Cognitive-behavioral therapy for insomnia an option for kids with sleep trouble
Insomnia is broadly defined as difficulty falling asleep, staying asleep and/or subjective, poor-quality (“non-restorative”) sleep.
Everyone has problems sleeping at times; however, a diagnosis of insomnia is made if sleep problems persist for more than one month and result in some degree of daytime impairment. Untreated insomnia can result in chronic sleep loss that can cause excessive daytime sleepiness and impact daytime functioning, which may range from fatigue, moodiness/irritability or mild cognitive or behavioral problems (difficulties with concentration/attention, hyperactivity) to significant effects on mood, behavior or school performance. Chronic insomnia also increases the risk of physical and mental illness.
Given the negative impact of chronic poor sleep, it is important to have sleep problems evaluated and treated. Behavioral treatments are the first line treatment for insomnia and involve improving sleep without the use of medications, as there are no medications that are FDA-approved for the treatment of insomnia in youth. Cognitive-behavioral therapy for insomnia, commonly referred to as CBT-I, is a safe and effective treatment that aims to help children and adolescents identify and replace thoughts and behaviors that cause or worsen sleep problems with thoughts and behaviors that promote sound sleep.
CBT-I requires regular (usually weekly or biweekly) visits with a sleep provider who will work with you and your child to help change the way he or she sleeps. The frequency of treatment may vary from as few as two sessions to as many as eight of more sessions, depending on the specific sleep concerns and progress. At the beginning of treatment, a comprehensive sleep evaluation will be conducted to determine factors that are underlying or contributing to sleep difficulties and to help develop an effective treatment plan. As part of this initial evaluation, you will be asked to keep a sleep log of your child’s sleep patterns for one to two weeks and your child may be asked to wear an actigraph, a portable wristwatch-like device which records and stores more objective information about body movements and sleep-wake patterns.
After this initial evaluation, treatment is individualized and each session is focused on learning specific cognitive and behavioral strategies to improve sleep. The cognitive part of CBT-I involves teaching your child techniques to quiet his or her busy mind at night to relax and fall asleep. Your child will learn strategies to recognize, modify or eliminate unhelpful/negative thoughts or worries that interfere with his or her ability to sleep, including unrealistic beliefs and attitudes about sleep and the possible daytime consequences of poor sleep (e.g. “I’ll never be able to fall asleep tonight,” “If I can’t fall asleep, I won’t be able to get up in the morning and I’ll miss my test”).
The behavioral part of CBT-I involves identifying and changing behaviors that may keep your child from sleeping well and developing good sleep habits to promote quality sleep. Treatment is tailored to each child or adolescent and may include some combination of the following techniques:
- Sleep restriction: This strategy involves temporarily restricting the total time in bed to current amount of sleep each night to decrease the amount of time spent in bed awake. Being extra-sleepy can help your child fall asleep quickly and stay asleep. Once sleep has improved, the amount of time in bed is gradually increased until desired bedtime is reached.
- Stimulus control: This technique involves eliminating any activities in bed that are not conducive to sleeping to disrupt the association between being in bed and wakefulness (and strengthen the association between being in bed and sleepiness). Stimulus control instructions often include only going to bed when sleepy, leaving the bed (and possibly bedroom) to engage in a quiet activity if not asleep within 15-20 minutes and only using the bed for sleeping both during the day and at night (not watching TV, doing homework, worrying, etc.).
- Sleep hygiene: This involves learning positive sleep practices and habits that are important for getting sound sleep, such as establishing an optimal sleep environment, implementing a developmentally appropriate and consistent bedtime and wakeup time (no matter how much sleep you got the night before!), avoiding naps, establishing a calming, consistent bedtime routine, decreasing stimulation near bedtime (caffeine, physical activity, conflict/stress) and removing electronics from the bedroom.
- Relaxation training: Increased mental activity at night (such as worrying or not being able to “switch off” an active, busy mind) or stress about not being able to fall asleep leads to increased activity and tension in the body, which further interferes with the ability to unwind and fall asleep. Relaxation strategies, such as deep breathing, visual imagery, progressive muscle relaxation, autogenics, meditation and mindfulness can be used to help quiet the mind and calm the body at night and improve sleep.
Given the potential negative consequences of chronic sleep loss, it’s important to actively treat sleep problems. CBT-I is a safe and effective way to treat insomnia in children and adolescents without the use of medications. CBT-I is generally short term, but the skills learned during this treatment can lead to lasting, improved sleep if positive habits are maintained.
Terese Amble, PsyD, LP, is a pediatric psychologist in the sleep center at Children’s Hospitals and Clinics of Minnesota.