International Journal of Disability, D evelopm ent and E ducation, Vol. 46, N o.

2, 1999

The Effects of Extinction in the Treatment of Sleep Problems with a Child with a Physical Disability
R OBER T D ID D EN & J AN
D E M O OR Faculty of Social Sciences, Department of Special Education, U niversity of N ijm egen, P.O . Box 9104, 6500 HE N ijmegen, T he N etherlands

I NG E W IC HIN K K RUIT
Kastanjehof Rehabilitation Center, Apeldoorn, The Netherlands

Sleep problems are comm on am ong young children with developmental disabilities. In many cases, parental attention has shaped and reinforced these problems. In the present study, extinction of parental attention was effective in the elim ination and long-term maintenance of nighttime crying with a young child with a physical disability.
AB STRA CT

Introduction Chronic sleep problems with developm entally disabled children can be described as problem s with settling to sleep and frequent nigh ttim e waking. Results from a study by Clem ents, W ing, and D unn (1986) with a sam ple of 155 children with intellectual disability showed that 34% had at least one type of sleep problem. M oreover, both types of sleep problem s frequently coexist. That sleep problems with young children with intellectual disability are highly persistent has been suggested by a follow -up study by Quin (1991) in which he showed that in at least half of the cases these problem s persisted into later childhood. Chronic sleep problem s m ay have detrim ental effects on the well-being of both child and parents. For exam ple, fatigue with the child may function as an establishing operatio n for daytim e behaviour problems. For exam ple, Kennedy and M eyer (1996) showed that sleep deprivation was associated with increased frequency of escape-related self-injurious behavio ur in the classroom with two students with intellectual disability. A lso, parents m ay experience longstanding stress and fatigue, as well as curtailm ent of social life due to chronic sleep problem s with their child. A num ber of behavio ural procedures have been developed to treat sleep problem s with nonhandicapped children, such as scheduled awakenings, stim ulus control, and extinction (see France & Hudson, 1990). R esults from these studies suggest that in many cases parental attention may have shaped and reinforced sleep problem s, in that nighttim e disruptive behaviours m ay com e under the control of positive reinISSN 1034-912X (print)/ISSN 1465-346X (online)/99/020247-06

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forcers (e.g., Blam pied & France, 1993). Consequently, extinction, that is, planned ignoring, m ay be a viable treatment option. Although treatm ent effects of extinction are well-documented with nondisabled young children, empirical studies of children with developm ental disabilitie s are relative ly rare. For example, D idden, Curfs, Sikkem a, and D e M oor (1998) have shown that extinction was effective in the treatm ent of sleep problem s with four young children with developm ental disabilitie s whose sleep problem s were m aintained by parental attention. T he present study was designed to assess ef cacy of extinction of parental attention on the frequency of nigh ttime crying with a child with a physical disability.

M ethod Participant and Setting The participant was Jan-M aarten (a pseudonym), a 2.5-year-old child with a leftside paresis of his arm , shoulder, eyelid, and diaph ragm . His IQ was near normal. He was the fourth child of a two-parent fam ily and attended a rehabilitation centre for handicapped children. He showed sleep problem s (i.e., nighttim e crying) for at least 12 m onths. Jan-M aarten was referred to the centre by his parents for analysis and treatm ent of his sleep problem s. Functional assessment and treatm ent of his sleep problem s were carried out in the home setting.

Description of Sleep Problems Jan-M aarten was put to bed between 19.30 and 21.00 each nigh t. Although he typically fell asleep within a few m inutes, he frequently awoke during the nigh t and began to cry and call out for his mother. W hen his mother arrive d at his bed, he imm ediately stopped crying and began to smile. In his bedroom the m other would offer him a preferred drink and he was allo wed to sit on her lap for several m inutes. He was then put into bed again . A fter she had left, he would begin to cry again within a few m inutes. H is mother alw ays paid attention to his crying to prevent the other children from waking.

Functional Assessment D uring six nights of baseline, functional assessment was conducted to identify the function of sleep problem s with Jan-M aarten. First, an interview with both parents was conducted to obtain information on m edical history, type of sleep problem, its em ergence and development, its frequency and duratio n, as well as its antecedents and consequences. Second, over six nights the parents described antecedent and consequent events as well as type and duration of nigh ttime crying on standardised sheets. It was hypothesised that Jan-M aarten s nighttim e crying was positively reinforced by parental attention. H e alm ost always im m ediately stopped crying when his mother arrive d at his bedside (see also Description of Sleep Problem s). Usually, he

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would receive a preferred drink. He showed no signs of anxiety or fear while being put into bed or upon waking and he could be easily comforted. M edical causes, such as nighttim e seizures or obstruction of upper airw ays, were ruled out.

Treatment Follow ing functional assessment, the parents were informed about the procedure of extinction of attention. A nongraduated extinction procedure was chosen (France & Hudson, 1990). Parents were instructed to put Jan-M aarten into bed at 20.00 each nigh t using a xed bedtim e routine. A fter bidding the child G oodnigh t, they had to leave his bedroom and were instructed not to re-enter his bedroom until the next morning. N ighttim e crying was com pletely ignored. Jan-M aarten would be given extra positive attention during breakfast if he had slept quietly throughout the night. In case of illn ess, parents were instructed to provide m inimal care to avoid reinforcement. Parents were inform ed to expect an initial, albeit tem porary, increase (i.e., extinction burst) in the num ber of m inutes of targe t behaviours during the rst nigh ts of treatm ent.

Design D ata were collected in an AB-design with follow -up. The num ber of nights of baseline was determ ined a priori to control for reactive intervention. Follow-up data were collected three months after intervention. Extinction was in effect during follow -up.

Recording N igh ttim e disruptive behaviour was de ned as crying sustained for at least 1 m in. The observatio n period was divided into intervals of 1 min. Each night one of the parents recorded the number of m inutes of crying on standardised sheets during conditions of baseline, extinction, and follow-up. R ecording began when JanM aarten was put into bed and lasted until he woke up in the m orning.

Reliability D uring 20% of the nigh ts, evenly distrib uted across conditions, data on interrater reliab ility were collected. D uring these nights, one of the parents independently recorded the num ber of m inutes of nighttim e crying. To control for observer drift, parents were never informed about the percentage of agre em ent. Percentage agreement on occurrence was calculated on an interval-b y-interval basis: num ber of agreements divided by the num ber of agre em ent plus disagreement, m ultiplied by 100. M ean percentage agre em ent was 98% .

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F IG . 1. Number of Minutes of Nighttime Crying During Conditions of Baseline, Extinction, and Follow-up

Results Figu re 1 depicts the num ber of minutes of nighttim e crying during conditions of baseline, extinction, and follow -up. The m ean num ber of m inutes of nighttim e crying during baseline was 20. D uring the rst two nigh ts of treatm ent, the num ber of m inutes increased substantially. However, after three more nigh ts, the num ber of minutes of nighttim e crying decreased to near zero. A tem porary increase after 16 nigh ts was probably due to illn ess. D uring follow-up Jan-M aarten showed no nigh ttime disruptive behavio urs.

Discussion Results of this study show that extinction was effective in decreasing the num ber of minutes of nighttim e crying of a physically handicapped child. T he problem s had existed for at least 12 months before baseline data were collected. The results of the present study con rm results of studies with nondisabled young children (D urand &

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M indell, 1990; France & Hudson, 1990; Rolider & Van Houten, 1984) and young children with developm ental disabilities (D idden et al., 1998). D ata collected during a three-month follow -up and anecdotal reports from parents thereafter show that treatm ent effects were m aintained. Ef cacy of the treatm ent should be viewed in the light of the fact that during baseline the num ber of m inutes of nighttim e crying would not reach higher levels due to frequent parental intervention. However, com forting the child as often as possible failed to decrease crying. On the contrary, parental attention appeared to have strengthened nigh ttime crying. A side effect of extinction treatm ent for the present behavio ur problem m ay be an exacerbation, albeit tem porary, of nighttim e crying during the rst two nigh ts (see also Lerm an & Iw ata, 1995). Our data suggest such a burst, and parents were inform ed to expect such an effect. The latter is im portant as an initial increase is suggestive of the effectiveness of treatment and should, therefore, not lead to withdrawal of treatm ent. Also, in clinical practice parents som etim es suggest that ignoring prolonged crying during the nigh t m ay result in the child feeling insecure and rejected. H owever, anecdotal observations from the authors as well as em piric al research in this area (France, 199 2) fail to reveal such detrim ental side effects of treatm ent. In the present study, the follow ing m ethodological shortcomings should be mentioned. First, our ndings are only suggestive of a functional relationship between the child s nigh ttime crying and parental attention. However, a return to baseline, as would be required in case of a reversal design, was unacceptable to the parents. Second, we failed to collect data on procedural integrity, which may have invalid ated our conclusions. France and Hudson (1990) have put forw ard solutions for these m ethodological problems. Parents found it dif cult to ignore the crying, especially during the rst three nigh ts of treatm ent. Therefore, daily contact between behavioural therapist and parents during the rst week of treatm ent is necessary and feedback should be given on (problem s with) im plem entation and (side-)effects of the treatm ent.

Auth or Note W e would lik e to thank Pieter C. D uker for his suggestions on improving the manuscript and Cam illa van Beugen for her assistance.

References
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