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Children with autism spectrum disorder (ASD) report high rates of sleep problems. In 2012, the Autism Treatment Network/ Autism Intervention Research Network on Physical Health (ATN/AIR-P) Sleep Committee developed a pathway to address these concerns. Since its publication, ATN/AIR-P clinicians and parents have identified night wakings as a refractory problem unaddressed by the pathway. We reviewed the existing literature and identified 76 scholarly articles that provided data on night waking in children with ASD. Based on the available literature, we propose an updated practice pathway to identify and treat night wakings in children with ASD.
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BACKGROUND: A growing body of evidence for digital interventions to improve sleep shows promising effects. The interventions investigated so far have been primarily web-based; however, app-based interventions may reach a wider audience and be more suitable for daily use. OBJECTIVE: This study aims to evaluate the intervention effects, adherence, and acceptance of an unguided app-based intervention for individuals who wish to improve their sleep. METHODS: In a randomized controlled trial, we evaluated the effects of an app-based short intervention (Refresh) to improve sleep compared with a waitlist condition. Refresh is an 8-week unguided intervention covering the principles of cognitive behavioral therapy for insomnia (CBT-I) and including a sleep diary. The primary outcome was sleep quality (insomnia symptoms) as self-assessed by the Regensburg Insomnia Scale (RIS). The secondary outcomes were depression (9-item Patient Health Questionnaire [PHQ-9] score) and perceived insomnia-related impairment. RESULTS: We included 371 participants, of which 245 reported poor sleep at baseline. About 1 in 3 participants who were allocated to the intervention group never accessed the intervention. Active participants completed on average 4 out of 8 chapters. Retention rates were 67.4% (n=250) at postassessment and 57.7% (n=214) at the 6-month follow-up. At postintervention, insomnia symptoms in the intervention group had improved more than those in the waitlist group, with a small effect (d=0.26) in the whole sample and a medium effect (d=0.45) in the subgroup with poor sleep. Effects in the intervention group were maintained at follow-up. Perceived insomnia-related impairment also improved from pre- to postassessment. No significant intervention effect on depression was detected. Working alliance and acceptance were moderate to good. CONCLUSIONS: An app-based, unguided intervention is a feasible and effective option to scale-up CBT-I-based treatment, but intervention uptake and adherence need to be carefully addressed. TRIAL REGISTRATION: ISRCTN Registry ISRCTN53553517; https://www.isrctn.com/ISRCTN53553517.
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Cognitive behavioral therapy for insomnia (CBT-I) is the universally recommended treatment of choice for insomnia disorder based on its safety and posttreatment durability of benefit. However, CBT-I does not help all patients achieve remission. The second most evidence-based treatment, hypnotic pharmacotherapy (PCT), does not resolve perpetuating factors of insomnia, resulting in potential waning of benefit and dependence. This article presents a rationale that supports consideration of hypnotic augmentation of CBT-I (COMB), along with a review of select randomized controlled trials relevant to clinical decision-making.
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Terapia Cognitivo-Conductual , Trastornos del Inicio y del Mantenimiento del Sueño , Humanos , Trastornos del Inicio y del Mantenimiento del Sueño/tratamiento farmacológico , Hipnóticos y Sedantes/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Resultado del TratamientoRESUMEN
Objectives: A large proportion of individuals with chronic pain experience insomnia-related symptoms which can be persistent in nature, and negatively impact one's quality of life. This single arm trial aimed to investigate the feasibility and preliminary efficacy of CBT-I, adapted for people with chronic musculoskeletal pain, delivered via telehealth. Methods: We conducted a single arm feasibility trial in which 10 adult women (M age = 50.76 years, SD = 8.03 years) with self-reported insomnia and a diagnosed chronic musculoskeletal chronic pain received six CBT-I individual treatment sessions over 6-10 weeks. Treatment was delivered via telehealth. Participants completed weekly sleep diaries, and self-reported measures of insomnia, pain, anxiety and depression pre-treatment, post-treatment, and one-month follow-up. Results: The trial yielded, high levels of compliance with intervention protocols, and affirmative feedback on satisfaction which demonstrated feasibility. The enrolment rate into the study was 37% (27 participants screened, 10 participants enrolled). The intervention was associated with statistically and clinically meaningful improvements in self-reported insomnia severity. There were statistically significant improvements in sleep efficiency, wake after sleep onset, sleep onset latency, anxiety and depression. Conclusion: Adapted CBT-I delivered via telehealth may be a feasible, acceptable, and efficacious therapeutic approach for individuals with co-existent sleep and chronic pain. Future trials should adopt a randomized design against usual care.
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Insomnia disorder is highly prevalent, and has been identified as a risk factor for many psychiatric problems, including depression, suicide ideation and suicide death. Previous studies have found that cognitive behavioral therapy for insomnia (CBT-I) reduce depression and suicidal ideation in samples with high levels of suicidal ideation. This study aims to investigate associations of CBT-I with suicidal ideation in a sample of 522 patients primarily seeking internet-delivered treatment for insomnia in regular psychiatric care. The sample had high pretreatment insomnia severity levels and a relatively high level of comorbid depression symptoms. Suicidal ideation levels were relatively low pretreatment but still improved significantly after CBT-I. Contrary to previous findings, the strongest predictor of changes in suicidal ideation were improvements in depressive symptoms, rather than improvements in insomnia. We conclude that suicidal ideation may not be a major problem in these patients primarily seeking treatment for insomnia, despite comorbid depressive symptoms, but that suicidal ideation still improves following CBT-i. Considering the increased risk for patients with untreated insomnia to develop depression, this finding is of interest for prevention of suicidal ideation.
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INTRODUCTION: Brief (≤4 sessions) behavioral treatment for insomnia (BBTi) improves insomnia symptoms in older adults. Findings for BBTi-related improvements in objective cognition are mixed, with our recent trial reporting no effects. Metacognition (appraisal of one's own performance) has not been examined. This study examined the effects of BBTi on metacognition in older adults with insomnia. METHODS: Older adults with insomnia [N = 62, Mage = 69.45 (SD = 7.71)] were randomized to 4-weeks of BBTi (n = 32; psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation, review/maintenance) or self-monitoring control (SMC; n = 30; social conversations). Throughout the study (2 week baseline, 4 week treatment, 2 week post-treament, 2 week 3-month followup), participants completed daily paper/pencil cognitive tasks (measuring verbal memory, attention, processing speed and reasoning) and provided daily metacognition ratings of their performance in four areas: quality, satisfaction, compared to same age peers, compared to own ability. Two-week averages of metacognitive ratings were calculated for baseline, treatment-first half, treatment-second half, post-treatment, and 3-month follow-up. Multilevel Modeling examined treatment effects (BBTi/SMC) over time on metacognition, controlling for age and sex. RESULTS: A significant group by time interaction (p = 0.05) revealed consistent improvements over time in better metacognitive ratings relative to same age peers for BBTi. Specifically, baseline ratings [mean (M) = 51.21, standard error (SE) = 3.15] improved at first half of treatment (M = 56.65, SE = 3.15, p < 0.001), maintained improvement at second-half of treatment (p = 0.18), showed additional improvement at post-treatment (M = 60.79, SE = 3.15, p = 0.02), and maintained improvement at follow-up (M = 62.30, SE = 3.15; p = 0.02). SMC prompted inconsistent and smaller improvements between baseline (M = 53.24, SE = 3.29) and first-half of treatment (M = 56.62, SE = 3.28; p = 0.004), with additional improvement at second-half of treatment (M = 59.39, SE = 3.28; p = 0.02) that was maintained at post-treatment (p = 0.73) and returned to levels observed at first-half of treatment (M = 57.78, SE = 3.21; p = 0.55). Significant main effects of time (all ps < 0.001) for other metacognition variables (Quality, Satisfaction, Compared to own ability) indicated general improvements over time for both groups. DISCUSSION: Metacognition generally improved over time regardless of treatment. BBTi selectively improved ratings of performance relative to same age peers. Repeated objective testing alone may improve metacognition in older adults with insomnia. Better understanding of metacognition and how to improve it has important implications for older adults as metacognitive complaints have been associated with mild cognitive impairment.
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Metacognición , Trastornos del Inicio y del Mantenimiento del Sueño , Anciano , Terapia Conductista , Humanos , Persona de Mediana Edad , Sueño , Trastornos del Inicio y del Mantenimiento del Sueño/terapia , Resultado del TratamientoRESUMEN
BACKGROUND: Task-switching deficits are common in older adults and in those with insomnia. Such deficits may be driven by difficulties with sleep continuity and dampened homeostatic sleep drive. OBJECTIVE: To identify the aspects of task switching affected by insomnia and its treatment, and to determine whether such effects are associated with sleep continuity and homeostatic sleep drive. METHODS: Polysomnographic sleep and task switching were tested in healthy older adults aged 60-93 years with insomnia (n = 48) and normal sleeping controls (n = 51). Assessments were repeated in the insomnia group after eight weeks of cognitive behavioral treatment for insomnia. Sleep measures included wake after sleep onset (WASO) and quantitative indices of homeostatic sleep drive (delta power during nonrapid eye movement [NREM] sleep and the ratio of delta power during the first and second NREM periods). A cued task-switching paradigm instructed participants to perform one of two tasks with varying preparatory cue-target intervals, manipulating task alternation, task repetition, and task preparation. RESULTS: The effect of preparatory cues on accuracy was diminished in the insomnia group compared with that in controls. Across the two groups, a stronger effect of preparatory cues was associated with a higher delta sleep ratio. Following insomnia treatment, task-repetition accuracy significantly improved. This improvement was associated with improvements in WASO. There were no group or treatment effects on response time or task alternation accuracy. CONCLUSIONS: Effects of insomnia diagnosis and treatment apply to conditions that depend on the maintenance of a task set, rather than a domain general effect across task switching. Such effects are associated with homeostatic sleep drive and sleep continuity.