ing children and as many as 67% to 73% of
Wilbraham Road, Springfield, Massachusetts 01119
(e-mail: [email protected]). children with an autism spectrum disorder (ASD;
doi: 10.1002/jaba.16 Johnson, 1991; Polimeni, Richdale, & Francis,

161
162 C. SANDY JIN et al.

2005; Souders et al., 2009). Although there is a focused on pediatric sleep problems is scarce in
notion that children eventually grow out of the comparison to that available for other problem
developmental phase characterized by sleep behavior (e.g., self-injury or classroom disrup-
disturbance, the persistence of these problems tion; Kahng, Iwata, & Lewin, 2002), several
suggests that they do not subside with age notable studies have described effective interven-
(Kataria et al., 1987; Zuckerman et al., 1987). tion. For instance, France and Hudson (1990)
Parents are likely to consult with pediatricians demonstrated the success of a stimulus control
for assistance with sleep problems, but a national procedure (e.g., routine bedtime stories prior to
survey of pediatric residency programs found that placing the child in bed) and extinction (i.e., not
pediatricians receive only about 5 hr of training attending to the child after the bid good night
on addressing sleep problems. A significant unless absolutely necessary) for decreasing night
number of pediatricians suggest to parents that waking and improving overall sleep quality in
children will outgrow these problems (Mindell seven infants with sleep problems. Piazza and
et al., 1994) and therefore do not prescribe Fisher (1991b) described an effective faded
treatment. When treatments are recommended, bedtime with response cost procedure that
they are often pharmacological, and the prevalence increased the amount of appropriate sleep in
of pharmacological intervention is especially high four individuals with intellectual disabilities.
for children with disabilities who experience sleep Three children were being served in an inpatient
problems. Owens, Rosen, and Mindell (2003) hospital unit, and one child’s evaluation occurred
surveyed a sample of 671 community-based while he was an outpatient. Treatment compo-
primary care pediatricians and found that more nents involved (a) bidding the child goodnight
than 50% of them have prescribed medications 30 min past the average sleep-onset time from
and that more than 75% of them have baseline and fading the bedtime earlier by 30 min
recommended nonprescription drugs for pediat- on the next night if the child was able to fall asleep
ric insomnia (insomnia refers to difficulties falling within 15 min of bedtime, (b) not allowing the
or staying asleep). Stojanovski, Rasu, Balk- child to go to bed prior to the scheduled bedtime
rishnan, and Nahata (2007) reported that as or sleep past the scheduled wake time, and (c) a
many as 81% of children’s visits to pediatricians, response cost procedure that involved keeping the
psychiatrists, and family physicians for sleep child awake and away from bed for 1 hr if sleep-
problems result in medication prescriptions. onset delay was more than 15 min. Ashbaugh
These practices persist despite the lack of clear and Peck (1998) systematically replicated these
clinical guidelines for prescribing practices and effects in a home setting with a 2-year-old
limited research on the long-term efficacy, typically developing child. Considered together,
tolerability, and social acceptability of pharmaco- Friman et al. (1999) and Freeman (2006)
logical intervention (Rosen, Owens, Scher, & demonstrated the positive effects of extinction
Glaze, 2002). and a bedtime pass on the sleep-interfering
The need for efficacious treatments to both behaviors (i.e., crying at night and leaving the
address and prevent sleep problems in young bedroom) of six children of typical development.
children is obvious. Recent reviews of empirically Using the pass resulted in a brief trip outside the
supported treatments for pediatric sleep problems bedroom and access to the parent’s attention. In
encourage the application of strategies derived sum, these studies demonstrate the efficacy of
from a behavior-analytic approach (Kuhn & behavioral tactics for specific sleep problems.
Elliott, 2003; Mindell, 1999; Mindell, Kuhn, The behavioral literature is not without some
Lewin, Meltzer, & Sadeh, 2006). Although the limitations. First, the extent to which caregivers
behavioral assessment and treatment literature are able to implement typical behavioral
 SLEEP ASSESSMENT 163

interventions in home environments remains behavioral quietude (lying quietly in bed;

largely unknown. More home-based studies, such Blampied & France, 1993) because it is a
as that modeled in the single application by measurable dimension that always precedes the
Ashbaugh and Peck (1998), are needed with target behavior of falling asleep. We begin with
parents as the primary interventionists under the the assumption that lying quietly and falling
conditions in which children’s sleep problems asleep are operant behaviors maintained by the
typically occur. Second, the majority of existing reinforcing event of sleep1 (Bootzin, 1977). Just
behavioral studies rely exclusively on parental as is the case for any other operant, stimuli in the
reports of sleeping and waking (e.g., Ashbaugh & environment acquire discriminative properties
Peck; Freeman, 2006; Friman et al., 1999). that serve to signal the availability of the
Therefore, more behavioral interventions should reinforcer, in this case, sleep. Discriminative
be evaluated with additional objective measure- stimuli that often occasion falling asleep include
ment systems in place. Third, most studies do not dimly lit rooms, cool temperatures, particular
report social validity measures or describe pillows, blankets, stuffed animals, rocking,
parental involvement in the development of the patting, or the mere presence of a parent. Certain
intervention; therefore, the social acceptability of environmental operations may also establish the
behavioral interventions for sleep problems value of sleep as a reinforcer and evoke behavior
should be more routinely evaluated. Fourth, that has historically resulted in that reinforcer,
efficacious tactics such as faded bedtime with similar to the manner in which establishing
response cost (Ashbaugh & Peck; Piazza & Fisher, operations enter into contingencies that control
1991b), bedtime pass (Freeman, 2006; Friman other important behavior (Michael, 1982).
et al., 1999; B. A. Moore, Friman, Fruzzetti, & Deprivation of sleep, which may occur from
MacAleese, 2007), scheduled awakenings insufficient amounts of sleep, extended time since
(Adams & Rickert, 1989; Johnson & Lerner, last sleep, or poor-quality sleep, establishes the
1985), positive routines (Adams & Rickert, value of sleep and momentarily increases the
1989; Christodulu & Durand, 2004; Milan, probability of behavioral quietude. Certain
Mitchell, Berger, & Pierson, 1981), and varia- supplements or drugs like melatonin or clonidine
tions of extinction (France & Blampied, 2005; also can temporarily establish the value of sleep.
France & Hudson, 1990; Lawton, France, & The main point is that a coherent contingency
Blampied, 1991) are available; however, the analysis of sleep problems is possible when
prescription of these tactics is not necessarily behavioral quietude and falling asleep are selected
assessment based or predicated on idiosyncratic as the target responses.
variables that maintain sleep problems. We Effective intervention is probably more likely
believe that effective and socially valid interven- when the controlling variables are also understood
tion is more likely when treatments are designed for operants that occur after a child is bid good
based on an understanding of the individual night and that appear to interfere with behavioral
factors that influence the problem behavior, and quietude and thus preclude falling asleep.
therefore should be individualized from assess-
ment information. 1
It is important to note that a thorough account of sleep
Behavioral, as opposed to pharmacological, cannot be divorced from an understanding of the selection
treatment of pediatric sleep problems begins with history on a phylogenetic level (e.g., Heath, Kendler, Eaves,
a look at the target behavior through the lens of a & Martin, 1990; M. Moore, Slane, Mindell, Burt, &
contingency. We are interested in the behavior of Klump, 2011) and cultural level (e.g., cosleeping or sleeping
alone; Jenni & O’Connor, 2005; Owens, 2004) in addition
lying quietly in bed and falling asleep. Procedur- to that which is selected on an ontogenetic level (reinforce-
ally, we focus on developing a period of ment history).
164 C. SANDY JIN et al.

Common interfering behaviors include calling out children indicated that the sleep problems had
or leaving the bed, crying for parents to return to persisted for many years and were highly stressful
the bedroom, eating, watching television, playing and disruptive to their family life.
with toys in bed, or talking to oneself in bed. Walter was a 7-year-old typically developing
Another assumption is that the reinforcers for the boy who reportedly experienced delayed sleep
interfering behavior may vary and may be either onset. Walter’s parents often discovered that he
automatic (i.e., they do not require mediation by was still awake 1 or more hours after bidding him
another person; e.g., reading books or repetitively goodnight. Parents said that he took items such as
manipulating toys or other objects) or socially toys, stuffed animals, or books to his bed when it
mediated, and may be either positive or negative. was time for sleep. They also reported that he
For example, crying out may be positively talked to himself or got out of bed to ask
reinforced with a glass of milk or extended parental questions or communicate his inability to fall
presence in the child’s bed. By contrast, crying out asleep. Walter had been taken to an outpatient
may be negatively reinforced by a parent who clinic for evaluation of obsessive and compulsive
regularly removes the child from his or her behavior, but neither assessment nor treatment
bedroom when he or she cries. A thoroughgoing affected his sleep patterns. Although he was
assessment of sleep problems would involve some reported to usually sleep through the night, his
attempt to identify the reinforcers for these parents found him to appear tired when he woke
behaviors as well as their associated establishing up in the morning. Parents had attempted to
operations and discriminative stimuli. remove books and toys from the bedroom,
The purpose of the present study was to instructed Walter to count sheep, talked to him
address the aforementioned limitations of the about the questions he asked, or instructed him
behavioral literature on pediatric sleep problems. to think about events that occurred during the
We evaluated an assessment and treatment model day to help him fall asleep. Parental goals for
to be used by behavior analysts who work in Walter’s sleep included reduction of sleep-onset
homes with parents in an attempt to resolve one delay to 30 min or less, elimination of sleep-
or more of their child’s sleep problems. The goal interfering behavior, and achievement of an age-
of this model was to develop individualized, appropriate amount of sleep (about 10.5 hr).
comprehensive, and socially acceptable interven- Andy was a 9-year-old boy who had been
tions to address sleep problems based on the diagnosed with an ASD and who reportedly
idiosyncratic results of assessment. Data on the experienced delayed sleep onset and night
efficacy and acceptability of the model are awakenings of extended duration. Parents re-
presented for three families. ported that they had a difficult time settling him
to bed because he engaged in stereotypy in the
form of body rocking, head shaking, and
METHOD
repetitive manipulation of items such as papers,
Participants and Settings socks, clothes, or pillowcases during bedtime. He
Three children, 7 to 9 years old, and their also screamed and threw tantrums on some
parents participated in our evaluation. They were occasions. Parents often found Andy awake when
recruited via flyers posted at local child-care centers they checked on him in the middle of the night or
and pediatricians’ offices. They were the second, early in the morning with socks or other clothing
third, and fourth children to participate in the items out of the drawers. They had previously
Western New England University’s sleep program attempted to put Andy in a tight wrap prior to
(the first participant’s sleep data were used to refine bedtime, to hide in the bedroom and instruct him
our measurement systems). The parents of all three to go to bed, to hold him in bed when he did not
 SLEEP ASSESSMENT 165

stay in bed, and to give him cold baths as part of Measurement Systems
the bedtime routine to help settle him to sleep. Sleep diaries. We asked the parents to observe
Clonidine had also been prescribed for his sleep and record information each day about their
problems and had been administered for about child’s sleep. Parents documented the time (a)
12 months prior to our study. His parents they bid the child goodnight, (b) when the child
expressed concern about potential side effects fell asleep, (c) of night awakenings and resump-
associated with its prolonged use. Parental goals tion of sleep (if any), (d) of morning awakening,
for Andy’s sleep were to reduce sleep-onset delay and (e) of any naps during each 24-hr cycle. The
to 15 min or less, to eliminate sleep-interfering sleep diary also included open-ended questions
behaviors, to reduce night wakings, and to regarding bedtime routine noncompliance, sleep-
eliminate medication. interfering behaviors, and parental presence or
Lou was also a 9-year-old boy with an ASD cosleeping (if any).
who reportedly experienced difficulty falling Infrared nighttime video. A Sony high-defini-
asleep and frequently woke up in the middle of tion camcorder with infrared illumination was
the night or early in the morning. His parents placed in an inconspicuous location in each child’s
reported that he frequently got out of bed to bedroom. The camcorder continuously recorded
request that a parent sleep with him. If a parent the child’s nighttime behavior. Parents were
did not lie down with Lou, he was reported to instructed to turn on the camcorder and its
sing songs, walk around the house to turn on all night-shot mode before bidding the child good-
the lights, or try to sleep in the parents’ bedroom. night and to turn off the camcorder in the
Lou’s father had been staying or sleeping on the morning shortly after beginning the morning
floor in Lou’s bedroom almost every night until routine. Video recordings served to complement
Lou fell asleep to prevent him from leaving the the information obtained from the sleep diary and
bedroom. Lou’s mother had also tried to lie with allowed us to more precisely measure the child’s
him in bed until he fell asleep or when he woke up sleep-interfering behaviors during the settling
in the middle of the night. Both parents reported period. Observation, however, was limited to
poor sleep quality of their own due to constant behavior that occurred in and around each child’s
nighttime interactions with Lou. Melatonin and bed. Video data were collected on a minimum of
Benadryl had also been used to address the sleep 30% of the nights with each family, but we
problems in the past but with reported limited obtained as much video data as possible. The
success. Parental sleep goals for Lou were amount of obtained video data depended on the
reduction of sleep-onset delay to 15 min or availability of the camcorder and the number of
less, elimination of interfering behaviors, reduc- errors in setting up the equipment (e.g., night-
tion of night and early wakings, achievement of shot mode not turned on or the camcorder not
an age-appropriate amount of sleep (about 10.25 plugged in at night).
hr), and elimination of parental presence at night,
medication, and supplements. Dependent Variables
The study took place in the children’s homes, Sleep-onset delay was defined as the amount of
and their parents implemented all treatment time (in minutes) elapsed from when the parents
components. All three children slept in their own bid the child goodnight to when the child fell
bedrooms (i.e., without siblings). Walter slept in asleep. We observed the child from bidding
a regular bed without rails, Andy slept on a goodnight to falling asleep continuously via video
bottom bunk bed, and Lou slept in a bed with to record the duration of sleep-onset delay using
rails. All three children went to bed in dark or data-collection software. Data collectors turned
dimly lit bedrooms (with night-lights). on an assigned key when bidding goodnight to
166 C. SANDY JIN et al.

the child and turned it off when 10 min had hours by dividing the amount of sleep within the
elapsed without any signs of being awake (see ideal sleep zone by the goal amount of sleep and
awake definition below). converting the result to a percentage. Ideal sleep
Sleep-interfering behaviors were characterized zone was determined with sensitivity to the
as any behavior that occurred after bidding parents’ goal and the developmentally appropri-
goodnight that may interfere with behavioral ate amount of sleep (Ferber, 2006; Weissbluth
quietude and falling asleep. We defined interfering et al., 1981). We calculated duration of night
behavior as time (in minutes) spent (a) vocalizing waking by summing the number of awake
(any audible vocalization coming from the child intervals from when the child fell asleep to 1 hr
such as singing, humming, giggling, crying, calling prior to the child’s appropriate wake time
out, making requests, talking, or screaming with (determined from each child’s developmental
the exclusion of sneezing, coughing, or yawning), norms) and multiplying the sum by 30 min.
(b) getting out and staying out of bed (child left the In sum, direct measures from the video were
the bed or was not in bed), (c) sitting up (no contact available for sleep-onset delay, individual top-
between back and head to any part of the bed) or ographies of sleep-interfering behavior, night
standing in bed, and (d) engaging in stereotypy waking, and amount of sleep. The same measures
(head shaking, body rocking, or the child’s hands (with the exception of interfering behavior) were
actively manipulating or repeatedly flapping any also available from the diaries. Calculation for all
items such as books, video games, toys, papers, diary-based measures followed the same criteria as
socks, clothing pieces, pillowcases, and curtains). the video-based measures. Finally, we recorded
Sleep-interfering behavior was recorded from the other events, such as bedtime music, parental
video, and real-time data were collected using the presence, and the use of clonidine, melatonin, or
same computer data-collection program. Benadryl from the sleep diaries.
We used paper and pencil to record entire sleep
duration using a time-sampling procedure with Interobserver Agreement
30-min intervals. The observation period during Interobserver agreement was assessed by
each sampling interval was 1 min to allow having a second observer independently score
sufficient time to examine whether the child at least 20% of baseline and treatment video
was asleep or awake (i.e., we observed for 1 min sessions for all three children. Agreement data for
every 30 min to detect whether the child was sleep-onset delay, overall sleep-interfering behav-
awake or asleep in bed). Asleep was defined as the ior, and specific sleep-interfering behaviors
child in bed lying on his back, stomach, or side (vocalizations, out of bed, sitting up or standing,
without any signs of being awake, or covers and stereotypy) were collected for 43%, 36%,
covered his entire body with minimal physical and 25% of baseline sessions and 24%, 28%, and
movement. Awake was defined as any occurrence 22% of treatment sessions for Walter, Andy, and
of sleep-interfering behavior (see definition Lou, respectively, and 20% of follow-up sessions
above) with the addition of eyes open (if eyes for Walter. Agreement was calculated by parti-
were visible), whispering, looking up with head tioning the observation duration (i.e., from
leaving pillow, quiet babbling, quiet humming, bidding goodnight until the child fell asleep)
or excessive physical movement in bed or under into 10-s intervals and dividing the smaller
the blanket. After we scored the entire night of duration of scored responses by the larger
video using the time-sampling procedure, we duration within each interval; results were then
calculated total sleep by summing the number of converted to a percentage and averaged across all
asleep intervals and multiplying it by 30 min. We intervals. For all three children, mean agreement
then calculated percentage of sleep during goal was 95% for sleep-onset delay (range, 81% to
 SLEEP ASSESSMENT 167

100%), 97% for vocalizations (range, 86% functional assessment interview designed to
to 100%), 99% for out of bed (range, 93% to identify specific sleep problems and the idiosyn-
100%), 97% for sitting up and standing (range, cratic environmental variables that contribute to
85% to 100%), and 99% for stereotypy (range, each child’s sleep problems in order to inform an
90% to 100%). individualized intervention that each family finds
Agreement data for asleep and awake were acceptable. Specific features of the interview
collected for 29%, 21%, and 25% of baseline include (a) history of the child’s sleep problems;
sessions and 24%, 20%, and 22% of treatment (b) a joint determination of sleep goals; (c)
sessions for Walter, Andy, and Lou, respectively, identification of specific sleep problems (e.g.,
and 20% of follow-up sessions for Walter. bedtime routine noncompliance, delayed sleep
Observers’ data were compared on an interval- onset, night awakenings, early awakenings), a
by-interval basis. An agreement was scored in any description of the antecedent conditions under
interval in which both observers scored either which the specific sleep problems occurred, and
awake or asleep, and a disagreement was scored in the types of interactions (if any) that occur
any interval in which one observer scored awake following the specific sleep problems; (d)
and the other scored asleep. Agreement statistics identification of the child’s current sleep schedule
were calculated by dividing the number of and likely sleep dependencies (those items,
agreement intervals by the number of agreement events, or interactions that appeared to occasion
plus disagreement intervals and converting the sleep), (e) identification of the topographies of
result to a percentage. For all three children, mean possible interfering behaviors and their likely
agreement was 100%. reinforcers, and (f ) descriptions of treatment
options from which parents can choose. The
Procedure results obtained from the interview (and obser-
Baseline. Prior to baseline, we obtained basic vations from the video) informed the design of
information on each child’s sleep problems and individualized and comprehensive treatments.
ensured that there were no severe medical or Treatments. Comprehensive treatments for
health-related concerns (all children had been each child included procedures to enhance the
evaluated by their physicians to rule out insomnia establishing operations and discriminative stimuli
secondary to a medical condition). We informed for behavioral quietude and to weaken the
the parents about the study’s purpose, proce- contingencies for sleep-interfering behaviors. To
dures, and measurement commitments (i.e., reduce sleep-onset delay, we attempted to
diary and in-home video recordings) and establish the value of sleep by adjusting the
obtained consent for participation. At the child’s sleep schedule based on developmental
beginning of baseline, we instructed the parents norms and their current sleep phases (Piazza &
not to change anything they had been doing to Fisher, 1991b). To reduce sleep-interfering
promote good sleep. Parents worked with their behavior, we disrupted the contingency between
pediatricians to alter and ultimately eliminate the interfering behavior and its putative rein-
medications for sleep during baseline. forcement and provided access to the putative
Assessment. After collecting an amount of reinforcer only before bedtime or independent of
baseline data that was sufficient to detect the interfering behavior. Night waking was
treatment effects, we arranged an open-ended indirectly addressed with treatments for interfer-
interview with each family, which was guided by ing behavior, but we also attempted to eliminate
the Sleep Assessment and Treatment Tool (SATT; inappropriate sleep dependencies (e.g., events
see Supporting Information for relevant sections that were present only during the settling period,
of the SATT). The SATT is an open-ended e.g., music) and to establish gradually new sleep
168 C. SANDY JIN et al.

dependencies on salient events that were available than 1 hr. To reduce sleep-onset delay, the value of
at bedtime and throughout the night. Total sleep sleep was established by moving his bedtime
was indirectly addressed by these components. forward by 1.5 hr at the start of the treatment and
Walter. Assessment results indicated that Wal- moving the bedtime back by 30 min only if he was
ter had delayed sleep onset and was usually bid able to fall asleep within 15 min (Piazza & Fisher,
goodnight at least 1 hr before he fell asleep. We 1991b). Parents continued the faded bedtime
first established the value of sleep by bidding procedure until the desirable bedtime was reached.
Walter goodnight closer to his natural sleep phase We also informed the parents about the develop-
(when he typically fell asleep). We did this by mentally appropriate amount of sleep (just over
pushing Walter’s bedtime forward by 1 hr and 10 hr) and cautioned them against allowing him to
gradually moving it back by 30 min if he fell sleep past the desirable wake time.
asleep within 30 min (his goal range of sleep- Andy engaged in sleep-interfering behaviors
onset delay had been determined jointly with his that primarily involved repetitively manipulating
parents) until a desirable bedtime was reached. We items such as papers, socks, clothing pieces,
also asked the parents to keep his sleep schedule pillowcases, and curtains, rocking his body back
consistent so that the amount of sleep he received and forth, and shaking his head (on some
each night was developmentally appropriate. occasions, he jumped back and forth, ran around
Walter also engaged in sleep-interfering behav- in the bedroom, and made indecipherable
ior in the forms of (a) manipulating items such as sounds). Parents typically left immediately after
books, magazines, or paper that were in his bed at bidding goodnight, and the interfering behaviors
bedtime; (b) periodically interacting with siblings; occurred in the bedroom while he was alone;
and (c) getting out of bed to ask “big questions” interfering behaviors were likely maintained by
pertaining to mathematics or religion or to consequences produced directly by his own
communicate his inability to fall asleep. Based behavior (i.e., automatic reinforcement). Based
on assessment results, the putative reinforcers for on this interpretation, treatment involved first
Walter’s sleep-interfering behavior were access to instructing parents to allow Andy to engage in
books, magazines, papers, and parental or sibling stereotypy for 30 min before his bedtime routine.
attention. For treatment, we instructed parents to This was arranged to decrease the value of the
provide access to these putative reinforcers before automatic reinforcers for stereotypy while in bed
bedtime by allowing access to books, magazines, (see Lang et al., 2010, for the abolishing effects of
and paper for at least 20 min before getting ready access to stereotypy). During this period, he had
for bed, and by arranging a period of qualitatively access to items such as paper, socks, and clothing
rich social interaction and a period of question pieces, and he was allowed to engage in
asking and answering with the parents. Access to stereotypy. The second component involved
these same putative reinforcers was then restricted restricting access to these likely reinforcers after
after bedtime by making items such as books and bedtime by instructing the parents to gently
magazines unavailable, not addressing any ques- interrupt instances of stereotypy and guide Andy
tions after bidding goodnight, and gently guiding back to bed. A video-based baby monitor was
Walter back to bed when he got out of bed. Parents used by the parents to determine when to go into
were asked to keep a neutral facial expression, to the bedroom and interrupt stereotypy.
make minimal eye contact, and to minimize SATT results indicated that Andy had lengthy
conversation with Walter when he was out of bed. night wakings during which he engaged in
Parents then again bid Walter goodnight. interfering behaviors. His inappropriate sleep
Andy. Assessment results for Andy indicated dependency appeared to be music. Andy’s parents
delayed sleep onset that usually lasted for more turned on a CD player that played music for
 SLEEP ASSESSMENT 169

about 45 min every night when they bid him Based on SATT results, the likely reinforcers for
goodnight; this stimulation was not present for Lou’s sleep-interfering behaviors were access to
the entire night, thus increasing the likelihood parent attention and access to tangible items in the
that brief night-waking episodes sometimes form of toys, books, and music. Parents provided
resulted in full awakenings. Based on this access to attention (during story time as men-
interpretation, parents were asked to eliminate tioned above) and toys, books, and music (during
music at bedtime and throughout the night. We free play as mentioned above) before they bid
wanted Andy’s sleep environment to stay consis- goodnight. To restrict access to toys and books
tent throughout the entire night so that when he after bedtime, parents implemented a bedroom
woke up in the middle of the night, the same clean-up routine with Lou before story time to
conditions under which he fell asleep would be signal that these items were inaccessible. Parents
present and thus be more likely to reoccasion then disrupted the contingency for interfering
falling sleep. Night wakings were also indirectly behavior by visiting Lou on a time-based schedule.
addressed with the treatments for interfering Parental visits were made independent of Lou’s
behavior. However, we instructed the parents to behavior. Visits were frequent for the first few
gently and quietly guide Andy back to bed, tuck nights, with more time between each visit (5 s,
him in, and bid him goodnight to reinitiate the 10 s, 30 s, 1 min, 5 min, 10 min, 30 min), and
sleep sequence any time he left his bedroom in the were progressively thinned by eliminating the first
middle of the night (this rarely occurred). visit every second night. This strategy was similar
Lou. Lou experienced delayed sleep onset of to noncontingent reinforcement with progressive-
30 min to 1 hr. Based on SATTresults, he had an ly increasing fixed-time intervals (Vollmer, Iwata,
overly stimulating bedtime routine that began 30 Zarcone, Smith, & Mazaleski, 1993). Parents
to 40 min before he was bid goodnight (40 min maintained a neutral facial expression with
of watching TV, browsing the web, playing with minimal language and eye contact, gently tucked
toys, or listening to dance music with headphones Lou in if he was out of bed, and bid him goodnight.
after he had changed into pajamas and brushed Treatments for Lou’s night waking first involved
his teeth). To address the sleep-onset delay, we elimination of inappropriate sleep dependencies.
rearranged the order of the bedtime activities so Lou relied on both the presence of his parents and
that the period of highly stimulating games and music (through headphones). Time-based visiting
activities occurred before he changed into was implemented, and headphone use was
pajamas and brushed his teeth. The stimulating prevented. We then attempted to develop a new
activities were thus further removed from the dependency by adding a sound machine that
time in which behavioral quietude was expected. provided constant white noise throughout the
Lou was given a choice board to access different night. Parents were instructed to turn it on right
activities; choices included activities that de- after saying goodnight and to turn it off when Lou
creased in intensity as bedtime approached. To woke up in the morning. Night waking was also
promote behavioral quietude, we introduced a indirectly addressed by treatments for interfering
more relaxed transition activity by having the behavior; however, we also instructed the parents
parents read a story and offer quiet social to simply guide Lou back to bed if he got up (this
interaction just before they bid him goodnight. rarely occurred).
Lou’s interfering behavior included getting out Parent training. A 2-hr parent training session
of bed, singing songs, playing with toys or video was conducted with each family to review the
games, and reciting stories when parents were not rationale and specifics of each treatment strategy.
present. On many nights, his father slept in the Behavioral skills training, which included in-
bed or on the bedroom floor to attend to Lou. structions, modeling, role-play, and feedback, was
170 C. SANDY JIN et al.

used to ensure that parents could implement each observed whether (a) toys and books were absent
of the treatment components correctly. Parents after bidding goodnight, (b) the sound machine
role-played the procedure with the therapist was turned on after bidding goodnight, (c) the
acting as the child. They were invited to contact times of bidding goodnight and waking the child
the first author at any time to ask questions or were consistent with the prescribed sleep
discuss any challenges they encountered. The first schedule, and (d) parents withheld visits after
author visited families at least twice per week to bidding goodnight or visited based on the
download the video data and to provide feedback recommended schedule (a correct response was
on treatment implementation. They were also scored if parents visited within 2 min of the
given a checklist composed of the individual scheduled interval). Treatment integrity was
treatment components to indicate whether a calculated by dividing the number of correctly
particular strategy was implemented. If a particu- implemented components by the number of
lar strategy was not carried out when applicable, applicable components and converting the result
parents commented on any challenges they to a percentage. Treatment implementation was
experienced or other factors that hindered treat- calculated by dividing the number of imple-
ment implementation. We calculated the percent- mented components by the number of applicable
age of treatment implementation by dividing the components for a particular night and converting
number of implemented components by the the result to a percentage. Mean percentages of
number of applicable components for a particular treatment integrity were 100%, 90% (range,
night and converting the result to a percentage. 75% to 100%), and 82% (range, 75% to 100%)
Parents’ self-reported average percentages were for Walter, Andy, and Lou, respectively.
86% (range, 67% to 100%), 91% (range, 71% to Social validity. To assess whether our treatment
100%), and 100% for Lou, Andy, and Walter, package resulted in socially meaningful changes
respectively. for the families, parents completed a social validity
Treatment integrity. We measured treatment questionnaire at the end of the treatment. The
integrity by observing parent behavior from video questionnaire asked the parents about the extent
recordings for at least 20% of the treatment to which they found the (a) assessment procedures
nights. Data were collected only on the treatment acceptable, (b) treatment package acceptable, (c)
components that could be measured from the improvement in their child’s sleep satisfactory, and
video. For Walter, we observed whether (a) toys or (d) sleep consultation helpful. We also invited
books were absent from the bed after bidding parents to provide any additional comments
goodnight, (b) the times of bidding the child regarding these four areas.
goodnight and waking the child were consistent
with the prescribed sleep schedule, and (c) Design
parents withheld visiting the child after bidding We assessed treatment efficacy using a non-
goodnight or visited only to interrupt instances of concurrent multiple baseline design across
sibling interaction or playing with toys. For Andy, subjects.
we observed whether (a) toys, socks, or stimulat-
ing items were absent after bidding goodnight;
RESULTS
(b) music was turned off after bidding goodnight;
(c) the times of bidding goodnight and waking Agreement between Video-Based and Diary
the child were consistent with the prescribed Measures
sleep schedule; and (d) parents withheld visits Both video and diary data are displayed in
after bidding goodnight or visited only to Figures 1, 3, and 4 to allow visual inspection of
interrupt instances of stereotypy. For Lou, we the consistency of the two measures. It is
 SLEEP ASSESSMENT 171

120
Baseline Treatment Follow-up
100
Diary
80 Video

60 Goal Range of
Sleep Onset Delay
40 Walter

20

Clonidine: 0.50 mg 0.25 mg 0.00 mg

120
Sleep Onset Delay (min)

100

80

60

40
Andy
20

0
0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg

120 Parent Presence

100

80 Time-based Visiting

60

40
Lou
20

0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Nights

Figure 1. The duration of sleep-onset delay (in minutes) for all three children. The horizontal gray bar for each panel
represents the target range of sleep-onset delay jointly determined with the parents. For Andy, clonidine was titrated from
0.50 mg to 0.25 mg and 0 mg before treatment. For Lou, melatonin and Benadryl were eliminated at the beginning of
baseline, reinstated for a brief period at parents’ request, and eliminated again before treatment. The vertical bar represents the
nights in which the parents did not leave the bedroom after bidding goodnight (they stayed in the bedroom until the child fell
asleep or slept in the bedroom).

important to note that both measures were onset delay was highly variable (Walter: diary
sensitive to and capable of detecting the M ¼ 55 min, video M ¼ 55 min; Andy: diary
implementation of the independent variable. M ¼ 30 min, video M ¼ 16 min; Lou: diary
M ¼ 28 min, video M ¼ 20 min). After imple-
Effect on Sleep-Onset Delay mentation of the individualized intervention,
Figure 1 shows the effect of the treatment there was an immediate decrease in the level and
package on sleep-onset delay. In baseline, sleep- variability of sleep-onset delay for Walter (diary
172 C. SANDY JIN et al.

M ¼ 24 min, video M ¼ 21 min) and Andy treatment and follow-up conditions, with larger
(diary M ¼ 13 min, video M ¼ 8 min) with and more evident decreases in the level and
more nights falling within the target range. Short variability of sitting up or standing and stereotypy
sleep onsets were maintained for Walter at the 3- (in the form of object manipulation). Decreases
month follow-up (diary M ¼ 27 min, video in the level and variability of all four sleep-
M ¼ 14 min). interfering behaviors were also observed for Andy.
There was a delayed treatment effect for Lou. For Lou, a reduction was observed only for
Mean sleep-onset delay during treatment was vocalization following treatment due to the low
17 min from the diary measure and 14 min from baseline occurrence of the other forms of
the video measure; however, the delays were interfering behavior.
shorter at the end of treatment (M for last 7
nights ¼ 7 min). Based on parents’ preference, Effect on Night Waking
they remained in the bedroom while all the other Figure 3 depicts the effects of the treat-
treatment components were in place during the ment package on the duration of night waking
first 2 weeks. Parents then implemented the time- (quiet wakefulness and early awakenings were
based visiting component. included with this measure). Night waking was
generally low for Walter throughout the analysis;
Effect on Interfering Behavior nevertheless, it decreased during treatment
Figure 2 depicts the effect of the treatments on (baseline diary M ¼ 8 min, video M ¼ 12 min;
the duration of individual topographies of sleep- treatment diary M ¼ 2 min, video M ¼
interfering behavior. For Walter, all four top- 4 min). Near-zero night wakings were observed
ographies decreased to near-zero levels in the for Walter at follow-up. Andy’s mean night

Baseline Treatment Follow-up Baseline Treatment Baseline Treatment

20 50 80
Vocalization (min)

15 40 60
30
10 40
20
5 10 20

0 0 0
20 50 80
Out-of-bed (min)

15 40 60
30
10 40
20
5 10 20

0 0 0
20 50 80
or Standing (min)

15 40 60
Sitting up

30
10 40
20
5 10 20

0 0 0
20 50 80
Stereotypy (min)

15 40 60
30
10 40
20
5 10 20
Walter Andy Lou
0 0 0
10 20 30 40 50 60 70 10 20 30 40 50 60 70 10 20 30 40 50 60 70
Nights

Figure 2. The duration of individual topographies of sleep-interfering behavior (in minutes) for Walter, Andy, and Lou.
 SLEEP ASSESSMENT 173
100
Baseline Treatment Follow-up
90
80
70
60
Diary
50 Video
40
30
20
10 Walter
0

Clonidine: 0.50 mg 0.25 mg 0.00 mg

160
Night Waking (min)

140
120
100
80
60
40
20 Andy

0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg

450
400 Parent Presence
350
300
Time-based Visiting
250
200
150
100
50 Lou
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Nights

Figure 3. The duration of night waking (in minutes) for Walter, Andy, and Lou. Developmental norms were used to
calculate the duration of night waking. Quiet wakings (e.g., eyes open) and early wakings are also included with this measure.

waking was 12 min (diary data) and 26 min more episodes of night waking for Andy. This
(video data) in baseline. Night waking decreased was likely a function of more quiet wakefulness
to a mean of 3 min (diary data) and 22 min (eyes open in bed), to which the parent diary
(video data) following treatment. Video detected was not as sensitive (typically not considered
174 C. SANDY JIN et al.

Baseline Treatment Follow-up

100

80

60 Diary
Video
40

20
Walter
0
Clonidine: 0.50 mg 0.25 mg 0.00 mg
Estimates of Percentage of Sleep

100
During Goal Hours

80

60

40

20
Andy
0
0/0 mg 5/25 mg Melatonin/Benadryl: 0/0 mg

100

80

Time-based Visiting
60

40

20
Lou
0
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Nights

Figure 4. Estimates of percentage of sleep during goal hours.

to be a problem by many families). There Effect on Total Amount of Sleep

was also a decrease in night waking for Lou Figure 4 depicts the effect of the intervention
from baseline (diary M ¼ 49 min, video M ¼ on the percentage of sleep during goal hours.
58 min) to treatment (diary M ¼ 24 min, video For example, if the ideal sleep zone was from
M ¼ 19 min). 9:00 p.m. to 7:00 a.m. and the child slept from
 SLEEP ASSESSMENT 175

12:00 a.m. to 9:00 a.m., the percentage of sleep in these profiles because it was consistent with the
during goal hours would be 70%. For both video data and we had diary data for more nights
Walter and Andy, there was a slight decrease in for all children. Depicted measures for each child
variability in the percentage of sleep and more include sleep-onset delay, interfering behavior,
stability following treatment. Lou’s percentage of night waking, and percentage of goal sleep.
sleep, by contrast, was highly variable in baseline. Additional measures for Andy are the use of
On some nights, the percentage of sleep during music and clonidine; additional measures repre-
goal hours was as low as 40%. After treatment, sented for Lou are parental presence and the use
variability appeared to decrease, especially during of melatonin and Benadryl. The criteria for
the final 2 weeks of treatment. meeting the sleep goals were fairly strict and were
as follows: less than 30 min of sleep-onset delay
Effect on Sleep Goals for All Measures for Walter and 15 min for Andy and Lou, less
Figure 5 depicts whether the sleep goals were than 2 min of interfering behavior, 0 min of
met across multiple sleep-related measures for night waking, greater than 90% of goal sleep, the
each child. This goal chart provides a convenient absence of disruptive music (Andy), 0 mg of
sleep profile and conveys the extent to which clonidine (Andy), the absence of parental
sleep goals were achieved and whether the child presence (Lou), and 0 mg of melatonin or
was a better and more independent sleeper Benadryl (Lou). For all three children, there
following treatment. Diary data (with the were more nights during which sleep goals were
exception of interfering behavior) are depicted met during treatment than in baseline (mean

Baseline Treatment
Sleep Onset Delay < 30 min
Interfering Behavior < 2 min Met
Night Waking = 0 min Unmet
Percent of Goal Sleep > 90% Walter

Sleep Onset Delay < 15 min

Sleep Goals

Interfering Behavior < 2 min

Night Waking = 0 min
Percent of Goal Sleep > 90%
Disruptive Music = None
Clonidine = None Andy

Sleep Onset Delay < 15 min *

Interfering Behavior < 2 min
Night Waking = 0 min
Percent of Goal Sleep > 90%
Parent Presence = None
Melatonin and Benadryl = None Lou

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75

Nights

Figure 5. This figure depicts whether the sleep goals were met across different dependent measures for each child. Filled
squares represent nights during which a particular sleep goal was met, and open squares represent nights during which a
particular sleep goal was not met. Measures for all three children include sleep-onset delay, interfering behavior, night waking,
and total sleep. Additional measures are disruptive music and the use of clonidine for Andy and parent presence and the use of
melatonin and Benadryl for Lou. The asterisk above Lou’s graph indicates the start of time-based visiting.
176 C. SANDY JIN et al.

percentages of sleep goals met for first 10 baseline assessment of the problem behavior (Iwata,
nights were 43%, 59%, and 35% for Walter, Dorsey, Slifer, Bauman, & Richman, 1982/
Andy, and Lou, respectively; mean percentages of 1994; Iwata, Wong, Riordan, Dorsey, & Lau,
sleep goals met for the last 10 treatment nights 1982), and functional assessments have become
were 93%, 93%, and 88% for Walter, Andy, and the hallmark of behavioral intervention for severe
Lou, respectively) demonstrating a positive effect problem behaviors such as aggression and self-
on multiple measures as a function of the injury (Hanley, Iwata, & McCord, 2003; Kahng
personalized treatments. et al., 2002). Sleep problems, such as delayed
sleep onset, sleep-interfering behaviors, and night
Social Acceptability waking, have historically been exempt from
On a 7-point Likert scale (1 ¼ not acceptable, functional assessment processes. Behavioral sleep
not satisfied, not helpful, and 7 ¼ highly accept- intervention has thus far yielded a variety of
able, highly satisfied, very helpful), the average efficacious tactics, but the conditions under
rating from the social acceptability questionnaire which each should be applied are not apparent,
for all three families and all four questions was 6.8 and the extent to which treatments are based on
(range, 6 to 7). unique features of the sleeper’s history or present
sleeping conditions is not clear. A review of this
literature suggests that specific tactics be applied
DISCUSSION
to specific types of sleep problems (e.g., progres-
Decreases in sleep-onset delay and sleep- sive waiting or bedtime pass for crying and
interfering behaviors and improvements in other leaving the bedroom, France & Blampied, 2005;
measures of sleep were evident for all three Freeman, 2006; Friman et al., 1999; Lawton
children following the implementation of com- et al., 1991; B. A. Moore et al., 2007; scheduled
prehensive and individualized behavioral inter- awakenings for night waking, Johnson & Lerner,
ventions. This effect was immediate for two 1985; Rickert & Johnson, 1988; faded bedtime
children (Walter and Andy) and was delayed for and response cost for delayed sleep onset,
the third child (Lou). Medication (clonidine and Ashbaugh & Peck, 1998; Piazza & Fisher,
Benadryl) and supplement use (melatonin) were 1991a, 1991b). Therefore, the conditions be-
eliminated for the two children who had been yond the topography of the sleep problem under
taking them, and parental presence while the which a particular tactic should be selected or the
child fell asleep was eliminated for the one child conditions under which tactics should be
who was dependent on adult presence to fall combined into more comprehensive strategies
asleep. Finally, the parents who implemented the have not been outlined.
interventions in their homes reported high levels The present study demonstrates the utility and
of satisfaction with the assessment procedures, acceptability of a synthesis model from which
treatment packages, improvements in their child’s efficacious tactics can be combined into compre-
sleep, and the consultation process. hensive treatments. The selection of tactics and
Our results demonstrate the efficacy of a the features of each tactic are based on individu-
comprehensive treatment model for children’s alized factors that influence various sleep prob-
sleep problems that is predicated on a thorough lems, with both the sleep problems and the likely
assessment of possible factors that influenced controlling variables identified via an open-ended
sleep problems for each child. Identification of interview process guided by the SATT. In
the likely controlling variables for problem addition, multiple measures were considered to
behavior from which personally relevant inter- determine when or if healthy sleep was achieved
ventions can be derived necessitates a functional and was done so via acceptable means.
 SLEEP ASSESSMENT 177

The primary advantages of using the SATT Therefore, we recommend that these measures be
prior to developing a treatment for sleep used simultaneously or that the video-based
problems are that the specific sleep problems, measures be used at least initially to calibrate
parental goals, and possible controlling variables parent-based measurement systems. In addition,
can be identified and thus inform the particulars clear benefits are associated with each measure-
of treatment. In essence, researchers and practi- ment system. For instance, parent diaries are
tioners may be more likely to design contingency- important for detecting problems that occur
based interventions if they first ask parents, who outside the bedroom (e.g., sleeping at other
have the most direct and frequent contact with locations, nighttime routine noncompliance) and
the sleep problems, informed questions about throughout the day (e.g., naps at school).
possible controlling variables. By incorporating Although video recordings may be intrusive for
parents into the assessment and treatment certain families and require monitoring and data
process, practitioners may be more likely to extraction, they are essential for precise measure-
build effective relationships and develop socially ment of the amount of sleep-interfering behaviors
acceptable treatments that parents are willing to and quiet wakefulness. Technical difficulties we
implement in their homes with consistency and encountered included parents forgetting to turn
integrity. It is also possible that a general on the night-shot mode or plug in the camcorder.
treatment package without the use of SATT Our study is sufficiently analytic in that the
would also yield improvement in sleep. Future experimental design allows one to infer that
researchers should compare the efficacy of a behavior changes were a function of the changes
general treatment package against a SATT-based in the sleep environments outlined in the treat-
intervention. However, at this point, we believe ments. However, our analysis does not allow
that effective and socially valid intervention is identification of the independent effects of the
more likely when treatments are individualized individual treatment components on the observed
from the assessment information. changes in behavior. In this way, our study might be
The effects of the comprehensive interventions considered insufficiently analytic (Baer, Wolf, &
were demonstrated in a multiple baseline design Risley, 1968). We believe, however, that the sleep-
(i.e., large changes in target behaviors were intervention literature contains a sufficient num-
observed when and only when the treatment ber of examples that show the isolated effects of
packages were in place) with somewhat redun- specific tactics (Adams & Rickert, 1989; Ashbaugh
dant measurement systems. Agreement between & Peck, 1998; Christodulu & Durand, 2004;
diary- and video-based measures was satisfactory France & Blampied, 2005; France & Hudson,
for all three families. Both video data and sleep 1990; Lawton et al., 1991; Piazza & Fisher, 1991a,
diaries also showed sensitivity to the intervention 1991b; Rickert & Johnson, 1988) and that a
despite some discrepancies between the two synthesis of this literature serves the important
measures on particular nights. These findings function of demonstrating the utility of a
suggest that when video recordings may be functional and comprehensive behavioral ap-
intrusive for the family or impose too much effort proach for addressing sleep problems in the places
to extract the data, parental diaries may be relied they occur, by the people who experience them,
on exclusively. However, we caution against an and in a way that leaves little ambiguity about the
exclusive adoption of sleep-diary data because it is extent to which the problems were solved. This
possible that there was an interaction effect comprehensive approach yielded high levels of
between the video and diary data; that is, the social acceptability, indicating that the treatments
accuracy of parents’ data might have been a were not only effective for each child’s sleep
function of the camcorder in the bedroom. problems but also were meaningful for the families
178 C. SANDY JIN et al.

involved. We believe that more evaluations of Chavin, W., & Tinson, S. (1980). The developing child:
highly synthetic treatments that are based on an children with sleep difficulties. Health Visitor, 53, 477–
480.
understanding of the variables that influence Christodulu, K. V., & Durand, V. M. (2004). Reducing
problem behavior should be conducted and bedtime disturbance and night waking using positive
published by behavior analysts as a means of bedtime routines and sleep restriction. Focus on Autism
and Other Developmental Disabilities, 19, 130–139. doi:
moving our field along the continuum from 10.1177/10883576040190030101
efficacy-oriented to more effectiveness-oriented Ferber, R. (2006). Solve your child’s sleep problems (rev. ed.).
research (Hoagwood, Hibbs, Brent, & Jensen, New York, NY: Fireside.
1995). This type of research does not preclude France, K. G., & Blampied, N. M. (2005). Modifications of
systematic ignoring in the management of infant sleep
more microanalytic treatment evaluations; it may disturbance: Efficacy and infant distress. Child &
simply complement such analyses. In that spirit, we Family Behavior Therapy, 27, 1–16. doi: 10.1300/
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France, K. G., & Hudson, S. M. (1990). Behavior
independent and interactive effects of the treat- management of infant sleep disturbance. Journal of
ment components that addressed sleep dependen- Applied Behavior Analysis, 23, 91–98. doi: 10.1901/
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Freeman, K. A. (2006). Treating bedtime resistance with the
the latter, we also believe comparative analyses of bedtime pass: A systematic replication and component
typical extinction procedures, time-based rein- analysis with 3-year-olds. Journal of Applied Behavior
forcement (as was conducted with Lou), and the Analysis, 39, 423–428. doi: 10.1901/jaba.2006.34-05
bedtime pass (in which an alternative behavior is Friman, P. C., Hoff, K. E., Schnoes, C., Freeman, K. A.,
Woods, D. W., & Blum, N. (1999). The bedtime pass:
reinforced; Friman et al., 1999) are important areas An approach to bedtime crying and leaving the room.
for further research. Archives of Pediatrics & Adolescent Medicine, 153, 1027–
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Received March 27, 2012
Stojanovski, S. D., Rasu, R. S., Balkrishnan, R., & Nahata,
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pediatric sleep difficulties in US outpatient settings. Action Editor, Timothy Vollmer

Supporting Information

Additional supporting information may be found in the online version of this

article at the publisher’s web-site.

Appendix S1. Relevant Sections of the Sleep Assessment and Treatment Tool