Behavioral sleep medicine

Insomnia, which is the most common sleep disorder in the population as well as the most common disorder treated by BSM practitioners, is typically evaluated with a clinical interview and two weeks of sleep diaries.[13] The clinical interview examines topics such as sleep patterns, sleep history, psychiatric history, medications, substance use, and relevant medical, developmental, social, occupational, cultural, and environmental factors.[19][20] For young children, the clinical interview and sleep diaries would be completed primarily by a parent.[8]

Standardized questionnaires may be used to evaluate the severity of the sleep problem or assess for other possible sleep problems. Example questionnaires commonly used with adults include: Insomnia Severity Index,[21] Pittsburgh Sleep Quality Index,[22] Epworth Sleepiness Scale,[23] and STOP-Bang.[24] The Brief Infant Sleep Questionnaire[25] is commonly used to assess sleep/wake patterns in infants and small children. Questionnaires commonly used with children and their parents include: Children's Sleep Habits Questionnaire,[26] the Pediatric Sleep Questionnaire,[27] and the Children's Report of Sleep Patterns.[28] Questionnaires commonly used with adolescents include: The Adolescent Sleep Wake Scale[29] and the Adolescent Sleep Hygiene Scale.[29]

Overnight sleep studies (polysomnography) are not necessary or recommended to diagnose insomnia.[13] Polysomnography is used to rule out the presence of other disorders which may require medical treatment, such as sleep apnea, periodic limb movement disorder, and rapid eye movement sleep behavior disorder. An MSLT is used to rule out disorders of hypersomnolence such as narcolepsy.

Actigraphy is sometimes used to gain information about sleep timing and assess for possible circadian rhythm disorders.[13]

Assessment of other sleep concerns follow similar procedures to those for assessing insomnia. By the time individuals are referred to a BSM specialist, they have often already seen a sleep medicine provider and completed any necessary testing such as polysomnography, MSLT, or actigraphy. In that case, the BSM provider conducts a clinical interview and administers questionnaires if needed. Individuals are often asked to track their sleep or sleep-related symptoms such as nightmares or sleepwalking episodes that are the focus of treatment.

The most common sleep complaints of parents of infants include requiring a parent or specific condition, like rocking, or bouncing, to fall asleep, and struggling to return to sleep during nighttime awakenings. Among toddlers and preschoolers, nighttime fears or resisting/stalling at bedtime (and therefore delaying sleep onset) are common, as well as bedtime co-sleeping with parents or siblings. In school-aged youth, problems with falling or staying asleep due to poor sleep hygiene are common.[8]

Insufficient sleep (sleeping under the recommended 8–10 hours) is common in adolescence. The other most common sleep disorders of adolescence include insomnia and delayed sleep-wake phase disorder. High rates of insufficient sleep in adolescence are partially attributed to a mismatch between adolescent biology and school start times.[31] Because adolescents experience a natural shift in their circadian rhythm around puberty (with a preference for later bedtimes and wake times), the American Academy of Pediatrics recommends that high schools start no earlier than 8:30am.[32]

Evidence-based treatments for childhood behavioral sleep disorders vary by developmental level, but typically include heavy parental involvement.[33] Interventions generally focus on:[8]

• Stabilizing the timing of the sleep/wake schedule to be consistent on school nights and weekends
• Scheduling enough time in bed to meet clinical guidelines for developmentally appropriate sleep duration
• Promoting healthy bedtime routines that help prepare the body for sleep
• Empowering parents to set limits and rules around expected bedtime behavior
• Promoting independent sleep
• Promoting consistent sleep locations
• Addressing any other barriers to sleep onset (such as nightmares, bedtime fears, fear of the dark, anxiety, depression, pain or discomfort, etc.)
• Addressing family-level barriers to consistently wearing CPAP to treat obstructive sleep apnea and hypoventilation

Treatment with parents of infants emphasizes the implementation of safe sleeping practices in order to reduce the risk of sudden infant death syndrome. The recommends that infants 0–12 months of age sleep:

• On their back
• On their own protected sleep surface, such as a crib or other firm sleep surface, and not in the parent's bed, chair, or sofa
• With no heavy blankets, pillows, bumper pads or positioning devices near to them

Evidence-based treatments used to treat adult sleep-related disorders include:

• Cognitive behavioral therapy for insomnia (CBT-I). This is an evidence-based, non-pharmacological treatment for insomnia disorder that uses education and systematic changes to insomnia-related behaviors, thoughts, and environment to change the factors that maintain chronic difficulties with falling asleep, staying asleep, and getting restorative sleep. CBT-I is the first-line treatment for insomnia disorder as recommended by the American College of Physicians[5] and American Academy of Sleep Medicine.[13] It is effective for insomnia disorder that occurs alone or along with other medical or psychiatric symptoms.[34][35]
• Intensive sleep retraining[36]
• Mindfulness-based therapy for insomnia (MBTI)[37][38]
• Imagery rehearsal therapy (IRT) for nightmare disorder[7]
• Exposure, relaxation, and rescripting therapy (ERRT) for nightmare disorder[39][7]
• Motivational enhancement therapy for improving adherence to CPAP treatment[40][14]
• Exposure therapy for CPAP claustrophobia[10][4]
• Behavioral therapy for circadian rhythm sleep-wake disorders[6]
• Clinical hypnosis for NREM parasomnias[41][42]
• Cognitive behavioral therapy for hypersomnia[11]
• Sleep extension[43][44]