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Posted by Gregory Harper, RRT, RCP on February 21, 1998 at 13:49:06:In Reply to: Toddler Wakes Up Screaming - Nightly posted by Amy Perry on February 18, 1998 at 07:21:20:
I know from my experience with my children that sleep problems can be troubling for both children and adults.The term "parasomnia" refers to a wide variety of disruptive sleep-related events: behaviors and
experiences that occur only-or predominantly- during the sleep period. These events are usually
infrequent and mild. However, they may occur often enough, or be sufficiently severe or bothersome enough, to require medical attention.The most common type of parasomnia is the disorders of arousal", which includes confusional
arousals, sleepwalking, and sleep terrors. Essentially, they arise because a person is in a mixed state of being both asleep and awake, generally coming from the deepest stage of non-dreaming sleep (NREM)/ slow wave sleep (SWS) to a lighter stage of sleep or wakefulness. The child is awake enough to act out complex behaviors, but asleep enough not to be aware of, or remember, them.Throughout the night there is rhythmic cycling between between wakefulness, NREM sleep, and
REM sleep. The length of each cycle is about 90 minutes with a range of 60-110 minutes. Within
15 minutes, children will be in their deepest sleep of the the night. This will last from 45 to 75 minutes. From this period there will be a transition to a brief period of wakefulness, a lighter stage of NREM sleep, or REM sleep before a return to NREM sleep (SWS) again. It is during
this transition from SWS to the next sleep cycle that partial arousals occur most often. During this period of children with partial arousals appear "caught" between deep NREM sleep and full
arousal.These disorders are very common in young children and they usually do not indicate significant
psychiatric or psychological problems. Such disorders tend to run in families and might be made worse when a child is over tired, has a fever, or is taking certain medications. They may occur during periods of stress, or wax and wane with "good" weeks and "bad" weeks.SLEEPWALKING (SW):
SW is commonly seen in older children. It ranges from simply getting out of bed and walking
around the room (Calm SW) to prolonged and complex actions, including going to another part of the house or out into the yard, acting upset, and making sounds that are garbled or unintelligible (Agitated SW).SW is very common and may occur with an incidence of up to 40% in children 6-16 years of age.
CONFUSIONAL AROUSALS (CA):
CA are often labled as "sleep terrors". They are usually seen in infants and toddlers, but adults
may experience them also. These arousals may seem quite bizzare and even frightening to the parent watching them.A CA usually starts some movement or moaning, progressing to crying and perhaps calling out.
The child may simply cry inconsolably. Eyes may be opened or closed, and perspiration is usually marked. A look of "terror" is not described. Rather the child is felt to look very confused,
agitated, upset, or "possessed".These periods can last anywhere from 1 minute up to 40 minutes. Five to 15 minutes is typical.
Even if the child calls to the parents, he usually does not recognize them. Holding and cuddling
do not provide reassurance; instead, the child often resists and becomes progressively more
agitated. Even vigorous attempts to wake the child may not be successful. The evens usually terminate spontaneously dispite the parents perception of "success" in trying to wake the child.Even when this happened with my child and I knew, on an intellectual basis, that the event would
terminate without my intervention, I could not help but try to reassure her (note: I got over this after a few nights and my compassion gave way to my need for sleep). In fact, the more the
parent try to intercede, the longer the episodes may last.The episode usually ends with the child calming, waking briefly, and only wanting to return to
sleep.SLEEP TERRORS (ST):
ST are the most extreme and dramatic form of arousal disorders and are uncommon in young
children. They are more often seen in older children and young adults and are the most
distressing of the arousal disorders to witness.These events usually begin very rapidly (unlike CA which builds-up gradually), with the child bolting upright with a "bloodcurdling" scream or shout. He may continue to cry or scream. The eyes are usually wide open and bulging, the heart is racing, breathing is rapid and there is often
sweating. The facial expression is one of intense fear. In a full blown episode the child may jump
out of bed and run blindly, sometimes out of the house, as if away from some unseen threat. This
may be very dangerous for both the child and the parent who tries to intervene because the child
is totally unaware of what they are doing.These events are usually shorter than CA, generally terminating within a few minutes and the child usually has no memory or only some "memory" for the event in the morning. ST are much worse
to watch than experience. People who have sleep terrors do not remember the episode or recall
vivid dream images, unlike those who have typical nightmares or bad dreams.PRECIPITATING FACTORS FOR AROUSALS:
I. Constitutional or predisposing factors;
1. Genetic 2. Developmental 3. Sleep deprivation 4. Chaotic wake/sleep scheduling 5. Psychologic
II. Precipitating factors;
1. Endogenous
a. Obstructive sleep apnea
b. Gastroesophageal reflux
c. Seizures
d. Periodic movements of sleep2. Exogenous
a. Stimulation-auditory, tactile, or visual
b. DrugsTREATMENT:
In most cases, no treatment is necesary. The child and family can be assured that these events
rarely indicate any serious underlying medical or psychiatric problem. In children, the number of
events tends to decrease as the children get older.To be safe, simple measures should be taken. Clearing the bedroom of obstructions, securing
windows, sleepingon the first floor, and installing locks or alarms on windows and doors will add a degree of security for the family.In severe cases involving injury, violence, excessive eating, or disruption of others, treatment may be very effective. Treatment may include medical intervention with prescripion drugs or behavioral modification through hypnosis or relaxation/mental imagery.
WHEN TO SEE A DOCTOR:
You should contact your physician if parasomnias cause:
1. Potential injurious behavior that is violent or may cause injury.
2. Extreme disruption to other household members.
3. Excessive daytime sleepiness.In these cases, formal evaluation at a sleep center is warranted.
I hope this has answered some of your questions. Please let me know if I can be of further
assistance.Greg
1. "Parasomnias: Things that go bump in the night. What they are and what to do", American Sleep Disoders Association. 1610- 14th St. N.W. Suite 300, Rochester, MN 55901
2. "Princles and Practice of Sleep Medicine in the Child", Ferber and Kryger, 1995, pp 99-106,
Saunders.
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