Lehigh Valley Health Network Department of Family Medicine, Allentown, PA (Drs. Smith, Colistra, Shawver, Wilson); University of South Florida Morsani College of Medicine, Tampa (Drs. Smith, Colistra, Wilson); Valley Health Partners Family Health Center, Allentown, PA (Drs. Colistra, Shawver, Wilson); Neighborhood Centers of the Lehigh Valley, Allentown, PA (Dr. Smith) angela.colistra@lvhn.org
The authors reported no potential conflict of interest relevant to this article.
Cognitive behavioral therapy for insomnia (CBT-I).US and European guidelines recommend CBT-I—a multicomponent, nonpharmacologic, insomnia-focused psychotherapy—as a first-line treatment for short- and long-term insomnia32,41,42 across a wide range of patient demographics.17,43-47 CBT-I is a multiweek intensive treatment that combines sleep hygiene practices with cognitive therapy and behavioral interventions, including stimulus control, sleep restriction, and relaxation training.32,48 CBT-I monotherapy has been shown to have greater efficacy than sleep hygiene education for patients with insomnia, especially for those with medical or psychiatric comorbidities.49 It also has been shown to be effective when delivered in person or even digitally.50-52 For example, CBT-I Coach is a mobile application for people who are already engaged in CBT-I with a health care provider; it provides a structured program to alleviate symptoms.53
Although CBT-I methods are appropriate for adolescents and school-aged children, evaluations of the efficacy of the individual components (stimulus control, arousal reduction, cognitive therapy, improved sleep hygiene practices, and sleep restriction) are needed to understand what methods are most effective in this population.9
Cognitive and/or behavioral Interventions. Cognitive therapy (to change negative thoughts about sleep) and behavioral interventions (eg, changes to sleep routines, sleep restriction, moving the child’s bedtime to match the time of falling asleep [bedtime fading],41 stimulus control)9,43,54-56 may be used independently. Separate meta-analyses support the use of cognitive and behavioral interventions for adolescent insomnia,9,43 school-aged children with insomnia and sleep difficulties,43,49 and adolescents with sleep difficulties and daytime fatigue.41 The trials for children and adolescents followed the same recommendations for treatment as CBT-I but often used fewer components of the treatment, resulting in focused cognitive or behavioral interventions.
Cognitive behavioral therapy for insomnia is a first-line treatment for short- and long-term insomnia across a wide range of patients.
One controlled evaluation showed support for separate cognitive and behavioral techniques for insomnia in children.54 A meta-analysis (6 studies; N = 529) found that total sleep time, as measured with actigraphy, improved among school-aged children and adolescents with insomnia after treatment with 4 or more types of cognitive or behavioral therapy sessions.43 Sleep-onset latency, measured by actigraphy and sleep diaries, decreased in the intervention group.43
A controlled evaluation of CBT for behavioral insomnia in school-aged children (N = 42) randomized participants to CBT (n = 21) or waitlist control (n = 21).54 The 6 CBT sessions combined behavioral sleep medicine techniques (ie, sleep restriction) with anxiety treatment techniques (eg, cognitive restructuring).54 Those in the intervention group showed statistically significant improvement in sleep latency, wake-after-sleep onset, and sleep efficiency (all P ≤ .003), compared with controls.54 Total sleep time was unaffected by the intervention. A notable change was the number of patients who still had an insomnia diagnosis postintervention. Among children in the CBT group, 14.3% met diagnostic criteria vs 95% of children in the control group.54 Similarly, at the 1-month follow-up, 9.5% of CBT group members still had insomnia, compared with 86.7% of the control group participants.54
Continue to: Multiple randomized and nonranomized studies...
