Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit.

Challenges exist in access to high-quality care for insomnia disorder. After the recent publication of a clinical practice guideline on behavioral and psychological treatments for insomnia in adults, the American Academy of Sleep Medicine (AASM) hosted a 1-day virtual Insomnia Summit in September 2022 to discuss improving care for patients with insomnia disorder. Fifty participants representing a variety of organizations (eg, medical, psychological, and nursing associations; patient advocacy groups; and federal institutions) participated in the event. Videos highlighting patient perspectives on insomnia and an overview of current insomnia disorder treatment guidelines were followed by thematic sessions, each with 3 to 4 brief, topical presentations by content experts. Breakout groups were used to brainstorm and prioritize issues in each thematic area. Top barriers to care for insomnia disorder include limited access, limited awareness of treatment options, low perceived value of insomnia treatment, and an insufficient number of trained clinicians. Top facilitators of high-quality care include education and awareness, novel care models to increase access, expanding the insomnia patient care workforce, incorporating research into practice, and increasing reimbursement for psychotherapies. Priorities for the future include increasing awareness among patients and providers, increasing the number of skilled behavioral sleep medicine providers, increasing advocacy efforts to address insurance issues (eg, billing, reimbursement, and performance measures), and working collaboratively with multidisciplinary organizations to achieve common goals. These priorities highlight that goals set to improve accessible, high-quality care for insomnia disorder will require sustained, coordinated efforts to increase awareness, improve reimbursement, and grow the necessary skilled health care workforce. CITATION: Schotland H, Wickwire E, Aaronson RM, et al. Increasing access to evidence-based insomnia care in the United States: findings from an American Academy of Sleep Medicine stakeholder summit. J Clin Sleep Med. 2024;20(3):455-459.

Sleep Patterns and School Readiness of Pre-Kindergarteners from Racially and Ethnically Diverse, Low-Income Backgrounds.

OBJECTIVE: To explore patterns in parent-reported child sleep health and to investigate connections between such patterns and school readiness for newly enrolled prekindergarten (PreK) attendees from racially and ethnically diverse, low-income backgrounds. STUDY DESIGN: In a secondary analysis from a larger multiple-cohort longitudinal observational study of prekindergartners in low-income families, parental reports of sleep health for 351 children (mean age, 52.8 ± 3.5 months) during the first month of PreK were analyzed. Children also had completed direct assessments measuring language, literacy, mathematics, and executive functioning, and teachers rated children's social-emotional-behavioral competencies and approaches to learning at PreK entry. We performed latent class analyses to identify patterns in sleep health and used regression models to examine concurrent associations between child sleep health patterns and school readiness competencies across 6 domains: language, literacy, mathematics, executive functioning, social-emotional-behavioral, and approaches to learning. RESULTS: Two classes emerged reflecting more and less desirable patterns of sleep health. Children classified in the earlier, longer, consistent sleep health class (87% of children) experienced earlier bedtimes, longer night-time sleep durations, more consistent sleep routines, less caffeine consumption ≤3 hours before bedtime, and scored higher on a direct assessment of expressive vocabulary and on teacher-reported measures of social-emotional-behavioral competencies and learning approaches than their peers in the later, shorter, inconsistent sleep health class (13% of children). CONCLUSIONS: Consistent sleep routines and more optimal sleep health may serve as a protective mechanism for the language development, social-emotional-behavioral regulation, and approaches to learning of PreK from racially and ethnically diverse, low-income backgrounds. Clinician-parent discussions regarding optimal sleep health may provide key opportunities for targeted education that promotes school readiness skill development.

Later Start, Longer Sleep: Implications of Middle School Start Times.

BACKGROUND: Although adolescents generally get less than the recommended 9 hours of sleep per night, research and effort to delay school start times have generally focused on high schools. This study assesses the relation between school start times and sleep in middle school students while accounting for potentially confounding demographic variables. METHODS: Seventh and eighth grade students attending 8 late starting schools (∼8:00 am, n = 630) and 3 early starting schools (∼7:23 am, n = 343) from a diverse suburban school district completed online surveys about their sleep behaviors. Doubly robust inverse probability of treatment weighted regression estimates of the effects of later school start time on student bedtimes, sleep duration, and daytime sleepiness were generated. RESULTS: Attending a school starting 37 minutes later was associated with an average of 17 additional minutes of sleep per weeknight, despite an average bedtime 15 minutes later. Students attending late starting schools were less sleepy than their counterparts in early starting schools, and more likely to be wide awake. CONCLUSIONS: Later school start times were significantly associated with improved sleep outcomes for early adolescents, providing support for the movement to delay school start times for middle schools.

Variable School Start Times and Middle School Student's Sleep Health and Academic Performance.

PURPOSE: Improving sleep health among adolescents is a national health priority and implementing healthy school start times (SSTs) is an important strategy to achieve these goals. This study leveraged the differences in middle school SST in a large district to evaluate associations between SST, sleep health, and academic performance. METHODS: This cross-sectional study draws data from a county-wide surveillance survey. Participants were three cohorts of eighth graders (n = 26,440). The school district is unique because SST ranged from 7:20 a.m. to 8:10 a.m. Path analysis and probit regression were used to analyze associations between SST and self-report measures of weekday sleep duration, grades, and homework controlling for demographic variables (sex, race, and socioeconomic status). The independent contributions of SST and sleep duration to academic performance were also analyzed. RESULTS: Earlier SST was associated with decreased sleep duration (χ2 = 173, p < .0001) and deficient sleep (≤7 hours) among 45% of students. Students with SST before 7:45 a.m. were at increased risk of decreased sleep duration, academic performance, and academic effort. Path analysis models demonstrated the independent contributions of sleep duration, SST, and variable effects for demographic variables. CONCLUSIONS: This is the first study to evaluate the independent contributions of SST and sleep to academic performance in a large sample of middle school students. Deficient sleep was prevalent, and the earliest SST was associated with decrements in sleep and academics. These findings support the prioritization of policy initiatives to implement healthy SST for younger adolescents and highlight the importance of sleep health education disparities among race and gender groups.

Sleep Patterns and Academic Performance During Preparation for College Entrance Exam in Chinese Adolescents.

BACKGROUND: Deficient sleep is linked to detrimental outcomes in health and school performance for adolescents. This study characterized sleep patterns in Chinese adolescents preparing for the College Entrance Exam (CEE) and evaluated the association between sleep patterns, self-rated academic performance, and the CEE scores. METHODS: A sample of 481 Chinese adolescents in 12th grade (ages 16-19 years) completed questionnaires about sleep patterns, academic performance, academic stress, and sociodemographic factors 4-6 weeks before the CEE in June 2013. The CEE scores for each student also were obtained. RESULTS: A total of 21% of the students had bedtimes after 12:00 am, 78.3% had sleep latency longer than 30 minutes, 14.6% had wake time earlier than 6:00 am, and the vast majority (94.4%) had sleep duration less than 8 hours. After adjusting for selected confounders such as academic stress, prolonged sleep latency was associated with poorer self-reported academic performance, and late bedtime was associated with higher CEE score. CONCLUSIONS: Our findings highlight the complex association between sleep and academic performance. Assessing and monitoring sleep patterns in adolescents during periods of high academic demand and stress may yield important recommendations for their health and safety as well as establishing optimal sleep and study habits.

Quality measures for the care of patients with insomnia.

ABSTRACT: The American Academy of Sleep Medicine (AASM) commissioned five Workgroups to develop quality measures to optimize management and care for patients with common sleep disorders including insomnia. Following the AASM process for quality measure development, this document describes measurement methods for two desirable outcomes of therapy, improving sleep quality or satisfaction, and improving daytime function, and for four processes important to achieving these goals. To achieve the outcome of improving sleep quality or satisfaction, pre- and post-treatment assessment of sleep quality or satisfaction and providing an evidence-based treatment are recommended. To realize the outcome of improving daytime functioning, pre- and post-treatment assessment of daytime functioning, provision of an evidence-based treatment, and assessment of treatment-related side effects are recommended. All insomnia measures described in this report were developed by the Insomnia Quality Measures Workgroup and approved by the AASM Quality Measures Task Force and the AASM Board of Directors. The AASM recommends the use of these measures as part of quality improvement programs that will enhance the ability to improve care for patients with insomnia.

Associations between physical activity, sedentary time, sleep duration and daytime sleepiness in US adults.

OBJECTIVE: To examine the associations between objectively measured physical activity (PA) or sedentary behavior and self-reported sleep duration or daytime sleepiness in a nationally representative sample of healthy US adults (N=2128). METHODS: We report analyses of four aspects of sedentary behavior and PA derived from accelerometry data (minutes of sedentary time, activity counts/minute, Minutes of Moderate and Vigorous PA [MVPA], and MVPA in 10-minute bouts) versus self-report of sleep duration and frequency of daytime sleepiness from the 2005-2006 National Health and Nutrition Examination Survey. RESULTS: Age and sex dependence of associations between PA and sleep were observed. Aspects of PA were significantly lower in adults reporting more frequent daytime sleepiness in younger (20-39) and older (≥ 60) age groups, but not in middle-aged (40-59), respondents. In younger respondents, PA increased with sleep duration, but in middle aged and older respondents PA was either unrelated to sleep duration or lower in those reporting ≥ 8 h of sleep. Objectively measured sedentary time showed limited evidence of associations with sleep duration. CONCLUSIONS: Further research delineating the relationships between sleep and PA is important because both activities have been implicated in diverse health outcomes as well as in the etiology of obesity.

Ethical issues in the conduct of clinical trials in obstructive sleep apnea.

Scientifically rigorous clinical trials are needed to test continuous positive airway pressure's (CPAP) effect on important clinical endpoints known to be associated with obstructive sleep apnea, such as myocardial infarction, cardiac arrhythmias, stroke, mortality, seizures, and cognitive function. In this "Special Article," we review the regulatory and ethical issues that surround the design and conduct of CPAP trials, including selection of the appropriate control condition, exclusion criteria, and follow-up duration.

Polysomnographic characteristics of a referred sample of children with sickle cell disease.

STUDY OBJECTIVES: To describe polysomnographic parameters and their clinical correlates in a referred sample of children with sickle cell disease (SCD). METHODS: This was a retrospective medical record review of 55 consecutive children aged 2-18 years with SCD (hemoglobin [Hb] SS and Hb SC genotypes) undergoing polysomnography for evaluation of sleep disordered breathing. Polysomnography values were compared between SCD genotypes, 4 age groups, and adenotonsillectomy status using descriptive and nonparametric statistics. RESULTS: Obstructive sleep apnea (OSA) was diagnosed in 38/55 (69%) children. Polysomnographic parameters differed significantly between Hb SS and Hb SC genotypes only on arterial oxyhemoglobin saturation (SpO2; 95.2 +/- 3.8 vs. 98.0 +/- 0.8, respectively, p < 0.01) and percent of sleep time below SpO2 90% (T90; 8.0 +/- 22.0 vs. 0.01 +/- 0.02, respectively, p < 0.05). Increasing age was associated with decreasing SpO2 (rho = -0.282, p < 0.05), obstructive apnea-hypopnea index (OAHI; rho = -0.364, p < 0.01), total arousal index (rho -0.272, p < 0.05) and respiratory arousal index (rho = -0.349, p < 0.01). Periodic limb movements in sleep (PLM) averaged 4.7 +/- 8.8/h, with a PLM index > 5/h in 5/17 children without OSA. Post- adenotonsillectomy, 8/10 children had OSA, but compared to untreated OSA-positive children they had a lower mean OAHI (4.4 +/- 5.5 vs. 8.9 +/- 12.5) and a lower T90 (1.6 +/- 4.2 vs. 9.2 +/- 24.9). CONCLUSIONS: Both OSA and PLMs were common in children with SCD. Children with Hb SS experienced more severe nocturnal oxygen desaturation than did those with Hb SC. Post-adenotonsillectomy, most children had OSA, although they experienced fewer obstructive respiratory events and less severe nocturnal oxygen desaturation than did untreated OSA-positive children.

Children show individual night-to-night variability of periodic limb movements in sleep.

STUDY OBJECTIVE: Several studies have documented the occurrence of significant night-to-night variability of periodic limb movements in sleep (PLMS) in adults.The aim of this study was to investigate the night-tonight variability of PLMS in children. DESIGN AND MEASUREMENTS: Two to 4 nights of polysomnography were performed as part of a multisite, placebo-controlled study investigating the effects of carbidopa/levodopa on attention-deficit/hyperactivity disorder in children who were not taking other medications that impacted the central nervous system. Baseline polysomnograms from all children and endpoint polysomnograms from children who were randomly assigned to a placebo group were scored using International Restless Legs Syndrome Study Group criteria for PLMS. PLMS indexes from 101 sleep studies of 36 children, aged 7 to 12 years, were compared. INTERVENTIONS: N/A. RESULTS: For all 36 children as a group, PLMS index on Night 1 was predictive of PLMS index on Night 2 (odds ratio 7.0, 95% confidence interval 1.4-38.4), suggesting that overall diagnostic classification (PLMS index above or below 5/h) was accurate. In addition, for the 15 children with 5 or more PLMS per hour on either night, there was no significant group difference on Night 1 versus Night 2 for mean PLMS index (10.6 vs 8.5/h, P = 0.92) or chance of having 5 or more PLMS per hour, indicating no first-night effect. When looking at individual data, however, 9 of these 15 children (60%) had PLMS indexes over and under the 5 per hour cutoff on these 2 nights. Of these 15, 10 had clinical diagnoses of restless legs syndrome and 5 of periodic limb movement disorder (PLMD). The PLMS indexes of all children who were medication free for a third and fourth night (n = 7) or just a third night (n = 2) and had not shown a PLMS index of 5 or greater on either of the first 2 nights remained under this threshold. CONCLUSIONS: In this sample of children, considerable individual night-to-night variability of PLMS indexes was observed. This finding has important clinical relevance for the diagnosis of restless legs syndrome and PLMD and may have an impact on future studies that correlate individual PLMS severity with frequently associated symptoms, such as negative affect, fatigue, and inattention. Our data, however, also suggest that individual PLMS variability is random and not likely to skew the group-level analysis of treatment outcome studies.

Sleep characteristics of youth with functional abdominal pain and a healthy comparison group.

OBJECTIVE: To describe sleep problems among youth with and without functional abdominal pain (FAP). METHODS: Participants were 8-15 years of age diagnosed with FAP (n = 67) or healthy pain-free comparisons (n = 80). Parents and participants completed instruments assessing sleep, psychiatric status, and FAP symptoms. Parent and child reports of sleep problems were compared across groups and the association of FAP to behavioral sleep problems was assessed controlling for psychopathology. RESULTS: Children with FAP were reported to have more symptoms of behavioral sleep disorders (BSD), as well as increased nightmares and daytime tiredness than the comparison group. There were no group differences in total sleep time. Logistic regression analysis indicated that FAP was associated with a significantly increased risk of BSD symptoms [Odds ratio (OR): 4.17] after controlling for psychopathology. CONCLUSION: Sleep problems in youth with FAP warrant clinical attention and future research should continue to explore sleep problems that co-occur with and independent of psychopathology.

Behavioral treatment of bedtime problems and night wakings in infants and young children.

This paper reviews the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. It is based on a review of 52 treatment studies by a task force appointed by the American Academy of Sleep Medicine to develop practice parameters on behavioral treatments for the clinical management of bedtime problems and night wakings in young children. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodified extinction and preventive parent education. In addition, support is provided for graduated extinction, bedtime fading/positive routines, and scheduled awakenings. Additional research is needed to examine delivery methods of treatment, longer-term efficacy, and the role of pharmacological agents. Furthermore, pediatric sleep researchers are strongly encouraged to develop standardized diagnostic criteria and more objective measures, and to come to a consensus on critical outcome variables.

Preliminary evidence for sleep complaints among children referred for anxiety.

BACKGROUND AND PURPOSE: Clinical observation suggests that sleep complaints are common among youth with anxiety disorders though empirical data documenting this co-occurrence of symptoms are generally unavailable. PATIENTS AND METHODS: Based on retrospective chart reviews, the current study examined rates of several types of parent-reported sleep complaints among a sample of (n=35) purely anxious children and adolescents (ANX). Sleep complaints were examined in terms of age (children versus adolescents) and type of anxiety diagnosis (generalized anxiety versus other anxious diagnoses). Rates of sleep complaints among anxious youth also were compared to those among (n=38) healthy control children and (n=33) children referred for sleep problems. RESULTS: The presence of at least one intermittent sleep complaint was reported by 83% of parents of ANX, with almost half reporting at least one frequent sleep complaint. Rates of sleep complaints among anxious children versus adolescents were similar. Children with generalized anxiety disorder (GAD) had a significantly greater number of sleep complaints than children with other types of anxiety disorders, though rates for specific items varied. Although parents of sleep-referred children reported the highest rates of sleep complaints overall, the frequency of several specific types of sleep complaints was highly similar among ANX and sleep-referred children. CONCLUSIONS: Findings indicate that certain sleep complaints are common among ANX. The need for appropriate assessment practices is discussed.

Measuring mood and complex behavior in natural environments: use of ecological momentary assessment in pediatric affective disorders.

This article describes the theoretical background and methodology of ecological momentary assessment (EMA) and reports results from a pilot study using EMA techniques in 16 children and adolescents with affective disorders and 5 subjects who were healthy and at low risk to develop future affective disorders. Multiple daily assessments of the subjects' mood, thoughts, and behaviors were performed in their natural environments using brief interviews on cellular phone calls by the study staff and by wrist actigraphy. The pilot results demonstrated that the EMA methodology is feasible in this population, as 17 of 21 subjects were able to complete the entire 8-week protocol. The potential usefulness of the EMA methodology is illustrated by specific case reports. Potential applications of the EMA methodology to the study of neurobehavioral systems and the pathophysiology of pediatric affective disorders are discussed.

Pathways to adolescent health sleep regulation and behavior.

There are several converging reasons to focus on sleep regulation in relation to healthy adolescent development: (a) Sleep appears to be particularly important during periods of brain maturation; (b) there are substantial biological and psychosocial changes in sleep and circadian regulation exist across pubertal development; (c) interactions between physical and psychosocial domains can lead to dramatic alterations in sleep patterns and habits during adolescence; (d) increasing evidence that many adolescents frequently obtain insufficient sleep exists; (e) there is mounting evidence that sleep deprivation has its greatest negative effects on the control of behavior, emotion, and attention, a regulatory interface that is critical in the development of social and academic competence, and psychiatric disorders; (f) the most obvious direct health consequences of insufficient sleep are high-risk behaviors associated with substance abuse and automobile accidents; (g) substantial evidence for bidirectional effects between sleep and behavioral/emotional regulation exists. Although the past decade has seen research progress in these areas, there continue to be major gaps in existing knowledge and a paucity of well-controlled studies to guide specific health policy decisions and recommendations regarding sleep in adolescence. In particular, there is need for improved understanding of the acute and chronic effects of inadequate sleep in adolescents, guidelines for defining adequate sleep in adolescents, and a better delineation of the links among sleep, behavior, and affect regulation. Finally, this paper briefly examines one specific application of this knowledge area regarding early starting times among some high schools.

Preliminary evidence of behavioral and cognitive sequelae of obstructive sleep apnea in children.

OBJECTIVES: To characterize the daytime sequelae of obstructive sleep apnea (OSA) in children. BACKGROUND: OSA syndrome is a common disorder in children with estimates of prevalence ranging from 1.1 to 2.9%. Numerous studies have documented neuropsychological deficits in adults with OSA, although only a few preliminary studies have described these problems in children with OSA. METHODS: In the present study, otherwise healthy children with OSA (n=28), and a healthy age-matched comparison group (n=10) were assessed with standard measures of sleep, behavior, and cognitive function. RESULTS: Children with OSA had significantly more behavior problems than the healthy comparison group based on parents' reports (F=7.29, P<0.005). Children diagnosed with moderate to severe OSA had significantly lower scores on a timed cancellation task that assesses sustained attention (F=10.0, P<0.01). A significant association was found between OSA severity (rho=-86, P<0.01) and measures of verbal ability. CONCLUSIONS: These initial findings suggest that there are identifiable daytime sequelae of childhood OSA and that it is important to evaluate these daytime disturbances in making determinations about intervention.