Çocuk ve Ergenlerde Uyku Bozukluklarının Bilişsel Davranışçı Terapisi
Özet
Bu bölüm, çocuk ve ergenlerde yaygın görülen insomnia ve diğer uyku bozukluklarının tedavisinde Bilişsel Davranışçı Terapi (BDT-i) yaklaşımını detaylandırmaktadır. Uyku kalitesindeki bozulmaların çocuklarda akademik performans, duygu düzenleme ve bağışıklık sistemi üzerinde ciddi olumsuz etkileri olduğu vurgulanmaktadır. Uyku regülasyonu temel olarak homeostatik sistem (uyku dürtüsü) ve sirkadiyen sistem (biyolojik saat) tarafından yönetilse de, insomnia hastalarında "koşullu uyarılma" ve "bilişsel uyarılma" sistemlerinin uykuyu engellediği belirtilmektedir. BDT-i; uyaran kontrolü, uyku kısıtlaması, gevşeme egzersizleri, uyku hijyeni ve bilişsel yeniden yapılandırma gibi çok bileşenli tekniklerden oluşmaktadır. Uyaran kontrolü, yatağın sadece uykuyla ilişkilendirilmesini hedeflerken; uyku kısıtlaması, uyku basıncını artırmak için yatakta geçirilen süreyi düzenler. Araştırmalar, BDT-i'nin yetişkinlerde farmakoterapiye benzer etki gücüne sahip olduğunu ve etkilerinin daha kalıcı olduğunu; çocuk ve ergenlerde ise uyku verimliliği ve gündüz işlevselliğinde anlamlı iyileşmeler sağladığını göstermektedir. Tedavi süreci, uyku günlükleri ile takip edilen değerlendirme seanslarından başlayarak, hatalı inançların düzeltildiği ve sağlıklı uyku rutinlerinin oluşturulduğu yapılandırılmış bir programı kapsamaktadır.
This section details the Cognitive Behavioral Therapy (CBT-i) approach in the treatment of insomnia and other sleep disorders commonly seen in children and adolescents. It is emphasized that impairments in sleep quality have serious negative effects on academic performance, emotion regulation, and the immune system in children. Although sleep regulation is primarily managed by the homeostatic system (sleep drive) and the circadian system (biological clock), it is noted that in insomnia patients, "conditioned arousal" and "cognitive arousal" systems prevent sleep. CBT-i consists of multi-component techniques such as stimulus control, sleep restriction, relaxation exercises, sleep hygiene, and cognitive restructuring. While stimulus control aims to associate the bed only with sleep, sleep restriction regulates the time spent in bed to increase sleep pressure. Research shows that CBT-i has a similar efficacy to pharmacotherapy in adults with more lasting effects, and in children and adolescents, it provides significant improvements in sleep efficiency and daytime functioning. The treatment process involves a structured program starting from assessment sessions monitored with sleep diaries, where faulty beliefs are corrected and healthy sleep routines are established.
Referanslar
Chorney DB, Detweiler MF, Morris TL, et al. The interplay of sleep disturbance, anxiety, and depression in children. J Pediatr Psychol. 2008;33 (4):339–48.
Dohnt H, Gradisar M, Short MA. Insomnia and its symptoms in adolescents: comparing dsm-iv and icsd-ii diagnostic criteria. J Clin Sleep Med. 2012;8 (3):295–9.
Ma Z-R, Shi L-J, Deng M-H. Efficacy of cognitive behavioral therapy in children and adolescents with insomnia: a systematic review and meta-analysis. Brazilian J Med Biol Res. 2018;51 (6).
Dewald-Kaufmann J, de Bruin E, Michael G. Cognitive behavioral therapy for insomnia (cbt-i) in school-aged children and adolescents. Sleep Med Clin. 2019;14 (2):155–65.
Sateia MJ. International classification of sleep disorders-third edition highlights and modifications. Chest. 2014;146 (5):1387–94.
Sadeh A, Gruber R, Raviv A. Sleep, neurobehavioral functioning, and behavior problems in school-age children. Child Dev. 2002;73 (2):405–17.
Chervin RD, Clarke DF, Huffman JL, et al. School performance, race, and other correlates of sleep-disordered breathing in children. Sleep Med. 2003;4 (1):21–7.
Schutte-Rodin SL, Broch L, Buysee D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4 (5):487–504.
National Institutes of Health State. National institutes of health state of the science conference statement: manifestations and management of chronic insomnia in adults june 13-15, 2005. Sleep. 2005;28 (9):1049–57.
Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an american academy of sleep medicine clinical practice guideline. J Clin Sleep Med. 2021;17 (2):255–62.
Wilson S, Anderson K, Baldwin D, et al. British association for psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: an update. J Psychopharmacol. 2019;33 (8):923–47.
Borbély AA, Daan S, Wirz-Justice A, et al. The two-process model of sleep regulation: a reappraisal. J Sleep Res. 2016;25 (2):131–43.
Espie CA. Overcoming insomnia and sleep problems: a self help guide using cognitive behavioural techniques [Internet]. C. Shapiro and EP Sloan. Sleep in …. Robinson; 2006. 388 p.
Carney CE, Posner D. Cognitive behavior therapy for insomnia in those with depression. Cogn Behav Ther Insomnia Those with Depress. 2015;226.
Harvey AG. Pre-sleep cognitive activity: a comparison of sleep-onset insomniacs and good sleepers. Br J Clin Psychol. 2000;39 (3):275–86.
Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987;10 (4):541–53.
Blake MJ, Sheeber LB, Youssef GJ, et al. Systematic review and meta-analysis of adolescent cognitive–behavioral sleep interventions. Clin Child Fam Psychol Rev. 2017;20 (3):227–49.
Edinger JD, Sampson WS. A primary care “friendly” cognitive behavioral insomnia therapy. Sleep. 2003;26 (2):177–82.
Bothelius K, Kyhle K, Espie CA, et al. Manual-guided cognitive-behavioural therapy for insomnia delivered by ordinary primary care personnel in general medical practice: a randomized controlled effectiveness trial. J Sleep Res. 2013;22 (6):688–96.
Lovato N, Lack L, Wright H, et al. Evaluation of a brief treatment program of cognitive behavior therapy for insomnia in older adults. Sleep. 2014;37 (1):117–26.
Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171 (10):887–95.
Trauer JM, Qian MY, Doyle JS, et al. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163 (3):191–204.
Huedo-Medina TB, Kirsch I, Middlemass J, et al. Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the food and drug administration. BMJ. 2013;346 (7889).
Espie CA, Inglis SJ, Tessier S, et al. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behav Res Ther. 2001;39 (1):45–60.
Edinger JD, Wohlgemuth WK, Radtke RA, et al. Cognitive behavioral therapy for treatment of chronic primary insomnia a randomized controlled trial. J Am Med Assoc. 2001;285 (14):1856–64.
Riemann D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009;13 (3):205–14.
Mitchell MD, Gehrman P, Perlis M, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;13 :40.
Morgenthaler T, Kramer M, Alessi C, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. an american academy of sleep medicine report. Sleep. 2006;29 (11):1415–9.
Kratochvil CJ, Owens JA. Pharmacotherapy of pediatric insomnia. J Am Acad Child Adolesc Psychiatry. 2009;48 (2):99–107.
Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014;39 (8):932–48.
Cankardas S, İnce B. Effectiveness of behavioural interventions for childhood sleep problems: a review study. J Cogn Psychother Res. 2019;(0):1.
Paine S, Gradisar M. A randomised controlled trial of cognitive-behaviour therapy for behavioural insomnia of childhood in school-aged children. Behav Res Ther. 2011;49 (6–7):379–88.
Schlarb AA, Bihlmaier I, Velten-Schurian K, et al. Short- and long-term effects of cbt-i in groups for school-age children suffering from chronic insomnia: the kiss-program. Behav Sleep Med. 2018;16 (4):380–97.
Blake MJ, Blake LM, Schwartz O, et al. Who benefits from adolescent sleep interventions? moderators of treatment efficacy in a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep intervention for at-risk adolescents. J Child Psychol Psychiatry Allied Discip. 2018;59 (6):637–49.
Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29 (11):1398–414.
Bonnet MH, Arand DL. Hyperarousal and insomnia: state of the science. Sleep Med Rev. 2010;14 (1):9–15.
Edinger JD, Carney CE. Overcoming insomnia: a cognitive-behavioral therapy approach workbook (treatments that work). Oxford University Press; 2014. 104 p.
Morin CM. Insomnia: psychological assessment and management [Internet]. New York: Guilford Press; 1993. 238 p.
Carney CE, Edinger JD, Meyer B, et al. Symptom-focused rumination and sleep disturbance. Behav Sleep Med. 2006;4 (4):228–41.
Semler CN, Harvey AG. Daytime functioning in primary insomnia: does attentional focus contribute to real or perceived impairment? Behav Sleep Med. 2006;4 (2):85–103.
Espie CA, Broomfield NM, MacMahon KMA, et al. The attention-intention-effort pathway in the development of psychophysiologic insomnia: a theoretical review. Sleep Med Rev. 2006;10 (4):215–45.
Edinger JD, Bonnet MH, Bootzin RR, et al. Derivation of research diagnostic criteria for insomnia: report of an american academy of sleep medicine work group. Sleep. 2004;27 (8):1567–96.
