Cathleen C. Piazza

Assessment and Behavioral Treatment of Feeding and Sleeping Disorders in Children with Autism Spectrum Disorders

Children diagnosed with autism or autism spectrum disorders (ASD) are more likely than other children to exhibit behaviors characteristic of a feeding or sleeping disorder. Parents of children with these disorders may be extremely concerned about the health and safety of their child. Sleeping and feeding problems can cause a great deal of stress to parents and other family members. Behavioral assessment and treatment procedures have been developed to address behavior problems related to sleeping and feeding disorders. This article reviews the literature about assessment and treatment, and provides recommendations regarding services to family members of individuals diagnosed with ASD and feeding or sleeping disorders.

Sleep patterns in children and young adults with mental retardation and severe behavior disorders.

The 24‐hour sleep‐wake schedules of 51 individuals (age 3 to 21 years) with mental retardation and severe behavior disorders were recorded using a direct‐observation data collection system over an average period of approximately one month. The patients in the study had significantly less total sleep and less night sleep than their peers of the same age, and 88% had disturbances of sleep:delays in getting to sleep, frequent night waking or early waking. ‘Appropriate’ sleep, a measure of the amount and regularity of sleep, correlated positively with standardized measures of IQ and expressive language. ‘Total’ sleep, that is, the overall number of hours, was not correlated with measures of cognitive functioning. The findings are compared with those from other studies describing the sleep of individuals with mental retardation.

FUNCTIONAL ANALYSIS AND TREATMENT OF MULTIPLY CONTROLLED INAPPROPRIATE MEALTIME BEHAVIOR

Functional analyses identified children whose inappropriate mealtime behavior was maintained by escape and adult attention. Function-based extinction procedures were tested individually and in combination. Attention extinction alone did not result in decreases in inappropriate mealtime behavior or a significant increase in acceptance. By contrast, escape extinction alone resulted in a decrease in inappropriate mealtime behavior and an increase in acceptance. However, inappropriate mealtime behavior did not decrease to clinically acceptable levels. A combined extinction technique (i.e., escape and attention extinction) resulted in a decrease in inappropriate mealtime behavior to clinically acceptable levels and high and stable acceptance.

Aberrant sleep patterns in children with the rett syndrome

Previous studies on the characteristics of disturbed sleep/wake patterns in children with the Rett syndrome have yielded inconsistent findings. In the current study, momentary time sampling procedures were used to measure the sleep/wake patterns of 20 girls with classical Rett syndrome. These patients had significantly more total sleep than age peers (M = 110.1; Zm = 2.58; p = .01), significantly less nighttime sleep (M = 80.8; Zm = -7.53; p less than .0001), and significantly more daytime sleep (M = 24.5; Zm = 8.71; p less than .0001). Night sleep was negatively correlated with age (r = -.59; p less than .01); day sleep was positively correlated with age (r = .54; p = .01). These girls also displayed night wakings on 20.9% of nights, delayed sleep onset on 67.8% of nights and early wakings on 24.5% of nights. These data clearly demonstrate that children with the Rett syndrome have markedly impaired sleep/wake patterns and suggests that the sleep dysfunction may worsen over time.

Empirically derived consequences: A data-based method for prescribing treatments for destructive behavior

Behavioral treatments are often prescribed on the basis of a functional assessment. However, in a significant number of cases, functional assessment results are equivocal or suggest that internal stimuli are maintaining the behavior. In this investigation, we evaluated an alternative data-based assessment that may be useful in such cases. This assessment was used to identify reinforcers and punishers based on the reinforcement assessment procedure described by Pace, Ivancic, Edwards, Iwata, and Page (1985). We then assessed whether empirically derived reinforcers and punishers could be combined to treat the destructive behaviors of two clients. For both clients, the rates of destructive behavior decreased markedly. The results suggest that empirically derived consequences may be useful in decreasing destructive behavior when a functional assessment is inconclusive or is consistent with the hypothesis that the behavior is stereo-typic and maintained by internal stimuli.

Behavioral treatment of sleep dysfunction in patients with the Rett syndrome.

Aberrant sleep patterns are commonly experienced by girls with the Rett syndrome. In this investigation, the problematic sleep of three girls with the Rett syndrome was regulated using a bedtime fading procedure with response cost. The treatment involved systematically delaying the bedtime and utilized a response cost component, removing the child from bed for one hour, when the child did not experience short latency to sleep onset. Daytime sleep was interrupted, except during regularly scheduled naps. A fading procedure was then successfully utilized to advance the bedtimes. This treatment resulted in more regular sleep patterns for the girls by increasing appropriate nighttime sleep, reducing inappropriate daytime sleep and reducing problematic nighttime behaviors (e.g., night wakings). These preliminary findings are important because they suggest that the dysfunctional sleep patterns of girls with the Rett syndrome may be amenable to behavioral treatments.

Bedtime fading in the treatment of pediatric insomnia

In this paper, the sleep-wake cycles of two children with severe sleep problems were regulated by delaying bedtimes, thus increasing the probability of short latency to sleep onset. A fading procedure was then utilized to advance the bedtimes and gradually increase duration of sleep. Several treatments had previously been attempted with both of these patients without success. The advantages of this treatment over other interventions for pediatric sleep disorders are discussed.

Using Chronotherapy to Treat Severe Sleep Problems: A Case Study

Chronotherapy was used to treat severe sleep problems (irregular sleep onset times, frequent night and early wakings, and short total sleep times) in a girl with mental retardation. Chronotherapy involved systematically delaying the childs bedtime each night while maintaining a regular schedule during waking hours until an age-appropriate bedtime was achieved. Immediate improvements in the childs sleep pattern were observed with the introduction of treatment, and an age-appropriate bedtime was achieved in 11 days. Four months of follow-up data indicated that improvements maintained in the home. Although chronotherapy was developed specifically for adults with delayed sleep phase insomnia, the current results suggest that the treatment may be useful for other populations and problems.

A COMPARISON OF SENSORY INTEGRATIVE AND BEHAVIORAL THERAPIES AS TREATMENT FOR PEDIATRIC FEEDING DISORDERS

We compared the effects of escape extinction (EE) plus noncontingent reinforcement (NCR) with sensory integration therapy as treatment for the feeding problems of 2 children. Results indicated that EE plus NCR was more effective in increasing acceptance, decreasing inappropriate behavior, and increasing amount consumed relative to sensory integration for both children. The results are discussed in terms of the challenges of evaluating sensory-integration-based treatments, and the reasons why component analyses of multicomponent treatments like sensory integration are important.

ESCAPE AS REINFORCEMENT AND ESCAPE EXTINCTION IN THE TREATMENT OF FEEDING PROBLEMS

Given the effectiveness of putative escape extinction as treatment for feeding problems, it is surprising that little is known about the effects of escape as reinforcement for appropriate eating during treatment. In the current investigation, we examined the effectiveness of escape as reinforcement for mouth clean (a product measure of swallowing), escape as reinforcement for mouth clean plus escape extinction (EE), and EE alone as treatment for the food refusal of 5 children. Results were similar to those of previous studies, in that reinforcement alone did not result in increases in mouth clean or decreases in inappropriate behavior (e.g., Piazza, Patel, Gulotta, Sevin, & Layer, 2003). Increases in mouth clean and decreases in inappropriate behavior occurred when the therapist implemented EE independent of the presence or absence of reinforcement. Results are discussed in terms of the role of negative reinforcement in the etiology and treatment of feeding problems.