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International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2021 Jan 11;68(5):624–632. doi: 10.1080/20473869.2020.1855692

Behavioral assessment and faded bedtime intervention for delayed sleep-onset in an adult with autism spectrum disorder

James K Luiselli 1,✉, Jill M Harper 2, Matthew Leach 3, Kerrianne J Murphy 3, Katherine Luke 3
PMCID: PMC9542872  PMID: 36210902

Abstract

Faded bedtime has been evaluated as a behavioral intervention for delayed sleep-onset principally with children and youth who have intellectual and developmental disabilities in hospital and home settings. The present case report describes behavioral assessment and faded bedtime intervention in a 21-year old adult man with autism spectrum disorder at a community-based group home. The study also documented the effects of family home visits on the man’s sleep when he returned to the group home. Compared to a pre-intervention (baseline) phase, faded bedtime was associated with increased intervals of recorded sleep and a decrease in sleep-onset latency over several months of implementation. We discuss clinical implications of the case and generality of findings across populations and settings.

Keywords: autism spectrum disorder, behavioral sleep intervention, faded bedtime, sleep- onset delay

Many children and youth with autism spectrum disorder (ASD) have difficulty initiating and maintaining sleep (Kotagal and Broomall 2012, Mannion and Leader 2014, Tyagi et al. 2019, Waddington et al. 2020). Specifically, the problem of delayed sleep-onset, also described a prolonged sleep-onset latency (SOL), refers to the amount of time it takes a person to transition from a state of wakefulness to falling asleep (Herrmann 2016, Malow et al. 2006). As the result of delayed sleep-onset, children and youth with ASD may sleep less than the recommended hours per day (Hirshkowitz et al. 2015, Paruthi et al. 2016) and have poor sleep efficiency (Reed and Sacco 2016). Notably, reduced sleep duration and poor quality sleep in ASD stemming from delayed sleep-onset and problems such as early morning waking, bedtime resistance, and unwanted co-sleeping negatively impacts language and communication development (Hollway et al. 2013), daily living skills (Sikora et al. 2012), neurocognitive functioning (Buckhalt 2013), physical wellbeing (Colton and Altevogt 2006), and maternal mental health (Hodge et al. 2013, Meltzer 2011). Further, delayed sleep-onset can exacerbate daytime challenging behaviors such as aggression, self-injury, and stereotypy (Cortesi et al. 2010, Goldman et al. 2011, Schreck et al. 2004).

Faded bedtime is a behavioral intervention that has been effective in reducing delayed sleep-onset in children and youth who have ASD as well as intellectual disability and other neurodevelopmental disorders (Durand 2014, Luiselli 2020a). The usual components of faded bedtime are (a) scheduling a person’s time to bed 30 min past the time of typical sleep-onset, (b) gradually moving back or advancing that time 30 min if the person did or did not fall asleep within 15 min the night before, (c) restricting daytime sleep (e.g. napping), and (d) keeping a consistent morning wake up time. Faded bedtime appears to function as a combination of respondent and operant conditioning in which “delaying bedtime and restricting access to sleep may alter the reinforcing value of sleep and changes the probability of achieving rapid sleep-onset and engaging in sleep compatible behaviors” (Sanberg et al. 2018, p.4272).

In the first evaluation of faded bedtime, Piazza and Fisher (1991) targeted three children and one adult (4-19 years old) with intellectual and developmental disabilities on a specialized inpatient hospital unit. After determining their average sleep-onset time in baseline, intervention started by scheduling bedtime 30 min later. If the participants fell asleep within 15 min of bedtime, it was scheduled 30 min earlier the next night. If the participants did not fall asleep within 15 min, their next-night bedtime was delayed by 30 min. Thus, bedtime was adjusted every day depending on sleep-onset time the previous night. Unit staff also kept the participants out of their bedrooms for 60 min (response cost) contingent on periods of wakefulness exceeding 15 min before re-implementing the faded bedtime intervention. This combination of procedures increased hours of sustained sleep in all of the children and the adult and three of them also had decreased periods of daytime sleep and night waking.

Several modifications of the Piazza and Fisher (1991) faded bedtime protocol have been conducted. Ashbaugh and Peck (1998) reduced lengthy sleep-onset in a 2-year old typically developing child by having parents delay her usual bedtime by two hours, put her to bed 30 min earlier the next night if she had fallen asleep within 15 min of going to bed the night before, and implement response cost for 30 min instead of 60 min. Delemere and Douvani (2018) reported positive effects of parent-implemented faded bedtime without response cost in reducing delayed sleep-onset in six children with ASD (2-7 years old). Several other studies successfully treated delayed sleep-onset and co-occurring sleep problems (e.g. night waking, bedtime resistance, unwanted co-sleeping) in children with ASD (2-14 years old) through home-based interventions that combined faded bedtime with other behavioral methods such as preventing access to sleep- interfering activities, establishing sound sleep hygiene practices, providing soothing pre-bedtime stimulation, and eliminating reinforcing consequences for problem behavior (Jin et al. 2013, McLay et al. 2019, 2020, Sanberg et al. 2018, van Deuers et al. 2019).

It is estimated that approximately 8.5 to 44.7% of adults with ASD and intellectual disability also experience sleep problems, including delayed sleep-onset (Baker and Richdale 2015, Ballester et al. 2019, Hare et al. 2006, Matson et al. 2008, van de Wouw et al. 2012). Similar to children and adolescents, there is evidence that sleep problems among adults with disabilities are associated with impaired daytime functioning, co- morbid psychopathology, and cognitive deficits (Limoges et al. 2013, Lenjavi et al. 2010, Tani et al. 2003). However, behavioral interventions to treat sleep problems have rarely targeted adults who have ASD and intellectual disability (Luiselli 2020a; Shanahan et al. 2019). For example, only two single-case studies were identified that evaluated the effectiveness of faded bedtime as intervention for delayed sleep-onset with adults (18- and 19-years old) (Luiselli et al. 2020b; Piazza and Fisher 1991).

More research with adults is necessary to determine whether faded bedtime can be implemented successfully with persons who have a lengthier history of delayed sleep-onset. As well, the settings for intervention evaluation have been an inpatient hospital unit (Piazza and Fisher 1991) and family homes (Ashbaugh and Peck 1998, Jin et al. 2013, McLay et al. 2019, Sanberg et al. 2018, van Deuers et al. 2019) but not other residential living arrangements that support persons with ASD and intellectual disability. Further, other than Delemere and Douvani (2018), studies have combined faded bedtime with additional intervention procedures. Isolating the singular effects of faded bedtime would be informative and offer care providers a practical intervention that can be easily trained and applied compared to more procedurally complex programs.

Our purpose in the present study was to evaluate the effects of faded bedtime alone on persistent delayed sleep-onset in an adult with ASD living in a community-based group home. In addition to contributing to the sparse literature on behavioral sleep intervention with adults, the study also featured a fixed- versus daily-adjusting bedtime schedule and assessed social validity (Wolf 1978) of intervention application and outcome among the care providers who implemented procedures.

Methods

Participant and setting

Ned was a 21-year old man who had been diagnosed with ASD and attention deficit hyperactivity disorder (ADHD). He was non-verbal and communicated expressively through gestures, vocal approximations, and an assistive device (iPad with TP Compass™ application). Ned was able to ask for preferred items, request activities, and follow one-step instructions. Based on testing results from the Assessment of Basic Language and Learning Skills-Revised (ABLLS-R) (Partington 2006) and Assessment of Functional Living Skills (AFLS) (Partington and Mueller 2015), he could perform rudimentary self-care, daily living, motor, and social skills with partial support from care providers. Ned sometimes demonstrated behaviors such as aggression (hitting care providers), self-injury, and noncompliance which were addressed with systematic behavior support plans. His preferences included music, music videos, picture books, physical play, and snack foods. Throughout the study he received lorazepam (2 mg) and divalproex (1,000 mg) daily.

The setting was a residential school that Ned entered approximately five years preceding the study. On weekdays, he attended a classroom with five other students who had similar developmental disabilities, a primary teacher, and several teacher assistants. He lived in a community-based group home with seven other students under the supervision of care providers who were present during day, evening, and overnight hours. A ratio of one classroom staff and one group home care provider to two students was maintained in both locations. Classroom and group home instruction with Ned followed a modified curriculum focusing on functional academic, adaptive living, communication, pre-vocational, social, and leisure skills.

As a residential student, Ned typically returned to his parent’s nearby home on weekends. They reported that he usually went to bed when requested but did not have a standard bedtime. At his parent’s home he was often awake for extended periods at night, taking many hours to fall asleep, and sometimes remaining awake through the early morning. The typical pattern at the group home was Ned demonstrating excessive latency to sleep onset on the first night he returned from home visitation with a variable trend of 0.5 to 4 h each night thereafter. Once Ned fell asleep at the group home, he slept soundly until wake-up time at 7:00 am.

In the group home, conditions at bedtime were kept quiet to facilitate sleep among all of the students. Ned did not have access to electronic devices or was allowed to engage in stimulating activities immediately before and after he went to bed. He did not have a roommate, his bedroom had curtains on the windows, and overhead lighting was turned off at night to further limit ambient stimulation.

The study was approved by a research review committee at the residential school. Ned’s parents also consented to his participation.

Measurement

Measurement consisted of a designated care provider observing Ned in his bedroom for 10-15 s and recording whether he was asleep (in bed with eyes closed) or awake in or out of bed at the conclusion of consecutive 30-min intervals. Interval recording started when he was verbally instructed, “It is time to go to bed,” and continued through 7:00 am the next day. The sleep data were entered into a direct observation and computer-assisted sleep monitoring system developed at the residential school (Shlesinger et al. 2020) that time-stamped, saved, and registered digital sleep code entries with an off-site overnight supervisor. The sleep monitoring system also sent an alert if the designated care provider had not entered sleep data within a +/- 7 min window every 30-min interval.

Care providers were trained to implement the direct observation and computer-assisted sleep monitoring system when they began employment at the group home. A group home manager conducted training through instructions and demonstration while watching care providers perform the necessary steps and confirming they were competent. Throughout all phases of the study, we evaluated implementation fidelity by computing the percentage of 30-min sleep recording intervals in which data were entered correctly within the +/- 7-min window (number of recorded intervals/total intervals x 100). Implementation fidelity during the study was 100%

The dependent measures were percent intervals sleeping and hours to sleep-onset. Percent intervals sleeping was computed by dividing the number of 30-min observation intervals that Ned was recorded asleep by the total intervals (asleep + awake) and multiplying by 100. Hours to sleep onset was computed as the sum of 30-min observation intervals Ned was recorded awake preceding the first interval he was recorded asleep. In illustration, if Ned was in bed at 10:00 pm, recorded awake at 10:30 pm, 11:00 pm, and 11:30 pm, and recorded asleep at 12:00 am, his time to sleep onset would be 1.5 h. The number of 30-min observation intervals varied during baseline and intervention according to the bedtime that was in effect within those phases, described below.

Procedures

The study was an A-B-C-B single-case design (Kazdin 2011) comprised of a baseline phase (A) and two intervention phases (B and C). During baseline and intervention, Ned was not permitted to sleep during the day and his wake up time each morning was held constant at 7:00 am.

Baseline

A care provider assigned to Ned assisted him with a self-care routine that lasted approximately 10 min prior to a standard 9:00 pm bedtime. Upon completing the routine, the care provider supervised Ned entering his bedroom and getting into bed. The care provider conducting the 30-min bedroom observations after bedtime did not interact with Ned if he was awake in his bed. If Ned was out of bed, the care provider instructed him to return and confirmed that he had settled before exiting the bedroom. Other than preparing Ned for bedtime and conducting observations, there were no other formalized procedures during baseline or interventions that addressed delayed sleep-onset.

Preintervention assessment

We conducted functional behavioral assessment (FBA) before intervention to isolate antecedent and consequence variables associated with Ned’s delayed sleep-onset (McLay et al. 2019, van Deuers et al. 2020). The FBA was conducted exclusively at the group home because Ned’s parents declined home intervention to address his sleep problems in that setting. Specifically, FBA consisted of (a) observations of Ned at bedtime, (b) interviews with group home supervisors, and (c) review of baseline sleep data. Assessment results indicated that there were no environmental conditions or competing activities at the group home that appeared to interfere with Ned falling asleep. Further, Ned generally responded compliantly when instructed to go to bed without challenging behaviors which prolonged latency to sleep-onset. Third, the group home care providers had been trained to withhold reinforcing consequences of wakefulness, for example, not providing Ned with social attention or access to sleep-inhibiting objects and devices. Finally, routine consultation from a physician and nursing team at the residential school ruled out medical causes for his chronic delayed sleep-onset.

The most consistent finding from FBA was lengthy delayed sleep-onset that Ned demonstrated on the first nights immediately following home visitation with his parents. Ned’s erratic sleep at home, described previously, suggested a poorly consolidated sleep-wake cycle that may have affected his ability to fall asleep within a reasonable amount of time at the group home. Alternatively, this sleep pattern possibly reflected an extinction burst from the absence of reinforcement at the group home he possibly contacted during overnight family visits (e.g. parental attention). Another influence, though not confirmed, may have been poor sleep hygiene practices and inconsistent bedtime routine when Ned was away from the group home (Jan et al. 2008, Mindell et al. 2009).

Faded bedtime

The basis for a faded bedtime intervention was to condition more rapid sleep-onset by first having Ned stay awake longer before going to bed and gradually moving to an earlier time. All baseline conditions remained in effect during intervention with the exception that Ned’s bedtime was delayed to 10:30 pm. We adjusted his prior 9:00 pm bedtime based on the average hours to sleep onset recorded for 38 consecutive nights in the baseline phase (M = 1.6 h). Also, delaying bedtime more than 30 min beyond his baseline average (Piazza and Fisher 1991) was intended to increase the probability he would fall asleep more rapidly after going to bed. During the period preceding the pre-bedtime routine and new 10:30 pm bedtime, Ned was allowed to relax for several minutes in a first-floor or basement living room while listening to calming music or watching a quiet television show with lights dimmed. He was also able to look at books while lying on a soft-cushion “bean bag” chair, occasionally interacting briefly with care providers who monitored his activities. As another variation to the conventional faded bedtime intervention, Ned’s bedtime was not adjusted daily depending on sleep-onset time the night before. This alteration made it possible for care providers to consistently follow the intervention protocol compared to a scheduled bedtime that shifted every day and provided further evaluation of a fixed daily schedule.

Ned’s bedtime moved to 10:00 pm following visual inspection of sleep data during the first intervention phase which indicated a pattern of decreased latency to sleep-onset over 33 consecutive nights. When greater variability and slightly longer average time to sleep-onset was recorded across 55 consecutive nights at the 10:00 pm bedtime, we returned briefly to and maintained the more effective 10:30 pm bedtime in a final intervention phase lasting five consecutive nights.

Faded bedtime was the only sleep intervention implemented with Ned at the group home. His regular schedule of home visitation also continued without interruption and parents did not alter how they approached and managed his sleep at home.

Social validity assessment

The group home supervisor distributed a questionnaire to nine care providers (M age = 29 years) who had implemented the faded bedtime intervention with Ned. The questionnaire presented the following five statements: (1) Ned needed a sleep intervention plan to help him fall asleep more quickly, (2) The sleep intervention plan was easy to implement with Ned, (3) Ned responded positively to the sleep intervention plan, (4) Staff were able to implement the sleep intervention plan consistently with Ned, and (5) I would recommend the sleep intervention plan for other students. For each statement, the care providers checked one rating on a five-point Likert- type scale (1: strongly disagree, 2: disagree, 3; neither disagree nor agree, 4: agree, 5: strongly agree). Care providers completed the questionnaire independently and all of them returned it to the group home supervisor.

Results

Figure 1 shows the percent intervals sleeping on consecutive nights preceding and on the first nights immediately following home visitation with phase averages depicted in Figure 2. In the baseline phase, sleeping averaged 80.3% (range = 71.4-95.2%) on nights preceding home visitation and 51.6% (range = 38.0-71.4%) on the first nights immediately following home visitation. Recorded intervals of sleep increased to an average of 93.4% (range = 82.3-100%) with reduced variability on nights preceding home visitation during the 10:30 pm faded bedtime phase. The average was 58.7% (range = 17.3-82.3%) on first nights immediately following home visitation. Shifting to a 10:00 pm faded bedtime was associated with a temporary increase in recorded sleep intervals on nights preceding home visitation, followed by decreased percent for several weeks, then an increasing trend resulting in a phase average of 89.6% (range = 72.2-100%). On first nights immediately following home visitation, sleeping averaged 53.7% (range = 27.7- 77.7%). In the return to a 10:30 pm bedtime, intervals with sleeping averaged 91.8% (range = 82.3- 100%) on nights preceding home visitation and the one night immediately following home visitation was 64.7%.

Figure 1.

Figure 1.

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Percent intervals sleeping recorded on consecutive nights during baseline and faded bedtime phases. Gray-shaded data points represent nights immediately following home visitation.

Figure 2.

Figure 2.

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Average percent intervals sleeping recorded during baseline and faded bedtime phases on nights preceding home visitation and nights immediately following home visitation.

Data displayed in Figure 3 show that during the baseline phase, Ned averaged 1.6 h (range = .5-3.5 h) to sleep onset on nights preceding home visitation compared to 4.9 h (range = 3-6.5 h) on first nights immediately following home visitation. With intervention, average time to sleep-onset on nights preceding home visitation averaged .53 h (range = 0-1.5 h) at the 10:30 pm bedtime, .96 h (range = 0-3 h) at the 10:00pm bedtime, and .87 h (range = 0-1.5 h) at the reinstated 10:30 pm bedtime. Comparable data on the first nights immediately following home visitation were 3.5 h (range = 1.5-6 h) at the 10:30 pm bedtime, 3.6 h (range = 2-8 h) at the 10:00 pm bedtime, and 3.5 h on the one night at the 10:30 pm bedtime.

Figure 3.

Figure 3.

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Average hours to sleep onset recorded during baseline and faded bedtime phases on nights preceding home visitation and nights immediately following home visitation.

In summary, Ned fell asleep more quickly and had higher percent of recorded sleep intervals during intervention compared to baseline. The 10:30 pm bedtime was slightly superior to a 10:00 pm bedtime on average. There was a clear pattern of excessively longer sleep-onset on first nights that Ned returned from home visitation in both baseline and intervention phases. Figure 3 shows that this pattern attenuated somewhat with faded bedtime as the average hours to sleep- onset decreased relative to baseline though at a clinically insignificant level. However, the effects of home visits notwithstanding, the moderate improvement Ned achieved for percent intervals sleeping and hours to sleep-onset during intervention in the group home were nonetheless meaningful and contributed to his general wellbeing and quality of life.

The highest ratings on the social validity questionnaire were that the sleep intervention plan was easy to implement (M = 4.0) and was implemented consistently (M = 4.0). On average, the group home care providers neither disagreed nor agreed that Ned responded positively to the sleep intervention plan (M = 3.8), he needed a sleep intervention plan to help his fall asleep more quickly (M = 3.7), and they would recommend the sleep intervention plan for other students (M = 3.2)

Discussion

Study results support previous research on the effects of faded bedtime as behavioral intervention for delayed sleep-onset in persons with ASD and intellectual disability (Ashbaugh and Peck 1998, Delemere and Douvani 2018, Piazza and Fisher 1991). As noted previously, faded bedtime has usually been evaluated in combination with other procedures including response cost and contingency management among children and youth in hospital and home settings. Our findings suggest that faded bedtime alone can be effective and with adults living in residential- care facilities. Another contribution of the study was demonstrating through behavioral assessment the effect home visitation had on the time required for Ned to fall asleep immediately following his return to the group home. One outcome of faded bedtime appears to have been reducing the carry over effect from home on delayed sleep-onset evident in the baseline phase. That is, the latency to sleep-onset during intervention decreased more rapidly over consecutive nights despite the still evident impact of home visits. Though limited to a single case, study findings may be a catalyst for more experimentally controlled research with multiple participants, particularly adults, who demonstrate delayed sleep-onset and reduced duration of continuous sleep.

Our case formulation was that Ned had “learned” to stay awake after going to bed based on a behavioral history with his parents and insufficient physiological sleep pressure from a too early 9:00 pm bedtime at the group home. Faded bedtime possibly functioned as an establishing operation (EO) by inducing fatigue and making falling asleep more reinforcing (Jin et al. 2013). The comparison between 10:30 pm and 10:00 pm bedtimes was largely to determine an optimal schedule that could be maintained with Ned. When the study concluded, the decision was to stay with the 10:30 pm bedtime because it was deemed normatively appropriate for his age (Hirshkowitz et al. 2015, Paruthi et al. 2016) and easily managed by group home care providers.

The response cost component in previous faded bedtime research consisted of keeping individuals awake for 60 min (Piazza and Fisher 1991) and 30 min (Ashbaugh and Peck 1998) when they had not fallen asleep within a defined latency after being put to bed. We did not implement response cost with Ned to avoid extra burden on group home care providers who were responsible for supporting other students in the group home. Also, care providers anticipated that Ned might react negatively if required to get in and out of bed depending on his sleep status during the night. Another deviation from faded bedtime with response cost was not adjusting Ned’s bedtime back or ahead every night based on the time he fell asleep the night before. Flexible versus fixed daily bedtimes could affect sleep-onset differently but have yet to be compared in faded bedtime research. However, in previous single-case studies we found that maintaining a fixed faded bedtime schedule without daily adjustment was associated with reduced latency to sleep-onset and increased sleep duration in an adolescent and adult with ASD (Luiselli et al. 2020a, 2020b). Thus, this variation from the conventional method of faded bedtime appears to be a reasonable treatment option.

On average, the group home care providers agreed that faded bedtime was easy to implement and they were able to do so consistently. More equivocal ratings were recorded for Ned’s response to intervention and recommendation for other students. Social validity assessment in previous studies has generally found acceptance and approval of behavioral sleep methods (Jin et al. 2013, van Deuers et al. 2019) although in some cases, respondents “perceived the interventions to require a great deal of effort and time to implement” (McLay et al. 2019, p.14). Additional social validity assessment specifically targeting faded bedtime is needed as it is not uncommon for direct consumers such as care providers to judge the objectives, procedures, outcomes, and benefits of intervention differently (Carter and Wheeler 2019, Luiselli 2020b).

One concern raised from the study was whether the desirable sleep outcomes with Ned might have been more robust if FBA and intervention were implemented in the family home. The benefits of training parents to apply behavioral procedures for sleep problems is well established (Jin et al. 2013, McLay et al. 2019, Sanberg et al. 2018, van Deuers et al. 2019) and may have assisted Ned in several ways. For example, FBA could identify antecedent and consequence variables which contributed to Ned sleeping poorly at home per parent report and inform interventions to address these problems. If parent implemented procedures were effective, perhaps the immediate post-visitation effect on Ned’s sleep in the group home would have been eliminated and resulted in less variability recorded for percent intervals sleeping and time to sleep-onset.

The methodology of sleep monitoring and data recording in the study was efficient and performed with fidelity but as a type of momentary time sampling, only provided an estimate of sleep-onset and sleep duration derived from a percent-of-intervals measure. Sensitivity and accuracy of data recording could have been enhanced by scheduling shorter observation intervals. Or, whenever possible, conducting sleep measurement through time-lapse video recording and motion detection can capture multiple sleep indices (e.g. sleep-onset latency, total hours of sleep, sleep-interfering behavior) continuously during the night (Jin et al. 2013, Lesser et al. 2019, McLay et al. 2019, van Deuers et al. 2019).

The positive results of faded bedtime notwithstanding, the study was not an experimental analysis that replicated data trends and levels within repeated baseline and intervention phases. Also, the study extended over a period of 130 days, a relatively long-term evaluation, but without more distant follow-up assessment. Another study limitation was not formally assessing procedural integrity of the faded bedtime intervention. However, supervisor observations indicated that group home care providers implemented procedures accurately and without impediments. Finally, care providers performed sleep measurement with 100% fidelity but the study did not assess inter-observer agreement of their data recording.

From the perspective of clinical practice, it appears that faded bedtime has good generality and can be recommended as an empirically supported intervention for delayed sleep-onset in children, youth, and adults who have ASD and intellectual disability. Establishing control over delayed sleep-onset by adjusting time to bed is a relatively facile stimulus-change procedure that most care providers should be able to implement efficiently in multiple settings. For persons whose delayed sleep-onset is influenced by several variables or if faded bedtime alone is not fully effective, other methods that focus on good sleep hygiene practices and function-based intervention procedures can be added (Jin et al. 2013, McLay et al. 2019, Sanberg et al. 2018, van Deuers et al. 2019).

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics approval

All procedures were in accordance with the ethical standards of the institutional and/or national research committee and were in accordance with U.S. Federal Policy for the Protection of Human Subjects.

Funding

The authors declare that no funding was associated with this research.

Data availability statement

Research data are not shared.

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