Intended for healthcare professionals

Practice Clinical updates

Assessment and initial management of suspected behavioural insomnia in pre-adolescent children

BMJ 2018; 363 doi: (Published 16 October 2018) Cite this as: BMJ 2018;363:k3797

Second-wave behavioural techniques and pharmacology the last stand in sleep problems?

I was curious to read this clinical update on suspected behavioural insomnia in pre-adolescent children, coming from the standpoint of a clinician who meets parents affected by their child's sleep problems. I think the parental involvement in this article is an excellent touch and it has been really helpful and concise overview of how to assess sleep problems.

However, the statement that "behavioural and sleep hygiene approaches are the bedrock of treatment" appears to be backed-up by the one systematic review and would suggest to a casual reader that authorities in paediatric sleep disorders believe that these are the only approaches known.

I am aware that first and second-wave psychology and behavioural techniques are in fact not the end of the road, and there is an exceptionally important body of research and practice being carried out by Dr Pamela Douglas and colleagues in Australia at the Possums Research Facility. Dr Pamela Douglas has written a fascinating and exceptionally well-informed tranche of research and practice into infant sleep in particular.

Reading this clinical update, I was also mindful of Dr Douglas' passionate open letter to a doctor in Australia making use of his position as an authority on infant sleep to have desperate parents queueing outside his door for public-funded consultations.

We are always as clinical practitioners (health visitors included) working in a field of big business - infant formula and diet (I note the obesity links with insomnia), pharmacology (I refer to recent scandalous reports of how frequently melatonin is being prescribed off-licence for child sleep issues) and many independently-operating, unregulated sleep 'trainers and experts'.

I would have appreciated a small caveat at the end that perhaps there are still more questions than answers on this topic. Taking a history of early infancy and development - including birth, mental and physical trauma at birth, breast-feeding and for how long - may also help unpack the problem. Certainly parents probably only present to a healthcare practitioner many months or even years after the issues first started, out of embarrassment and hope that it would 'get better'.

Competing interests: No competing interests

06 November 2018
Munira C Blacking
Consultant Psychiatrist
Bedfordshire, UK