EFFECTIVENESS OF WEIGHTED BLANKETS AS AN INTERVENTION FOR SLEEP PROBLEMS IN CHILDREN WITH AUTISM Thesis submitted in partial fulfilment of a Master of Science in Child and Family Psychology at the University of Canterbury by Jane Charleson University of Canterbury 2014 2 Contents List of Tables ................................................................................................................. 6 List of Figures ................................................................................................................ 7 Acknowledgements ........................................................................................................ 8 Abstract .......................................................................................................................... 9 Chapter 1 Introduction ................................................................................................. 10 Definition of autism spectrum disorder ................................................................... 11 Development of sleep in children ............................................................................ 12 Assessment of sleep ................................................................................................. 14 Definition of sleep problems .................................................................................... 16 Prevalence and nature of sleep problems in children with autism ........................... 18 Development and maintenance of sleep problems in children with autism ............. 19 The wider implications of sleep problems for children and parents ........................ 23 Chapter 2 Literature review ......................................................................................... 25 Search process .......................................................................................................... 25 Somatosensory stimulation ...................................................................................... 26 Theoretical framework of somatosensory interventions .......................................... 27 Definitions and effectiveness of somatosensory interventions ................................ 29 Treatment acceptability of somatosensory therapies ............................................... 37 Critique and summary of research on somatosensory therapies .............................. 40 3 Behavioural interventions ........................................................................................ 43 Theoretical framework of behavioural interventions ............................................... 44 Definitions and effectiveness of behavioural interventions ..................................... 45 Summary of research on behavioural interventions ................................................. 57 Rationale for the study and research questions ........................................................ 58 Chapter 3 Method ........................................................................................................ 61 Ethics and participant consent.................................................................................. 62 Research Design ....................................................................................................... 62 Participants ............................................................................................................... 64 Setting ...................................................................................................................... 67 Materials .................................................................................................................. 68 Measurement ............................................................................................................ 70 Treatment acceptability and social validity ............................................................. 72 Procedure ................................................................................................................. 72 Data analysis ............................................................................................................ 75 Chapter 4 Results ......................................................................................................... 76 Quality of data .......................................................................................................... 76 Sensory characteristics of participants ..................................................................... 77 Sleep diary data ........................................................................................................ 78 Actigraph data .......................................................................................................... 91 Summary across participants ................................................................................... 97 4 Behavioural intervention .......................................................................................... 98 Treatment Acceptability ........................................................................................... 99 Chapter 5 Discussion ................................................................................................. 102 Research questions ................................................................................................. 102 Factors impacting on the results ............................................................................ 108 Limitations of the current study ............................................................................. 109 Recommendations for future research ................................................................... 110 Clinical implications .............................................................................................. 111 Conclusions ............................................................................................................ 112 References .................................................................................................................. 113 Appendices ................................................................................................................. 131 Appendix A. Letter of Ethics Approval ............................................................. 131 Appendix B. Advertisement............................................................................... 132 Appendix C. Parent Information Sheet .............................................................. 133 Appendix D. Additional Information ................................................................. 137 Appendix E. Child Information Sheet ............................................................... 139 Appendix F. Guidelines for Use ........................................................................ 141 Appendix G. Parent Consent Form .................................................................... 143 Appendix H. Child Consent Form ..................................................................... 144 Appendix I. Treatment Evaluation Inventory .................................................... 145 Appendix J. Sleep Diary .................................................................................... 148 5 List of Tables Table 1 Summary of participant characteristics……………………………………...67 Table 2 Short sensory profile scores…………………...…………………………….79 Table 3 Average (SD) sleep diary sleep parameter scores across phases……………80 Table 4 Average (SD) actigraph sleep parameter scores across phases……………...81 Table 5 Parent reported number of nights co-sleeping……………………………….90 6 List of Figures Figure 1 Outline of phases of the experiment………………………………………..64 Figure 2 Parent report of sleep onset delay…………………………………………..84 Figure 3 Parent report of night waking………………………………………………86 Figure 4 Parent report of total sleep duration………………………………………...89 Figure 5 Actigraph data of minutes awake…………………………………………...91 Figure 6 Actigraph data of number of long wake episodes…………………………..92 Figure 7 Actigraph data of minutes asleep…………………………………………...93 Figure 8 Actigraph data of sleep fragmentation index……………………………….94 Figure 9 Actigraph data of sleep efficiency (%)……………………………………..95 Figure 10 Actigraph data of activity index…………………………………………...96 7 Acknowledgements I would like to acknowledge a number of people whose continued support has enabled me to complete this study. Firstly, to the families who participated in this study; without your commitment and motivation this project would not have been possible. To my family, thank you for your never ending belief in my abilities to complete this thesis and the time, energy and day-to-day support that you have provided me with over the past year. I would also like to acknowledge the support of my supervisors, Associate Professor Karyn France and Associate Professor Neville Blampied who have provided suggestions and support along the way. Lastly, to my friends who have listened to my successes and struggles along the way. 8 Abstract Sleep problems are common in children with ASD. Despite this, evidence for interventions, particularly alternative approaches such as weighted blankets is limited. Aims. The aims of the study were to examine weighted blankets for: (1) their effectiveness as an intervention for sleep problems; (2) their impact on sleep state organisation; (3) their impact on night-time movement; (4) the sensory characteristics of children responding to the intervention; (5) parent’s perceptions of the intervention; (6) behavioural interventions