Scheduled Awakenings Research Articles

Nocturnal sodium oxybate increases the anterior cingulate cortex magnetic resonance glutamate signal upon awakening.

Clinical guidelines recommend sodium oxybate (SXB; the sodium salt of γ-hydroxybutyrate) for the treatment of disturbed sleep and excessive daytime sleepiness in narcolepsy, yet the underlying mode of action is elusive. In a randomised controlled trial in 20 healthy volunteers, we aimed at establishing neurochemical changes in the anterior cingulate cortex (ACC) following SXB-enhanced sleep. The ACC is a core neural hub regulating vigilance in humans. At 2:30 a.m., we administered in a double-blind cross-over manner an oral dose of 50 mg/kg SXB or placebo, to enhance electroencephalography-defined sleep intensity in the second half of nocturnal sleep (11:00 p.m. to 7:00 a.m.). Upon scheduled awakening, we assessed subjective sleepiness, tiredness and mood and measured two-dimensional, J-resolved, point-resolved magnetic resonance spectroscopy (PRESS) localisation at 3-Tesla field strength. Following brain scanning, we used validated tools to quantify psychomotor vigilance test (PVT) performance and executive functioning. We analysed the data with independent t tests, false discovery rate (FDR) corrected for multiple comparisons. The morning glutamate signal (at 8:30 a.m.) in the ACC was specifically increased after SXB-enhanced sleep in all participants in whom good-quality spectroscopy data were available (n=16; pFDR < 0.002). Further, global vigilance (10th-90th inter-percentile range on the PVT) was improved (pFDR < 0.04) and median PVT response time was shorter (pFDR < 0.04) compared to placebo. The data indicate that elevated glutamate in the ACC could provide a neurochemical mechanism underlying SXB's pro-vigilant efficacy in disorders of hypersomnolence.

Behavioural sleep problems in children.

Behavioural sleep problems are very common in children and are concerns for many parents. This review discusses normal sleep physiology and sleep development and focuses on common behavioural sleep problems in childhood, including behavioural insomnia of childhood, parasomnias and sleep-related movement disorders, highlighting their clinical features and management. Behavioural insomnia of childhood is characterised by learned difficulties in falling asleep and/or staying asleep. Management includes establishing bedtime routines and behavioural techniques. Parasomnias include confusional arousals, sleepwalking, sleep terrors and nightmares, and these usually resolve with time. Management includes parental reassurance and behavioural interventions such as scheduled awakening. With regards to sleep enuresis, management includes behavioural modifications, enuresis alarm and desmopressin. Sleep-related movement disorders include sleep-related bruxism and sleep-related rhythmic movements, of which body rocking is the most common. Early identification and management of behavioural sleep problems may prevent their negative impact on children as well as their families.

The circadian system modulates the cortisol awakening response in humans.

In humans, circulating cortisol usually peaks 30-60 min after awakening from nocturnal sleep, this is commonly referred to as the cortisol awakening response (CAR). We examined the extent to which the CAR is influenced by the circadian system, independent of behaviors including sleep. We examined the CAR in 34 adults (20 female) using two complementary multiday in-laboratory circadian protocols performed in dim light, throughout which behavioral factors were uniformly distributed across the 24-hour circadian cycle. Protocol 1 consisted of 10 identical consecutive 5-hour 20-minute sleep/wake cycles, and protocol 2 consisted of 5 identical consecutive 18-hour sleep/wake cycles. Salivary melatonin was used as the circadian phase marker (0° = dim light melatonin onset). During each sleep/wake cycle, salivary cortisol was measured upon scheduled awakening and 50-minutes later, with the change in cortisol defined as the CAR. Cosinor analyses were used to detect any significant circadian rhythmicity in the CAR. In secondary analyses, we adjusted the models for time awake before lights on, total sleep time, percent of rapid eye movement (REM) sleep, and percent of non-rapid eye movement (NREM) sleep. Both protocols revealed a similar circadian rhythm in the CAR, with peaks occurring at a circadian phase corresponding to 3:40-3:45 a.m., with no detectable CAR during the circadian phases corresponding to the afternoon. In addition to the sinusoidal component of the circadian rhythm, total sleep time was also associated with the CAR for protocol 1. The percent of sleep spent in REM or NREM sleep were not associated with the CAR in either protocol. Our results show that the CAR exhibits a robust circadian rhythm that persists even after adjusting for prior sleep. Presuming that the CAR optimizes physiological responses to the anticipated stressors related to awakening, these findings may have implications for shift workers who wake up at unusual circadian phases. A blunted CAR in shift workers upon awakening in the evening may result in diminished responses to stressors.

0817 Conquering Two Sleep Birds with One Iron stone: The Case of Resolved Restless Sleep Disorder and Parasomnia with Iron Therapy

Abstract Introduction Restless Sleep Disorder (RSD) is characterized by frequent nocturnal movements of large muscle groups or a complaint of restless sleep by observers with associated daytime dysfunction.1 RSD, like other movement disorders of sleep, is associated with low iron stores.2 Children with RSD have increased NREM sleep instability and a propensity for parasomnia.2 No reports to date have demonstrated the use of iron therapy for parasomnia in patients with RSD. Furthermore, studies are limited in very young children with this disorder as they currently fall outside proposed diagnostic criteria.1 Report of Cases: A 2 year-old male presented to the sleep clinic with parental complaints of nightly sleep initiation and maintenance difficulty, mild snoring, restless sleep, episodes of sleepwalking and night terrors multiple times per week. Symptoms worsened over 6 months and were associated with daytime irritability and behavioral problems. Sleep quality measures assessed progress between visits: the PROMIS Sleep Disturbance (PROMIS SD) and Sleep Related Impairment (PROMIS SRI). Serum ferritin was initially 20ug/L. Polysmnogram demonstrated no significant sleep related breathing disorder, a large muscle group movement index of 14, periodic limb movement index of 3. Initial treatment included oral iron therapy, scheduled awakenings, and hypnotic dose melatonin. The sleep psychologist addressed limit setting and negative sleep associations with improved insomnia symptoms but parasomnia and restless sleep continued. The parent noted reduction in both movements and parasomnia frequency after one month of iron therapy. After a 3 month period on treatment, the parent reported complete cessation of the parasomnia, drastic reduction in restlessness, and near resolution of insomnia. Sleep quality measure PROMIS SD improved by 11, demonstrating reduced sleep disturbance. PROMIS SRI did not change. Ferritin level increased to 47ug/L. Conclusion RSD in a very young child with NREM parasomnia responded to oral iron therapy improving overall sleep quality. This case demonstrates the relationship between relative iron deficiency, RSD and associated parasomnia. Support (If Any) 1. DelRosso LM, Ferri R, Allen RP, et al. Consensus diagnostic criteria for a newly defined pediatric sleep disorder: restless sleep disorder(RSD).SleepMed.2020;75:335-340. 2. Leung W, Singh I, McWilliams S, Stockler S, Ipsiroglu OS. Iron deficiency and sleep - A scoping review. SleepMedRev.2020;51:101274

0215 Impact of sleep inertia on visual search performance during combined sleep restriction and circadian misalignment

Abstract Introduction Circadian phase and homeostatic sleep drive affect selective visual attention during sleep inertia (SI), a period of cognitive performance decrement upon awakening that dissipates with time. This study examined the combined effects of circadian misalignment and sleep restriction on visual search performance during SI. Methods Twenty adults (mean±standard deviation [SD] age 25.7±4.2 years; 12M, 8F) completed a 39-day protocol. Prior to a 4-day in-laboratory visit, participants maintained habitual 8h sleep schedules for 2 weeks at home. In-laboratory sleep opportunities (1 per day) were timed to induce varying levels of both circadian misalignment and sleep restriction: 8h on night 1, 3h on night 2, and 3h on mornings 3 and 4. After 3 days of recovery sleep at home (unscheduled), participants repeated the entire protocol. SI was assessed with the Serial Visual Search Task, a measure of selective visual attention, ~ 1, 16, and 31 min after electroencephalogram (EEG) verified awakening following each 3h sleep opportunity. The task required participants to determine whether a target was present or absent among nontarget distractors. Outcomes included median reaction times (RT) and number of missed targets. Sleep opportunities with ≥4.5 min of EEG-verified wakefulness in the 30 min prior to scheduled awakening were excluded from analysis. Data were analyzed with mixed-model ANOVA. Results Mean±SD average amount of wakefulness in the 30 min and 10 min prior to SI testing was 1.2±0.11 and 0.43±0.06 minutes, respectively. Following all sleep opportunities, median RT for overall correct responses and for correct response to target absent trials improved with time since awakening (all p&amp;lt;0.05). In contrast, median RT for correct responses to target present trials improved and number of missed targets worsened with time since awakening following the morning 3 sleep opportunity only (all p&amp;lt;0.05). Conclusion Reaction speed was impaired during SI regardless of circadian timing or level of homeostatic sleep drive, whereas missing targets appears to be dependent upon circadian phase and the level of homeostatic sleep debt. These findings have important implications for military and first responders. Support (If Any) Office of Naval Research MURI N00014-15-1-2809; NIH TR001082; Undergraduate Research Opportunities Grant, University of Colorado Boulder.

A novel bedtime pulsatile-release caffeine formula ameliorates sleep inertia symptoms immediately upon awakening

Sleep inertia is a disabling state of grogginess and impaired vigilance immediately upon awakening. The adenosine receptor antagonist, caffeine, is widely used to reduce sleep inertia symptoms, yet the initial, most severe impairments are hardly alleviated by post-awakening caffeine intake. To ameliorate this disabling state more potently, we developed an innovative, delayed, pulsatile-release caffeine formulation targeting an efficacious dose briefly before planned awakening. We comprehensively tested this formulation in two separate studies. First, we established the in vivo caffeine release profile in 10 young men. Subsequently, we investigated in placebo-controlled, double-blind, cross-over fashion the formulation’s ability to improve sleep inertia in 22 sleep-restricted volunteers. Following oral administration of 160 mg caffeine at 22:30, we kept volunteers awake until 03:00, to increase sleep inertia symptoms upon scheduled awakening at 07:00. Immediately upon awakening, we quantified subjective state, psychomotor vigilance, cognitive performance, and followed the evolution of the cortisol awakening response. We also recorded standard polysomnography during nocturnal sleep and a 1-h nap opportunity at 08:00. Compared to placebo, the engineered caffeine formula accelerated the reaction time on the psychomotor vigilance task, increased positive and reduced negative affect scores, improved sleep inertia ratings, prolonged the cortisol awakening response, and delayed nap sleep latency one hour after scheduled awakening. Based on these findings, we conclude that this novel, pulsatile-release caffeine formulation facilitates the sleep-to-wake transition in sleep-restricted healthy adults. We propose that individuals suffering from disabling sleep inertia may benefit from this innovative approach.Trials registration: NCT04975360.

Trait Interindividual Differences in the Magnitude of Subjective Sleepiness from Sleep Inertia.

In shift work settings and on-call operations, workers may be at risk of sleep inertia when called to action immediately after awakening from sleep. However, individuals may differ substantially in their susceptibility to sleep inertia. We investigated this using data from a laboratory study in which 20 healthy young adults were each exposed to 36 h of total sleep deprivation, preceded by a baseline sleep period and followed by a recovery sleep period, on three separate occasions. In the week prior to each laboratory session and on the corresponding baseline night in the laboratory, participants either extended their sleep period to 12 h/day or restricted it to 6 h/day. During periods of wakefulness in the laboratory, starting right after scheduled awakening, participants completed neurobehavioral tests every 2 h. Testing included the Karolinska Sleepiness Scale to measure subjective sleepiness, for which the data were analyzed with nonlinear mixed-effects regression to quantify sleep inertia. This revealed considerable interindividual differences in the magnitude of sleep inertia, which were highly stable within individuals after both baseline and recovery sleep periods, regardless of study condition. Our results demonstrate that interindividual differences in subjective sleepiness due to sleep inertia are substantial and constitute a trait.

Behavioral insomnia in infants and young children.

In infants and young children, bedtime problems and night waking are common and the main presentations of insomnia. Poor sleep may critically impact the daytime functioning and mood of the child and their caregivers. A comprehensive sleep history, a sleep diary/log, and the BEARS (Bedtime problems, Excessive daytime sleepiness, Awakenings during the night, Regularity and duration of sleep, and Sleep-disordered breathing) sleep screen are useful for diagnosing sleep problems in young children. Behavioral therapies for this type of insomnia include extinction, bedtime fading with positive routines, and scheduled awakening. Previous studies of behavioral interventions for young children showed significant improvements in sleep-onset latency, night waking frequency, and night waking duration. Parent education about their child’s sleep, bedtime routines, and sleep hygiene is essential for treatment.

0257 Preliminary Findings: Attentional Bias for Food Cues Unrelated to Time Awake or Circadian Phase During Forced Desynchrony in Adolescents

Abstract Introduction Sleep quantity and quality influence attentional bias, and attentional bias for food cues has been associated with body weight. Whether the endogenous circadian cycle and/or time from awakening to bedtime contribute to attentional bias for food and differences in weight remain unclear. Using a 28-h forced desynchrony (FD) design, we hypothesized that adolescents with overweight (OW) and obesity (O) would have more attentional bias for food cues later in the wake episode and at a later circadian phase compared to adolescents with a healthy weight (HW). Methods 50 (28 male) adolescents (12-15yr) completed 7 FD cycles. Participants completed an attentional bias task that included three food word categories (savory, sweet, fruits/vegetables) and one non-food word category (school supplies). The task was completed at 6 fixed times each cycle: Task 1 was 1.3h after scheduled awaking, Task 2 was 2h after Task 1, and Tasks 3–6 followed at 3-h intervals. Weight categorization used body mass index (BMI) percentiles (CDC): HW (&amp;gt;5th and &amp;lt;85th; n=24), OW (85th and &amp;lt;95th; n=13), or O (≥95th; n=14). Endogenous circadian period was determined using salivary melatonin onsets (Mean: HW=23.88h; OW=24.01h; O=23.86h). Effect of circadian phase and time since scheduled awakening was assessed by mixed effects modeling using 6 circadian and 6 time-awake bins. Results We found no significant differences between weight groups in attentional bias for any of the food categories (p’s &amp;gt;.05). We also saw no significant time awake effects or circadian influence on attentional bias, nor did time awake or circadian phase moderate the associations between weight category and attentional bias (p’s &amp;gt;.05). Conclusion Weight groups did not impact food-related attentional bias across the wake episode or circadian phase. Future directions will explore whether attentional bias for food types predicts food choice and food consumption in this study. Support DK101046

Current approaches to the diagnosis and treatment of behavioral insomnia in children

Behavioral insomnia is the most common sleep disorder in young children. It significantly reduces the quality of parent's life and is one of the common complaints to a pediatrician or neurologist. The basis treatment of childhood insomnia is behavioral therapy, which includes sleep hygiene, age-appropriate daily routine and sleep associations, stable bedtime routines, positive reinforcement, bedtime fading, scheduled awakenings. Although a systematic ignoring («crying it out») is effective and widely used in behavioral therapy, it has low compliance and its safety is insufficiently studied. Therefore, a systematic ignoring is not a priority method of behavioral therapy and should not be used in children under 6 months of age. Behavioral therapy of childhood insomnia is complemented by psychological and informational support from parents, and in some cases, drug therapy. Prevention includes education of expectant parents on baby sleep hygiene.

The neurophysiological basis of the discrepancy between objective and subjective sleep during the sleep onset period: an EEG-fMRI study

Subjective perception of sleep is not necessarily consistent with electroencephalography (EEG) indications of sleep. The mismatch between subjective reports and objective measures is often referred to as "sleep state misperception." Previous studies evince that this mismatch is found in both patients with insomnia and in normal sleepers, but the neurophysiological mechanism remains unclear. The aim of the study is to explore the neurophysiological basis of this mechanism, from the perspective of both EEG power and functional magnetic resonance imaging (fMRI) fluctuations. Thirty-six healthy young adults participated in the study. Simultaneous EEG and fMRI recordings were conducted while the participants were trying to fall asleep in an MRI scanner at approximately 9:00 pm. They were awakened after achieving stable N1 or N2 sleep, or after 90 min without falling into stable sleep. Next they were asked to recall their conscious experiences from the moment immediately prior to awakening. Sixty-one instances of scheduled awakenings were collected: 21 of these after having achieved stable stage N2 sleep; 12, during stage N1 sleep; and, 20 during the waking state. Relative to those awakenings without subjective-objective discrepancy (n = 27), these awakenings with discrepancy (n = 14) were associated with lower θ power, as well as higher α, β, and γ power. Moreover, we found that participants who exhibited the discrepancy, compared with those who did not, evinced a higher amplitude of low-frequency fluctuation levels in the prefrontal cortex. These results lend support to the conjecture that the subjective-objective discrepancy is associated with central nervous system hyperarousal.

Behavioral Treatments for Non-Rapid Eye Movement Parasomnias in Children

Non-rapid eye movement (NREM) parasomnias are common in childhood and include a range of clinical presentations including confusional arousals, sleepwalking, sleep terrors, and sleep-related eating disorder. While parasomnia episodes can be dramatic and elicit concern from parents, parasomnias are predominantly benign and self-limited. A comprehensive clinical evaluation is necessary for appropriate diagnosis and ruling out underlying medical disorders. For youth with parasomnia episodes that are infrequent or limited in severity, standard treatment recommendations, including safety measures and minimizing triggering factors, are highlighted. Scheduled awakening is an evidence-based behavioral treatment that can be effective at decreasing or resolving frequent and severe NREM parasomnias but may be burdensome for parents to implement.

Behavioral Interventions for Parasomnias

Parasomnias are phenomena which may arise from NREM sleep (confusional arousals, sleep terrors, and sleepwalking) or REM sleep (nightmares). All are more common in children. While generally benign and outgrown with age, they may come to clinical attention when sufficiently disruptive to the patient or the patient’s family and in some cases may pose significant safety concerns. In addition to proper preventative measures, behavioral techniques—such as alteration of sleep timings, implementation of scheduled awakenings, and psychotherapy—are important tools in the clinician’s armamentarium. Research into the effectiveness of these interventions primarily consists of case series. However, particularly in the treatment of nightmare disorder, several randomized controlled studies also support their use and in fact suggest they may equally if not more effective as pharmacotherapy for treatment of these common sleep disorders.

Sleep inertia, sleep homeostatic and circadian influences on higher-order cognitive functions.

Sleep inertia, sleep homeostatic and circadian processes modulate cognition, including reaction time, memory, mood and alertness. How these processes influence higher-order cognitive functions is not well known. Six participants completed a 73-day-long study that included two 14-day-long 28-h forced desynchrony protocols to examine separate and interacting influences of sleep inertia, sleep homeostasis and circadian phase on higher-order cognitive functions of inhibitory control and selective visual attention. Cognitive performance for most measures was impaired immediately after scheduled awakening and improved during the first ~2-4h of wakefulness (decreasing sleep inertia); worsened thereafter until scheduled bedtime (increasing sleep homeostasis); and was worst at ~60° and best at ~240° (circadian modulation, with worst and best phases corresponding to ~09:00 and ~21:00hours, respectively, in individuals with a habitual wake time of 07:00hours). The relative influences of sleep inertia, sleep homeostasis and circadian phase depended on the specific higher-order cognitive function task examined. Inhibitory control appeared to be modulated most strongly by circadian phase, whereas selective visual attention for a spatial-configuration search task was modulated most strongly by sleep inertia. These findings demonstrate that some higher-order cognitive processes are differentially sensitive to different sleep-wake regulatory processes. Differential modulation of cognitive functions by different sleep-wake regulatory processes has important implications for understanding mechanisms contributing to performance impairments during adverse circadian phases, sleep deprivation and/or upon awakening from sleep.

Behavioral Interventions for Sleep Problems in Children With Autism Spectrum Disorders: Current Findings and Future Directions

To examine behavioral interventions for sleep problems in children with autism spectrum disorders (ASD). A systematic review evaluating all published studies examining the effectiveness of behavioral treatment of sleep problems in children with ASD is presented. Based on the Chambless criteria for treatment efficacy, both standard extinction and scheduled awakenings met criteria for possibly efficacious interventions for sleep problems in children with ASD. Some positive outcomes have been reported, but there has not been enough research examining graduated extinction, faded bedtime, stimulus fading and chronotherapy to make any firm conclusions regarding treatment efficacy for children with ASD. Although more rigorous research is required in order for any sleep interventions for children with ASD to be considered probably efficacious or well-established, the current literature should be used to guide clinical decisions and direct research questions.

Endogenous Circadian Rhythm in Vasovagal Response to Head-Up Tilt

The incidence of syncope exhibits a daily pattern with more occurrences in the morning, possibly as a result of influences from the endogenous circadian system and/or the daily pattern of behavioral/emotional stimuli. This study tested the hypothesis that the circadian system modulates cardiovascular responses to postural stress, leading to increased susceptibility to syncope at specific times of day. Twelve subjects underwent a 13-day in-laboratory protocol in which subjects' sleep-wake cycles were adjusted to 20 hours for 12 cycles. A 15-minute tilt-table test (60° head-up) was performed ≈4.5 hours after scheduled awakening in each cycle so that 12 tests in each subject were distributed evenly across the circadian cycle. Of 144 tests, signs/symptoms of presyncope were observed in 21 tests in 6 subjects. These presyncope events displayed a clear circadian rhythm (P=0.028) with almost all cases (17/21) occurring in the half of the circadian cycle corresponding to the biological night (10:30 pm to 10:30 am). Significant circadian rhythms were also observed in hemodynamic and autonomic function markers (blood pressure, heart rate, epinephrine, norepinephrine, and indices of cardiac vagal tone) that may underlie the circadian rhythm of presyncope susceptibility. The circadian system affects cardiovascular responses to postural stress, resulting in greater susceptibility to presyncope during the night. This finding suggests that night-shift workers and people with disrupted sleep at night may have greater risk of syncope as a result of their exposure to postural stress during the biological night.

Treatment of insomnia in adults and children: a practice‐friendly review of research

Chronic insomnia affects nearly 16% of adults and up to 25% of children. Many clinicians are unfamiliar with the research and practice of psychological treatments of insomnia and thus do not use them with their patients. The primary goals of this article were to (a) review the research support for psychological treatments of adult and child insomnia, and (b) describe those treatments with the highest level of research support in enough detail to allow practitioners to begin to utilize them with their own patients. The adult psychological treatments with the best research support are stimulus control, progressive muscle relaxation, and multimodal cognitive-behavioral therapy, followed by multimodal behavioral therapy, sleep restriction, biofeedback, and paradoxical intention. The child psychological treatments with the highest level of research support are preventive parent education, unmodified extinction, and extinction with parental presence, followed by graduated extinction, bedtime fading/positive routines, and scheduled awakenings.

Treatment of nightmares in the context of posttraumatic stress disorder

Nightmares are a common feature of posttraumatic stress disorder (PTSD) and are frequently resistant to treatment. Two emerging treatments for nightmares are pharmacotherapy with prazosin and psychotherapy using imagery rehearsal (IR). A case illustration demonstrates the application of these treatments with a client suffering from chronic, severe PTSD. The case illustrates the use of these strategies for managing PTSD-related nightmares, as well as the novel approach of scheduled awakenings following relapse.

Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children

This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodified extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.

Practice Parameters for Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children

Bedtime problems and frequent night wakings are highly prevalent in infants, toddlers, and preschoolers. Evidence suggests that sleep disruption and/or insufficient sleep have potential deleterious effects on children's cognitive development, regulation of affect, attention, health outcomes, and overall quality of life, as well as secondary effects on parental and family functioning. Furthermore, longitudinal studies have demonstrated that sleep problems first presenting in infancy may become chronic, persisting into the preschool and school-aged years. A solid body of literature now exists supporting the use of empirically-based behavioral management strategies to treat bedtime problems and night wakings in infants, toddlers, and preschoolers. The following practice parameters present recommendations for the use of behavioral (i.e., non-pharmacological) treatments of bedtime problems and night wakings in young children (aged 0 - 4. years 11 months). A companion review paper on which the recommendations are based was prepared by a taskforce appointed by the Standards of Practice Committee (SPC) of the American Academy of Sleep Medicine (AASM), and summarizes the peer-reviewed scientific literature on this topic. The authors of the review paper evaluated the evidence presented by the reviewed studies according to modified Sackett criteria. Using this information and a grading system described by Eddy (i.e., standard, guideline or option), the Standards of Practice Committee and Board of Directors of the American Academy of Sleep Medicine determined levels of treatment recommendation presented in the practice parameters below. These practice parameters provide 3 types of recommendations. First, recommendations are provided indicating that behavioral interventions are effective in the treatment of bedtime problems and night wakings in young children, producing reliable and significant clinical improvement in sleep parameters. Second, recommendations are made regarding specific behavioral therapies, including: (1) unmodified extinction, extinction with parental presence, and preventive parent education are all rated as individually effective therapies in the treatment of bedtime problems and night wakings (Standards), and (2) graduated extinction, bedtime fading/positive routines and scheduled awakenings are rated as individually effective therapies in the treatment of bedtime problems and night wakings but with less certainty (Guidelines). There was insufficient evidence to recommend standardized bedtime routines and positive reinforcement as single therapies. In addition, although behavioral therapies for bedtime problems and night wakings are often combined, there was insufficient evidence available to recommend one individual therapy over another or to recommend an individual therapy over a combination of therapies. Finally, recommendations are provided regarding the beneficial effects of behavioral treatments on secondary outcomes, including daytime functioning (child) and parental well-being.