Effects of mindfulness-based stress reduction and an organizational health intervention on Dutch teachers' mental health.

This study aimed to test the effectiveness of mindfulness-based stress reduction (MBSR) combined with an organizational health intervention. A cluster randomized controlled trial was conducted in five Dutch secondary vocational schools. Teachers were assigned to Intervention Group 1 (IG1; MBSR) or 2 (IG2; MBSR and an organizational health intervention), or to the Waiting List Group. The primary outcome variable was mindfulness. Secondary outcomes included other mental health outcomes, work performance, personal competencies, and work-related perceptions. Data was collected before (T0), immediately after (T1), and three (T2) and nine months (T3) after the MBSR training and analyzed applying repeated measures between-subjects designs. As the additional intervention showed no effects, IG1 and IG2 were merged (IG). MBSR had positive short-term effects on the total mindfulness score, its dimensions 'observing' and 'non-reactivity', and the work engagement dimension 'dedication'. Long-term effects were found for the total mindfulness score, its dimensions 'observing', 'non-reactivity', and 'non-judging', sleep quality complaints, negative emotions, and negative work-home interaction. IG displayed a larger short- and long-term decrease in organizational commitment. No significant differences were found for work performance, personal competencies, and work-related perceptions. Although teachers did not perceive a decrease in job demands after the training, they felt more mindful and lowered their organizational commitment. Their mental health improved and their dedication during work increased. These findings may suggest that enhanced mindfulness enabled them to mentally disengage from work during their leisure time, which allowed them to experience fewer symptoms of psychological strain. The trail is registered with the Dutch Trial Register (www.trialregister.nl): NL5581 (July 2016).

Correction: Protocol of the Healthy Brain Study: An accessible resource for understanding the human brain and how it dynamically and individually operates in its bio-social context.

[This corrects the article DOI: 10.1371/journal.pone.0260952.].

Protocol of the Healthy Brain Study: An accessible resource for understanding the human brain and how it dynamically and individually operates in its bio-social context.

The endeavor to understand the human brain has seen more progress in the last few decades than in the previous two millennia. Still, our understanding of how the human brain relates to behavior in the real world and how this link is modulated by biological, social, and environmental factors is limited. To address this, we designed the Healthy Brain Study (HBS), an interdisciplinary, longitudinal, cohort study based on multidimensional, dynamic assessments in both the laboratory and the real world. Here, we describe the rationale and design of the currently ongoing HBS. The HBS is examining a population-based sample of 1,000 healthy participants (age 30-39) who are thoroughly studied across an entire year. Data are collected through cognitive, affective, behavioral, and physiological testing, neuroimaging, bio-sampling, questionnaires, ecological momentary assessment, and real-world assessments using wearable devices. These data will become an accessible resource for the scientific community enabling the next step in understanding the human brain and how it dynamically and individually operates in its bio-social context. An access procedure to the collected data and bio-samples is in place and published on https://www.healthybrainstudy.nl/en/data-and-methods/access. Trail registration: https://www.trialregister.nl/trial/7955.

Using Systems Dynamics for Capturing the Multicausality of Factors Affecting Health System Capacity in Latin America while Responding to the COVID-19 Pandemic.

Similar interventions to stop the spread of COVID-19 led to different outcomes in Latin American countries. This study aimed to capture the multicausality of factors affecting HS-capacity that could help plan a more effective response, considering health as well as social aspects. A facilitated GMB was constructed by experts and validated with a survey from a wider population. Statistical analyses estimated the impact of the main factors to the HS-capacity and revealed the differences in its mechanisms. The results show a similar four-factor structure in all countries that includes public administration, preparedness, information, and collective self-efficacy. The factors are correlated and have mediating effects with HS-capacity; this is the base for differences among countries. HS-capacity has a strong relation with public administration in Bolivia, while in Nicaragua and Uruguay it is related through preparedness. Nicaragua lacks information as a mediation effect with HS-capacity whereas Bolivia and Uruguay have, respectively, small and large mediation effects with it. These outcomes increase the understanding of the pandemic based on country-specific context and can aid policymaking in low-and middle-income countries by including these factors in future pandemic response models.

The ADaptive Ability Performance Test (ADAPT): A new instrument for measuring adaptive skills in people with intellectual disabilities and borderline intellectual functioning.

BACKGROUND: Since the DSM-5, adaptive functioning has taken a prominent place in the classification of intellectual disability (ID). The ADAPT was developed to assess adaptive skills in individuals with ID. METHOD: A total of 2,081 ADAPTs from clients with suspected ID or borderline intellectual functioning and 129 ADAPTs from people from the general population (non-ID) were collected, along with background characteristics. RESULTS: Internal consistency of the ADAPT was high (α = 0.98). ADAPT scores were positively associated with IQ, educational level and level of independent living. Furthermore, individuals without ID scored significantly higher than the clients on all of the 65 ADAPT items. Reference values were established for different IQ groups and living situations. CONCLUSION: Results suggest that the ADAPT is a valid instrument for measuring adaptive skills in individuals with ID. The reference values may be used for the purpose of estimating the level of ID and the needed intensity of support.

Effects of Mindfulness-Based Stress Reduction Training on Healthcare Professionals' Mental Health: Results from a Pilot Study Testing Its Predictive Validity in a Specialized Hospital Setting.

This pilot study aimed to evaluate the feasibility and acceptability of a Mindfulness-Based Stress Reduction (MBSR) training and to examine positive and negative symptom-focused mental health variables. The mental health variables were used to test the predictive validity of the training among healthcare professionals. Thirty healthcare professionals participated in this non-randomized pre-post intervention pilot study. The questionnaire on mental health was filled in twice. Baseline and post-intervention differences were tested with paired samples t-tests and Wilcoxon signed-rank tests. The participants' evaluation of the training was assessed with a five-item questionnaire. The recruitment and retention were successful, and participants' evaluation of the training itself was positive but the influence on daily life was rated only moderately positive. In comparison with baseline at post-intervention participants showed significant improvements in general mindfulness, the burnout dimension personal accomplishment, quality of sleep, positive emotions, and self-efficacy. A significant decrease was found in the burnout dimension emotional exhaustion, stress level, negative emotions at work, and worrying. No significant changes were found for the burnout dimension mental distance, and work engagement. The measures showed ample within-person differences and low, medium, or high effect sizes. The current trial approach of the MBSR training seems feasible and acceptable. Our results suggest that mindfulness, burnout, stress level, quality of sleep, positive emotions at work, negative emotions at work, self-efficacy, and worrying are meaningful mental health variables for inclusion in a larger-scale Randomized Controlled Trial on the effects of MBSR.

A study protocol for a cluster randomised controlled trial on mindfulness-based stress reduction: studying effects of mindfulness-based stress reduction and an additional organisational health intervention on mental health and work-related perceptions of teachers in Dutch secondary vocational schools.

BACKGROUND: Dutch teachers in secondary vocational schools suffer from stress and burnout complaints that can cause considerable problems at work. This paper presents a study design that can be used to evaluate the short-term and long-term effectiveness of mindfulness-based stress reduction (MBSR), a person-focused intervention, both within and outside of the context of an additional organisational health intervention. METHODS: The proposed study comprises a cluster randomised controlled trial that will be conducted in at least three secondary vocational schools, to which teachers will be recruited from three types of courses: Care, Technology, and Economy. The allocation of the intervention programme to the participating schools will be randomised. The teachers from each school will be assigned to intervention group 1 (IG 1), intervention group 2 (IG 2), or the waiting list group (WG). IG 1 will receive MBSR training and IG 2 will receive MBSR training combined with an additional organisational health intervention. WG, that is the control group, will receive MBSR training one year later. The primary outcome variable of the proposed study is mindfulness, which will be measured using the Dutch version of the Five Facet Mindfulness Questionnaire (FFMQ-NL). In the conceptual model, the effects of teachers' mindfulness resulting from the intervention programmes (MBSR training and MBSR training combined with an additional organisational health intervention) will be related to salient (secondary outcome) variables: mental health outcomes (e.g., burnout, work engagement), work performance, work-related perceptions (job demands and job resources), and personal competencies (e.g., occupational self-efficacy). Data will be collected before (T0) and immediately after the MBSR training (T1), and 3 (T2) and 9 months (T3) after the training. The power analysis revealed a required sample size of 66 teachers (22 in each group). DISCUSSION: The proposed study aims to provide insight into (1) the short-term and long-term effects of MBSR on teachers' mental health, (2) the possible enhancing effects of the additional organisational health intervention, and (3) the teachers' experiences with the interventions (working mechanisms, steps in the mindfulness change process). Strengths of this study design are the use of both positive and negative outcomes, the wide range of outcomes, both outcome and process measures, longitudinal data, mixed methods, and an integral approach. Although the proposed study protocol may not address all weaknesses of current studies (e.g., self-selection bias, self-reporting of data, the Hawthorne effect), it is innovative in many ways and can be expected to make important contributions to both the scientific and practical debate on how to beat work-related stress and occupational burnout, and on how to enhance work engagement and work performance. TRIAL REGISTRATION: Dutch Trial Register (www.trialregister.nl): NL5581. Registered on 6 July 2016.

Pivotal response treatment: A study into the relationship between therapist characteristics and fidelity of implementation.

LAY ABSTRACT: Pivotal response treatment is a naturalistic behavioral intervention that teaches pivotal skills to children with autism spectrum disorder to produce widespread gains in other skills. Although most children with autism spectrum disorder benefit from pivotal response treatment, intervention outcomes vary considerably among children. Fidelity of intervention implementation (i.e. the extent to which an intervention is implemented as intended) may affect intervention outcomes. In this study, we studied the relationship between fidelity of pivotal response treatment implementation and therapist characteristics, such as therapist personality, therapist-child relationship, therapist attitude toward evidence-based practices, and therapist experience. We also explored whether a child's age and autism symptom severity were related to pivotal response treatment fidelity. Participants were 41 pivotal response treatment therapists who videotaped three pivotal response treatment sessions and completed four questionnaires to measure therapist characteristics. This study found that therapists' openness to innovation and their experience with pivotal response treatment predicted fidelity of implementation. Therapist personality, therapist-child relationship, and child characteristics were not related to pivotal response treatment fidelity. The results of this study emphasize that it is important (1) to target therapists' attitudes toward innovation prior to or during training in pivotal response treatment and (2) to provide therapists with ongoing supervision and feedback after training to increase fidelity of implementation and thus to improve intervention outcomes for children with autism spectrum disorder.

Understanding the Contribution of HRM Bundles for Employee Outcomes Across the Life-Span.

Using the Job Demands-Resources model literature and the life-span theory as scholarly frameworks, we examined the effects of job demands and job resources as mediators in the relationship between bundles of used HRM practices and employee outcomes. In addition, we tested for age differences in our research model. Findings confirmed the hypothesized original 2-factor structure representing maintenance and development HRM practices. Structural Equation Modeling analyses showed that the maintenance HRM bundle related directly and negatively to employee outcomes, without moderating effects of age. However, job resources appeared to mediate this relationship in a positive way as it also did for the development HRM bundle. Whereas this study showed the 'driving power' of the actual use of HRM bundles through job resources, regardless of the employee's age, this study also suggests a 'dark side' of HRM. In particular, we found that development HRM bundles may also increase job demands, which, in turn, may result in lower levels of beneficial employee outcomes. These empirical outcomes demonstrate the strength of the driving power eliciting from job resources preceded by any HRM bundle. Moreover, this effect appears to apply to employees of all ages. Our moderated-mediation model appeared robust for several control variables. Overall, this study provides an extension of the well-known Job Demands-Resources model by including maintenance and development bundles of HRM practices used by employees that have a differential effect on job demands and job resources which in turn have an impact on employee outcomes.

Bridge Over an Aging Population: Examining Longitudinal Relations Among Human Resource Management, Social Support, and Employee Outcomes Among Bridge Workers.

This two-wave complete panel study aims to examine human resource management (HRM) bundles of practices in relation to social support [i.e., leader-member exchange (LMX), coworker exchange (CWX)] and employee outcomes (i.e., work engagement, employability, and health), within a context of workers aged 65+. Based upon the social exchange theory and the Job Demands-Resources (JD-R) framework, it was hypothesized that HRM bundles at Time 1 would increase bridge workers' outcomes at Time 2, and that this relationship would be mediated by perceptions of LMX and CWX at Time 2. Using a longitudinal design, hypotheses were tested in a unique sample of Dutch bridge employees (N = 228). Results of several structural equation modeling analyses revealed no significant associations between HRM bundles, and social support, moreover, no significant associations were found in relation to employee outcomes. However, the results of the best-fitting final model revealed the importance of the impact of social support on employee (65+) outcomes over time.

Cognitive deficits in problematic drinkers with and without mild to borderline intellectual disability.

We examined cognitive deficits in problematic drinkers with and without mild to borderline intellectual disability (MBID). Problematic drinkers were expected to show a significantly lower estimated performance IQ (PIQ), but not a lower estimated verbal IQ (VIQ), compared to light drinkers. Participants ( N = 474) were divided into four groups based on IQ and severity of alcohol use-related problems. IQ was estimated using (a short form of) the Wechsler Adult Intelligence Scale third edition. Severity of alcohol use-related problems was assessed using the Alcohol Use Disorder Identification Test. Overall, there were no significant differences between light and problematic drinkers on estimated VIQ. Within the group without MBID, estimated PIQ was significantly lower. Estimated PIQ was not lower in problematic drinkers with MBID compared to light drinkers with MBID. The results are indicative of cognitive deficits in problematic drinkers without MBID. Screening for cognitive deficits with additional instruments is advised.

Eye movement desensitisation and reprocessing therapy for posttraumatic stress disorder in a child and an adolescent with mild to borderline intellectual disability: A multiple baseline across subjects study.

BACKGROUND: This study explored the effectiveness of eye movement desensitisation and reprocessing (EMDR) therapy for post-traumatic stress disorder (PTSD) in persons with mild to borderline intellectual disability (MBID) using a multiple baseline across subjects design. METHODS: One child and one adolescent with MBID, who met diagnostic criteria for PTSD according to a PTSD clinical interview (i.e., ADIS-C PTSD section), adapted and validated for this target group, were offered four sessions of EMDR. PTSD symptoms were measured before, during and after EMDR, and at six weeks follow-up. RESULTS: For both participants, number of PTSD symptoms decreased in response to treatment and both no longer met PTSD criteria at post-treatment. This result was maintained at 6-week follow-up. CONCLUSIONS: The results of this study add further support to the notion that EMDR can be an effective treatment for PTSD in children and adolescents with MBID. Replication of this study in larger samples and using a randomized controlled design is warranted.

Substance use in individuals with mild to borderline intellectual disability: A comparison between self-report, collateral-report and biomarker analysis.

BACKGROUND AND AIMS: Individuals with mild or borderline intellectual disability (MBID) are at risk of substance use (SU). At present, it is unclear which strategy is the best for assessing SU in individuals with MBID. This study compares three strategies, namely self-report, collateral-report, and biomarker analysis. METHODS AND PROCEDURES: In a sample of 112 participants with MBID from six Dutch facilities providing care to individuals with intellectual disabilities, willingness to participate, SU rates, and agreement between the three strategies were explored. The Substance use and misuse in Intellectual Disability - Questionnaire (SumID-Q; self-report) assesses lifetime use, use in the previous month, and recent use of tobacco, alcohol, cannabis, and stimulants. The Substance use and misuse in Intellectual Disability - Collateral-report questionnaire (SumID-CR; collateral-report) assesses staff members' report of participants' SU over the same reference periods as the SumID-Q. Biomarkers for SU, such as cotinine (metabolite of nicotine), ethanol, tetrahydrocannabinol (THC), and its metabolite THCCOOH, benzoylecgonine (metabolite of cocaine), and amphetamines were assessed in urine, hair, and sweat patches. RESULTS: Willingness to provide biomarker samples was significantly lower compared to willingness to complete the SumID-Q (p<0.001). Most participants reported smoking, drinking alcohol, and using cannabis at least once in their lives, and about a fifth had ever used stimulants. Collateralreported lifetime use was significantly lower. However, self-reported past month and recent SU rates did not differ significantly from the rates from collateral-reports or biomarkers, with the exception of lower alcohol use rates found in biomarker analysis. The agreement between self-report and biomarker analysis was substantial (kappas 0.60-0.89), except for alcohol use (kappa 0.06). Disagreement between SumID-Q and biomarkers concerned mainly over-reporting of the SumID-Q. The agreement between SumID-CR and biomarker analysis was moderate to substantial (kappas 0.48 - 0.88), again with the exception of alcohol (kappa 0.02). CONCLUSIONS AND IMPLICATIONS: In this study, the three strategies that were used to assess SU in individuals with MBID differed significantly in participation rates, but not in SU rates. Several explanations for the better-than-expected performance of self- and collateral-reports are presented. We conclude that for individuals with MBID, self-report combined with collateralreport can be used to assess current SU, and this combination may contribute to collaborative, early intervention efforts to reduce SU and its related harms in this vulnerable group.

The Role of Executive Control and Readiness to Change in Problematic Drinkers with Mild to Borderline Intellectual Disability.

BACKGROUND: Problematic alcohol use is associated with neuropsychological consequences, including cognitive biases. The goal of the study was to explore the moderating role of executive control and readiness to change on the relationship between alcohol use and cognitive biases in light and problematic drinkers with and without mild to borderline intellectual disability (MBID). METHOD: Participants (N = 112) performed the visual dot probe task to measure the strength of the cognitive biases. Executive control was measured using two computerised tasks for working memory capacity (Corsi block-tapping task) and inhibitory control (Go/No-go task). Readiness to change was measured using the Readiness to Change Questionnaire. RESULTS: No cognitive biases or executive dysfunctions were found in problematic drinkers. Working memory capacity and inhibitory control were impaired among individuals with MBID, irrespective of severity of alcohol use-related problems. Executive control and readiness to change did not moderate the relationship between alcohol use and cognitive biases. CONCLUSION: The results fail to support the dual-process models of addiction, but results need to be treated with caution given the problematic psychometric qualities of the visual dot probe task. Implementing a neurocognitive assessment and protocols in the treatment of substance use disorders seems premature.

Assessing posttraumatic stress disorder in children with mild to borderline intellectual disabilities.

BACKGROUND: Evidence suggests that children with mild to borderline intellectual disabilities (MBID; IQ 50-85) have an elevated risk for both being exposed to potentially traumatic events and developing a posttraumatic stress disorder (PTSD). In this target group, PTSD often remains undiscovered due to a lack of diagnostic instruments. Valid instruments for the assessment of PTSD in children with MBID are therefore needed. OBJECTIVE: The aim of the current study was to validate the adapted PTSD section of the Anxiety Disorders Interview Schedule for Children (ADIS-C) for the assessment of PTSD in children with MBID according to DSM-IV-TR and DSM-5 criteria. METHOD: Eighty children (aged 6-18 years) with MBID who were referred to an outpatient psychiatric service and their primary caregivers were interviewed using the adapted ADIS-C. RESULTS: The adapted ADIS-C PTSD section has excellent interrater reliability and good convergent validity. PTSD symptoms described spontaneously by children with MBID and their caregivers closely matched those included in the DSM-IV-TR and DSM-5. Many of the children who met Criterion A did not meet PTSD symptom criteria. Conversely, children meeting the full PTSD criteria were more likely than other children with MBID to have been exposed to at least one traumatic event meeting Criterion A and to a higher total number of potentially traumatic events. CONCLUSIONS: The results support the reliability and validity of the adapted ADIS-C PTSD section for assessing PTSD in children with MBID. The use of this clinical interview helps to improve detection of PTSD and subsequent access to trauma-focused interventions for this at risk target group.

Psychometric properties of a Dutch version of the behavior problems inventory-01 (BPI-01).

There are only a limited number of Dutch validated measurement instruments for measuring behavioral problems in people with a moderate to profound intellectual disability. In this study, the psychometric properties of a Dutch version of the behavior Problems Inventory-01 (BPI-01; Rojahn et al., 2001) have been investigated among 195 people with a moderate to profound intellectual disability who live in a residential facility. The BPI-01 was completed by 42 informants (staff members) of 23 care units. The inter-rater reliability, intra-rater reliability and internal consistency turned out to be good. Factor analysis confirmed two of the three a priori factors and the third factor was a mix of self-injurious (SIB) behavior and stereotypic behavior. The BPI-01 was compared to the Aberrant Behavior Checklist (Aman et al., 1985a) and showed a good convergent validity. This study shows that a Dutch version of the BPI-01 has good psychometric properties for measuring behavior problems in individuals with moderate to profound intellectual disability.

Incontinence in individuals with Angelman syndrome: a comparative study.

Frequency and type of incontinence and variables associated with incontinence were assessed in individuals with Angelman syndrome (AS; n=71) and in a matched control group (n=69) consisting of individuals with non-specific intellectual disability (ID). A Dutch version of the "Parental Questionnaire: Enuresis/Urinary Incontinence" (Beetz, von Gontard, & Lettgen, 1994) was administered and information on primary caretakers' perspectives regarding each individual's incontinence was gathered. Results show that diurnal incontinence and fecal incontinence during the day more frequently occurred in the control group than in the AS group. In both groups, nocturnal enuresis was the most common form of incontinence. More incontinence was seen in individuals with AS who were younger, had a lower level of adaptive functioning and/or had epilepsy. Individuals with AS were able to stay dry for longer periods of time than the controls and often showed both in-toilet urination and urinary accidents during the day, whereas accidents and correct voids during the day were more set apart in the control group. Also, persons with AS had a lower micturition frequency implying possible voiding postponement. Both groups showed high rates of LUTS (lower urinary tract symptoms) possibly indicative of functional bladder disorders such as voiding postponement, dysfunctional voiding, or even an underactive bladder. In general, most primary caretakers reported severe intellectual disability as the main cause for urinary incontinence. Based on these results incontinence does not appear to be part of the behavioral phenotype of Angelman syndrome. Therefore, pediatric or urologic diagnostics and treatment are recommended for all persons with incontinence and intellectual disability. Further implications for practice and research are given.

Therapist characteristics predict discrete trial teaching procedural fidelity.

Early intensive behavioral intervention is generally effective for children with autism spectrum disorder but is associated with variability in treatment outcome and quality of treatment delivery may contribute to this. This study examined the relationship between therapist personality, attitude toward individuals with a disability, and perceived relationship between therapist and child on procedural fidelity. Discrete Trial Teaching (DTT) was provided at a preschool for children with intellectual disabilities. Seventy DTT sessions between 22 therapists and 35 children were videotaped and analyzed. Data on therapist's attitude toward individuals with a disability, therapist's personality traits, and perceived relationship between therapist and child were also collected. Procedural fidelity was high and significantly related to therapist's attitude toward individuals with a disability, therapist's openness to experience, and perceived relationship between therapist and child. Therapists with high procedural fidelity tended to have a more positive attitude toward individuals with disabilities on the cognitive dimension, a more negative attitude toward individuals with disabilities on the affect dimension, lower levels of openness to experience, and perceived the relationship between themselves and the child as less positive.

Executive control in long-term abstinent alcoholics with mild to borderline intellectual disability: the relationship with IQ and severity of alcohol use-related problems.

Deficits in executive control might be related to alcohol abuse in individuals with mild to borderline intellectual disability (MBID). The goal of the present study was to test the relationship between executive control (i.e., working memory capacity, inhibitory control and delay discounting), IQ and chronic alcohol use. Participants (N=40) were divided into four groups based on IQ and severity of alcohol use-related problems (heavy and light drinkers with and without MBID). They were all admitted to a psychiatric treatment facility and long-term abstinent at the time of testing. Contrary to the expectations, executive control was not consistently impaired among individuals with MBID. Results showed that working memory capacity did seem to be impaired, whereas inhibitory control and delay discounting did not. Moreover, there were no differences between heavy and light drinkers on any of the parameters and having a dual diagnosis (heavy drinkers with MBID) did not result in additive negative effects on executive control. It is suggested that alcohol-related cognitive impairment is temporary and decreases over time after cessation of drinking.

Exploration of differences in types of sleep disturbance and severity of sleep problems between individuals with Cri du Chat syndrome, Down's syndrome, and Jacobsen syndrome: a case control study.

The prevalence of sleep problems in individuals with intellectual disability (ID) seems to vary between genetic syndromes associated with ID. Different types of sleep disturbances may indicate underlying causes of sleep problems and these types of sleep disturbances may vary between different genetic syndromes. We examined and compared five types of sleep disturbance as well as severity of sleep problems in individuals with Cri du Chat syndrome (CDC), Down's syndrome (DS), Jacobsen syndrome (JS), and individuals with non-specific ID (NS). We used Simonds and Parraga's Sleep Questionnaire (1982) to assess prevalence of types of sleep disturbance and to explore differences in types of sleep disturbance and severity of sleep problems between the four diagnostic groups. In each group, mean scores for Snoring were significantly higher than those for Sleep apnea and Snoring was the most prevalent type of sleep disturbance in CDC, DS, and JS. The mean score on Complaints related to sleep was remarkably high in the JS group. There were no differences in severity of sleep problems between groups. These findings suggest that snoring is an important underlying cause of sleep problems in individuals with CDS, DS, and JS.