Table 1.

Modified CBT-I for adults with intellectual disabilities

Technique	Method	General advice
Anchoring the day	Setting a fixed rising time that is maintained 7 days a week, no matter how tired the individual is or how little they have slept. This technique aims to optimise the homeostatic sleep drive.	Easier to achieve with the aid of carers and if there is something to get up for, i.e. structured daytime activity. We recommend setting an alarm so the anchor time is kept constant.
Natural light exposure	Ideally, within 2 h of rising, the individual gains access to natural light (even if it seems dull outside). A minimum of 20 min is recommended. This technique aims to optimise the circadian rhythm.	Easier to achieve if there is structured daytime activity with regular meal times (which also feeds into the circadian clock). If it is possible to walk to daytime activities (e.g. college, day centre, etc.) or schedule exercise for this time, it can become part of the individual's usual routine.
Stimulus Control	Ideally, the bed and bedroom should be kept for sleep, intimacy and getting dressed only. All other activities should be kept outside the bed/bedroom. This technique is based on classical conditioning, and aims to re-establish that the bed/bedroom is a place for sleep as opposed to a place for wakeful activities.	If the individual has access to only one room, encourage them not to sit on the bed or use it for activities other than sleep. The bedroom can be made to look different in the day as opposed to the night (e.g. using a different bed cover during the day, or placing a plant in the room during the day and taking it away at night). This will help the mind to know when the room is in day or night mode.
Buffer zone	This is a period, usually of at least 90 min before bed, where the body and mind are moved into a state of relaxation ready for sleep. We advise beginning the buffer zone with a warm bath and afterwards keeping rooms dimly lit, and letting the individual engage in relaxing (i.e. non-stimulating) activities before it is time for bed.	If the individual does not have access to a bath, then trialling a shower can also be helpful. A risk assessment must be carried out prior to recommending bathing, e.g. it may be unsuitable for some individuals with epilepsy.
Sleep rescheduling	In this technique, the total sleep time is closely matched to the total time in bed (often by keeping sleep diaries and/or actigraphy). This will increase the internal sleep drive (in conjunction with anchoring the day) and reduce hyperarousal. This technique has been used on its own and as part of multimodal CBT-I to good effect in adults with intellectual disabilities.34	This technique may require careful carer education, as often adults with intellectual disabilities have bedtimes that are too early forced upon them. It should be used with caution in adults with intellectual disabilities who have comorbidities which can be made worse by temporary sleep restriction/loss, e.g. epilepsy, migraine, bipolar affective disorder.42
Miscellaneous	Engagement in regular exercise (ideally getting out of breath if safe to do so). Structured daytime activity. Regular meal times. Discourage eating during the night if the individual cannot sleep or giving extra attention at this time point.	All of the techniques in this table require patience and persistence in order to be effective. Initially sleep may worsen, as the usual routine is being changed, which can be anxiety-provoking. Trialling one technique at a time may mitigate this potential difficulty.