Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model.

Despite cognitive behaviour therapy for insomnia (CBT-I) being the first-line intervention for the disorder, it is often not readily available to patients in need. The stepped care model (SCM) represents an approach to facilitating efficient and wide-ranging provision of evidence-based care to those with insomnia. The SCM reflects a pyramid of therapeutics based on CBT-I gradually increasing in clinical intensity and addressing clinical complexity. By applying CBT-I through the SCM it is hoped that the treatment gap can be bridged such that not only more patients can be reached, but that clinical resource can be more effectively distributed, with patients receiving more tailored care as needed. Nevertheless, this should not be done at the risk of a lower quality of care being offered, and high-standard training for clinicians and scrutiny of non-clinician led interventions remains important. As national health laws within European countries have substantial differences, the application of the SCM as it relates to the treatment of insomnia may be challenged by contrasting interpretations. In order that the SCM is appropriately implemented: (a) only evidence-based CBT-I treatments should be promoted within the model; (b) clinicians involved in SCM should be suitably qualified to offer CBT in general, and have appropriate further training in CBT-I; (c) professionals involved in interventions not included in the SCM, but related to it, such as preventive and educational programmes, diagnostic procedures, and pharmacological treatments, should also have good knowledge of the SCM in order to promote correct allocation to the appropriate interventional step.

Child maltreatment and sleep: Two pathways explaining the link.

Many children suffer from maltreatment and show the aftermath of these experiences even in adulthood. Child maltreatment can lead to impaired sleep. This study examines pathways in which the association between child maltreatment and impaired sleep can be explained. In a cross-sectional questionnaire survey, maltreatment experiences (Childhood Trauma Questionnaire), romantic relationship satisfaction (Couple Satisfaction Index), attachment (Revised Adult Attachment Scale), cognitive hyperarousal (Emotion Control Questionnaire-rehearsal) and insomnia symptoms (Insomnia Severity Index) were assessed in 314 individuals aged 18-83 years and currently in a committed romantic relationship. Eligible participants (N = 57, aged 18-70 years) took part in an additional sleep assessment (actigraphy) and completed a questionnaire on sleep quality (Pittsburgh Sleep Quality Index). Demographic data were also assessed. Impaired subjective sleep was significantly predicted by child maltreatment experiences. In addition, rumination and romantic relationship satisfaction mediated the association between child maltreatment and adult sleep quality. A serial mediation from child maltreatment via comfort with closeness and romantic relationship satisfaction on sleep quality was found. Therapeutic treatments should focus more on sleep quality. Furthermore, they should also consider rumination to decrease the effect of child maltreatment on sleep quality. Sleep should also be taken into account in emotional regulation therapies for children as well as couples therapy in adulthood to decrease the effect of sleep impairments and child maltreatment on further life.

Consequences of child maltreatment: A glimpse at stress and sleep.

The present study goal was to provide further information on the association of maltreatment experiences in childhood (CM) and impaired sleep taking the hyperarousal theory of insomnia and stress reaction into account. In all, 62 participants took part in the study. CM history (Childhood Trauma Questionnaire) and subjective sleep quality (Pittsburgh Sleep Quality Index) were assessed before study commencement. In addition, participants wore an actigraph for 6-7 consecutive nights and completed a sleep log during this time. After 3-4 days, the participants took part in a laboratory stress paradigm (Maastricht Acute Stress Test) with 29 participants in the experimental and 31 in the control condition. Saliva cortisol samples were taken before and after the experiment and heart rate variability was assessed. CM was positively correlated with impaired subjectively assessed sleep in adulthood. The stress manipulation led to heightened subjective and physiological stress. Although lower cortisol changes after and lower mean heart rate values during the stress induction were found in the CM group, the differences were not statistically significant. There was no observable sleep reactivity on the stress induction. Stress and CM appear to have long-term effects on subjective sleep. Acute social stress does not directly worsen sleep quality, neither in participants with nor without a history of CM. However, the association underlines the importance of prevention and intervention. When treating sleep impairments, potential CM experiences should be taken into account.

Stress reactivity in salivary cortisol and electrocardiogram in adolescents: Investigating sleep disturbances and insomnia.

This study examined the role of sleep disturbances and insomnia in the context of stress reactivity in adolescence. One-hundred and thirty-five 11-18 year olds (Mage  = 14.2 years, SD = 1.9, 52% female) completed the Trier Social Stress Test for Children. Salivary cortisol and subjective stress ratings were collected at six time points, and heart rate as well as heart rate variability were measured pre-, during and post-stress induction. Additionally, sleep disturbances and insomnia diagnosis were assessed by a self-report questionnaire and a sleep interview. Robust mixed models investigated if adolescents with compared with adolescents without (a) sleep disturbances and (b) insomnia differ regarding cortisol, heart rate, heart rate variability and psychological stress reactivity considering gender effects. The results indicated that boys with high sleep disturbances showed higher cortisol activity compared with boys with low sleep disturbances, B = 0.88, p < 0.05. Moreover, in boys with insomnia, heart rate and alpha 1 significantly differ less than in boys without insomnia. These findings support the notion of sex differences regarding the association between poor sleep and increased activity of the hypothalamic-pituitary-adrenal axis, and a less adaptable autonomic nervous system in boys in response to an experimental social stress task.

A single-arm pilot study: can a parental sleep intervention for sleep-disturbed young children in individual settings improve children's sleep, crying, eating, and parental distress in mothers and fathers?

BACKGROUND: Early sleep problems co-occur with crying, eating problems, and parental distress. This study investigates the impact of a parent-focused intervention to improve child sleep with the following aims: (1) To assess the impact on child sleep (sleep onset latency, frequency and duration of nighttime awakenings, frequency of bed-sharing, and nighttime food intake, total nighttime sleep duration, and sleep efficiency), child crying (frequency of crying episodes, of unexplained and unsoothable crying and of crying out of defiance), child eating difficulties, and parental distress of mothers and fathers. (2) To assess the maintenance of any changes in these areas longitudinally, at 3-month, 6-month, and 12-month follow-ups. (3) To explore at the within-subjects level, how children's sleep, crying, eating, and parental distress changed together across all study measurement points. METHODS: In this single-arm pilot study, the parents of 60 children participated in six individual sessions of a parent-focused multimodal age-adjusted cognitive-behavioral intervention to improve child sleep. Parents of 39 children (46% girls, age in months M = 22.41, SD = 12.43) completed pre- and at least one measure after the intervention. Sleep diary, questionnaire for crying, feeding, sleeping, and parental stress index (short-form) were assessed pre, post, three, six, and 12 months after the intervention. RESULTS: Significantly, sleep (decreased sleep onset latency, frequency, duration of nighttime awakenings, bed-sharing, nighttime food intake; increased total nighttime sleep duration, sleep efficiency), crying (reduced frequency of crying episodes, unexplained and unsoothable crying), and parental distress (reduced) changed, which remained partially stable over follow-up. The frequency of crying episodes decreased with fewer nighttime awakenings; morning crying with increased nighttime feeding; unexplained and unsoothable crying with higher sleep efficiency; crying due to defiance with more nighttime awakenings, sleep efficiency, and bed-sharing. Eating problems decreased with shorter night awakenings and time; maternal distress with fewer nighttime awakenings, paternal with less child's nighttime feeding, unexplained and unsoothable crying, and time. CONCLUSIONS: A parental sleep intervention for sleep-disturbed young children could be promising to reduce children's sleep problems, crying, eating problems and parental distress. Future studies should consider more personal contact during the follow-up to reduce the drop-out rate and a randomized-controlled design. TRIAL REGISTRATION: The study was retrospectively registered at the German Clinical Trials Register (ID: DRKS00028578, registration date: 21.03.2022).

Dealing with sleep problems during home confinement due to the COVID-19 outbreak: Practical recommendations from a task force of the European CBT-I Academy.

In the current global home confinement situation due to the COVID-19 outbreak, most individuals are exposed to an unprecedented stressful situation of unknown duration. This may not only increase daytime stress, anxiety and depression levels, but also disrupt sleep. Importantly, because of the fundamental role that sleep plays in emotion regulation, sleep disturbance can have direct consequences upon next day emotional functioning. In this paper, we summarize what is known about the stress-sleep link and confinement as well as effective insomnia treatment. We discuss those effects of the current home confinement situation that can disrupt sleep but also those that could benefit sleep quality. We suggest adaptions of cognitive behavioural therapy elements that are feasible to implement for those facing changed work schedules and requirements, those with health anxiety and those handling childcare and home-schooling, whilst also recognizing the general limitations imposed on physical exercise and social interaction. Managing sleep problems as best as possible during home confinement can limit stress and possibly prevent disruptions of social relationships.

The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment.

Insomnia, the most prevalent sleep disorder worldwide, confers marked risks for both physical and mental health. Furthermore, insomnia is associated with considerable direct and indirect healthcare costs. Recent guidelines in the US and Europe unequivocally conclude that cognitive behavioural therapy for insomnia (CBT-I) should be the first-line treatment for the disorder. Current treatment approaches are in stark contrast to these clear recommendations, not least across Europe, where, if any treatment at all is delivered, hypnotic medication still is the dominant therapeutic modality. To address this situation, a Task Force of the European Sleep Research Society and the European Insomnia Network met in May 2018. The Task Force proposed establishing a European CBT-I Academy that would enable a Europe-wide system of standardized CBT-I training and training centre accreditation. This article summarizes the deliberations of the Task Force concerning definition and ingredients of CBT-I, preconditions for health professionals to teach CBT-I, the way in which CBT-I should be taught, who should be taught CBT-I and to whom CBT-I should be administered. Furthermore, diverse aspects of CBT-I care and delivery were discussed and incorporated into a stepped-care model for insomnia.

External Validity of the Multicomponent Group Treatment KiSS for School-Aged Children With Insomnia.

Background: Insomnia is common in school-aged children and often associated with other mental disorders. Here, we investigated the effectiveness and acceptance of the KiSS program in an "all-comer" pediatric insomnia clinic. Participants/Methods: Forty-five families (children: 5-10 years, 57.8% female) were randomly assigned to the multicomponent six-session KiSS treatment (CBT-I, hypnotherapy, and imaginations) or a wait-list control group. A sleep diary was recorded before intervention or waiting time, immediately after, as well as 3, 6, and 12 months postintervention (primary outcome: sleep efficiency, SE; sleep-onset latency, SOL). Results: Sleep improved significantly after the KiSS intervention. Three to 12 months after the intervention, only 1.75% of treated children still met the diagnostic criteria for insomnia. SE improved to 96%, and both SOL (reduced to 23 min) and total sleep time were normalized. All improvements were stable for at least one year after the intervention. KiSS was well accepted (0% dropout during intervention) and well tolerated. Conclusions: Treatment with the multimodal sleep training KiSS leads to positive changes in the sleep of children with insomnia, including a subset of children that presented with comorbid mental disorders. With only three sessions for parents and three sessions for children, the treatment can be readily implemented as a stand-alone treatment or be combined with other interventions. Dismantling studies and studies with an active control group are ongoing.

Aetiology and treatment of nightmare disorder: State of the art and future perspectives.

This consensus paper provides an overview of the state of the art in research on the aetiology and treatment of nightmare disorder and outlines further perspectives on these issues. It presents a definition of nightmares and nightmare disorder followed by epidemiological findings, and then explains existing models of nightmare aetiology in traumatized and non-traumatized individuals. Chronic nightmares develop through the interaction of elevated hyperarousal and impaired fear extinction. This interplay is assumed to be facilitated by trait affect distress elicited by traumatic experiences, early childhood adversity and trait susceptibility, as well as by elevated thought suppression and potentially sleep-disordered breathing. Accordingly, different treatment options for nightmares focus on their meaning, on the chronic repetition of the nightmare or on maladaptive beliefs. Clinically, knowledge of healthcare providers about nightmare disorder and the delivery of evidence-based interventions in the healthcare system is discussed. Based on these findings, we highlight some future perspectives and potential further developments of nightmare treatments and research into nightmare aetiology.

[Learning how to Sleep: Principles and Guidelines for Diagnostics and Treatment for Insomnia and Nightmares in Childhood and Adolescence]. / Schlafen kann man lernen: Leitlinienbasierte Diagnostik und Behandlung von Insomnien und Alpträumen im Kindes- und Jugendalter.

Learning how to Sleep: Principles and Guidelines for Diagnostics and Treatment for Insomnia and Nightmares in Childhood and Adolescence Impaired sleep, short sleep duration and sleep disorders appears also in early life. The most frequent sleep disorders are insomnia and nightmares. Risk of chronification is high and daytime impairments are extensively from emotion regulation problems, impaired performance, and aggression up to suicidality. Therefore, early diagnostic and treatment is necessary. As symptoms vary according to age, treatment should be strictly age-dependent. Various guideline-oriented and age-dependent treatments will be presented. Beyond, parents often have daytime impairments due to the child's sleep problem and therefore report an improvement of their own sleep after treatment. However, more studies are necessary and randomized controlled and age-oriented studies are necessary with inclusion of comorbid disorders or address sleep disorders in the context of mental disorders. In addition, efficacy of sleep treatment in mental disorders should be studied.

Let's talk about sleep: a systematic review of psychological interventions to improve sleep in college students.

Sleep problems are a common occurrence in college students. Insomnia, nightmares and impaired sleep quality lead to several mental health issues, as well as impaired academic performance. Although different sleep programmes exist, a systematic overview comparing their effectiveness is still missing. This systematic review aims to provide an overview of psychological interventions to improve sleep in college students. Seven databases were searched from November to December 2016 (MEDLINE, EMBASE, PsycINFO, Cinahl, Cochrane Library, PubMed, OpenSigle). The search string included search terms from three different topics: sleep, intervention and college students. Outcome measures included subjective as well as objective measures and focused on sleep, sleep-related and mental health variables. Twenty-seven studies met the inclusion criteria. They were assigned to four intervention categories: (1) sleep hygiene, (2) cognitive-behavioural therapy (CBT), (3) relaxation, mindfulness and hypnotherapy and (4) other psychotherapeutic interventions. Fifteen studies were randomized controlled trials. While sleep hygiene interventions provided small to medium effects, the CBTs showed large effects. The variability of the effect sizes was especially large in the relaxation category, ranging from very small to very large effect sizes. Other psychotherapeutic interventions showed medium effects. CBT approaches provided the best effects for the improvement of different sleep variables in college students. Five studies included insomnia patients. The other three intervention categories also showed promising results with overall medium effects. In the future, CBT should be combined with relaxation techniques, mindfulness and hypnotherapy. Furthermore, the interventions should broaden their target group and include more sleep disorders.

Sleep better, feel better? Effects of a CBT-I and HT-I sleep training on mental health, quality of life and stress coping in university students: a randomized pilot controlled trial.

BACKGROUND: The SWIS sleep training for university students showed promising results regarding subjective and objective sleep parameters. As sleep disorders and impaired sleep quality are closely related to various aspects of mental health, the current study examines the effects of the SWIS sleep training on mental health in university students. METHODS: Fifty six university students (M = 25.84, SD = 5.06) participated in the study, 68% were women. Forty one were randomly assigned to the SWIS treatment (pre-post-follow-up), 15 to a Waiting List Control condition (WLC, pre-post). Besides sleep-related measures, the students completed four online questionnaires measuring mental health, quality of life and stress coping strategies. Effect sizes for the pre-post data were compared between the conditions, long-term effects were calculated with repeated measures ANOVA or Friedman ANOVA. Long-term clinical changes were analyzed with the Reliable Change Index (RCI). RESULTS: The pre-post comparisons between SWIS and WLC revealed lower depression scores in both conditions, a better physical state in the SWIS condition and less maladaptive stress coping strategies in the WLC students. The long-term results of SWIS provided significant improvements regarding the students' somatic complaints, reduced anxiety, an improved physical state and a better quality of life with moderate to large effect sizes. Most of the significant improvements occurred between pre- and follow-up measurement. These statistically significant results were also reflected in clinically significant changes from pre- to follow-up-test. CONCLUSIONS: SWIS and WLC condition both improved in two mental health variables immediately after the training. These findings may be explained by unspecific treatment expectation effects in the WLC. Interestingly, most mental health outcomes showed significant improvements after 3 months, but not immediately after the training. These positive long-term effects of the SWIS training on mental health indicate that the transfer of strategies might simply need more time to affect the students' mental health. TRIAL REGISTRATION: The current study was retrospectively registered at German Clinical Trials Register (ID: DRKS00014338 , registration date: 20.04.2018, enrolment of first participant: 14.04.2015).

Short- and Long-Term Effects of CBT-I in Groups for School-Age Children Suffering From Chronic Insomnia: The KiSS-Program.

OBJECTIVE/BACKGROUND: This intervention study evaluates the short- and long-term effects of cognitive behavior therapy for insomnia (CBT-I) in groups for school-age children and their parents, named the KiSS-program. CBT-I was implemented in three sessions for children and three sessions for parents. PARTICIPANTS AND METHODS: All in all, 112 children with chronic childhood insomnia were randomly assigned to a wait-list (WL) control or treatment condition. RESULTS: According to subjective measures as well as objective wrist actigraphy, children in the CBT-I condition reported greater improvements in sleep behavior immediately after the treatment compared to the WL group. Improvements in sleep behavior after CBT-I persisted over the 3-, 6-, and 12-month follow-up assessments. CONCLUSIONS: The present study is the first randomized controlled trial that provides evidence for the long-term effectiveness of CBT-I in treating school-age children with chronic insomnia.

[Therapy of insomnia and nightmares in childhood and adolescence]. / Therapie von Insomnien und Albträumen im Kindes- und Jugendalter.

Therapy of insomnia and nightmares in childhood and adolescence Abstract. Sleep problems and sleep disorders have a high prevalence in childhood and adolescence. Normally, such conditions persist and often become chronic. Daytime impairments are widespread with concentration deficits, mental problems, and also a higher suicide risk. Therefore, early and effective interventions are necessary. As symptoms change with age, therapy should be adjusted accordingly. Various strategies for infants and toddlers, schoolchildren, and adolescents will be named. In addition, evidence of these therapy strategies will be shown. All in all, more randomized controlled studies addressing children and adolescents are needed. Furthermore, studies with children and adolescents suffering from comorbid disorders or mental disorders and sleep problems should be conducted.

[Review: Sleep and mental disorders in childhood and adolescence]. / Review: Schlafprobleme und psychische Störungen im Kindes- und Jugendalter.

REVIEW: Sleep and mental disorders in childhood and adolescence Abstract. Sleep problems and disorders are common in childhood and adolescence. This review aims to throw light on the relationship between sleep problems and mental disorders in childhood and adolescence. Sleep problems and disorders appear to be risk factors for mental disorders as comorbidities, as symptoms, and as effects of mental disorders. Frequently, there is an interaction between sleep behaviour and psychopathology so that sleep problems contribute to the intensity and maintenance of mental disorders. This bidirectional association is observed in early childhood as well as in school-aged children and in adolescents. Many studies show that this association has a long-term nature beyond child development. Both environmental and genetic factors seem to play a role in the development and maintenance of the relationship between sleep problems and mental disorders. Various research articles show that treatment of mental disorders and treatment of sleep disorders influence each other in a positive way. Therefore, it is strongly advised to consider sleep problems in diagnosis and treatment but also in prevention of mental disorders.

Overweight in adolescent, psychiatric inpatients: A problem of general or food-specific impulsivity?

Adolescent psychiatric patients are vulnerable to weight problems and show an overrepresentation of overweight compared to the healthy population. One potential factor that can contribute to the etiology of overweight is higher impulsivity. As of yet, it is unclear whether it is a general impulse control deficit or weight-related aspects such as lower impulse control in response to food that have an impact on body weight. As this may have therapeutic implications, the current study investigated differences between overweight and non-overweight adolescent psychiatric inpatients (N = 98; aged 12-20) in relation to trait impulsivity and behavioral inhibition performance. The Barratt Impulsiveness Scale and two go/no-go paradigms with neutral and food-related stimulus materials were applied. Results indicated no significant differences concerning trait impulsivity, but revealed that overweight inpatients had significantly more difficulties in inhibition performance (i.e. they reacted more impulsively) in response to both food and neutral stimuli compared to non-overweight inpatients. Furthermore, no specific inhibition deficit for high-caloric vs. low-caloric food cues emerged in overweight inpatients, whereas non-overweight participants showed significantly lower inhibition skills in response to high-caloric than low-caloric food stimuli. The results highlight a rather general, non-food-specific reduced inhibition performance in an overweight adolescent psychiatric population. Further research is necessary to enhance the understanding of the role of impulsivity in terms of body weight status in this high-risk group of adolescent inpatients.

The Children's Sleep Comic: Psychometrics of a Self-rating Instrument for Childhood Insomnia.

The Children's Sleep Comic is a standardized self-report questionnaire for assessing insomnia in children ages 5-11 years. The goal of the present study is to introduce a revised version of this measure and to present psychometrics and a cut-off score. Therefore, the revised Children's Sleep Comic, the Sleep Self Report, the Children's Sleep Habits Questionnaire, and the Child Behavior Checklist were applied to a sample of 393 children and their parents. Of the parents who participated voluntarily, a subsample (n = 176) was interviewed on the phone to diagnose their children with sleep disorders according to the International Classification of Sleep Disorders, if applicable. The results indicated that the Children's Sleep Comic is a reliable self-rating instrument for diagnosing childhood insomnia. Internal consistency was α = 0.83; and convergent and divergent validity were adequate. The child-friendly format can foster a good therapeutic relationship, and thus establish the basis for successful intervention.

Measuring Somatic Complaints in Primary School Children: Validation and Revision of the German Children's Somatization Inventory (CSI) and its Parental Version.

The objective was a psychometric examination of a German translation of the Children's Somatization Inventory (CSI) and its parents' version (P-CSI) and a replication of the item selection process of Walker et al. in J Pediatr Psychol 34:430-440 [5] for their revised version to create shorter German versions. Based on a school sample of 1,539 parents and 731 children, we explored the psychometric properties and dimensionality of the original and a shortened revised version. A clinical sample of 70 parental reports served as an additional sample. Walker et al.'s item selection could be largely replicated. Dimensionality differed between samples and versions (original vs. revised), but original DSM-III symptom clusters could mostly be identified. Symptom intensity was associated with age and mental health. Internal consistency, test-retest- and inter-rater reliability were good. Both German versions, the CSI and the P-CSI can be regarded as a useful screening instrument for somatic complaints in children.

[Efficacy of the ¼Tuebinger-Intensiv-Programm für Eltern« in Treating Childhood Anxieties - A Pilot Study]. / Die Wirksamkeit des Tübinger-Intensiv-Programms bei Müttern und Vätern ängstlicher Kinder - Eine Pilotstudie.

Anxiety problems among young children are highly prevalent and related to family factors such as parenting behavior or parental psychological health. The current pilot study examined the effectiveness of the non-specific, short-term, behavioral-hypnotherapeutic parent training Tipe in treating abnormal childhood anxieties. Childhood anxiety, parenting behavior, parenting sense of competence, and psychological stress of the parents were measured at three points in time (pretest, posttest, 3-month follow-up). Obtained data was compared to a waiting-list control condition. After participating, parents of the treatment condition reported less dysfunctional parenting behavior, less psychological stress, and higher parenting sense of competence. Their children were significantly less anxious. These effects were stable after three months. Families of the waiting-list control condition, however, showed no significant changes. We conclude that a general behavioral-hypnotherapeutic parent training positively affects the course of childhood anxiety problems.

Placebo effects in children: a review.

Of more than 155,000 PubMed citations found with the search term "placebo," only ~9,000 (5.8%) included the terms "children" or "adolescents." When all these papers were screened, only ~2,000 of them investigated the placebo effect per se, and of those, only ~50 (2.5%) discussed the placebo effect in children and adolescents. In this narrative review, we explore four aspects of the placebo response in children and adolescents: (i) the legal and ethical limitations and restrictions for the inclusion of children in clinical trials as well as in experimental (placebo) research that may explain the poor knowledge base; (ii) the question of whether or not the placebo effect is larger in children and adolescents as compared with adults; (iii) whether the mechanisms underlying the placebo effect are similar between children and adults; and (iv) whether mediators and moderators of the placebo effect are comparable between children and adults. We finally discuss some of the consequences from the current placebo research in adults that may affect both experimental and clinical research in children and adolescents.