title: The Zurich 3-step concept for the management of behavioral sleep disorders in children: a before-and-after study.
abstract: OBJECTIVE
  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 significant decrease in nocturnal wake duration (Cohen's d = -0.34) and a significant 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 findings 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.
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.|Department of Psychosomatics and Psychiatry, University Children's Hospital, Zurich, Switzerland.
authors.forename: Helene
authors.initials: H
authors.lastname: Werner
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Hunkeler
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Caroline
authors.initials: C
authors.lastname: Benz
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Luciano
authors.initials: L
authors.lastname: Molinari
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Caroline
authors.initials: C
authors.lastname: Guyer
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Fabienne
authors.initials: F
authors.lastname: Häfliger
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.|Children's Research Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Reto
authors.initials: R
authors.lastname: Huber
authors.affiliation: Child Development Center, University Children's Hospital, Zurich, Switzerland.|Children's Research Center, University Children's Hospital, Zurich, Switzerland.
authors.forename: Oskar G
authors.initials: OG
authors.lastname: Jenni
mesh_terms: D056044:Actigraphy; D001521:Behavior Therapy / Q000379:methods; D002653:Child Behavior Disorders / Q000628:therapy*; D002675:Child, Preschool; D002940:Circadian Rhythm; D065187:Controlled Before-After Studies; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008499:Medical Records; D012893:Sleep Wake Disorders / Q000628:therapy*; D016896:Treatment Outcome
keywords: children; insomnia; intervention; sleep problems; sleep regulation