Behavioral Interventions for Sleep

Crystal Ebert

Problems with Sleep

Many have psychosocial roots Are associated with mental illness
Anxiety disorders preceded insomnia 73% of the time Insomnia preceded depression 69% of the time

Often have a strong emotional loading Treatment usually requires lifestyle change Longitudinal studies have demonstrated that sleep problems first presenting in infancy may become chronic, persisting into the preschool and schoolaged years

Behavioral Insomnia Interventions

Unmodified Extinction
Child goes to bed at designated time & parents ignore the child until morning

Graduated Extinction
Parents ignore the child for pre-determined periods before briefly checking with gradually increasing time between checks

Sleep Hygiene
Maintain regular sleep-wake cycle Get exposure to natural light in the morning Engage in daily cardiovascular exercise Avoid vigorous exercise 3-4 hrs prior to bed Avoid high glycemic foods as bedtime snacks Limit napping until sleep improves Sleep in a dark, quiet, cool room Limit exposure to stressful imagery from books, TV, etc. Limit the use of electronics, especially cellphones

Sleep Induction Practices

Mindfulness meditation Progressive muscle relaxation Breathing exercises Self-hypnosis Guided imagery Gentle yoga Biofeedback and neurofeedback

Stimulus Control Therapy

Use the bed for sleep only Go to bed only when sleepy Do not watch the clock If sleep onset more than 20 mins. get out of bed, engage in a restful activity, & return to bed when sleepy.

Sleep Restriction Therapy

Limit amount of time in bed to actual sleep time:
Define optimal sleep length as goal Set initial time in bed as current average total sleep time Get up at the same time every day Increase time in bed by 15-20 minutes/week when sleep efficiency (total sleep time/time in bed x 100%) >90% Decrease time in bed when sleep efficiency <80%

Dusk Simulation
Dim the lights 2-3 hrs before bed Dim monitors Use book lights for reading Cover appliance LED lights Install black out drapes Use motion detector night lights Filter out the blue wavelength of light from electronics

Summary of Treatment for Sleep Problems

Treat symptomatically Minimize the use of psychotropic & hypnotic medications Emphasize cognitive aspects of sleep induction Organize treatment components around personalized evening ritual Encourage ongoing telling of sleep stories

Resources
American Academy of Sleep Medicine www.aasmnet.org Society of Behavioral Sleep Medicine www.behavioralsleep.org Sleep Diary Forms: http://sleep.buffalo.edu/sleepdiary.pdf Low Blue Lights www.lowbluelights.com Epworth Sleepiness Scale http://epworthsleepinessscale.com

References
Johnson, E. O., Roth, T., &Breslau, N. (2006). The association of insomnia with anxiety disorders & depression: Exploration of the direction of risk. Journal of Psychiatric Research, 40, 700-708 Morgenthaler , T.I., Owens, J., Alessi , C., Boehlecke, B., Brown, T.M., Coleman, J., Jr., . . . Swick, T.J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29, 127781. Naiman, R. (2011). Insomnia. In S. Rakel (Ed.), Integrative Medicine, 3rd ed. (pp. 66-77). Philadelphia, PA: Elsevier. Sheldon, S.H., Ferber, R., Kryger, M.H. (2005). Principles And Practice Of Pediatric Sleep Medicine. Elsevier.