The role of psychiatric symptoms, sociodemographic factors, and baseline sleep variables on pediatric insomnia treatment outcomes in a clinically referred population.

STUDY OBJECTIVES: The current study aimed to examine clinically relevant psychiatric and sociodemographic predictors of insomnia treatment outcomes in pediatric patients clinically referred for insomnia. METHODS: Pediatric patients (N = 1428; ages 1.5 - 18 years), presenting for insomnia evaluation in a medical/sleep center-based behavioral sleep clinic were followed for treatment as clinically indicated. According to patient age, parent/patients completed validated measures of insomnia severity, psychiatric symptoms, and sociodemographic measures. Patients were also categorized by treatment outcome status (i.e., not recommended to follow-up after initial evaluation and treatment session, successful treatment completion, lost to follow-up after initial evaluation and treatment session, and early termination) according to the clinically indicated treatment recommended and dose of treatment received. RESULTS: Youth had elevated scores on psychiatric screening indexes with affective problems being highest for all age groups. Other co-morbid sleep disorders were present in nearly 25% of insomnia patients and use of sleep aids (melatonin; hypnotics) was commonplace. Baseline insomnia severity significantly predicted sleep treatment trajectories and post-treatment insomnia severity with large effects for all age groups. Other clinically relevant predictors of insomnia treatment outcomes included medication use and externalizing mental health concerns in younger patients and internalizing mental health concerns and chronological age in older patients. Lack of treatment follow-up and premature treatment termination was observed for patients with the worst insomnia symptoms at time of initial evaluation. CONCLUSIONS: Pediatric health providers delivering insomnia treatment should take a developmentally sensitive approach that is proactive with regards to managing treatment barriers that are likely influenced by severity of insomnia and co-morbid mental health concerns.

Advancing Patient-Centered Care: An International Survey of Adolescent Perspectives on Insomnia.

OBJECTIVE: The study objective was to inform patient-centered care for adolescent insomnia by describing adolescents' perspectives on insomnia. Specific constructs of interest included: 1) factors that contributed to insomnia development or maintenance, 2) impact of insomnia on day-to-day life, 3) recommended research priorities, and 4) overall experience living with insomnia. METHOD: A convenience sample of adolescents (ages 13-18 years) self-identifying with insomnia symptoms was recruited through social media. Respondents (n = 3,014) completed an online survey. Responses to an open-ended item assessing patient experience were coded using thematic analysis. RESULTS: Participants identified as 70.8% White non-Hispanic, 77.0% female, and lived in one of five English-speaking countries (United States, United Kingdom, Canada, Australia, or New Zealand). Most (87.5%) met DSM-V diagnostic criteria for insomnia. The most common contributory factors to insomnia endorsed were stress (72.1%) and depressed mood (63.6%), while common impact areas were mood (72.2%), focus (61.0%), and pain (49.7%). Patient-centered research priorities were identifying insomnia causes (66.4%) and early detection (66.1%). Common adolescent experiences included high distress levels, feelings of invalidation, and helplessness about their insomnia. CONCLUSIONS: Adolescents with insomnia offer a unique perspective that should inform patient-centered research and care. There is a need for heightened screening and awareness about insomnia as a condition that causes significant distress and impairment for adolescents. To provide validating care, providers should recognize the multifaceted causes of insomnia.

Current Considerations in the Diagnosis and Treatment of Circadian Rhythm Sleep-Wake Disorders in Children.

Circadian Rhythm Sleep-Wake Disorders (CRSWDs) are important sleep disorders whose unifying feature is a mismatch between the preferred or required times for sleep and wakefulness and the endogenous circadian drives for these. Their etiology, presentation, and treatment can be different in pediatric patients as compared to adults. Evaluation of these disorders must be performed while viewed through the lens of a patient's comorbid conditions. Newer methods of assessment promise to provide greater diagnostic clarity and critical insights into how circadian physiology affects overall health and disease states. Effective clinical management of CRSWDs is multimodal, requiring an integrated approach across disciplines. Therapeutic success depends upon appropriately timed nonpharmacologic and pharmacologic interventions. A better understanding of the genetic predispositions for and causes of CRSWDs has led to novel clinical opportunities for diagnosis and improved therapeutics.

Caregiver experiences helping children with Down syndrome use positive airway pressure to treat obstructive sleep apnea.

BACKGROUND/OBJECTIVE: While positive airway pressure (PAP) is an efficacious intervention for the treatment of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS), implementation and consistent use can be difficult. Caregiver perspectives and experiences using PAP are described with the aim of informing clinical practice. METHODS: Qualitative semi-structured phone interviews were conducted with 40 caregivers (i.e., mothers) of children with DS and OSAS treated with PAP for at least 6 months. Content analysis was used to identify themes associated with adherence and non-adherence. RESULTS: Respondents indicated variability in caregiver experience with the adoption of PAP and observed benefits of PAP. Varied experiences were attributed to several themes including accessing supplies, interactions with the medical team and equipment company, and patients' unique needs and behaviors, including the child's willingness and ability to adapt to PAP, sensory sensitivities, keeping the mask on all night, and differences in daytime behavior. Many families reported that desensitization with a reward system and trust within the caregiver-patient relationship were helpful. Caregiver suggestions for improving PAP adherence for families of children with DS included improving communication with the medical team and medical equipment company, emphasizing patience, using visual supports, and social support and education for extended family. CONCLUSIONS: Although family experiences varied, several actionable strategies by both the medical team and families emerged for improving the experience of and adherence to PAP in children with DS.

Factors affecting pediatric adherence to positive airway pressure: Patient- and caregiver-reported treatment barriers and sleep difficulties.

OBJECTIVE/BACKGROUND: Adherence to positive airway pressure (PAP) treatment among children and adolescents is often suboptimal. Little is understood about modifiable determinants of PAP adherence. We evaluated whether patient and caregiver-perceived treatment barriers (across behavioral, environmental, emotional, and physical domains), as well as insomnia severity, were associated with PAP adherence among youth with sleep disordered breathing (SDB). PATIENTS/METHODS: We conducted a retrospective review of 188 patients prescribed PAP, ages 2-19 years. At the clinical visit, PAP adherence was assessed via objective download/smartcard and patients and their caregivers completed validated standardized questionnaires on barriers to PAP adherence and sleep onset and maintenance difficulties. We tested predictors of PAP adherence using linear regression. RESULTS: On average, patients wore their PAP 2/3 of nights for 5.3 ± 3.4 h. Patients reported more barriers overall compared to caregivers, and specifically more behavioral and emotional barriers (e.g., over a third of patients reported they just want to forget about sleep apnea). After controlling for demographic/treatment characteristics, patient-reported barriers accounted for a significant proportion of the variance in percent nights used (51%) and average nightly use (42%). Greater difficulties with sleep maintenance predicted poorer PAP adherence (percent nights and nightly duration). CONCLUSIONS: Study findings suggest that assessment of both patient and caregiver-perceived barriers to PAP adherence, as well as evaluating for sleep maintenance concerns, may provide important treatment targets for promoting PAP adherence among youth. Results also support the potential benefit of a multi-disciplinary team-based approach to managing SDB and promoting PAP adherence.

Adolescent sleep myths: Identifying false beliefs that impact adolescent sleep and well-being.

OBJECTIVE: Commonly held beliefs about sleep unsupported by scientific evidence (ie, myths) among adolescents and their parents/caregivers may adversely influence sleep-related attitudes and behaviors among adolescents. Thus, identifying such myths with the goal of developing effective evidence-based counter-messages has the potential to improve sleep health in adolescents. METHOD: We identified myths with a panel of adolescent sleep health experts (n = 12) using the Delphi method in three sequential steps: (1) focus groups; (2) online discussion; and (3) closed-ended questionnaires with which the experts rated myths on: (1) falseness and (2) public health significance using 5-point Likert scales ranging from 1 (not at all false/important for public health) to 5 (extremely false/important for public health). Next, we explored the prevalence of the myths among a demographically diverse sample of parents/caregivers of adolescents in the United States. Finally, we report the counterevidence to refute each myth. RESULTS: Ten myths about adolescent sleep were identified by the experts using the Delphi method. The most prevalent myths were the beliefs that (1) "Going to bed and waking up late on the weekends is no big deal for adolescents, as long as they get enough sleep during that time," reported by 74% of parents/caregivers; (2) "If school starts later, adolescents will stay up that much later," reported by 69% of parents/caregivers; and (3) "Melatonin supplements are safe for adolescents because they are natural," reported by 66% of parents/caregivers. CONCLUSION: Parents/caregivers have the potential to serve as sleep health advocates for their adolescent and support their adolescent's sleep health behaviors. Our study found that many parents/caregivers endorse myths about adolescent sleep that may hinder their ability to support their adolescent's sleep health. Future research may explore methods for promoting evidence-based beliefs about adolescent sleep among parents/caregivers.

Randomized Behavioral Sleep Clinical Trial to Improve Outcomes in Children With Down Syndrome.

Parents of 30 school-age children with Down syndrome participated in a small-scale randomized clinical trial of a behavioral sleep treatment designed specifically for children with Down syndrome. The aim was to improve child sleep, child daytime behavior problems, caregiver sleep, and caregiver stress. The intervention spanned 5-8 weeks, and assessments occurred pre-treatment, immediately post-treatment, and three months post-treatment using a double-blinded design. Both the active treatment and a treatment-as-usual attention-controlled comparison group showed improvements in actigraphy and parent-report measures of child sleep, parent-reported child internalizing behaviors, and actigraphy measures of parent-sleep. The behavioral sleep treatment did not yield significantly different outcomes than a treatment-as-usual approach supplemented with non-sleep-specific behavioral or education sessions. Possible interpretations of study findings are discussed.

Impact of a Behavioral Sleep Intervention in Adolescents With ADHD: Feasibility, Acceptability, and Preliminary Effectiveness From a Pilot Open Trial.

OBJECTIVE: An open trial tested the feasibility, acceptability, and preliminary effectiveness of a behavioral sleep intervention in adolescents with ADHD. METHOD: Fourteen adolescents (ages 13-17 years; 50% male) with ADHD and co-occurring sleep problems received the cognitive-behavioral-based Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C). Adolescent, parent, and teacher ratings, actigraphy, and daily sleep diaries were collected at pre-intervention, post-intervention, and 3-month follow-up. RESULTS: Adolescents experienced moderate to large improvements in sleep, mental health symptoms, and daily life executive functioning from pre-treatment to post-treatment, and improvements were generally maintained at 3 months. Pre-intervention, 71.4% of adolescents were classified as poor sleepers and this was reduced to 21.4% and 28.6% at post-treatment and follow-up, respectively. CONCLUSION: This study provides strong preliminary evidence that TranS-C improves sleep and associated outcomes in adolescents with ADHD and co-occurring sleep problems. A randomized controlled trial is needed to rigorously test the efficacy of TranS-C in this population.

Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic.

STUDY OBJECTIVES: Sleep problems are highly comorbid with pediatric pain, yet there is a dearth of research on how pain and somatic complaints impact adolescent insomnia presentation and response to cognitive-behavioral therapy for insomnia (CBT-I). This study aims to (1) determine the prevalence of parent-reported somatic/pain complaints in adolescents with insomnia presenting to a behavioral sleep clinic, (2) assess the impact of somatic/pain complaints on initial sleep presentation, and (3) assess the impact of baseline somatic/pain complaints on response to CBT-I. METHODS: Participants included adolescents (n = 375) presenting to a behavioral sleep medicine center with a primary diagnosis of insomnia. As a part of clinical care, pre-evaluation measures were completed including the Pediatric Insomnia Severity Index, Adolescent Sleep Hygiene Scale, Adolescent Sleep Wake Scale, and Child Behavior Checklist. The Somatic Syndrome Scale of the Child Behavior Checklist measured somatic complaints and teens were categorized as endorsing pain if reported to experience aches/pains, headaches, or stomachaches. Adolescents completed the Pediatric Insomnia Severity Index at end of treatment. RESULTS: Most adolescents had parent-reported somatic (61.1%) and/or pain complaints: headaches (66.6%), stomachaches (48.5%), and aches/pains (45.1%). Greater somatic and pain complaints predicted a worse sleep presentation at intake (all P < .05). After controlling for insomnia severity at intake, neither end-of-treatment insomnia severity nor treatment status were predicted by somatic and pain complaints at intake. CONCLUSIONS: Results suggest that parent-reported somatic/pain complaints are prevalent in > 50% of adolescents seeking behavioral insomnia treatment. Although complaints are associated with more severe insomnia at intake, they do not appear to interfere with treatment response. CITATION: Van Dyk TR, Krietsch KN, King CD, Byars KC. Prevalence of somatic and pain complaints and associations with sleep disturbance in adolescents with insomnia presenting to a behavioral sleep medicine clinic. J Clin Sleep Med. 2022;18(1):151-160.

Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample.

STUDY OBJECTIVES: Children with overweight or obesity are more likely to experience sleep disorders, although the role of weight in pediatric insomnia treatment has not been examined. The current study examined the relationships of high body mass with pretreatment insomnia severity and global sleep problems and the potential moderating impact of weight on changes in insomnia severity following insomnia treatment. METHODS: Participants included 1,133 youth ages 2-18 years clinically referred for insomnia treatment. The Pediatric Insomnia Severity Index was collected at the initial assessment and throughout treatment as part of routine clinical care. Treatment status was coded as no treatment, early termination, and completed treatment. Secondary measures of global sleep problems at the initial assessment included the Adolescent Sleep Wake Scale, Adolescent Sleep Hygiene Scale, and Children's Sleep Habits Questionnaire. Medical chart review of visits within ± 3 months of baseline was used to obtain age-adjusted and sex-adjusted body mass index Z-score. RESULTS: Among adolescents, regression analyses found that higher body mass index Z-score modestly predicted baseline insomnia severity (P = .021) and worse sleep hygiene (P < .001). For children, higher body mass index Z-score was modestly associated with baseline total sleep problems (P = .006) but not insomnia severity (P = .792). Across ages, body mass index Z-score predicted neither treatment status nor insomnia improvement (P > .05). Findings were similar in categorical analyses comparing patients with overweight/obesity to healthy weight. CONCLUSIONS: Although there is evidence that children of higher body mass present for insomnia treatment with greater sleep concerns, body mass does not predict treatment completion or insomnia improvement. Data suggest insomnia treatment is effective irrespective of weight status. CITATION: Duraccio KM, Simmons DM, Beebe DW, Byars KC. Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample. J Clin Sleep Med. 2022;18(4):1083-1091.

Improvements in Sleep Correlate With Improvements in Clinical Outcomes Among Adolescents Undergoing Intensive Interdisciplinary Pain Treatment.

OBJECTIVES: Intensive interdisciplinary pain treatment (IIPT) programs have been shown to restore function, improve coping, and reduce pain in adolescents with chronic pain. Yet, little is known about patients' sleep during IIPT and whether or not improvements in pain treatment outcomes are associated with changes in sleep pre-to-post IIPT treatment. The objectives of the current study were to describe sleep among adolescents entering IIPT and examine associations between sleep parameters and IIPT treatment effects. MATERIALS AND METHODS: Self-reported sleep measures and clinical outcomes (eg, functional disability, coping, average pain), were collected from 44 adolescents (mean age=14.57, 68.2% female) at admission and discharge from an inpatient IIPT program. Wrist-worn actigraphy data and sleep diaries from participants' first week and last week in the program were analyzed to characterize sleep parameters. RESULTS: Participants self-reported poor sleep/wake patterns, high levels of insomnia symptoms, and subclinical problems with daytime sleepiness upon admission into IIPT, although actigraphic indices of sleep from the first week of IIPT admission were only just under clinical guidelines for healthy adolescent sleep. Better self-reported sleep quality assessed via aggregated sleep diaries from the first week was associated with improvement in average pain and disability over the course of the program. Furthermore, improvements in insomnia symptoms and daytime sleepiness throughout the program were positively correlated with concurrent improvements in functional disability and coping. DISCUSSION: Taken together, results suggest that sleep may be associated with IIPT treatment effects and pave the way for future research to continue examining these relationships.

Validation and confirmatory factor analysis of the pediatric Adherence Barriers to Continuous Positive Airway Pressure Questionnaire.

OBJECTIVE: To evaluate and refine a newly proposed factor structure for the Adherence Barriers to Continuous Positive Airway Pressure Questionnaire (ABCQ) and to present psychometric data from a large, geographically diverse sample of children and young adults with sleep disordered breathing (SDB) treated with positive airway pressure (PAP). METHODS: A sample of 181 patients prescribed PAP for treatment of SDB, ages 8-21 years, and caregivers (n = 234) of patients ages 2-21 years, completed the ABCQ during routine sleep medicine clinic visits. Adherence data from participants' PAP machines were obtained via electronic download, providing objective data on PAP adherence immediately preceding the clinic visit during which the ABCQ was completed. RESULTS: A three-factor structure (1. Behavior, Beliefs, Environment, 2. Emotional Barriers, & 3. Physical Barriers) exhibited good model fit in confirmatory factor analysis. Results indicate that the ABCQ has strong psychometric properties, including good internal consistency among subscales and strong convergent validity with objectively measured PAP adherence. Analysis of the Receiver Operator Characteristic Curve (ROC) yielded an ABCQ total cut-off score of 46.5 for patient report and 53.5 for caregiver report. Scores above the cutpoint predicted nonadherence to PAP, defined as failure to use PAP for ≥4 h on 70% of nights. CONCLUSIONS: The three-factor ABCQ appears to be a useful patient- and caregiver-report instrument to measure barriers to PAP treatment in children and young adults with sleep disordered breathing.

Sleep disturbance and sleep insufficiency in primary caregivers and their children with cystic fibrosis.

BACKGROUND: Chronically ill children and their parents are at risk for sleep disorders and associated morbidity. Sleep disturbance prevalence and the relationships between parent and child sleep among children with CF are not well defined. Clarifying the presence and impact of sleep disturbances among pediatric CF patients and their parents could lead to improved health in this population. METHODS: Cross-sectional study assessing parent-reported sleep in ninety-one CF patients (mean age 8.8 years; 53.8% female) and their primary caregivers. Sleep sufficiency determined using American Academy of Sleep Medicine guidelines; correlation coefficients computed for sleep problem domains; stepwise multiple linear regression determined predictive models for sleep duration. RESULTS: Parents reported concerns about their own sleep and that of their children. Night waking and daytime sleepiness were most common in parents; prolonged sleep latency was most common for children. Most parents and children had inadequate sleep duration. School-age children had the highest frequencies of overall sleep concerns and inadequate sleep. Most parent and child sleep problem domains were significantly associated, with large effects for similar parent and child problems. Stepwise multiple linear regression demonstrated that CF caregiver/patient sleep duration was significantly predicted by insomnia symptoms. CONCLUSIONS: Many CF children and their parents experience sleep difficulties including inadequate sleep duration, with presence of sleep problems in many families whose children with CF had normal lung function. These data suggest that sleep health should be a CF Care Model component and should be a health care focus for families of children with other chronic illness.

Utility of the Sleep Disorders Inventory for Students in Clinically Referred Youth With Insomnia: Risk Identification and Relationship With Polysomnographic Measures.

Objective/Background: This study evaluated the overall performance of the Sleep Disorders Inventory for Students (SDIS) in identifying sleep disorders risk and the sensitivity and specificity of specific SDIS subscales in a clinically referred sample of youth with insomnia. Participants: Youth (N = 1,329, M = 2.5-18.99 years) with insomnia, of whom 392 underwent clinically indicated diagnostic PSG within ± 6 months of SDIS screening. Methods: Risk identification for sleep disturbance warranting sleep specialist evaluation was determined based on elevation on any SDIS scale for the entire sample. Patients with obstructive sleep apnea (OSA) and periodic limb movement disorder (PMLD) based on PSG were evaluated in relation to SDIS-OSA and SDIS-PLMD subscales (T-scores ≥ 60), with sensitivity, specificity, and receiver operator characteristic curves computed. Results: Clinical elevation correctly identified 74.0% to 83.6% referred to a sleep specialist. Nearly 30% of the subsample undergoing PSG met criteria for OSA and 20.2% had PLMs. The SDIS-OSA subscale demonstrated low to fair sensitivity and specificity. The SDIS-PLMD subscale displayed low sensitivity and low (children) to fair (adolescents) specificity, with the area under the curve suggesting good classification accuracy for adolescents. Conclusions: The SDIS performed well in identifying overall sleep disturbance risk in a large pediatric insomnia sample, suggesting careful examination of all subscales and total score to increase confidence in referral to a sleep specialist. Sensitivity and specificity indices highlight challenges in identifying primary sleep disorder risk and raise potential research questions regarding measurement of parent perceptions in children with insomnia. Additional research in nationally representative samples is warranted.

Topical Review: A Biopsychosocial Framework for Pediatric Narcolepsy and Idiopathic Hypersomnia.

OBJECTIVE: Provide an overview of current research findings in pediatric central disorders of hypersomnolence (CDH) and propose a biopsychosocial model for clinical management, with a focus on interdisciplinary care and future directions for research and clinical practice. METHODS: Literature review drawing from pediatric and adult narcolepsy, as well as pediatric sleep and chronic pain research to develop an integrative biopsychosocial model for pediatric CDH. RESULTS: Youth with CDH are vulnerable to impairments in academics, emotional, and behavioral functioning, activity engagement and quality of life (QOL). There is a complex interrelationship between neurobiological features of disease, treatment-related factors, and psychological, sleep-related, and contextual factors across development. Research is limited largely to adults and pediatric narcolepsy type 1 and the mechanisms and evolution of morbidity remain poorly understood. CONCLUSIONS: In addition to first-line treatment (pharmacotherapy), routine screening of bio-behavioral and psychosocial functioning and QOL is needed to identify risk for compromised functioning warranting adjunctive interventions with behavioral health specialists.

Rates of Mental Health Symptoms and Associations With Self-Reported Sleep Quality and Sleep Hygiene in Adolescents Presenting for Insomnia Treatment.

STUDY OBJECTIVES: Despite high prevalence rates of both psychopathology and sleep problems during adolescence, as well as frequent co-occurrence, little is known about the mental health of adolescents presenting for insomnia evaluation and treatment. This study describes (1) rates of mental health symptoms and (2) associations of mental health symptoms with sleep behaviors and schedules in adolescents presenting to a behavioral sleep medicine clinic within an accredited sleep disorders center. METHODS: As a part of routine clinical care, 376 adolescents (ages 11 to 18 years) presenting for insomnia evaluation completed measures of insomnia and sleep behavior. Their caregiver reported on mental health diagnoses and symptoms. RESULTS: Adolescents had high rates of mental health diagnoses (75%) and clinically elevated symptoms (64%). Affective, anxiety, and attention deficit-hyperactivity disorder (ADHD) symptoms were most commonly reported. Mental health symptoms were related to sleep behaviors and insomnia severity, with ADHD symptoms and affective problems most consistently associated with disrupted sleep. CONCLUSIONS: Health providers should assess for mental health problems in youth presenting with sleep-related concerns. Intervening with both sleep and mental health problems should be considered to most effectively improve functioning.

Mental Health Diagnoses and Symptoms in Preschool and School Age Youth Presenting to Insomnia Evaluation: Prevalence and Associations with Sleep Disruption.

Objective/Background: Sleep problems and emotional and behavioral difficulties are highly correlated in community samples of youth and in youth presenting to mental health treatment. However, fewer studies have characterized the associations between sleep and psychopathology symptoms in youth presenting to pediatric sleep clinics. This retrospective, cross-sectional study examined the prevalence of psychopathology symptoms and their associations with sleep disruption in youth presenting to a behavioral sleep medicine clinic. Participants: Participants were 373 preschoolers (1.5 to 5 years old) and 300 school age youth (6 to 10 years old) presenting to a pediatric behavioral sleep medicine clinic with a primary insomnia diagnosis. Methods: As a part of routine clinical care, parents completed a battery of pre-evaluation measures assessing insomnia severity, sleep disturbance, history of mental health diagnosis, and psychopathology symptoms. Results: Both preschool and school age youth had high rates of parent-reported mental health diagnoses (35% and 74%, respectively) and clinically elevated psychopathology symptoms (69% of preschoolers and 77% of school age youth) at initial insomnia evaluation. These symptoms were significantly associated with sleep disruption, with ADHD and affective problems most consistently associated with sleep problems in preschoolers and symptoms of anxiety, affective, and behavioral problems most consistently associated with sleep problems in school age youth. Conclusions: Psychopathology symptoms should be regularly assessed in youth presenting to behavioral sleep medicine clinics. Further, the role of psychopathology should be considered in insomnia conceptualization and treatment and, when appropriate, psychopathology symptoms should be targeted in treatment or appropriate referrals should be made.

Validation of a Brief Insomnia Severity Measure in Youth Clinically Referred for Sleep Evaluation.

Objectives: Evaluate psychometric properties of the Pediatric Insomnia Severity Index (PISI), a brief measure of insomnia severity. Methods: Clinically referred youth ( n = 462; 283 males, 179 females, mean age = 7.28 ± 2.05 years) and their caregiver(s) completed sleep evaluation including the PISI, Children's Sleep Habits Questionnaire, and sleep disorders inventory for students. Tests of reliability and validity and confirmatory factor analysis (CFA) were conducted to assess PISI psychometric properties. Exploratory analyses were conducted to examine insomnia severity by insomnia diagnosis. Results: Measures of internal consistency for the PISI factor scores varied. CFA indicated that a two-factor model had optimal fit relative to a single-factor solution. Overall, convergent and discriminant validity of PISI factors were supported. Insomnia severity varied by diagnosis. Conclusions: Findings provide preliminary support for the reliability and validity of the PISI within a large pediatric sample and for its clinical utility as a brief measure of insomnia severity.

Use of Sleep Evaluations and Treatments in Children with Down Syndrome.

OBJECTIVE: To characterize practice patterns regarding sleep evaluation and intervention among children with Down syndrome (DS). METHOD: Data were obtained from electronic health records from 2009 to 2013 for a retrospective cohort of 954 children with DS, aged 5 to 21 years during the time sampled. International Classification of Diseases, Ninth Revision, diagnoses were used to identify children with obstructive sleep apnea and/or behavioral sleep disturbances. Primary outcomes were confirmed by participation in an overnight diagnostic polysomnography (PSG) and/or documented provision of specified sleep interventions including positive airway pressure, otolaryngology (ENT) surgery, sleep medication, and behavioral sleep therapy. RESULTS: Overall, 47.7% of children with DS had undergone PSG, 39.1% had diagnosed sleep problems, and of those diagnosed with sleep problems, 81.2% had received sleep intervention. Consistent with best practice clinical care, sleep treatments matched the diagnosed sleep problems. Age, gender, and race, but not body mass index (BMI), were associated with PSG completion rate and occurrence rates for ENT surgery and sleep medication usage. BMI was associated with obstructive sleep apnea. CONCLUSION: Despite high rates of reported sleep problems in children with DS, less than half underwent PSG. Children diagnosed with sleep problems received treatment consistent with their sleep diagnosis. However, age and gender were associated with differential rates of treatment delivery that was incongruous with prevalence rates for diagnosed sleep problems. These findings underscore the importance of screening for sleep problems in children with DS, and referring for and providing appropriate targeted sleep interventions.