Parasomnias include sleepwalking, sleep terrors, and confusional arousals. These occur during NREM sleep and are more likely during the first third of the night. They are most common in preschool children and are likely to resolve with time and developmental maturation. Sleepwalking is common and often benign but is sometimes associated with agitation or dangerous behaviors. Sleep terrors consist of an abrupt awakening with a loud scream, agitation, and unresponsiveness to caregivers’ attempts to console. Sleep terrors are differentiated
Sleep-onset the night intervention Minimize nocturnal parental response association subtype
Social disruptions Family stressors Night waking Regularize routines Refusal to sleep Family counseling
Illness Any chronically irritating Painful crying out Treat disease symptomatically disorder (e.g., otitis, dermatitis, asthma, or esophageal reflux)
DDAVP, 1-desamino-8-D-arginine vasopressin; OSA, obstructive sleep apnea.
from nightmares, which occur later in the night and result from arousal in REM or dreaming sleep. Children typically remember their nightmares but have no recollection of sleep terrors. Confusional arousals are similar to sleep terrors, tend to be less dramatic but last longer.
Circadian rhythm disorders are most common during adolescence but can occur at any age. They consist of an exaggerated delayed sleep phase, leading to the inability to arouse in the mornings and failure to meet sleep requirements. Many adolescents attempt to recoup lost sleep on the weekends. The resulting sleep deprivation leads to problems with cognition and emotional regulation.
Obstructive sleep apnea in childhood is not always obvious or easy to diagnose. OSA is commonly caused by tonsillar or adenoidal hypertrophy. A history of snoring is typical; some children may have excessive daytime sleepiness. Obese children are at increased risk for OSA. In toddlers OSA often is associated with poor growth, which improves when the obstruction is relieved by a tonsillectomy or adenoidectomy. Many children with OSA experience cognitive difficulties and school problems. Hyperactivity is also more common in these children than in age-matched controls.
Primary sleep disorders must be differentiated from sleep disorders associated with psychiatric and medical disorders. Psychoses, anxiety disorders, and substance abuse can present with disordered sleep. The clinician should also consider sleep-related epilepsy and developmental disorders.
Establishing a baseline of healthy sleep habits is essential toboth prevention and treatment of sleep disorders at all ages.
Consistent bedtime routine (∼30 min) to cue sleep Consistent ambient noise, light, temperature in bedroom Adequate food, hydration, socialization, and physical activity during the day
No television or other electronics in bedroom Avoidance of naps (unless developmentally appropriate)
Child allowed to develop self-soothing strategies
Parents are comfortable setting limits/boundaries
These include having a consistent and appropriate bedtime and bedtime routine, and close attention to sleep hygiene (seeTable 15-2). A bedtime routine should consist of three or foursoothing activities that help calm the child and signal that it istime for sleep. It should last no more than 30 minutes. Activities may include bathing, brushing teeth, reading a story, or singinga song. Even older children and adolescents require a consistent pre-bed routine. A transitional object such as a blanket orstuffed animal can be used to promote positive sleep associations and encourage self-soothing. The bedtime should be setearly enough to allow for sufficient nighttime sleep, and bothbedtime and morning wake time should be consistent, including on weekends. Televisions and other electronic devicesshould be removed from the bedroom because these can lead to delayed sleep onset and maladaptive sleep associations.