Behavioural insomnia and circadian rhythm disorders — branching viva

Station opening

Examiner: "Define behavioural insomnia of childhood and distinguish it from a circadian rhythm disorder." [1]

Strong candidate (must-hit)

• Defines behavioural insomnia of childhood as difficulty initiating or maintaining sleep that is learned and behavioural, present despite adequate sleep opportunity, with daytime consequences; names the sleep-onset association and limit-setting subtypes; and contrasts this with a circadian rhythm disorder, in which sleep quality is normal but the clock is set to the wrong time, delayed sleep-wake phase disorder being commonest in adolescents. [1] [8]

Weak candidate

• "It is just a child who won't sleep; I would give melatonin or a sedative to fix it." [2]

Branch A — The 15-month-old who wakes repeatedly

Examiner: "A 15-month-old wakes three or four times a night and can only be resettled by rocking. How do you treat her?" [1] [2]

Strong

• Recognises sleep-onset association type behavioural insomnia; explains that a learned cue (rocking) is required to bridge normal night arousals; treats behaviourally first-line with a consistent bedtime routine, graduated extinction (controlled comforting) and bedtime fading to teach independent settling; and warns parents that a brief increase in protest precedes improvement and that consistency is key. [1] [2]

Weak

• "Prescribe melatonin at bedtime and review in a few months." [6]

Branch B — The 15-year-old who cannot wake for school

Examiner: "A 15-year-old cannot sleep before 2am and cannot wake for school, but sleeps well and late at weekends. What is going on and what do you do?" [8] [9]

Strong

• Diagnoses delayed sleep-wake phase disorder from the stable late sleep onset, difficulty waking, and normal refreshing sleep on the delayed weekend schedule; explains the biological adolescent phase delay (the perfect storm); actively screens for depression and suicidal ideation; and treats with a fixed daily wake time, reduced evening light and screens, timed morning bright light, and low-dose evening melatonin timed hours before habitual sleep onset as a chronobiotic, with school liaison. [8] [9]

Weak

• "Tell him to stop being lazy and go to bed earlier." [9]

Branch C — The 6-year-old with autism and chronic insomnia

Examiner: "A 6-year-old with autism has chronic difficulty settling despite a good routine. What is your approach and where does melatonin fit?" [7] [6]

Strong

• Keeps behavioural strategies first-line but adapts them to the child's communication and sensory needs; treats coexisting anxiety and reviews the effect of any stimulant; and adds melatonin, noting its strongest evidence is in children with neurodevelopmental disorders, citing Gringras and colleagues' randomised trial showing improved sleep onset, and Bruni's recommendations for its use. [7] [6]

Weak

• "Autistic children just don't sleep; there is nothing to be done." [7]

Branch D — The remote family with limited sleep services

Examiner: "A family from a remote community cannot easily access a sleep clinic or actigraphy. How do you manage their child's sleep problem?" [8] [6]

Strong

• Relies on a structured sleep history and a one to two week sleep diary to make the diagnosis without laboratory tests; provides a clear written behavioural plan and parent education; uses melatonin as an adjunct where indicated; follows up by telehealth; and gives realistic, culturally appropriate advice that fits the family's housing and circumstances, acknowledging equity of access as an issue. [8] [6]

Weak

• "Do nothing until they can travel to a sleep laboratory." [8]

Close

Examiner: "Summarise your approach to the child who will not sleep in one sentence." [1] [8]

Strong

• "I take a sleep history and a sleep diary, confirm adequate sleep opportunity and exclude organic disorders, treat behavioural insomnia with behavioural techniques first-line, treat delayed sleep-wake phase disorder with a fixed wake time, morning bright light and correctly timed low-dose evening melatonin, and use melatonin as an adjunct — with its strongest evidence in children with neurodevelopmental disorders — rather than reaching first for a sedative." [1] [8]