Criteria

The international classification of sleep disorders (3rd edition, text revision) (ICSD-3-TR)[5]​​

This text of criteria is adapted from the ICSD-3-TR.[5]​​

The ICSD-3-TR has merged all presentations of insomnia (including behavioural insomnia of childhood and inadequate sleep hygiene) into a single diagnostic category: chronic insomnia disorder.

While the description of behavioural insomnia of childhood remains useful (as it defines aetiological factors that can guide formulation of targeted behavioural intervention strategies), there is limited empirical support for this diagnostic subtype. Further research is needed to clarify whether a definition should be reinstated. The ICSD-3-TR also no longer recognises the subtypes of behavioural insomnia of childhood, which included sleep-onset association type and limit-setting type.

Children must therefore meet all of the following criteria for chronic insomnia disorder, and assessment should include information from both the child and their carer:

  • Difficulty initiating or maintaining sleep, final awakening earlier than desired, a resistance to going to bed, or difficulty sleeping without a carer present

  • At least one symptom related to night-time sleep difficulty, such as fatigue/malaise, impaired concentration, impaired social/familial/academic performance, mood disturbance, daytime sleepiness, reduced motivation, and behavioural problems

  • The above cannot be explained by inadequate opportunity or circumstances for sleep

  • The sleep disturbance and associated daytime symptoms occur at least three times per week and have been present for at least three months

  • The sleep disturbance/associated symptoms are not due to another sleep disorder, mental disorder, or medication/substance use.

Previous subtypes of behavioural insomnia of childhood are described below for educational purposes only:

  • Sleep-onset association type is characterised by the child’s dependency on specific stimulation, objects, or settings for initiating or returning to sleep following an awakening; sleep onset is significantly delayed in the absence of these conditions

  • Limit-setting type is characterised by bedtime stalling or bedtime refusal resulting from inadequate limit-setting by a carer

  • A mixed type characterised by features of sleep-onset difficulties and bedtime resistance.

Although inadequate sleep hygiene is no longer recognised as a pathophysiological subtype of insomnia, activities that are inconsistent with the maintenance of good-quality sleep and normal daytime alertness are listed below for educational purposes only.

Practices can include:

  • Improper sleep scheduling consisting of frequent daytime napping, selecting highly variable bedtimes or rising times, or spending excessive amounts of time in bed

  • Routine use of products containing alcohol, nicotine, or caffeine, especially in the period preceding bedtime

  • Frequent use of the bed for activities other than sleep (e.g., eating or watching television)

  • Engaging in physically or mentally tiring activities too close to bedtime

  • Failure to maintain a comfortable sleeping environment.

Criteria for paediatric obstructive sleep apnoea (OSA) are as follows.

  • The carer reports at least one of the following:

    • snoring

    • Laboured, paradoxical, or obstructed breathing during the child’s sleep

    • Sleepiness, hyperactivity, behavioural problems, or learning and other cognitive problems.

  • Polysomnographic (PSG) recording demonstrates one of the following:

    • One or more OSAs, mixed apnoeas, or hypopnoeas per hour of sleep

    • A pattern of obstructive hypoventilation, defined as at least 25% of total sleep time with hypercapnia (PaCO₂ >50 mmHg) in association with one or more of the following: snoring; flattening of the inspiratory nasal pressure waveform; paradoxical thoracoabdominal motion.

  • The disorder is not better explained by another sleep disorder, a medical or neurological disorder, medication use, or a substance misuse disorder.

Criteria for narcolepsy type 1 (previously narcolepsy with cataplexy) are as follows:

  • The patient has a complaint of excessive daytime sleepiness.

  • One of the following is present:

    • A definite history of cataplexy, defined as sudden and transient episodes of loss of muscle tone triggered by emotions, and either: a mean sleep latency of 8 minutes or less and two or more sleep-onset REM periods (SOREMPs) on a multiple sleep latency test (MSLT); or a SOREMP on nocturnal polysomnogram (within 15 minutes of sleep onset)

    • Hypocretin-1 levels in the cerebrospinal fluid are ≤110 picograms/mL or <1/3 of mean normal control values.

  • The hypersomnia is not better explained by another sleep disorder, a mental disorder, or medication/substance use or withdrawal.

Narcolepsy type 2 is also characterised by excessive daytime sleepiness and abnormal polysomnography/MSLT findings; however, typical cataplexy is absent.

Criteria for delayed sleep-wake phase disorder are as follows:

  • There is a delay in the phase of the major sleep period in relation to the desired sleep time and wake-up time, as evidenced by a chronic or recurrent complaint of inability to fall asleep at a desired conventional clock time together with the inability to awaken at a desired and socially acceptable time

  • The symptoms have been present for at least 3 months

  • When allowed to choose their preferred schedule, patients will exhibit improved sleep quality and duration for age and maintain a delayed, but stable, phase of entrainment to the 24-hour sleep-wake pattern

  • Sleep log or actigraphy monitoring (including sleep diary) for at least 7 days (14 days preferable, both school days and free days) demonstrates a delay in the timing of the habitual sleep period

  • The sleep disturbance is not better explained by another sleep disorder, a medical disorder, a mental disorder, or medication/substance use or withdrawal.

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