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Behavioral Sleep Medicine is a relatively new discipline with roots in Behavioral Medicine and a specific focus on behavioral aspects of Sleep Medicine. While cognitive behavioral therapy for insomnia is most closely identified with Behavioral Sleep Medicine, the discipline and its practitioners offer a wider array of interventions for pediatric and adult sleep disorders. Despite the existence of these evidenced-based behavioral strategies for the major sleep disorders, it is the exception, rather than the norm, when behavioral sleep medicine is fully integrated into a sleep medicine practice. A brief history of Behavioral Sleep Medicine, challenges to achieving greater integration, progress made to date, and suggestions for the immediate future are presented.

Study Objectives: To examine the association of sleep problems with psychiatric symptoms in children evaluated at a university-based outpatient child psychiatry clinic., Methods: Parents of 174 children attending psychiatric services completed a 47-item Childhood Sleep Questionnaire and the Behavioral Assessment System for Children. Psychiatric diagnosis was obtained through retrospective chart review. Sleep characteristics were compared among 4 diagnostic subcategories: attention-deficit/hyperactivity disorder (ADHD) alone (n=29), ADHD with comorbid mood and anxiety disorders (ADHD+; n=50), mood and anxiety disorders alone (n=67), and other psychiatric disorders (n= 28). Data from sleep habits survey of 174 community children without reported psychiatric history served as controls., Results: Children with psychiatric disorders had a significantly higher prevalence of sleep complaints compared with nonpsychiatric controls. Children with ADHD had frequent nocturnal awakenings, bad dreams, and bedtime struggles. In addition, the presence of leg jerks during sleep was particularly frequent in patients with ADHD compared with any other psychiatric disorder. More frequent nighttime awakenings were present in children with mood and anxiety disorders. Sleep duration and sleep latency strongly correlated with aggression, hyperactivity, and depression. Restless sleep scores highly correlated with all psychiatric symptoms., Conclusions: Sleep problems are highly prevalent among children with psychiatric disorders. Children with ADHD and comorbid anxiety or mood disorders are more likely to report sleep disturbances. Restless sleep, long sleep latency, short sleep duration, and frequent nocturnal awakenings correlate with the severity of psychiatric symptoms.

Background: Periodic limb movement disorder (PLMD) has recently emerged as a relatively frequent and markedly underdiagnosed condition in children that induces arousals and sleep fragmentation and leads to poor learning and behavioral problems. Because a cost-effective and widely available alternative to pediatric polysomnography is needed for diagnosis of limb movement disorders, this study sought to examine whether periodic leg movements in children could be reliably identified using recently developed actigraphy software., Methods: Bilateral actigraphs were worn around the feet by 99 children ages 4-12 years during standard clinical overnight polysomnography, which included bilateral anterior tibial electromyogram (EMG). Left and right leg movements were scored independently for comparison purposes., Results: Agreement between tibial EMG and actigraphy-derived events were initially low, with movement indices being overestimated by actigraphy. This agreement was improved when a correction factor based on the average number of movements during arousals as measured by EMG was applied. However, the correction factor itself was found to differ substantially for patients who were diagnosed with PLMD compared to other patients., Conclusions: A novel actigraphic approach currently used for detection of PLM events during sleep in adults is insufficiently accurate to permit reliable estimates in children.

There is considerable research evidence suggesting that sleep is biologically linked to mood disorders in adults. However, polysomographic and neuroendocrine studies in children and adolescents have not found consistent changes in sleep architecture paralleling adult major depression. This review provides a detailed description of sleep research that has been conducted in early-onset affective disorders, uncovers the potential limitations of the available data, and formulates future research directions in this important subject.

Sleep-disordered breathing in children has been associated with cognitive impairment. The purpose of this study was to examine the impact of tonsillectomy and adenoidectomy (T&A) on sleep, respiration and cognitive function in children of pre-school age with obstructive sleep apnoea (OSA) from a low-income community population. Altogether, 19 children attending state-funded pre-school programmes underwent overnight polysomnography and cognitive assessment before and following surgical treatment for OSA; 19 matched controls were also assessed. Following T&A, OSA subjects' delta sleep increased, rapid eye movement sleep decreased, and respiratory and arousal indices improved. There were no significant differences in OSA subjects' post-operative sleep or respiratory measures compared to controls. Prior to T&A, cognitive scores were significantly lower in OSA subjects versus controls; following T&A, OSA subjects' scores improved compared to pre-operative scores and did not differ from those of matched controls. Following tonsillectomy and adenoidectomy, at-risk pre-schoolers recruited directly from the community showed normalised sleep and respiratory patterns and improved cognitive scores. These findings, in this uniquely vulnerable population, which is unlikely to seek evaluation and treatment for obstructive sleep apnoea, underscore the potential value of outreach screening programmes for sleep-disordered breathing, particularly among low-income groups of pre-school age.

Background and Purpose: To assess the frequency and nature of clinical and psychiatric symptoms in children referred to a pediatric sleep center for evaluation of insomnia., Patients and Methods: A retrospective chart review of all children referred to the pediatric sleep medicine was conducted. Children presenting exclusively with sleep initiation and/or maintenance problems underwent a structured clinical psychiatric interview and their parents completed the behavioral assessment system for children (BASC), pediatric symptom checklist, the clinical attention problem scale and a detailed sleep questionnaire., Results: Twenty-three of 46 children (50%) with persistent insomnia had a professional diagnosis of another psychiatric disorder. In the remaining 50%, although parents denied any previous psychiatric history, 40% displayed psychiatric symptoms as documented by psychometric measures and clinical interview. A significant positive correlation was observed between depressive BASC score and sleep onset latency and an inverse correlation was present with REM sleep latency., Conclusion: The vast majority of children presenting with persistent insomnia exhibit clinical symptoms of an accompanying psychiatric disorder, suggesting that comprehensive psychometric assessments are warranted in this population.

Although the exact nature of sleep disturbances present in children with psychiatric disorders has not been studied extensively, it is apparent that children with significant emotional and behavioral problems are more likely to experience sleep difficulties. Children with sleep-related issues that are limited to bedtime can be managed effectively with specific cognitive-behavioral interventions. Children with more pervasive anxiety (eg, PTSD or OCD, mood disorders such as major depression or bipolar disorder, or neurodevelopmental disabilities such as autism) require a more exhaustive evaluation, and most of them also need sleep problems to be managed by sleep professionals using combinations of psychotherapeutic and pharmacologic approaches.

Frequently reported sleep problems in children with attention deficit-hyperactivity disorder (ADHD) referred to a pediatric sleep medicine center were assessed and compared with objective sleep assessments. A retrospective review of 97 children with ADHD (mean age of 8.3+/-3.0 years) was conducted. Polysomnography in 69 children revealed periodic limb movement disorder (PLMD) in 36% and sleep-disordered breathing in 7%, while actigraphy uncovered substantial variability in sleep schedules of 16 patients. Although parental subjective sleep complaints were verified by objective sleep assessments in a small proportion of cases, PLMD and night-to-night variability in sleep patterns were common.

Objective: To conduct a prospective case-controlled study of pediatric inpatients referred for consultation in a tertiary care children's medical center., Method: Referrals (n = 104) were matched with nonreferrals (n = 104) for age (4 to 18 years), gender, and illness type/severity and completed parent- and self-report (dependent on age) behavioral rating scales to assess for adjustment/functioning. Nurses completed in-hospital ratings of behavioral/adjustment difficulties. Goal attainment and satisfaction ratings were obtained from the referring physicians, parents/guardians, and the consultant., Results: Referrals exhibited more behavior/adjustment/coping difficulties than nonreferrals by parent, nurse, and self report. Frequently employed interventions included coping-strategies intervention, cognitive and behavioral therapies, and case management. Referring physician and consultant ratings of goal attainment were high, as were physician ratings of satisfaction and parent/guardian ratings of overall helpfulness., Conclusions: Pediatric inpatients referred by their physicians had significantly more internalizing and externalizing disturbances than their nonreferred hospitalized peers. Many of the behavioral and adjustment problems that lead to in-hospital consultation referral were evident in global behavior difficulties prior to hospitalization. Referring pediatricians, parents/guardians, and consultants rate the outcome as benefiting the patients via assisting in the overall management of their health concerns, coping, and adjustment.

The objective of the study was to compare polysomnographic patterns in two groups of preadolescent children with attention deficit hyperactivity disorder (ADHD) (a sleep clinic referral sample and a community sample) with control children. A prospective and observational study in the sleep clinic and the community was undertaken. Forty-seven ADHD children referred to the sleep clinic (ADHDcl), 53 ADHD children from a community survey (ADHDcom), and 49 control children underwent overnight polysomnography. Significant differences between the groups were observed for rapid-eye-movement (REM) sleep latency and percentage, and periodic limb movement index with associated arousals (PLMa). REM sleep latency was shorter in controls than ADHDcl and ADHDcom (p < 0.01) and REM% was highest in controls and lowest in ADHDcl (p < 0.001). PLMa was higher in ADHDcl than the other groups (p < 0.001), but there were no differences in PLMa between ADHDcom and controls. ADHD children display significant alterations in their sleep patterns, and ADHDcl are more likely to have an elevated PLMa than ADHDcom. In addition, REM sleep is affected by ADHD. We postulate that ADHDcl may represent a subset of children with ADHD at high risk for hyperactivity during sleep.

Objective: To investigate the effects of stimulant medications on subjective and objective sleep characteristics of children with attention deficit/hyperactivity disorder (ADHD) compared with control children., Methods: An observational study in the sleep clinic and the community. Children with characteristics of ADHD, both stimulant-medicated (n=53), and non-medicated (n=34), together with control children (n=53) completed a sleep habits questionnaire prior to undergoing full overnight polysomnographic assessment., Results: Medicated and non-medicated ADHD subjects were reported to have more sleep disturbances compared with controls. Both groups of ADHD children also demonstrated decreased REM sleep percentage compared with controls (P=0.006 for ADHDmed; P=0.02 for ADHDnon). However, the use of stimulant medication (n=53) was not associated with differences in subjective sleep quality or objective sleep measures, compared to ADHD children not taking any medication (n=34; P=n.s.)., Conclusions: Despite the high prevalence of reported sleep disturbance in children with ADHD, stimulant medication appears to have minimal effects on subjective and objective sleep characteristics in children with reported ADHD.

To characterize periodic limb movement disorder (PLMD) in a cohort of prepubertal children we examined sleep-related identifiable differences between children with PLMD and attention-deficit/hyperactivity disorder (ADHD), PLMD alone, and age-matched controls. Children were selected from a chart review of all children referred to a pediatric sleep medicine center and from a community survey of 5-7-year-old-children. Polysomnography (PSG) and parental report data from all children identified as having periodic limb movement index (PLMI) >5 were reviewed and compared with a cohort of age-matched controls. A total of 8.4% of children in the clinic-referred sample, and 11.9% of the children recruited from the community had PLMI >5. Of those, 44.4% were identified as having ADHD. Children with PLMD had significantly lower percentage of rapid eye movement (REM) than control children (P < 0.001). Children in the PLMD/ADHD group had a significantly greater number of arousals associated with PLM (PLMa) than children with PLMD only (P < 0.05). While a relationship between ADHD and PLMD was observed, it was weaker than previous reports (Chervin, R. D. et al. Sleep, 2002; 25: 213; Chervin, R. D. and Archbold, K. H. Sleep, 2001; 24: 313; Picchietti et al. J. Child Neurol., 1999; 13: 588; Picchietti et al. Mov. Disord., 1999; 14: 1000; Picchietti and Walters Sleep, 1999; 22: 297). Children in the PLMD/ADHD group were more likely to have PLMas than were children with PLMD only. We postulate that rather than a direct relationship between ADHD and PLMD, this link may be mediated by the presence of reduced REM sleep and more importantly by the sleep fragmentation associated with PLM-induced arousals.

Effectiveness and tolerability of melatonin was assessed in 32 children (mean age 9.6 +/- 4.5 years) with chronic sleep initiation and sleep maintenance problems treated naturalistically in a pediatric sleep medicine center. Children received melatonin for an average of 2.1 +/- 2.0 months at a final average dose of 2.0 +/- 1.2 mg administered 1 hour before bedtime. Twenty-nine (90.6%) children exhibited partial improvement to complete resolution of their sleep problems as measured by sleep latency time and number of awakenings reported by parents. Thus, melatonin may be effective, safe, and well tolerated in the treatment of chronic insomnia in children.