The Zurich 3-step concept for the management of behavioral sleep disorders in children: A before-and-after study

Abstract

Objectives: Several strategies have been found to be effective for the treatment of childhood behavioral sleep disorders. One which has yet to be evaluated is the Zurich 3-step concept, which combines basic notions of the two-process model of sleep regulation (introducing a regular rhythm and adjusting bedtime to sleep need) with behavioral strategies. This uncontrolled before-and-after study describes our concept and its step-wise approach, assesses changes in sleep-wake variables and behavior problems, and also examines associations between changes in sleep-wake variables and behavior problems. Methods: A total of 79 children with sleep problems (age range 6-47 months, 42% females) were included. Sleep problems were assessed by the Infant Sleep Questionnaire, sleep-wake variables by diary and actigraphy, and behavior problems of children ≥ 18 months by the Child Behavior Checklist. Results: A signifi cant decrease in nocturnal wake duration (Cohen's d = -0.34) and a signifi cant increase in the duration of the longest continuous nocturnal sleep period (Cohen's d = 0.19) were found from before to after intervention (on average 2.7 months, SD 1.5). The variability for sleep onset and end time decreased, and actigraphically measured circadian rest-activity cycle measures improved. Parent-reported internalizing and total behavior problems also decreased (Cohen's d = 0.66). Conclusions: The fi ndings of both objective and subjective assessment techniques suggest that the Zurich 3-step concept is effective. Thus, the intervention concept may be useful in clinical practice with sleep-disordered children.