Sleep Onset Problems Research Articles

Pediatric Sleep Difficulties after Moderate–Severe Traumatic Brain Injury

The objective of this study is to systematically investigate sleep following moderate-severe pediatric traumatic brain injury (TBI). School-aged children with moderate-severe TBI identified via hospital records were invited to participate, along with a school-age sibling. Subjective reports and objective actigraphy correlates of sleep were recorded: Children's Sleep Habits Questionnaire (CSHQ), Sleep Self-Report questionnaire (SSR), and 5-night actigraphy. TBI participants (n = 15) and their siblings (n = 15) participated. Significantly more sleep problems were parent-reported (CSHQ: p = 0.003; d = 1.57), self-reported (SSR: p = 0.003; d = 1.40), and actigraph-recorded in the TBI group (sleep efficiency: p = 0.003; d = 1.23; sleep latency: p = 0.018; d = 0.94). There was no evidence of circadian rhythm disorders, and daytime napping was not prevalent. Moderate-severe pediatric TBI was associated with sleep inefficiency in the form of sleep onset and maintenance problems. This preliminary study indicates that clinicians should be aware of sleep difficulties following pediatric TBI, and their potential associations with cognitive and behavioral problems in a group already at educational and psychosocial risk.

Insomnia-related complaints correlate with functional connectivity between sensory–motor regions

According to the hyperarousal theory of insomnia, difficulty in initiating or maintaining sleep occurs as a result of increased cognitive and physiological arousal caused by acute stressors and associated cognitive rumination, placing the individual in a perpetual cycle of hyperarousal and increased sensitivity to sensory stimulation. We tested the hypothesis that difficulty in initiating or maintaining sleep would be associated with increased functional connectivity between primary sensory processing and motor planning regions. Fifty-eight healthy adults (29 men, 29 women) completed a self-report inventory about sleep onset and maintenance problems and underwent a 6-min resting-state functional MRI scan. Bilateral regions of interest (ROIs) were placed in primary visual cortex, auditory cortex, olfactory cortex, and the supplementary motor cortex, and the mean processed signal time course was extracted and correlated with each of the other ROIs. Difficulty in falling asleep was associated with increased functional connectivity between the primary visual cortex and other sensory regions such as the primary auditory cortex, olfactory cortex, and the supplementary motor cortex. The primary auditory cortex also showed greater connectivity with the supplementary motor cortex in those with sleep initiation problems. Problems with sleep maintenance were associated with greater connectivity between the primary visual cortex and the olfactory cortex. Consistent with the predictions of the hyperarousal model, difficulty in falling asleep was associated with greater functional connectivity between primary sensory and supplementary motor regions. Such augmented functional connectivity may contribute to the sustained sensory processing of environmental stimuli, potentially prolonging the latency to sleep.

Contributions of circadian tendencies and behavioral problems to sleep onset problems of children with ADHD.

BackgroundChildren with attention-deficit/hyperactivity disorder (ADHD) are two to three times more likely to experience sleep problems. The purpose of this study is to determine the relative contributions of circadian preferences and behavioral problems to sleep onset problems experienced by children with ADHD and to test for a moderation effect of ADHD diagnosis on the impact of circadian preferences and externalizing problems on sleep onset problems.MethodsAfter initial screening, parents of children meeting inclusion criteria documented child bedtime over 4 nights, using a sleep log, and completed questionnaires regarding sleep, ADHD and demographics to assess bedtime routine prior to PSG. On the fifth night of the study, sleep was recorded via ambulatory assessment of sleep architecture in the child’s natural sleep environment employing portable polysomnography equipment. Seventy-five children (26 with ADHD and 49 controls) aged 7–11 years (mean age 8.61 years, SD 1.27 years) participated in the present study.ResultsIn both groups of children, externalizing problems yielded significant independent contributions to the explained variance in parental reports of bedtime resistance, whereas an evening circadian tendency contributed both to parental reports of sleep onset delay and to PSG-measured sleep-onset latency. No significant interaction effect of behavioral/circadian tendency with ADHD status was evident.ConclusionsSleep onset problems in ADHD are related to different etiologies that might require different interventional strategies and can be distinguished using the parental reports on the CSHQ.

Predictors of children's sleep onset and maintenance problems after road traffic accidents

Background: Sleep onset and maintenance problems are a frequent complaint after traumatic events in children. However, the association of traumatic experiences and disturbed sleep remains to be explained.Objective: To examine the incidence of sleep onset and maintenance problems in children after road traffic accidents and identify potential predictors of sleep onset and maintenance problems, including putative psychopathological mechanisms as well as stressors affecting the family system.Method: In 33 children treated for injuries after road traffic accidents, sleep and measures of psychopathology were assessed 10 days, 2 months, and 6 months after hospital admission. The predictive value of four clusters of predictor variables for children's sleep onset and maintenance problems was prospectively tested by multiple regression analyses. These clusters included socio-demographic, injury- and accident-related, and psychopathological variable clusters as well as factors reflecting stressors concerning mothers and family.Results: Children suffering from posttraumatic stress reported a prolonged subjective sleep latency. The severity of sleep onset and maintenance problems was predicted by female sex and the child's as well as mothers’ posttraumatic stress disorder (PTSD) severity.Conclusions: Sleep onset and maintenance problems in children after trauma appear to result from a complex interaction of multiple factors. Our findings support the transactional model of sleep-wake regulation that bears implications for the development of adequate intervention strategies.For the abstract or full text in other languages, please see Supplementary files under Reading Toolsonline

Pediatric Periodic Limb Movement Disorder: Sleep Symptom and Polysomnographic Correlates Compared to Obstructive Sleep Apnea

Although periodic limb movements in sleep (PLMS) have been described in multiple pediatric publications, periodic limb movement disorder (PLMD) has not. The aims of this study were to describe the prevalence, sleep-related correlates, and polysomnographic correlates of PLMD in a large pediatric case series, and compare these to pediatric obstructive sleep apnea (OSA). All PLMD cases (defined by International Classification of Sleep Disorders, 2nd edition criteria + respiratory disturbance index [RDI] < 3) and OSA cases (defined by RDI ≥ 3 + PLMS < 5), from a single pediatric sleep practice, over a 2-year time span, were included. Chart, questionnaire, and polysomnographic data were compiled. Of 468 referred children, 66 PLMD cases were identified (14%). The PLMD cases, mean age 8.1 years (range 1-17), were clinically characterized by frequent sleep onset and maintenance problems, difficulty awakening, restless sleep, leg pain/discomfort at night, and parasomnias. Compared to 90 OSA children, those with PLMD had a history of significantly more sleep onset and maintenance problems, leg pain/discomfort at night, parasomnias, getting out of bed at night, and family history of restless legs syndrome. Polysomnographically, PLMD cases had more awakenings, stage 1 sleep, stage shifts, and spontaneous arousals. These data indicate that pediatric PLMD has important clinical and polysomnographic correlates. In addition, PLMD has many characteristics that are different from pediatric OSA, suggesting that PLMD is a distinct pediatric sleep disorder, of which clinicians should be aware.

The prevalence of sleep problems in emergency medical technicians

To investigate the prevalence, demographic, and work associations of self-reported sleep complaints in US emergency medical technicians (EMTs) The mailed 2005 Longitudinal Emergency Medical Technician Attributes and Demographics Study (LEADS) questionnaire was distributed to selected EMTs that included 35 sleep-related questions. Questions were adapted from previously validated sleep medicine surveys, including the Epworth Sleepiness Scale (ESS), and were used to estimate the prevalence of different sleep problems. These sleep problems were analyzed in relation to demographic, health, satisfaction, and workplace characteristics. Responses of individuals who were not working as EMTs were used as a comparison group. Sleep problems in working EMTs were more prevalent than in a comparison group. Seventy percent of working EMTs had at least one sleep problem. The most common sleep problem was a risk of long sleep onset disorder (50%). EMTs with tiredness-related work difficulties were more than 50% as likely to report this problem. The prevalence of excessive daytime sleepiness (ESS > 10) was 36%; 6% of the EMTs had an ESS > 16. EMTs reporting tiredness-related work difficulties were more than twice as likely to have ESS scores >10 and more than three times as likely to ESS scores >16. Symptom-defined risk of sleep apnea was present in 5%. Risks of sleep onset and maintenance disorder problems were more prevalent among those who worked longer shifts and had longer work weeks and were associated with poorer job satisfaction and poorer health. Severe sleep problems and severe sleepiness at a level that may contribute to health and job issues are common in US EMTs. Although breathing disorders are common, behaviorally related sleep issues are more prevalent. These data support an increased focus on sleep onset and maintenance disorders.

Critical appraisal of ramelteon in the treatment of insomnia

Ramelteon is the first member of a novel class of hypnotics and acts as a selective melatonin receptor agonist. In 2005, ramelteon was approved by the US Food and Drug Administration for the treatment of insomnia characterized by sleep onset problems. Its unique mechanism of action made it a promising candidate compared with the widely used hypnotics that act on the benzodiazepine receptor complex. Several studies have examined its efficacy and safety as a hypnotic agent. The primary efficacy of ramelteon was found to lie in a decrease in latency to persistent sleep, as measured by polysomnographic tests. Other sleep-related measures, such as total sleep time and number of nightly awakenings, show less pronounced improvement when treated with ramelteon. In addition, no rebound insomnia or abuse potential was observed in clinical studies. Although additional studies are necessary, current data on the acute and next-morning effects of ramelteon did not indicate cognitive or psychomotor impairment. Overall, ramelteon is safe and well tolerated, although some questions remain regarding its long-term efficacy and safety. These issues and possibilities for use in other patient groups should be addressed in future research.

Nonrestorative Sleep: Have We Finally Found It?

Nonrestorative Sleep: Have We Finally Found It?

Neuroticism and sleep-onset: What is the long-term connection?

People with sleep-onset problems often experience neuroticism. To what extent the one problem leads to the other is unknown. We used self-reported data from a Swedish longitudinal project to examine developmental links between neuroticism and sleep-onset problems. A sample of 212 people, followed from birth to midlife, was part of a cohort study spanning 37 years. Adolescent neuroticism was measured at age 16 with the High School Personality Questionnaire (HSPQ, Form A) and in midlife at age 37 with the Eysenck Personality Questionnaire (EPQ). Sleep-onset problems were measured at ages 15 to 17, 25, and 37 with items developed for the Solna Project. Adolescent neuroticism failed to predict sleep-onset problems. Instead, sleep-onset problems in adolescence and young adulthood predicted midlife neuroticism. We found that sleep-onset problems during adolescence were a direct risk for midlife neuroticism, as well as, an indirect risk through continuance of sleep-onset problems into adulthood. This study provides longitudinal support for adolescent sleep-onset problems as a potent risk factor for heightened neuroticism in midlife.

Coherency of attention deficit/hyperactivity and sleep-related problems

In the process of the Cologne Children’s Sleep Study, we assessed whether the occurrence of symptoms indicative of sleep onset and maintenance problems, daytime sleepiness, sleep disordered breathing (SDB), and restless legs syndrome (RLS) is related to an increased risk for the presence of symptoms of hyperactivity (ADHD).

Long‐term follow‐up of melatonin treatment in children with ADHD and chronic sleep onset insomnia

We conducted this study to assess long-term melatonin treatment course, effectiveness and safety in children with attention-deficit/hyperactivity disorder (ADHD) and chronic sleep onset insomnia (CSOI). This was conducted by means of a structured questionnaire for the parents. The subjects of this study consisted of participants who previously participated in a randomised clinical trial on melatonin efficacy. The response rate was 93% (94/101). The mean time to follow up was 3.7 yr. No serious adverse events or treatment related co-morbidities were reported. Sixty-five percent of the children still used melatonin daily and 12% occasionally. Temporal discontinuation of treatment resulted in a delay of sleep onset in 92% of the children. Nine percent of the children could discontinue melatonin completely because of improvement of sleep onset insomnia. Long-term melatonin treatment was judged to be effective against sleep onset problems in 88% of the cases. Improvement of behaviour and mood was reported in 71% and 61% respectively. We conclude that melatonin remains an effective therapy on the long term for the treatment of CSOI in children with ADHD and has no safety concerns regarding serious adverse events or treatment related co-morbidity. Discontinuation of melatonin treatment usually leads to a relapse of sleep onset insomnia and in resuming melatonin treatment, even after several years of treatment.

Organizational Justice and Sleeping Problems: The Whitehall II Study

To test the hypothesis that organizational injustice contributes to sleeping problems. Poor sleep quality can be a marker of prolonged emotional stress and has been shown to have serious effects on the immune system and metabolism. Data were from the prospective Whitehall II study of white-collar British civil servants (3143 women and 6895 men, aged 35-55 years at baseline). Age, employment grade, health behaviors, and depressive symptoms were measured at Phase 1 (1985-1988) and baseline sleeping problems were assessed at Phase 2 (1989-1990). Organizational justice was assessed twice, at Phases 1 and 2. The outcome was mean of sleeping problems during Phases 5 (1997-1999) and 7 (2003-2004). In men, low organizational justice at Phase 1 and Phase 2 were associated with overall sleeping problems, sleep maintenance problems, sleep onset problems, and nonrefreshing sleep at Phases 5 and 7. In women, a significant association was observed between low organizational justice and overall sleeping problems and sleep onset problems. These associations were robust to adjustments for age, employment grade, health behaviors, job strain, depressive symptoms, and sleeping problems at baseline. This study shows that perceived unfair treatment at workplace is associated with increased risk of poor sleep quality in men and women, one potential mechanism through which justice at work may affect health.

Effects of early nightmares on the development of sleep disturbances in motor vehicle accident victims

The present study prospectively examined the extent to which trauma-related nightmares affected the subsequent development of insomnia symptoms in 314 motor vehicle accident (MVA) victims. Participants were assessed in-hospital and at 2 weeks, 6 weeks, 3 months, and 1 year post-MVA. Hierarchical linear regression analyses showed that 6-week PTSD symptoms (PTSS) and 3-month nightmares, but not 2-week nightmares were positively associated with sleep onset and maintenance problems reported at 3-month post-MVA. Nightmares reported at 3-months post-MVA were positively associated with 1-year sleep maintenance problems. These findings highlight the dynamic relationship between PTSS and sleep problems as well as the potential importance of early intervention for trauma-related nightmares as a means to prevent sleep problems after a traumatic experience.

Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: a population‐based study

This study compared parent-reported sleep characteristics in 2- to 5-year-old children with autism spectrum disorders (ASD) to children with other developmental delays (DD) and typical development (TD). We included 529 children (303 ASD [167 males], 63 DD [46 males], and 163 TD [134 males]) enrolled in the CHARGE study, an ongoing population-based case-control study. The mean age of participants was 3.6 years (standard deviation, 0.8 years). ASD diagnosis was confirmed with Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedules (ADOS). Cognitive and adaptive functioning was assessed using Mullen Scales of Early Learning (MSEL) and Vineland Adaptive Behavior Scales (VABS), respectively. Demographic, medical and sleep history information were ascertained from California birth records, telephone interview, medical assessments at clinic visit, and parent-administered questionnaires. Fifty-three percent of children with ASD had at least one frequent sleep problem, followed by 46% of children with DD, and 32% of the TD group (P < 0.0001). Exploratory factor analyses of sleep history data yielded two factors: sleep onset problems and night waking. Children with ASD had marginally higher sleep onset factor scores and significantly higher night waking factor scores compared with the TD group. Factor scores for children with DD were intermediate between the ASD and TD groups. Cognitive or adaptive development did not predict severity of sleep problems in the ASD group.

Early manifestations of restless legs syndrome in childhood and adolescence

Objective To describe the symptomatology reported by a series of children and adolescents who at initial consultation did not meet full diagnostic criteria for pediatric restless legs syndrome (RLS) but subsequently did so over the course of clinical follow-up. Methods Retrospective assessment of all patients with pediatric RLS receiving ongoing care in a pediatric sleep/neurology practice at a large multispecialty clinic ( n = 50). Eighteen children and adolescents who met inclusion and exclusion criteria were identified by chart review. All but one had undergone polysomnography. Results Detailed sleep histories were available for 10 girls and 8 boys, all of whom presented initially with clinical sleep disturbance. Mean age at the initial sleep evaluation was 10.3 years and mean age at RLS diagnosis was 14.7 years. Detailed descriptions of the sensory RLS symptoms were recorded. Retrospective age of onset for chronic clinical sleep disturbance was a mean of 3.1 years, with 10 families reporting onset in infancy. Of the 18, 16 reported chronic sleep-onset problems and eight sleep-maintenance problems at the time of initial evaluation. Ten had a history of growing pains. Thirteen were found to have a family history of RLS. Eleven of 17 had periodic leg movements in sleep (PLMS) ⩾5 per hour. Comorbidities included parasomnias (7), attention-deficit/hyperactivity disorder (ADHD) (13), oppositional defiant disorder (ODD) (4), anxiety disorders (6), and depression (5). Serum ferritin levels of <50 ng/mL were found in 16 of 18. Conclusions In this group of 18 children and adolescents, clinical sleep disturbance preceded a diagnosis of definite RLS by an average of 11.6 years. Many had a diagnosis of periodic limb movement disorder (PLMD) or met research criteria for probable or possible RLS prior to meeting criteria for definite RLS. These findings suggest that some aspects of RLS can occur long before full diagnostic criteria are present. Comorbidities were common, with parasomnias, ADHD, ODD, anxiety, and depression each found in more than 20% of these cases. The 2003 National Institutes of Health (NIH) diagnostic criteria for pediatric RLS are supported by this work.

Sleep architecture in children and adolescents with cystic fibrosis and the association with severity of lung disease

Previous studies have shown that sleep complaints are common in adult patients with cystic fibrosis (CF). However, there is very little data on sleep in children and adolescents with CF and the association with severity of lung disease. A prospective study was conducted in CF children and age-matched controls. All patients completed sleep questionnaire and underwent an overnight polysomnographic study. Thirty-eight children and adolescents met the criteria for entry into the analysis, 24 children and adolescents with CF (S) and 14 controls (C). Sleep complaints were common in children and adolescents with CF; 43.5% reported sleep onset problem, 39.1% reported sleep maintenance problem, 30.4% were noted to snore at night, and 73.9% reported daytime sleepiness. Children and adolescents with CF had a significant decrease in sleep efficiency [SE; 75.2 +/- 2.5% (S) vs 85.6 +/- 1.7%(C); P < 0.01], prolonged rapid eye movement (REM) latency [150.5 +/- 16.6 min (S) vs 85.6 +/- 11.0 min (C); P < 0.05], and reduction in percentage of REM sleep [12.7 +/- 1.5% (S) vs 18.3 +/- 1.3% (C); P < 0.05]. The degree of sleep disruption as indicated by SE was correlated with forced expiratory volume in one second (FEV(1); r = 0.52, P < 0.05). However, there was no significant correlation between SE and minimum oxygen saturation [r = 0.30, P=not significant (NS)] or SE and maximal end-tidal pCO(2) (r = 0.11, P=NS). It is concluded that children and adolescents with CF have frequent sleep complaints and significant alteration in the sleep architecture. The magnitude of sleep disruption is associated with severity of lung disease, but is not directly correlated with the degree of nocturnal hypoxemia or hypoventilation. It is speculated that sleep disruption in children and adolescents with CF may have an impact on quality of life and clinical outcomes in this population.

Sleep in Children with Asperger Syndrome

The prevalence of sleep disturbances in 52 children with Asperger syndrome (AS) as compared with 61 healthy controls (all subjects aged 5-17 years) was investigated. Problems with sleep onset and maintenance, sleep-related fears, negative attitudes toward sleeping, and daytime somnolence were more frequent among children with AS than among controls. Short sleep duration (<9 h) was almost twofold (59% vs. 32%), and the risk for sleep onset problems more than fivefold (53% vs. 10%) more common in the AS group than in the control group. Child-reported sleeping problems were also more prevalent in the AS group than in controls (58% vs. 7%). The results suggest that sleep disturbances should be routinely evaluated in children with AS.

Insomnia Subtypes and Their Relationships to Daytime Sleepiness in Patients with Obstructive Sleep Apnea

Background: Insomnia and obstructive sleep apnea syndrome (OSA) are the two most common sleep disorders. Studies showed that insomnia complaints were prevalent in OSA. Relatively little is known about the causes of insomnia in OSA and whether etiological factors differ for insomnia subtypes. We hypothesized that sleep onset problem was mainly due to hyperarousal and sleep maintenance difficulty was primarily related to sleep-disordered breathing. Objectives: To determine the prevalence of insomnia subtypes in OSA, compare subjects with sleep onset insomnia, sleep maintenance insomnia and no insomnia symptom, and study the relationship of insomnia subtypes to daytime sleepiness. Methods: We analyzed intake questionnaires and polysomnography and Multiple Sleep Latency Test results of 157 OSA patients. Results: Forty-two percent of the sample had at least one problematic insomnia symptom. The prevalence of sleep onset insomnia, sleep maintenance insomnia and insomnia with early awakening was 6, 26 and 19%, respectively. Patients with sleep onset insomnia had significantly lower apnea-hypopnea (AHI) and arousal indices. There were significant inverse relationships between sleep onset insomnia and measures of daytime sleepiness. On the contrary, subjects with repeated wakening had more severe subjective sleepiness. Results were similar in patients with AHI ≧5 or ≧15. Conclusions: Insomnia symptoms were common in OSA patients. Insomnia subtypes related differently to measures of daytime sleepiness. Our findings suggest that OSA patients with sleep onset insomnia may be in a state of hyperarousal. It is clinically relevant to examine insomnia subtypes, which may influence the treatment decision in sleep-disordered breathing.

A Longitudinal Follow-Up Study of Young Children's Sleep Patterns Using a Developmental Classification System

Sixty-eight families participated in a longitudinal study that included video observations of sleep during the 1st year of life and annual follow-up phone interviews until the children were 4 years of age. Results revealed that approximately 19% of children have a sleep problem at 2 years of age, defined either by research criteria or parental report, and that sleep problems diminished over time. Approximately 25% of children were reported to be cosleeping at each follow-up interview, but only a third of the parents reported this behavior to be problematic. A subgroup of infants (33%), who were considered stable, non-self-soothers in the 1st year, were more likely to have a sleep onset problem and be cosleeping at the 2-year follow-up assessment.

Sleep onset problems in two children with mild intellectual disability and epilepsy: Assessment and treatment in the home setting.

Abstract Sleep problems such as bedtime difficulties, frequent night waking and excessive daytime sleepiness are prevalent in children with epilepsy. In the present study, functional assessment of sleep onset problems in two young children with epilepsy was performed. Effects of bedtime fading and antipsychotic medication (pipamperon) in a 6-year-old boy, and melatonin in an 8-year-old girl were assessed on sleep latency. Treatment resulted in a marked decrease in sleep latency in both cases and effects were maintained after three months. Keywords: Sleep problems, epilepsy, developmental disabilities, bedtime fading, melatonin, anti-psychotic medication. Introduction Children with developmental disabilities are at increased risk for developing sleep problems. Several studies have shown that sleep problems are much more prevalent in children with developmental disabilities than in their nondisabled peers. An important risk factor for developing sleep problems is the presence of a seizure disorder. An association between sleep problems and epilepsy has been found in correlational (see e.g., Didden, Korzilius, Van Aperlo, Van Overloop, & De Vries, 2002; Quine, 1991) and quasi-experimental studies (see e.g., Stores, Wiggs, & Campling, 1998). Stores et al. compared sleep behaviors of 79 children with mild forms of epilepsy with healthy children from the general population matched for age and gender. They found that, compared to their controls, children with epilepsy showed significant higher rates of sleep disorder symptoms, especially those suggesting poor sleep quality and sleep-related anxieties. More recently, in a sample of 66 children with different types of epilepsy De Moor, Didden, Korzilius & Renier (in preparation) found that: (a) children with epilepsy have more sleep problems than those in a control group, (b) type of epilepsy was related to sleep problems (e.g. children with maligne epilepsy showed more sleep fragmentation than those with other types of epilepsy), and (c) sleep problems were positively related to severity of epileptic attacks. Furthermore, they found that both the severity of epilepsy and daytime problem behaviors were positively associated with sleep problems. Results of the above studies show that children with epilepsy are at increased risk for developing sleep problems. In most, if not all cases, both the presence of sleep problems and epilepsy have detrimental effects on the well-being of the child and his or her parent(s). Children may show daytime fatigue, irritability and hyperactivity and noncompliance. Furthermore, sleep problems, and especially sleep deprivation is associated with decreased cognitive functioning and learning during academic tasks. Many parents report fatigue and symptoms of depression as a result of longstanding sleep problems in their child. Given the adverse consequences of sleep problems, assessment and treatment are warranted. Undoubtedly, scientific knowledge about the treatment of sleep problems in children with developmental disabilities has increased during the past decades. Chronic sleep problems in children with developmental disabilities are usually complex, in that such problems may be caused by psychological and/or medical factors. Treatment of sleep problems includes various behavioral methods, such as stimulus control and sleep hygiene, extinction, sleep restriction, bedtime fading and chronotherapy. Medically oriented treatment include treatment of physical cause of sleep problems (e.g., reflux, pain), surgery (e.g., removal tonsils and adenoids in case they cause airway obstruction) and pharmacological approaches (e.g., melatonin, sedative medication) (for a review, see Didden & Sigafoos, 2001). It is recommended that a functional assessment of the sleep problems be conducted to identify possible relationships between disruptive sleep behaviors and parental management techniques (Didden, Curfs, Van Driel, & De Moor, 2002). …