The Role of Sleep... Lack of sleep can cause: Changes in mood
Decreased motor functions Poor attention span and performance
Hyperactivity/impulsivity Emotional and behavioral changes Reduced
cognitive functions (Dahl, 1996a; Dahl, 1999; Gmez et al., 2006;
Pilcher & Huffcutt, 1996; Touchette et al., 2007)
Slide 4
The Impact of Insufficient Sleep in Early Childhood Most
critical is the fact the Touchette et al. (2007) found evidence
that there is a critical period in early childhood where the lack
of sleep is particularly detrimental to various aspects of
development even if sleep duration normalizes later on (p.
1218).
Slide 5
The Importance of Sleep within the Family Context Reduced sleep
quality for a child can result in: Poor paternal and maternal
mental health A negative impact on parental sleep and marital
relationships Caregiver stress, fatigue, and moodiness Carryover
effects to other siblings (Dahl & El-Sheikh, 2007b; Meijer
& van den Witenboer, 2007; Meltzer & Mindell, 2007; Smart
& Hiscock, 2007)
Slide 6
Sleep in America Based on National Sleep Foundation
recommendations, infants should receive 14-15 hours of sleep a day,
while toddler should receive 12-14 hours. According to the Sleep in
America Poll (2004), 50% of infants and 34% of toddlers are not
getting enough sleep! This has serious, lasting implications for
todays children!!!
Slide 7
Sleep and the Blind All research shows that sleep problems are
significantly higher in individuals who are blind or visually
impaired than the general population, regardless of age. The degree
of vision loss positively correlates to having a sleep problem, as
does the presence of additional disabilities. (See Chapter I for
full references)
Slide 8
The Rationale for the High Rates Sleep is mainly regulated
through light perception which occurs when light is passed through
the retinohypothalamic tract (RHT) from the retina to the
suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN then
relays zeitgebers to the pineal glad, triggering the release of
melatonin to induce sleep at nighttime. Thus, the lack of light
perception by the retina = inappropriately timed release of
melatonin.
Slide 9
Zeitgebers and Circadian Rhythms Sleep is controlled by
circadian rhythms which are developed from zeitgebers (German for
time givers). Light is the strongest of zeitgebers, but other
lesser ones can be mealtimes, activities, and even noise levels.
Zeitgebers play a key role is the daily resetting of the circadian
clock to 24-hours.
Slide 10
Free-Running Circadian Rhythms and the Blind About 50% of
individuals who are blind have free- running circadian rhythms
(Morgenthaler, Lee-Chiong, et. al., 2007). This means those
individuals may have days as long as 25-hours, causing periods when
ones days and nights are completely switched!
Slide 11
Example of a Normal Circadian Rhythm in a Toddler (Lapierre
& Dumont, 1995, p. 121)
Slide 12
Example of a Free-Running Circadian Rhythm (Lapierre &
Dumont, 1995, p. 121)
Slide 13
The Problem Because sleep problems tend to persist from infancy
to later childhood (Mindell, 1993), especially in children with
disabilities (Quine, 1991), it is important for the parents of
young blind children to be aware of the possibility of such sleep
problems and to learn to deal with them effectively (Mindell &
De Marco, 1997, p. 37). Given the impact of sleep problems on a
childs development and learning, in addition to negative family
implications, early interventions for sleep problems in young
children who are blind or visually impaired are critical!
Slide 14
Intervention Types There are two major intervention types for
sleep problems in young children who are blind or visually
impaired. These include: Pharmacologic interventions Behavioral
interventions
Slide 15
Pharmacologic Interventions Consists for exogenous melatonin
supplements ranging in dosage from 0.02-10 mg Timing and dosing is
very difficult Works most effectively when initiated with a
circadian cycle closely resembling that of the desired pattern. We
are decades away from understanding the long term effects,
particularly in children who are pre- pubescent. Not regulated by
the FDA Not always effective Needed throughout ones lifetime
Slide 16
Behavioral Interventions Should be at the forefront of any plan
to address sleep problem. Safest and most cost-effective Should
start with good sleep hygiene and positive sleep associations, then
moving to extinction, graduated extinction, bedtime fading/positive
routines, scheduled awakenings, and parental education Found to be
over 80% effective across 53 treatment studies of infants and young
children reviewed by the American Academy of Sleep Medicine
(Mindell et al., 2006) Much more effective the younger it is
introduced, offering little help to adults
Slide 17
The Importance of Sleep Hygiene & Positive Sleep
Associations Sleep hygiene refers to factors such as optimizing the
environment, enforcing positive sleep routines, use of scheduling,
and avoiding caffeine in the evening. Sleep associations are those
behaviors that occur at the time of sleep initiation (Mindell &
Owens, 2010, p.33). Brief awakenings occur 5-7 times at night
(Dahl, 1996b). If the sleep associations that one falls asleep to
are no longer present during one of these awakenings, the
individual will fully awaken.
Slide 18
Can Ambient Water Sounds Improve Sleep? Anecdotal evidence of
an infant and toddler, both with septo-optic dysplasia, NLP, and no
other known disabilities. Gia Successfully used a bubble tube used
for 7 + years Sam Therapeutic water fountain created a very strong
association to nighttime sleep
Slide 19
The Theories... Both young children had polyphasic sleep
schedules, thus were undergoing circadian rhythm development
Typically weaker zeitgebers became stronger, primary ones Lack of
other confounding issues such as intellectual limitations and other
medical conditions The ambient water sound also acts a positive
sleep association Needs further research with empirical data
Slide 20
The Approved Proposal To formally test the effectiveness of a
bubble tube (the ambient water sound) in improving sleep problems
of three young children who are blind.
Slide 21
Materials Three bubble tubes Three ActiSleep Monitors which
meet the practice parameters of the American Academy of Sleep
Medicine (2007)* ActiLife analysis software program Sleep logs kept
by caregiver(s) *ActiGraphy is considered more reliable by sleep
logs (Ancoli-Israel et al., 2005)
Slide 22
Participant Criteria Three young children between the ages of 9
and 36-months-old (adjusted for prematurity) A visual acuity of NLP
or LP only Sleep problem as identified by caregiver(s) that include
one or more of the following: Trouble getting the child to sleep at
night, frequent and prolonged nighttime awakenings, and excessive
daytime sleepiness No other additional disabilities or major
medical conditions such as: Seizure disorders, chronic ear
infections, and gastroesophageal reflux Screened for other common
sleep disorders that include: Sleep walking, sleep terrors,
confusional arousals, bruxism, bedwetting, obstructive sleep apnea,
restless legs syndrome, periodic limb movement disorder,
narcolepsy, or insomnia Recruited from colleagues working in early
intervention, listservs, and organizations serving the
blind/VI
Slide 23
Participants Angela: 9-months-old with Septo-Optic Dysplasia
(SOD). Developed diabetes insipidus at the start of the 2 nd B
phase Lisa: 34-months-old with SOD with a history of growth hormone
deficiencies Emily: 32-months-old with Microphthalmia, Glaucoma,
& Sclerocornea
Slide 24
Procedure Single-subject A-B-A-B design Initial baseline phase
(A): Establish current sleep problems/circadian rhythm disorder
Initial intervention phase (B): Introduce bubble tube Baseline
reintroduced (A): Removal of bubble tube looking to establish a
trend back to the original baseline Intervention reintroduced (B):
Reintroduce the bubble tube looking to reestablish the initial B
phase
Slide 25
Independent & Dependent Variables Independent variable:
Activation of the bubble tube at nighttime Dependent variables:
Time to fall asleep Frequency and duration of nighttime awakenings
Frequency and duration of daytime naps Total time slept per a
24-hour period
Slide 26
Research Questions??? Does the use of a bubble tube at
nighttime help young children (9 to 36-months -old) who are blind
decrease the time it takes them to fall asleep at night? Does the
use of a bubble tube at nighttime help young children (9 to
36-months -old) who are blind decrease the frequency and duration
of nighttime awakenings? Does the use of a bubble tube at nighttime
help young children (9 to 36-months -old) who are blind decrease
the frequency and duration of daytime naps? Does the use of a
bubble tube at nighttime help young children (9 to 36-months-old)
increase their total time slept per day?
Slide 27
Angelas Sleep Patterns
Slide 28
Lisas Sleep Patterns
Slide 29
Emilys Sleep Patterns
Slide 30
Social Validity All families rated the effectiveness as
moderate (3 on a 1 5 scale) Angela Overall impact of sleep problems
at start and end was rated minimal Lisa Overall impact of sleep
problems at start was rated moderate, no impact at end Emily
Overall impact of sleep problems at start was rated as extremely
severe, highly severe at end Parents felt it worked the first time
and were going to try again during her next sleep cycle
Slide 31
Participant Variables Angela Diagnosis of diabetes insipidus
likely played a large role in sleep issues Lisa Lack of bedtime
routine and poor sleep hygiene Co-Slept with parents Engaged in
stimulating activities during nighttime awakenings Poor parental
knowledge on sleep Emily Possible timing error of when to start
bubble tube Importance of charting sleep patterns
Slide 32
Study Variables Difficulty in finding participants Significant
commitment by family Participants had very different sleep problems
Instrumentation Testing Effect History Maturation Parental
acceptance of problem
Slide 33
Limitations & Future Research Research Questions Overlap
Future research needed: Combine auditory sleep association stimuli
with parental education Broadening participant criteria Other
sounds including mp3s Timing of bubble tube with children that have
free running circadian rhythms
Slide 34
Implications for Early Intervention: Lack of sleep directly
impacts the success of early intervention services Importance of
working with families and helping them address sleep problems as
early as possible Education for parents on good sleep hygiene and
positive sleep associations is critical Sleep diaries and
monitoring sheets are pivotal in identifying the problem
Slide 35
Slide 36
Questions??? Donna Brostek Lee, Ph.D., TVI, COMS Western
Michigan University TCVI/OMC Program Co-Coordinator University of
Kentucky Assistant Professor Starting August 2012 E-mail:
[email protected]@uky.edu