Module 6

Promoting Sleep-Conducive Behaviour

Ensuring appropriate sensory supports, visual cues, sleep schedules and sleep hygiene can support children to sleep well and may be sufficient for many sleep programmes. However, it is also important to consider what you as a caregiver do or don’t do in response to certain sleep-related difficulties and whether this may unintentionally contribute to or maintain them. This may help you to understand why certain sleep-interfering behaviours might be occurring and to create a plan to address them.

This module covers:
  • Responding to sleep-related behaviour
  • Strategies for altering your responses
  • Selecting the best strategies for your child and family
  • Responding to Sleep-Related Behaviour

    There are a number of reasons why sleep-interfering behaviour might occur. As discussed in previous modules, this might be related to sensory needs, emotional distress, lack of understanding, physiological arousal, a distracting sleep environment, inadequate sleep pressure and so forth.

    Before adjusting your responses to your child’s sleep difficulties, consider the following questions:

    1. Is your child ready to fall asleep (Module 2)?
    2. Does your child have a consistent and calming bedroom environment and routine (Modules 3 and 4)?
    3. Does your child understand the bedtime routine and expectations (Module 4)?

    If you answered “no” to any of these questions, addressing these areas should be your priority. Additionally, you should consider whether your child’s bedtime routine and expectations are reasonable based on their developmental, emotional, and sensory capacity, which can fluctuate often. Flexibility is important for Autistic children; caregivers should adjust their expectations to align with their child’s needs. This might involve providing extra explanations or warnings, meeting sensory needs, using declarative language (e.g., “I wonder…” or “I noticed…”) to minimise stress around demands, and ensuring your child has time to finish activities or engage in special interests before bedtime (ideally earlier in the day).

    However, some sleep-interfering behaviours may occur for other reasons such as to get access to food, toys, devices or delay bedtime. These behaviours might be developmentally appropriate, acceptable and work well for you, your child and your family. If not, you may consider how such responses can inadvertently contribute to these behaviours. This is particularly important to assess once other needs have been addressed.


    Strategies for Altering Your Responses

    When the above considerations have been taken into account, you may consider whether altering your responses to your child will support your child’s sleep. The first step in doing so is to identify what response needs to be altered (e.g., your response to your child, their access to food, activities, toys or other items) and why (e.g., it is preventing your child from getting the amount and quality of sleep that they need).

    The next step is to determine the best approach. There are varying strategies to support you in this process; some are very gradual, while others are more immediate.  As many Autistic children experience heightened distress and/or discomfort with sudden changes to routines or patterns, it is strongly recommended any changes in your responses be accompanied by the supports discussed in previous modules (e.g., visual schedules, relaxation strategies) and that they are implemented gradually.

    Gradual Changes: Fading Caregiver Responses

    There are a number of different gradual approaches to fading caregiver responses or presence in the night, that can help your child to get good quality sleep. These procedures are not for everybody, and you should determine what is suitable, safe and acceptable for your family. You can do this by envisioning how these approaches might look and feel across different scenarios for yourself, your family and your child.

    The steps for each procedure outlined below provide examples of how they could be implemented. It is important to adapt the pace of these procedures (e.g., the frequency and duration of the timed breaks, the number of nights over which certain changes occur) to suit both you and your child’s needs. If you find the changes are causing distress, you may need to make alterations to make changes even more gradual or add additional supports as described in other modules – it’s ok to go back to the drawing board! If you have a video camera or monitor in your child’s room, you might use it to monitor and/or reassure your child while you are out of the room.

    Before commencing these procedures, you should discuss the plan with your child and family (using visual supports if helpful – see Module 4) to prepare them for the changes and identify any additional supports that can be used to facilitate the process.

    A Graduated Procedure

    A graduated procedure typically involves gradually modifying the amount of interaction that you have with your child while they are trying to get to sleep. This may be faded by reducing the amount of time spent responding to your child or responding less often to sleep-interfering behaviours (e.g., leaving their bed, calling out) when safe to do so.

    An example of the steps for using a graduated procedure include:

    1. Prepare in advance: Ensure all other supports are in place, such as a regular bedtime and bedtime routine, and any necessary sensory or visual supports.
    2. Choose a night to start: Select a night to begin the procedure. For many, a Friday is ideal as it is likely you and your child’s sleep will be disrupted, due to the change. For example, it may take longer for your child to settle to sleep due to reduced caregiver involvement, but this will typically improve as your child adapts. Also, consider you and your child’s emotional capacity on the chosen night. If either of you are feeling particularly stressed or exhausted, it may be better to start on another day.
    3. Set the initial wait time: Decide on the amount of time to wait before going back in to check on your child, after putting them to bed. A typical time to begin would be between 3-5 minutes, but you should select a time both you and your child will be comfortable with. If your child struggles with the concept of time, you may wish to provide your child with a reason for your leaving the room (e.g., “I am going to get a glass of water and will come back”) – see the Excuse-Me-Drill below.
    4. Begin the procedure: On the first night, follow your typical bedtime routine and put your child to bed. Once in bed, remind your child that you will be leaving the room for a set time, but that you will come back. Once your child has processed this, bid your child goodnight and leave the room. Wait the agreed time (e.g., 3 minutes) and then check on your child. During these checks, provide minimal (boring) interaction (e.g., you may remind your child that you came back as you said or gently rub your child’s arm before leaving the room) and keep them reasonably brief (1-2 mins). After checking, leave the room again and remind your child of the timeframe. Wait the same amount of time before going back into the room, unless you need to intervene to ensure your child’s physical and psychological safety. Continue this until your child is asleep. If and when your child falls asleep in your absence, you may wish to leave an object to symbolise that you did come back as you had said (e.g., a reassuring soft toy) for if they wake in the night.
    5. Gradually increase the wait time: On the nights that follow, wait an additional 2-3 minutes between visits until your child is able to fall asleep independently. If your child is having difficulty with the change, you might extend the time between visits more gradually or delay increasing the time as needed.
    6. Maintain consistency: These steps should be implemented at the beginning of the night and also following a night waking, so that there is consistency throughout the night.  

    The Excuse-Me Drill

    The Excuse-Me Drill, developed by Professor Brett Kuhn (Clinical Psychologist and sleep researcher at the University of Nebraska Medical Center) is another approach to fading caregiver interaction in the night. This procedure involves encouraging behaviours that support sleep and reducing your attention for behaviours that interfere with sleep. Based on the Excuse-Me Drill, the caregiver who is usually present when the child falls asleep will say “excuse me, I need to go and ­­­_______for a second. I will be right back”. The excuse can be anything from “excuse me while I put your book away,” “excuse me I need to go to the toilet” to “excuse me I need to go and check on the dog”. Upon return, you should provide praise for the child remaining in their bed quietly.

    An example of the steps for using the Excuse-Me Drill include:

    1. Prepare in advance: Ensure all other supports are in place, such as a regular bedtime and bedtime routine, and any necessary sensory supports.
    2. Choose a night to start: Select a night to begin the procedure. For many, a Friday is ideal as it is likely you and your child’s sleep will be disrupted, due to the change. For example, it may take longer for your child to settle to sleep due to reduced caregiver involvement, but this will typically improve as your child adapts. Also, consider your and your child’s emotional capacity on the chosen night. If either of you are feeling particularly stressed or exhausted, it may be better to start on another day.
    3. Begin the procedure: On the first night, follow your typical bedtime routine and put your child to bed. Once in bed, excuse yourself from the room (or even just the bed for a matter of seconds), return straight away (i.e., before they are out of sight) and provide praise for the child for remaining in their bed. Continue this until your child is asleep.
    4. Gradually increase the wait time: On subsequent nights, gradually extend the time you remain away from the bedroom (e.g., from a few seconds to a few minutes) and reduce the frequency of checks until eventually your child falls asleep when you are out of the room. As a general guide, you can double the average time you are away from the room each night, up to a maximum of 15 minutes, before returning to give praise to your child for laying calmly in bed.

    Faded Parental Presence

    The faded parental presence procedure involves incrementally fading your presence in the bedroom, until your child can fall asleep without you being present. Faded parental presence is typically used if you are sharing a bed with your child (either their bed or your own) and would like to stop.  It is important to note that it is not necessary to stop co-sleeping unless it is causing distress, discomfort or negatively affecting your and your child’s sleep and/or daytime functioning.

    An example of the steps for using a Faded Parental Presence procedure include:

    1. Prepare in advance: Ensure all other supports are in place, such as a regular bedtime and bedtime routine, and any necessary sensory and visual supports. Also consider sensory substitutions for your presence. You may ask yourself and your child, what about my presence do they like? For example, if your child’s comfort is related to warmth, you may provide them with a warm blanket or item. If your child’s comfort is related to pressure, you may provide them with compression clothing.
    2. Choose a night to start: Select a night to begin the procedure. For many, a Friday is ideal as it is likely you and your child’s sleep will be disrupted, due to the change. For example, it may take longer for your child to settle to sleep due to reduced caregiver involvement, but this will typically improve as your child adapts. Also, consider your and your child’s emotional capacity on the chosen night. If either of you are feeling particularly stressed or exhausted, it may be better to start on another day.
    3. Determine a starting point in the bedroom: If you usually lie down with your child while they fall asleep, you may begin by sitting in a chair or lying on a mattress beside the bed, until they fall asleep (Note – the size of this step can be as big or as small as you would like). Unless for health or safety reasons, you should avoid interacting with your child during this time, including talking or touching. You may provide clear instruction to go to sleep and/or direct them to appropriate sensory or relaxation supports.
    4. Incrementally alter your position in the bedroom: As your child adapts to the change (e.g., is settling comfortably and quietly over several nights), you may gradually move the chair or mattress further away from your child’s bed (e.g., 1-2 metres). Continue to stay in this new position until they fall asleep comfortably and quietly, both at the start of the night and following night wakings. Repeat this process until you are out of the bedroom and your child falls asleep independently. If not, return to your previous position in the room until they settle themselves to sleep comfortably and quietly.

    Note: If your child leaves their bed and/or expresses distress at any stage, respond calmly by reminding them that it is bedtime, providing appropriate sensory or relaxation support, and gently guiding them back to bed, if needed. You may also wish to consider an intermediate and gradual change instead.

    Gradual Changes: Fading Access to Tangible Items

    When the sleep difficulty is maintained by access to activities or toys (e.g., digital devices; excluding communicative devices), books/magazines, distracting toys), or food or drink (e.g., bottle of milk), you may consider exploring ways to gradually fade access to these in the same way that you would if you were fading caregiver responses. As above, these changes should be discussed with your child beforehand and accompanied by other supports (e.g., Module 4), to minimise any distress associated with change.

    Examples of ways to gradually alter access to tangible items interfering with sleep:

    1. Gradually reduce the amount of time your child has with the activity or item: For example, if your child typically has 30 minutes of device time while lying in bed, you might reduce this time by 5-minute increments, every 2-3 nights. You should provide ample warning before making changes and ensure your child has sufficient access to the device or activity during the day.
    1. Gradually reduce the value and/or impact of the item: For example, if your child uses a device before bed, switch from highly stimulating content to more neutral or calming content. If your child repeatedly requests food, offer a less preferred snack, such as carrot instead of ice-cream.
    1. Gradually reduce the number of items available: For example, if your child takes multiple devices to bed, then gradually reduce the number of devices (excluding communicative devices) from three – two – one over the course of several nights. Likewise, if your child requests food or drink while falling to sleep at the beginning of the or following a night waking, and this is not necessary to meet your child’s nutritional requirements, gradually reduce the amount provided over several nights.

    Reminder! These strategies should be considered as a final option following consistent implementation of strategies described in previous modules. When used, they should be combined with other strategies, particularly those that will help your child to understand any changes (Module 4). If you are not confident or comfortable with implementing these procedures, then we advise against doing so. Inconsistent (e.g., starting and stopping) and inappropriate (e.g., immediate removal or removal of a necessary item) implementation can lead to confusion and stress for both you and your child.