Diagnosis: Childhood insomnia Treatment Plan and Notes: 7-year-old C.B., a female patient, was brought to the clinic by her father and mother due to the difficulties she has been having with falling asleep.

 
Client Information:
Name: C.B.

Age: 7

Gender: Female
Visit Information:
B. was brought to the clinic by both her parents at 4:00 PM. after having difficulties falling asleep as she remained active past her bedtime.
Practice Management:
The visit was at the pediatric clinic and lasted for 40 minutes.

Diagnosis: Childhood insomnia
Treatment Plan and Notes:
7-year-old C.B., a female patient, was brought to the clinic by her father and mother due to the difficulties she has been having with falling asleep. The mother reports that she has difficulties putting C.B. to bed and having her fall asleep as she tends to become more active as her bedtime approaches which is set at 8 PM, and stays active past her bedtime. She notes that C.B. can stay awake and active up to 11 PM.

C.B. appeared alert and active during the visit and evaluation. She had no visible physical abnormalities during the examination. However, the mother notes that her father has been letting her take a sip of her coffee when he gets home at around 7 PM. He also lets her watch some television and funny videos on his phone. She reports that this has gone on for almost the last five months, which she suspects contributes to her difficulty falling asleep. She notes that they have argued over it, but the father insists that it is just a father-daughter thing. Based on the patient’s reported symptoms and the information provided by her parents, C.B. has been diagnosed with childhood insomnia. Coffee and other stimulating activities before bedtime are identified as the underlying factors.

All available options for managing C.B.’s sleeping difficulties were discussed with both parents. The mother notes that a friend had advised her to try using some sedatives she had given her. However, she was concerned about their safety. No medications are prescribed for C.B.’s conditions. The parents are educated on sleep hygiene. Accordingly, the father was advised not to give C.B. any coffee, let her use any electronic devices, or engage in any stimulating activities that interfere with her sleep routine. A strict bedtime routine was drafted, and music therapy was included in the sleep routine. The bedtime routine will include reduced exposure to electronic screens past 6 PM and playing soothing music in the house from 7:30 PM. The father was advised to try to be home early and bond with her daughter with storybooks as an alternative to using the phone. A follow-up appointment will be in two weeks. Medications will be prescribed if C.B.’s sleep does not improve after two weeks with the current intervention.