Behavioral Insomnia Of Childhood Research Articles

The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under.

Behavioral insomnia of childhood (BIC) and obstructive sleep apnea (OSA) are highly prevalent conditions affecting 10%-20% and 1%-5% of children, respectively. Studies in adults and adolescents have suggested that comorbid insomnia and OSA may have distinct clinical characteristics. The association between the two conditions in the pediatric population has not been thoroughly investigated. This study aimed to examine the association between BIC and OSA in young children. Children, 6 months to 10 years old, referred to a sleep specialist and polysomnography at the Hadassah Medical Center between 2018 and 2021 were included in this retrospective analysis. We excluded children with chromosomal and craniofacial abnormalities, posttonsillectomy, or neurological impairment. BIC diagnosis was extracted from the electronic health records in accordance with the International Classification of Sleep Disorders, third edition criteria. OSA was diagnosed by polysomnography (apnea-hypopnea index > 2 events/h). Of 312 children (age 4.42 ± 2.42 years), 126 (40.4%) were non-OSA non-BIC, 125 (40.1%) OSA non-BIC, 34 (10.9%) BIC non-OSA, and 27 (8.7%) comorbid insomnia and OSA. OSA and non-OSA children had a similar prevalence of BIC. Children in the comorbid insomnia and OSA group were significantly younger (2.22 ± 1.21 years). Younger age at polysomnography, premature birth, and increased periodic leg movements on polysomnography were independently associated with OSA in a multivariable analysis. Lower body mass index, regardless of OSA, was associated with BIC. Current findings do not support an association between behavioral insomnia of childhood and obstructive sleep apnea in children. Healthcare providers should consider each of these sleep disorders in children presenting with sleep difficulties since each has distinct diagnostic and therapeutic options. Yelov L, Reiter J, Meira E Cruz M, Gileles-Hillel A. The association of obstructive sleep apnea and behavioral insomnia in children ages 10 and under. J Clin Sleep Med. 2024;20(2):245-251.

0809 Development and validation of a questionnaire to assess toddler sleep

Abstract Introduction Few sleep questionnaires focus on toddlers, whose sleep is unique from both infants and older children. Fewer include both medical and behavioral items, or have been externally validated against polysomnograms (PSGs). Methods Caregivers of children 12 to 36 months old were recruited through social media, flyers in common hospital spaces, general pediatrics clinics, a pediatric neurology clinic, and at the sleep lab. A questionnaire using a 5-point Likert scale was developed. Questionnaire items pertained to behavioral issues, restless legs syndrome, sleep-disordered breathing, dysautonomia, feeding, attitudes toward sleep, and comorbidities. Factor analysis was used to determine which items represent distinct dimensions of toddler sleep. A diagnosis of sleep apnea was not included in the generation of the factors. Cronbach’s alpha was calculated to evaluate internal consistency within the derived factors. Sleep apnea was defined as the presence of either obstructive or central sleep apnea diagnosed by PSG. We used receiver operating characteristic (ROC) curves to determine which factors most closely estimate sleep apnea. Concordance of factors with the presence of sleep apnea was determined by measuring the area under the ROC curve (AUC). Results Responses from 720 caregivers of toddlers were used to generate the factors. External validation was performed using the PSG data of 35 children. One distinct factor emerged which had good concordance with a diagnosis of sleep apnea (AUC≥0.70). The factor was comprised of the following items: “My child has noisy breathing during sleep”, “My child snorts and gasps during sleep”, “My child snores”, “My child's breathing is heavy during sleep”, “My child breathes through their mouth while sleeping”, “My child breathes through their mouth during the day”, “My child "belly breathes" during sleep”; Cronbach’s alpha=0.83; AUC=0.70). Factors associated with daytime behavior, behavioral insomnia of childhood, and excessive daytime sleepiness were not associated with sleep apnea. Conclusion Obstructive features are most associated with sleep apnea, whereas daytime and bedtime behavioral characteristics, and excessive daytime sleepiness are not, unlike in studies of older children. This may reflect the natural history of sleep apnea in children. Further study with a larger sample size is required to confirm this finding. Support (if any) NIH 2T32HL110952-06

Lost in translation—the influence of language on infant sleep research

ObjectivesWe consider whether language shapes cultural interpretations of sleep in the family context using ethnographic data from the Czech Republic to explore one of the methods employed by Czech parents in helping their children aged 0-3 years to fall asleep. MethodsMulti-methodological ethnographic data were collected in the Czech Republic during 2015-2018 with supplemental online data obtained in 2020. This involved focus groups with 90 participants in mother-baby centers, and interviews with 30 families, supplemented with 468 online responses. ResultsIn the Czech Republic the use of parental presence with or without physical contact to help a child to fall asleep is a widespread practice. It is well-embedded within Czech culture and referred to by a widely known term: Uspávání. Parents expressed multiple motivations for using Uspávání to help their child sleep. DiscussionWithin much of the Anglophone sleep literature the practice of actively helping a child to fall asleep is perceived as problematic. A child who cannot fall asleep alone is considered to exhibit “behavioral insomnia of childhood,” and parents are advised to prevent this “sleep problem” by promoting self-soothing techniques in infancy. We suggest that as there is no English-language equivalent for the word Uspávání the concept it encapsulates is under-valued by sleep researchers, and the practice and its consequences are insufficiently researched. ConclusionsSome important variations in parental sleep practices that are embedded in everyday family systems lack English terminology; Uspávání is one such example. This may lead to researchers overlooking or rejecting the validity of such diverse family sleep practices. There is a need for more ethnographic research of sleep in the context of different cultural environments and family systems to explore how language constrains understanding of parent-child sleep.

Promoting Independent Sleep Onset in Young Children: Examination of the Excuse Me Drill

ABSTRACT Background: There is compelling evidence to support behavioral interventions as the first-line approach for bedtime resistance in young children. Among the behavioral treatment options, extinction (“cry it out”) has the most extensive empirical support and tends to produce the most rapid gains. There are well known problems with the use of extinction, however, including side effects (extinction burst, spontaneous recovery) and poor acceptance, not to mention that extinction fails to teach children appropriate replacement behaviors (what “to do”). This study introduces a new behavioral sleep intervention, the Excuse Me Drill, designed to address some of the limitations of extinction. The EMD was formally evaluated for the first time using a multiple-baseline research design across four participants with sleep disturbance.Participants: Participants included four children who were clinically referred to outpatient pediatric psychology clinics for the treatment of behavioral insomnia of childhood, and included one 2-year-old female, two 7-year-old females, and one 7-year-old male. All participants had a history of dependent sleep onset at bedtime (i.e., parents remained in the child’s bedroom upon sleep onset).Methods: A non-concurrent multiple baseline design across participants was used to experimentally evaluate the effectiveness of the EMD. During baseline, parents collected data on independent sleep onset and disruptive bedtime behaviors, but conducted the bedtime routine as usual. Immediately following baseline, parents implemented the EMD protocol until data indicated that children were consistently initiating sleep independently. Follow-up data were collected to determine the extent to which children continued to initiate sleep independently at bedtime in absence of the EMD. Results: Outcomes were promising as the EMD successfully taught all four children to initiate sleep independently and produced notable decreases in disruptive bedtime behavior. Results were maintained at follow-up for three of four participants. In addition, parents rated the EMD to be a socially acceptable procedure for their children. Conclusions: Results of this study indicate that the EMD was effective in promoting independent sleep onset and reducing disruptive bedtime behavior that maintained over time. The EMD should be considered to be a viable alternative to traditional extinction procedures for pediatric sleep disturbance. Implications for practice, limitations, and direction for future research are discussed.

Polysomnography Findings and Sleep Disorders in Children With Alternating Hemiplegia of Childhood.

Patients with alternating hemiplegia of childhood (AHC) experience bouts of hemiplegia and other paroxysmal spells that resolve during sleep. Patients often have multiple comorbidities that could negatively affect sleep, yet sleep quality and sleep pathology in AHC are not well characterized. This study aimed to report sleep data from both polysomnography (PSG) and clinical evaluations in children with AHC. We analyzed nocturnal PSG and clinical sleep evaluation results of a cohort of 22 consecutive pediatric patients with AHC who were seen in our AHC multidisciplinary clinic and who underwent evaluations according to our comprehensive AHC clinical pathway. This pathway includes, regardless of presenting symptoms, baseline PSG and evaluation by a board-certified pediatric sleep specialist. Out of 22 patients, 20 had at least one type of sleep problem. Six had obstructive sleep apnea as documented on polysomnogram, of whom two had no prior report of sleep-disordered breathing symptoms. Patients had abnormal mean overall apnea-hypopnea index of 5.8 (range 0-38.7) events/h and an abnormal mean arousal index of 15.0 (range 4.8-46.6) events/h. Based on sleep history, 16 patients had difficulty falling asleep, staying asleep, or both; 9 had behavioral insomnia of childhood; and 2 had delayed sleep-wake phase syndrome. Sleep dysfunction is common among children with AHC. Physicians should routinely screen for sleep pathology, with a low threshold to obtain a nocturnal PSG.

Individual and socio-demographic factors related to presenting problem and diagnostic impressions at a pediatric sleep clinic

ObjectiveIndividual and socio-demographic factors have been found to be associated with sleep disturbances in children. Few studies have examined these factors among children presenting for care at pediatric sleep clinics. This study examined individual and socio-demographic factors in association with presenting problems and diagnostic impressions for new patients at an interdisciplinary pediatric sleep clinic. MethodsData were collected from electronic medical records of 207 consecutive patients (54% male, 59% White, Meanage = 7.73, SD = 5.62). ResultsOlder age, female gender, and White race were associated with higher likelihood of presenting with difficulty falling asleep; younger age, male gender, and Black race were associated with higher likelihood of presenting with obstructive sleep apnea (OSA)-related concerns. Older age was associated with diagnostic impressions of inadequate sleep hygiene, insufficient sleep, circadian rhythm disorder/delayed sleep phase disorder, periodic limb movement disorder/restless legs syndrome, and insomnia, while younger age was associated with provisional OSA and behavioral insomnia of childhood (BIC) diagnoses. Male gender was associated with provisional OSA. White race was associated with BIC. Age-based analyses were also conducted to further understand the findings within a developmental context. ConclusionsAge- and gender-related findings converged with prevalence literature on pediatric sleep disorders. Race was only associated with presenting concern and BIC, and one association for neighborhood disadvantage was found within the age-based analysis. Results suggest a potential service delivery gap, with racial/ethnic minority youth being less likely to present for sleep services, despite prevalence data on the increased likelihood of sleep disturbances among these youth.

Cognition, temperament, and cerebral blood flow velocity in toddlers and preschool children with sleep-disordered breathing or behavioral insomnia of childhood

BackgroundCognitive decrements, problematic behaviors, and increased cerebral blood flow velocities (CBFVs) have been reported in children aged 3–7 years with sleep-disordered breathing (SDB). Whether similar impairments exist in younger children or those with behavioral insomnia of childhood (BIC) remains unclear. This study aimed to compare cognition and temperament in children aged 1–5 years with SDB or BIC to healthy control children, and to investigate whether cognitive or behavioral deficits associated with sleep problems are related to changes in CBFV. MethodToddlers and preschool-aged children (12–67 months) who had been referred for the clinical evaluation of SDB (n = 20) or BIC (n = 13) and a comparative sample of non-snoring healthy sleepers (controls; n = 77) were recruited from the community. Children underwent cognitive assessment (Mullen's Scale of Early Learning) and measurement of resting bilateral CBFV in the middle cerebral artery (MCA) using Transcranial Doppler. Parents completed temperament scales (Early Childhood or Childhood Behavior Questionnaire), a sleep problem questionnaire (Pediatric Sleep Problem Survey Instrument) and performed home-based pediatric sleep monitoring (Actigraphy and Sleep Diary). ResultsSDB children demonstrated impaired receptive skills, more hyperactive and energetic temperaments, and higher bilateral CBFV than controls and children with BIC. Logistic regression analyses indicated that impaired cognition, temperamental difficulties, and increased CBFV are independently associated with SDB. ConclusionsDuring early childhood, problematic temperaments, cognitive deficits, and altered cerebrovascular functioning are associated with SDB but not BIC. CBFV does not appear to mediate these daytime deficits and instead may be an independent outcome of SDB. The findings support the need for an early intervention in pediatric SDB.

Core Competencies for Health Professionals' Training in Pediatric Behavioral Sleep Care: A Delphi Study

The need to train non-sleep-specialist health professionals in evidence-based pediatric behavioral sleep care is well established. The objective of the present study was to develop a list of core competencies for training health professionals in assisting families of 1- to 10-year old children with behavioral insomnia of childhood. A modified Delphi methodology was employed, involving iterative rounds of surveys that were administered to 46 experts to obtain consensus on a core competency list. The final list captured areas relevant to the identification and treatment of pediatric behavioral sleep problems. This work has the potential to contribute to the development of training materials to prepare non-sleep-specialist health professionals to identify and treat pediatric behavioral sleep problems, ideally within stepped-care frameworks.

Toward a clinical and therapeutic classification of insomnia of childhood

Toward a clinical and therapeutic classification of insomnia of childhood

Behavioral Sleep Problems in Children and Adolescents

Sleep problems in children and adolescents are common, and they impact multiple domains of child and family functioning. Psychologists have a critical role in the assessment and treatment of sleep problems and are integral to interdisciplinary sleep teams. Certain sleep problems may be related to co-morbid psychological or developmental conditions, and others are considered to be primarily medical, yet behavioral approaches may be applicable. There are also sleep problems considered to be behavioral in etiology (e.g. inadequate sleep hygiene, behavioral insomnia of childhood, nightmares/bad dreams/nighttime fears, delayed sleep phase syndrome, and psychophysiological insomnia). In this article, the assessment of behavioral sleep problems, as well as specific behavioral sleep disorders, and their treatments will be discussed.

Mini-KiSS Online: an Internet-based intervention program for parents of young children with sleep problems – influence on parental behavior and children's sleep

PurposeBehavioral sleep problems are highly common in early childhood. These sleep problems have a high tendency to persist, and they may have deleterious effects on early brain development, attention, and mood regulation. Furthermore, secondary effects on parents and their relationship are documented. Negative parental cognition and behavior have been found to be important influencing factors of a child’s behavioral sleep problems. Therefore, in the current study we examined the acceptance and efficacy of a newly developed Internet-based intervention program called Mini-KiSS Online for sleep disturbances for children aged 6 months to 4 years and their parents.Patients and methodsFifty-five children (54.54% female; aged 8–57 months) suffering from psychophysiological insomnia or behavioral insomnia participated in the 6-week online treatment. Sleep problems and treatment acceptance were examined with a sleep diary, anamnestic questionnaires, a child behavior checklist (the Child Behavior Checklist 1.5–5), and treatment evaluation questionnaires.ResultsThe evaluation questionnaires showed a high acceptance of Mini-KiSS Online. Parents would recommend the treatment to other families, were glad to participate, and reported that they were able to deal with sleep-related problems of their child after Mini-KiSS Online. Parental behavior strategies changed with a reduction of dysfunctional strategies, such as staying or soothing the child until they fell asleep, allowing the child to get up again and play or watch TV, or reading them another bedtime story. Frequency and duration of night waking decreased as well as the need for external help to start or maintain sleep. All parameters changed significantly, not only in the questionnaires but also in the sleep diary.ConclusionMini-KiSS Online is shown to be a highly accepted and effective treatment to change parental behavior and reduce behavioral sleep problems in early childhood.

Bedtime problems and night wakings: treatment of behavioral insomnia of childhood

Bedtime problems and frequent night wakings are common sleep problems in infants and toddlers, affecting 20 to 30% of young children. Such problems, categorized as behavioral insomnia of childhood (BIC), lead to insufficient sleep, which contributes to multiple domains of child dysfunction. Behavioral treatments of BIC, such as extinction and positive routines are introduced, and supporting evidence is reviewed. Critical factors in developing a successful treatment plan include conducting a detailed assessment, collaboratively developing a plan that starts where the family is, and providing support between sessions. A case of a 3-year-old girl with BIC illustrates how treatment helped her to develop healthy sleep habits and taught her to sleep independently via graduated and standard extinction.

The Need for Interdisciplinary Pediatric Sleep Clinics

The purpose of this study was to describe the function and structure of an interdisciplinary outpatient pediatric sleep clinic. In addition, the frequency of individual and comorbid sleep diagnoses, the prevalence of comorbid medical or psychiatric disorders, and the types of treatment recommendations and referrals provided to patients at the end of their clinic visits was examined. Over a 4-month period, 265 consecutive patients were evaluated in the sleep clinic by trainees, nurses, and attendings in pulmonary medicine, neurology, and psychology. Obstructive sleep apnea was the most common diagnosis, followed by behavioral insomnia of childhood. Over half of the patients had a comorbid medical diagnosis, and 31% had a comorbid psychiatric diagnosis. Polysomnography was the most common recommendation, with 38% of patients receiving at least one behavioral recommendation. The results of this descriptive study support the need for an interdisciplinary approach to pediatric sleep medicine, providing broad training to trainees of all disciplines while improving the clinical care for children with sleep problems.

Behavioral parent-training approaches for the treatment of bedtime noncompliance in young children.

Abstract Bedtime is one of the most common and treatable types of child sleep problems. Children who are noncompliant at are more likely to exhibit daytime somnolescence, which may in turn lead children to exhibit daytime misbehavior, impaired social functioning and poorer school achievement. In addition, these problems can have a number of negative consequences for members of the child's family, including parental sleep deprivation and depression. Behavioral parent-training approaches are considered the treatments of choice for in young children. In this paper, we describe the evidence supporting a number of such approaches. We highlight several gaps in the treatment literature and we make recommendations for future research. Keywords: Bedtime Noncompliance, Parent Training, Sleep Problems ********** Bedtime in preschool and elementary-school school aged children is typically characterized by stalling, whining, or tantruming when approaches. Almost all children will exhibit these behaviors at some point in their young lives. Most parents have the skills to handle milder forms of noncompliance. However, when the intensity, duration, or frequency of these behaviors leads to disruptions in a family's functioning, mental health professionals can offer substantial help. These behaviors are best classified diagnostically as Behavioral Insomnia of Childhood, Limit-setting Type (2005 revision of the International Classification of Sleep Disorders; American Academy of Sleep Medicine). In this paper we will use the less awkward term bedtime noncompliance to describe this set of behaviors. Although some of the studies we will mention include infants, we will focus primarily on preschool and school aged children. For an excellent review of the entire class of sleep problems in children, including parasomnias, fears, and nightmare disorders see Sadeh (2005). There is evidence that is one of the most common childhood behavior problems. While many surveys of sleep problems in children lump sleep problems together, a few studies have examined prevalence rates of noncompliance. Estimates vary widely, but most studies suggest that 5-10% of school-aged children display significant (e.g. Blader, Koplewics, Abikoff, & Foley, 1997, Mindell, 1993). Sleep problems as a class account for almost 10% of presenting concerns in child and adolescent outpatient mental health centers (Meisbov, Schroeder, & Wesson, 1993). There is no doubt that many other families experience these problems and do not seek professional help. Research on Effects of Sleep Problems There is an increasing amount of clinical observation and research demonstrating that sleep problems, including noncompliance, can lead to insufficient sleep in children, which can, if chronic, lead to emotional, physical, behavioral, and cognitive problems (Dahl, 1996; Gais, Philal, Wagner, & Born, 2000; Kuhn, Mayfield & Kuhn, 1999; Lavigne, et al., 1999; Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006; Owens, 2004; Sadeh, Gruber, & Raviv, 2002). While not all children who are noncompliant with are sleep deprived, having nightly battles with parents (which often include delaying and moving from one bed to another in the middle of the night) leads many children to experience compromised sleep quality and reduced total sleep time. Mood problems associated with daytime sleepiness in children include exacerbation of negative mood, compromised mood regulation, and a decrease in positive affect (Dahl, 1996; Kuhn, Mayfield & Kuhn, 1999; Owens, 2004). Chronic sleep problems may also have deleterious effects on the cardiovascular, immune, and metabolic systems (Mindell et al., 2006; Owens, 2004). Behavioral correlates of decreased night sleep include hyperactivity, aggressiveness, oppositionality or noncompliant behavior, and poor impulse control (Lavigne, et al. …