in the same place. for the first five years, 2007–2011, during "grandfathering", there was a "practice pathway" for absm certified specialists while additional, coordinated requirements were to be added after 2011. the abpn provides information about the pathways, requirements and the exam on its website. additionally, there are currently four boards of the american osteopathic association bureau of osteopathic specialists that administer sleep medicine certification exams. the american osteopathic boards of family medicine, internal medicine, neurology & psychiatry, and ophthalmology & otolaryngology grant certificates of added qualification to qualified candidate physicians. sleep medicine is now a recognized subspecialty within anesthesiology, internal medicine, family medicine, pediatrics, otolaryngology, psychiatry and neurology in the us. certification in sleep medicine by the several "member boards" of the abms shows that the specialist: has demonstrated expertise in the diagnosis and management of clinical conditions that occur during sleep, that disturb sleep, or that are affected by disturbances in the wake–sleep cycle. this specialist is skilled in the analysis and interpretation of comprehensive polysomnography, and well-versed in emerging research and management of a sleep laboratory. pulmonologists, already subspecialists within internal medicine, may be accepted to sit for the board and be certified in sleep medicine after just a six-month fellowship, building on their knowledge of sleep-related breathing problems, rather than the usual twelve-month fellowship required of other specialists. sleep dentistry (bruxism, snoring and sleep apnea), while not recognized as one of the nine dental specialties, qualifies for board-certification by the american board of dental sleep medicine (abdsm). the resulting diplomate status is recognized by the aasm, and these dentists are organized in the academy of dental sleep medicine (usa). the qualified dentists collaborate with sleep doctors at accredited sleep centers and can provide several types of oral appliances or upper airway surgery to treat or manage sleep-related breathing disorders as well as tooth-grinding and clenching. laboratories for sleep-related breathing disorders are accredited by the aasm and are required to follow the code of medical ethics of the american medical association. the new and very detailed standards for accreditation are available online. sleep disorder centers, or clinics, are accredited by the same body, whether hospital-based, university-based or "freestanding"; they are required to provide testing and treatment for all sleep disorders and to have on staff a sleep specialist who has been certified by the american board of sleep medicine and otherwise meet similar standards. diagnostic methods pediatric polysomnography the taking of a thorough medical history while keeping in mind alternative diagnoses and the possibility of more than one ailment in the same patient is the first step. symptoms for very different sleep disorders may be similar and it must be determined whether any psychiatric problems are primary or secondary. the patient history includes previous attempts at treatment and coping and a careful medication review. differentiation of transient from chronic disorders and primary from secondary ones influences the direction of evaluation and treatment plans. the epworth sleepiness scale (ess), designed to give an indication of sleepiness and correlated with sleep apnea, or other questionnaires designed to measure excessive daytime sleepiness, are diagnostic tools that can be used repeatedly to measure results of treatment. a sleep diary, also called sleep log or sleep journal, kept by a patient at home for at least two weeks, while subjective, may help determine the extent and nature of sleep disturbance and the level of alertness in the normal environment. a parallel journal kept by a parent or bed partner, if any, can also be helpful. sleep logs can also be used for self-monitoring and in connection with behavioral and other treatment. the image at the top of this page, with nighttime in the middle and the weekend in the middle, shows a layout that can aid in noticing trends an actigraph unit is a motion-sensing device worn on the wrist, generally for one or two weeks. it gives a gross picture of sleep-wake cycles and is often used to verify the sleep diary. it is cost-efficient when full polysomnography is not required. polysomnography is performed in a sleep laboratory while the patient sleeps, preferably at his or her usual sleeping time. the polysomnogram (psg) objectively records sleep stages and respiratory events. it shows multiple channels of electroencephalogram (eeg), electrooculogram (eog), electrocardiogram (ecg), nasal and oral airflow, abdominal, chest and leg movements and blood oxygen levels. a single part of a polysomnogram is sometimes measured at home with portable equipment, for example oximetry, which records blood oxygen levels throughout the night. polysomnography is not routinely used in the evaluation of patients with insomnia or circadian rhythm disorders, except as needed to rule out other disorders. it will usually be a definitive test for sleep apnea. home sleep tests (hst)or home sleep apnea tests (hsat) are types of sleep studies that can be performed in a patient's home to identify obstructive sleep apnea. these devices are increasing in utilization due to their convenience and cost effectiveness. a multiple sleep latency test (mslt) is often performed during the entire day after polysomnography while the electrodes and other equipment are still in place. the patient is given nap opportunities every second hour; the test measures the number of minutes it takes from the start of a daytime nap period to the first signs of sleep. it is a measure of daytime sleepiness; it also shows whether rem sleep is achieved in a short nap, a typical indication of narcolepsy. imaging studies may be performed if a patient is to be evaluated for neurodegenerative disease or to determine the obstruction in obstructive sleep apnea. sleep questionnaires: there are some validated questionnaires in sleep medicine such as: tayside children's sleep questionnaire: a ten-item questionnaire for sleep disorders in children aged between one and five years old. children's sleep habits questionnaire cleveland adolescent sleepiness questionnaire (casq): there are 16 items to measure extreme sleepiness during the day in adolescents aged 11–17 years old. treatments normison (temazepam) is a benzodiazepine commonly prescribed for insomnia and other sleep disorders. when sleep complaints are secondary to pain, other medical or psychiatric diagnoses, or substance abuse, it may be necessary to treat both the underlying cause and the sleep problems. when the underlying cause of sleep problems is not immediately obvious, behavioral treatments are usually the first suggested. these range from patient education about sleep hygiene to cognitive behavioral therapy (cbt). studies of both younger and older adults have compared cbt to medication and found that cbt should be considered a first-line and cost-effective intervention for chronic insomnia, not least because gains may be maintained at long-term follow-up. sleep physicians and psychologists, at least in the us, are not in agreement about who should perform cbt nor whether sleep centers should be required to have psychologists on staff. in the uk the number of cbt-trained therapists is limited so cbt is not widely available on the nhs. behavioral therapies include progressive relaxation, stimulus control (to reassociate the bed with sleepiness), limiting time-in-bed to increase sleep efficiency and debunking misconceptions about sleep. pharmacotherapy is necessary for some conditions. medication may be useful for acute insomnia and for some of the parasomnias. it is almost always needed, along with scheduled short naps and close follow-up, in the treatment of narcolepsy and idiopathic hypersomnia. chronic circadian rhythm disorders, the most common of which is delayed sleep phase disorder, may be managed by specifically timed bright light therapy, usually in the morning, darkness therapy in the hours before bedtime, and timed oral administration of the hormone melatonin. chronotherapy has also been prescribed for circadian rhythm disorders, though results are generally short-lived. stimulants may also be prescribed. when these therapies are unsuccessful, counseling may be indicated to help a person adapt to and live with the condition. people with these disorders who have chosen a lifestyle in conformity with their sleeping schedules have no need of treatment, though they may need the diagnosis in order to avoid having to meet for appointments or meetings during their sleep time. cpap (positive airway pressure) machine continuous positive airway pressure (cpap), bilevel continuous positive airway pressure (bipap), or similar machines can be used nightly at home to effectively manage sleep-related breathing disorders such as apnea. in milder cases, oral appliances may be effective alternate treatments. for mild cases in obese people, weight reduction may be sufficient, but it is usually recommended as an adjunct to cpap treatment since sustaining weight loss is difficult. in some cases, upper airway surgery, generally performed by an otolaryngologist/head & neck surgeon or occasionally an oral and maxillofacial surgeon, is indicated. the treatments prevent airway collapse, which interrupts breathing during sleep. a 2001 study published by hans-werner gessmann in the journal of sleep medicine and sleep psychology found that patients who practiced a series of electrical stimulations of suprahyoidal tongue muscles for 20 minutes a day showed a marked decline in sleep apnea symptoms after two months. patients experienced an average of 36% fewer apnea episodes after successfully completing the treatments. according to the national cancer institute (nci), about 50% of cancer patients have trouble sleeping. difficulty sleeping can include restless leg syndrome (rls), sleeping that is fragmented, or insomnia. some reports show that up to 80% of patients who are undergoing cancer treatments experience some form of insomnia. one of the significant reasons for sleeping problems is stress, uncertainty, and fear. other patients have difficulty sleeping directly due to their treatments while others experience pain that affects sleep quality. other factors include diet and less than optimum sleeping conditions. cancer has also been shown to be a cause of increased sleep apnea, which adds to the potential issues.