Behavioral approaches to the treatment of sleep problems in children with developmental disorders: What is the state of the art?

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This paper reviews behavioral treatments for sleep problems in children with a developmental disorder (DD). Sleep problems are common in children with a DD and children’s sleep problems may be associated with adverse consequences including behaviour problems, compromised daytime functioning and family stress. However, the sleep intervention literature for these children is seriously lacking, with only extinction and graduated extinction approaches meeting criteria for a probably efficacious treatment for common sleeplessness problems. The investigation of behavioral treatments for other sleep difficulties remains in its infancy. The impact of sleep problems and successful treatment is largely unexplored, while professional awareness regarding sleep problems and their treatment appears poor. Sleep disturbances are one of the most frequently reported behaviour problems affecting children from the general population, with estimated prevalence rates of about 30% (Richman, 1981; Owens, Spirito, McGuinn, & Nobile, 2000). For children with developmental disorders (DDs), sleep disturbance is even more widespread and problems are typically more severe and persistent. Amongst children with intellectual disabilities (IDs) up to 86% of children aged less than six years were reported by parents to have ‘sleep problems’ (Bartlett, Rooney, & Spedding, 1985) with similar high rates (77%) even for children aged 12-16 years. Problems of sleeplessness (i.e., difficulty getting off to sleep, night waking, or early waking) appear to be the most commonly reported problems (Quine, 1991; Wiggs & Stores, 1996a). Prevalence data for aetiologically discrete samples is limited but studies have suggested that between 44% and 89% of children with autistic spectrum disorders (ASD) may have sleep difficulties, again with sleeplessness featuring prominently (Richdale, 1999; Wiggs & Stores, 2004). Interestingly, amongst ASD samples, high rates of sleep problems appear to occur independently of the presence of co-existing ID (Richdale & Prior, 1995; Patzold, Richdale & Tonge, 1998). True prevalence rates are difficult to assess and likely to vary depending on the age and nature of the group of children studied and the types of sleep disturbances investigated but it seems clear that perhaps the majority of children with DDs suffer from some form of sleep disturbance. There are over 80 different sleep disorders listed in the International Classification of Sleep Disorders (American Sleep Disorders Association [ASDA], 2001) but there are three main types of presenting sleep problems: sleeplessness, excessive sleepiness and episodes which are associated with/intrude into sleep (i.e., parasomnias). Most of the literature concerning sleep patterns of children with DDs does not make the distinction between ‘sleep problems’ and ‘sleep disorders’, with research largely describing presenting symptoms (e.g., “difficulty getting off to sleep”) based upon parents report. This is a limitation because management decisions need to be based upon correcting the underlying disorder and different sleep disorders can present with similar symptoms. For example, sleeplessness, taking the form of a difficulty getting to sleep at night, may amongst other things, result from disorders of the body clock, failure to learn appropriate bedtime behaviour or anxiety. Treatment for each of these causes, or underlying disorders, would be very different. The Significance of Sleep Disturbance The widespread problem of persistent sleep disturbance in children with DDs is especially concerning in view of the fact that sleep disturbance is associated with far-reaching and serious effects (Stores, 1996; 2001; Pilcher & Huffcutt, 1996; Fallone, Owens, & Deane 2002), likely to further compromise daytime functioning in children whose daytime functioning is already impaired by virtue