*4.1. Limitations*

The participants were obtained through convenience sampling methods and were comprised of caregiver–child dyads who volunteered to participate in the study via recruitment brochures. Given that the findings are minor and come from a small sample, a generalization of these results cannot be made.

The application of self-report measurement tools created some challenges. The Daily Caregiver Survey lacked any psychometric analysis; however, a critical component of the current study was to provide caregivers an opportunity to o ffer sleep quality perceptions and rate their child's mood throughout the study. Though the survey ratings o ffered a caregiver-friendly approach, there are inconsistencies in how the caregivers evaluated each participant's sleep habits, particularly as the caregivers could not be blinded to the study phases.

Culturally, education and healthcare professionals prescribe weighted blankets and vests at 10% of the child's body weight, though there is no empirical data to support such a practice. For this study, it was di fficult to determine if the weight of the blankets used were too light or too heavy.

The Hello Sense Sleep App was a proprietary tool, and, unfortunately, the researchers were not provided with its validity and reliability properties despite multiple requests. The authors did not conduct a thorough reliability study prior to implementing the study. The tracking device was typically attached to the participant's pillow, ye<sup>t</sup> if the participant left his/her bed to co-sleep with their parent, removing or dislodging of the tracking device from the pillow or sheet, a gap in the data collection would be introduced.

This highlights a challenge between finding an objective measure that can track sleep outcomes but not cause additional di fficulty in tactile SOR that could be caused by a wearable sleep tracking device. This study should be replicated with di fferent and potentially more reliable wearable sleep tracking devices appropriate for pediatric populations with tactile SOR.

Finally, the study's duration, 30 days with 14 days of intervention, may not have been long enough to measure a functional change. The rate at which the participants habituate to having a new/weighted blanket may have been slower than what the study could have captured.

### *4.2. Recommendations for Future Research*

Future research could employ a mixed-methods approach, exploring objective measures either as repeated measures or pre- and post-outcomes related to sleep quality. These outcomes could be paired with caregiver qualitative journals focused on documenting the child's physical activity during the day, evening rituals related to sleep hygiene, and their child's mood the morning after the use of a weighted blanket. A mixed-methods approach could capture missing data from the parent/caregiver's perspective on sleep quality changes while using a weighted blanket with their child. Further research could explore pairing structured sleep hygiene rituals with the child and their parent/caregiver along with a weighted blanket to explore how changes in habits and routines and a sensory-based intervention influence sleep quality in children. More robust research exploring the

effectiveness of weighted blankets on improving sleep quality among children with autism is needed. Specifically, research studies using a control (or waitlist) group, larger sample sizes in both the control and experimental group. Further research studies should employ reliable ye<sup>t</sup> affordable objective sleep-related measurement devices that would support the tactile SOR related challenges among some children with autism.

### *4.3. Key Points for Clinicians*


**Author Contributions:** Conceptualization, B.M.G.; methodology, B.M.G.; validation, B.M.G. & K.L.; formal analysis, B.M.G., K.L., J.S. & T.M.; data curation, B.M.G., K.L., J.S. and T.M.; writing—original draft preparation, B.M.G., K.L., J.S. & T.M.; writing—review and editing, B.M.G. & K.L.; supervision, B.M.G.; project administration, B.M.G. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The Human Subjects Committee approved the study at Idaho State University (Pocatello, ID) (on 10 February 2017, IRB-FY2016-170).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to being stored for only five years in accordance with human subject approval.

**Conflicts of Interest:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
