Method Participants

1. The use of Social Stories™ to help bedtime resistance in young school-aged children Liz Smith, Julie A. Hadwin & Cathy Hill • Introduction • Why is this an important area for Educational Psychologists? • Childhood sleep problems are highly prevalent and occur in around • 10%[1] to 37%[2] of young school-aged children. Studies in development • have highlighted links between disrupted and/or insufficient sleep and • behavioural, learning, emotional and social problems in young • children.[3] • Social Stories™ and Bedtime Resistance • Bedtime resistance is a term used to describe children who typically • refuse to go to bed or who repeatedly make requests in an attempt to • delay bedtime. It is the most common area of sleep-related difficulty • for school-aged children.[2,4] • Social Stories™ are short personalised stories designed to teach • children how to manage their own behaviour in situations that they find • particularly challenging or confusing. Social Stories™ were initially • designed for use with children with an autistic spectrum condition • (ASC). Recent studies have, however, found that they can also be • used to change behaviour in typically developing children, and are • particularly effective for those with perspective taking difficulties.[5] • Two studies have shown that a Social Story™ intervention can reduce • children’s disruptive bedtime behaviours.[6,7] However, both of these • studies used rewards as part of the intervention. In addition, indicators • of changes in sleep related behaviours relied solely on subjective • (parent report) measures of behaviour. • Aims of the Current Study • To investigate the effectiveness of a Social Story™ intervention in the area of bedtime resistance with a community sample of 5 to 6 year-old children. • To consider the individual contribution of the Social Story™ intervention in comparison to its use in combination with rewards. • To measure behaviour change using parent report measures of disruptive bedtime behaviours and actigraphy; an objective sleep measure. Method Participants Six children aged between 5 and 6 years old were recruited from 3 local primary schools. Parents reported that their child took over 30 minutes to settle at least twice a week. To measure sleep, general behaviour, language ability and perspective taking, we completed the Children’s Sleep Habits’ Questionnaire (CSHQ); the Strength and Difficulties Questionnaire; the British Picture Vocabulary Scale and a series tasks to assess perspective taking skills with each child. Social Story™ Intervention A Social Story™ was written for each child to help establish and facilitate their understanding of a bedtime routine and to provide specific reassurance and explanations where necessary. All stories followed Gray’s (2000) basic Social Story format and included photos of the child and parent at various stages in their bedtime routine.[8] The reward element included a daily sticker chart. Design Participants were randomly assigned to recieve either the Social Story™ intervention (n = 3) or a Social Story™ and reward intervention (n = 3). A multiple baseline method with a 6-month follow-up was employed. Participants had staggered start dates, one week apart, with every child completing a baseline, control, intervention and follow-up phase. Measures Parental report measures included a sleep diary, which recorded the number of disruptive bedtime behaviours displayed by the child each night and the CSHQ. Actigraphy, an objective measure of sleep, was also used throughout the duration of the study. This involved the child wearing an actiwatc movement monitor in the form of a small wrist watch device. • Results • Parent report measures • Frequency of disruptive bedtime behaviours per night (from sleep diary) • Total sleep disturbance score (from the CSHQ) • Bedtime resistance score (subscale of the CSHQ) • Note: B = Baseline (3 days), C = control week, I = Intervention week (social story™ or social story™ and reward). The follow-up • was one week in duration 6 months after the intervention week. • Figure 1: Graphs depicting group mean scores from the parental report measures • (sleep diary and CSHQ) taken at baseline, control, intervention and 6-month follow-up. • The mean number of disruptive bedtime behaviours for all participants • recorded during the baseline was 5.5 per night. This number reduced to • 0.7 during the intervention phase and 1.0 at follow-up. • Group analysis revealed a significant reduction over the 4 time points • for frequency of disruptive bedtime behaviours (F (3,12) = 7.64, p < 0.01), • bedtime resistance scores (F (3,12) = 3.41, p = 0.05) and total sleep • disturbance score (F (3,12) = 10.59, p = 0.01). • No significant differences were found between the group who received • just a Social Story™ and those who had a Social Story™ and rewards. • Planned comparison tests showed that the total sleep disturbance score • on the CSHQ was significantly lower during the intervention phase • compared to both baseline (p < 0.01) and control phases (p < 0.05). • Actigraphy data • Sleep onset time (time between lights out and sleep start) • Actual sleep time (total time spent actually asleep) • Sleep efficiency (the percentage of time in bed spent actually asleep). • Note: B = Baseline phase, C = control week, I = intervention week (social story™ or social story™ and reward). The follow-up was one week in duration 6 months after the intervention week. • Figure 2: Graphs depicting group mean scores from the actigraphy measure taken during baseline, control, intervention and 6 month follow-up. • No significant main effects were found for any of the measures. There was also no significant difference between the two groups. • Individual actigraphy data indicated that 2 participants in the Social Stories™ and reward group and who had low perspective taking skills showed a decrease in sleep onset time and an increase in actual sleep time and sleep efficiency during the intervention. • Note: B = Baseline phase, C = control week, I = intervention week (social story™ or social story™ and reward). • Figure 3: Graphs depicting individual scores for participants in the Social Stories and reward group taken during baseline, control, intervention and 6 month follow-up. • Conclusions • Parents report behavioural improvements for children in both groups, • suggesting little difference in this area regarding the use of Social Stories™ • when used alone or in combination with rewards. • Objective sleep measures showed little change throughout the study for • most children, with the notable exception of 2 boys in the Social Story™ • and reward group. These children had poorer perspective taking skills, • supporting previous research which suggests that Social Stories™are • particularly effective for children with some degree of perspective taking • difficulties.[5] • Implications for EP practice include further consideration of the wider use • of Social Story™ interventions. References [1] Stein, M. A., Mendelsohn, J., Obermeyer, H., Amromin, J., and Benca, R. (2001). Sleep and behaviour problems in school-aged children. Pediatrics, 107, 1-9 [2] Owens, J. A., Spirito, A, McGuinn, M., and Noble, C. (2000b). Sleep habits and sleep disturbance in elementary school aged children. Journal of Developmental and Behavioural Pediatrics, 21, 27-36. [3] Fallone,G., Acebo, C., Seifer, R., and Carskadon, M. A. (2005) Experimental restriction of sleep opportunity in children: Effects on teacher ratings. Sleep, 28. 1561-1567. [3] Touchette, E., Petit, D., Seguin, J., R., Bovin, M., Tremblay, R., E., Montplasir, J. Y. (2007). Associations between sleep duration Patterns and behavioural/cognitive functioning at school entrance. Sleep, 30. 1213-1219. [4] Blader, J. C., Koplewiez, H. S., Abikoff, H., and Foley, C. (1997). Sleep Problems of elementary school children. A community survey. Archives of Paediatric Adolescent Medicine, 151, 473-480. [5] Toplis, R., & Hadwin, J.A. (2006). Using social stories to change problematic lunchtime behaviours in school. Educational psychology in Practice, 22, 53-67. [6] Burke, R. V., Kuhn, B. R. and Peterson, J. l. (2004) Brief Report: a ‘storybook’ ending to children’s bedtime problems the use of a rewarding social story to reduce bedtime resistance and frequent night waking. Journalof Paediatric Psychology, 29. 389-396. [7] Moore, M., Meltzer, and Mindell, J. A. (2008) Bedtime problems and night waking in children. Primary Care Clinics in Office Practice, 35. 569-581. [8] Gray, C. (2000). The New Social Story Book: Illustrated Edition. Arlington: Future Horizons Inc