Table Of ContentC l i n i c a l r e s e a r c h
Aspects of sleep disorders in children and
adolescents
Gregory Stores, MA, MD, DPM, FRCPsych, FRCP
A
wareness of the importance of sleep disorders
medicine is undoubtedly gaining ground,but the pace of
progress is slow.The considerable amount of knowledge
that has accumulated in recent times remains underuti-
lized because awareness of these advances by both the
general public and professionals remains inadequate.This
is especially so regarding pediatric aspects of sleep and
its disorders.
Health education for parents and prospective parents
often pays little regard to sleep.With some commendable
exceptions, medical students, and specialist trainees,
including pediatricians and child psychiatrists,health vis-
itors,child psychologists,and teachers,receive little rele-
Sleep disorders in children and adolescents is a topic that vant instruction despite the fact that they all come into
has been, and remains, neglected in both public health contact with many young people whose sleep is dis-
education and professional training. Although much turbed,sometimes with serious consequences.
knowledge has been accumulated in recent times, it has This relative neglect of children is interesting historically.
been poorly disseminated and, therefore, relatively lit- To some degree it can be seen to reflect the very gradual
tle is put into practice. Only some general issues can be and sporadic emergence of pediatrics in general as a
discussed in this article. The aspects chosen relate mainly branch of medicine in its own right.At times (and in
to clinical practice, but they also have relevance for some respects still),children have been thought of as lit-
research. They concern various differences between sleep tle adults.
disorders in children and those in adults, the occurrence The extent to which this has been the case has been hotly
of such disorders in young people, their effects on psy- debated by historians.On various grounds,Aries1argued
chological and physical development, the essential (but that for many centuries childhood was not acknowledged
often ignored) distinction between sleep problems and as a distinct period of development.This view was con-
their underlying causes (ie, sleep disorders), types of sidered by some to have lingered on in some respects
sleep disturbance encountered at different ages during until as late as the 19th century;witness child labor and
development, and the differential diagnosis of certain
parasomnias that are at particular risk of being confused Keywords:sleep disorder; child; adolescent
with each other.
Author affiliations:Department of Psychiatry, University of Oxford, UK
© 2009, LLS SAS Dialogues Clin Neurosci.2009;11:81-90.
Address for correspondence:Professor Gregory Stores, North Gate House, 55
High Street, Dorchester on Thames, Oxfordshire OX10 7HN, UK
(e-mail: [email protected])
Copyright © 2009 LLS SAS. All rights reserved 81 www.dialogues-cns.org
C l i n i c a l r e s e a r c h
sometimes the use of severe punishment of the type can not slepe, but turneth & vexeth it self wt crying.
meted out to adults.Others have vigorously contested Therfore it shalbe good to prouoke it to a natural slepe
Aries’ claim,pointing out the various ways in which,from thus…
early times,children have been recognized by parents …the seades & the heades of popye,called chesbolles,
and both secular and Church law,for example,as being stamped with rosewater,and myxte with womans mylke,
very different from adults.2 and the whyte of an egge,beaten al together and made in
Despite this counterclaim,it is interesting to trace the a plaister causeth the chylde to receyue his natural slepe.
slow and (at least initially) faltering development of pedi- Knowledge of children’s sleep problems has improved
atrics as a specialty,the classic account of which remains considerably since Phaire’s time,but the attention paid
Still’s The History of Paediatrics,first published in 1931.3 to them still lags behind that regarding sleep disturbance
Hippocrates was probably the first eminent writer to pay in adults. The 2005 revision of the International
special attention to children’s diseases,followed,some Classification of Sleep Disorders (ICSD-2)5improved on
hundreds of years later,by Soranus and Galen and then, previous classification schemes,but its reference to chil-
much later again,Rhazes and Avicenna.Still describes dren’s disorders remains somewhat gestural.Similarly,
the gathering (although sporadic) momentum in more children’s sleep disorders,including their distinctive char-
recent centuries,often in relation to descriptions of indi- acteristics,are consistently under-represented at confer-
vidual pediatric conditions, but eventually leading to ences.
more systematic and comprehensive clinical accounts ICSD-2 describes nearly 100 sleep disorders,many of
and provision of pediatric services in the 19th and 20th which occur in children and adolescents.That being so,it
centuries. would be “mission impossible”to attempt even an out-
Along the way,a particularly notable figure,for whom line account of them all in this short article.Instead,just
Still seems to have had a special regard,was Thomas some aspects of sleep disorders in young people have
Phaire,a lawyer and physician,who in 1545 published been selected,chosen because they deserve special atten-
The Boke of Chyldren,the first pediatrics textbook writ- tion,as they are somewhat understated in usual accounts.
ten by an Englishman.4The book proved very popular, More detailed coverage of pediatric sleep medicine
and ran to several editions.It deserves special mention (including complete references) can be found else-
for many reasons,not least because it discusses children’s where.6,7A further,nontechnical source for lay readers
sleep problems and disorders. (including parents),or professionals with limited famil-
Phaire described (fancifully by modern standards) the iarity with the field,is also available.8
clinical features, supposed causes, and recommended
treatments for various “infirmities of children”: Comparison of children and adults
Although (as affirmeth Plinie) there are innumerable pas-
sions & diseases,where unto the bodye of man is subiecte, Discussion of the differences concerning sleep and its dis-
and as well maye chaunce in the young as in the olde:Yet orders between children and adults is appropriate
for moste commonly the tender age of children is chefely because of the basic importance of the topic for both clin-
vexed and greuved with these diseases folowyng. ical practice and research.Such differences can be iden-
He then lists 40 such diseases which include “watchyng tified in various respects.
out of measure,”(sleeplessness) “terryble dreames and
feare in the slepe,”“colyke and rumblyng in the guttes”(a Changes in sleep physiology
potential cause of bedtime settling difficulties), and
“pyssyng in bedde”! There are profound changes in sleep physiology during
The flavor of his account can be judged from the follow- childhood and adolescence for which there is no real coun-
ing example concerning ‘Of Watchyng Out of Measure’ terpart in adult life.Rapid eye movement (REM) sleep is
(substitute ‘v’ for ‘u’ in places): particularly abundant in very young children,perhaps
…it procedeth commonly by corrupcion of the mylke,or because of its importance for early brain development.The
to muche abundance,whiche ouerladeth the stomake,& circadian body clock takes time to develop but,from about
for lacke of good dygestion,vapours and fumes aryse into 6 months,should allow fairly continuous night-time sleep
the head,and infect the braine,by reason wherof the child without the need for repeated feeds at night.
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Sleep requirements noids are usually responsible in children.Although obe-
sity is increasingly an important factor at all ages,only a
These gradually lessen throughout childhood until about minority of children with OSA are overweight and,
the time of puberty,when the need for sleep might actu- indeed,very early onset may cause low body weight from
ally increase somewhat.This,combined with a physiolog- failure to thrive.
ical delay in the sleep phase at puberty (opposite to the Adult OSA generally causes sleepiness and reduced activ-
sleep phase advance in the elderly),as well as late-night ity.In contrast (as in other causes of excessive sleepiness
social activities,sets the scene for potentially severe sleep such as narcolepsy),some sleepy children are abnormally
deprivation and excessive daytime sleepiness (the active.This can lead to a diagnosis of attention-deficit
delayed sleep phase syndrome,or DSPS) which readily hyperactivity disorder (ADHD) and inappropriate treat-
leads to educational and social difficulties in adolescence. ment with stimulant drugs.
Pattern of occurrence of sleep behaviors and disorders Misdiagnosis
This differs between children and adults.Some sleep dis- There is a risk that certain sleep disorders will be misdi-
orders occur much more commonly in children and ado- agnosed at any age.12Possibly this risk is greater in chil-
lescents,notably bedtime settling and troublesome night- dren than adults because of the wider range of clinical
waking in young children (the result of not acquiring manifestations and alternative explanations for the
good sleep habits and overdependence on parental atten- behavioral changes involved both as primary features of
tion).Adolescent DSPS has just been mentioned.Other the sleep disorder but also because of secondary compli-
examples include rhythmic movement disorders (such as cations.Narcolepsy can be a case in point.13Diagnostic
head-banging),nocturnal enuresis,and arousal disorders problems can also arise from the fact that polysomno-
seen mainly in prepubertal children. graphic (PSG) criteria for OSA and narcolepsy are ill-
Interestingly,some sleep disorders previously thought to defined and different from those used for adult patients.
occur mainly or exclusively in adults are now recognized
in children,eg.,obstructive sleep apnea,restless legs syn- Significance
drome,9 periodic limb movements in sleep,10 and even
REM sleep behavior disorder (RBD).11 Many childhood sleep disorders can be expected to
resolve spontaneously in a way that is unusual in adults.
Etiological factors However,in the meantime (as at any age),persistent
sleep disturbance can have harmful effects on mood,
In explaining the cause of sleep problems at any age, behavior,performance,social function,and,sometimes,
both physical and psychological possibilities (perhaps in physical health.This can have particularly serious conse-
combination) have to be considered.In children,as in quences in young people especially,as poor management
adults,neurological,respiratory,metabolic,endocrine, of childhood sleep problems can also lead to their persis-
genetic,medication,or other physical factors may have tence into adult life.
an influence.That said,parenting practices play a major However,children’s sleep disorders are generally less
part in many children’s sleep problems.Parental knowl- associated with psychiatric illness.It is important for par-
edge, attitudes, and emotional state often determine ents to know that the strange sleep-related behavior (in,
whether a child’s sleep pattern is a problem or not.Some for example, head-banging or sleep terrors) is very
parents construe normal behavior as a problem;others unlikely to mean that their child has a serious psychiatric
do not seek help when they should,perhaps because they or medical disorder.
mistakenly think there is no treatment available.
Treatment and prognosis
Clinical manifestations and associations
Treatment of most children’s sleep disorders is,in prin-
Whereas obesity is a common feature of obstructive ciple,straightforward and likely to be effective if appro-
sleep apnea (OSA) in adults,enlarged tonsils and ade- priately selected and implemented with conviction.
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Unfortunately,however,many parents are unaware of than this.16Children with a learning disability,other neu-
frequently simple ways in which sleep problems in rodevelopmental disorders including autism,or psychi-
young children in particular can be prevented or mini- atric conditions almost invariably have their lives (and
mized by the way they deal with their child at bedtime those of their parents) further complicated by disturbed
or during the night. sleep and its consequences.The same can be said of chil-
Although it is true that many adults are also unaware dren with other types of chronic pediatric illness.
that their sleep problems are amenable to treatment,in Children with these various conditions do not have a new
a significant number of cases (say,of chronic insomnia), set of sleep disorders compared with other children;it is
effective treatment is less readily achieved than in chil- the pattern of occurrence of their sleep disorders that is
dren because the origins of the sleep problem and,there- different.Physical factors may loom large in the etiology
fore,the management required,is more complicated. of the sleep problem in many of these conditions (eg.
Especially in the treatment of insomnia or sleeplessness, OSA in Down syndrome) but behavioral factors (failure
medication has an even smaller part to play in children to develop satisfactory sleep habits) are very common
than it has in adults.Instead,behavioral methods (also overall.
often important for adults) are much more appropriate Similarly, these groups of children can generally be
and effective,14with the possible exception of sleepless- expected to respond to the same types of treatment as
ness in children with neurodevelopmental disorders and other children,providing the treatment programs are cor-
some other chronic pediatric conditions for whom fur- rect for the sleep disorder in question.One obstacle to
ther research on pharmacological approaches (including this is the mistaken view that,for example,serious sleep
the use of melatonin—a contentious topic still) is problems are inevitable in neurodevelopmentally disor-
required.15 dered children, and that the problems have to be
It might be argued that the relevant specialties and dis- endured because treatment will not work.This is not the
ciplines on which it is necessary to draw for assessment case,even when the sleep problem has already lasted
and management of children with disturbed sleep are some time but,sadly,for lack of information to the con-
wider than is the case with adults.The number of tradi- trary,many such children go untreated.
tional boundaries which have to be crossed in sleep med-
icine is considerable at any age,but in the case of young Developmental effects of
patients,in addition to medical specialties,for example, persistently not sleeping well
developmental psychology,and child and family psychi-
atry,often have to make their contributions.Different The potentially serious and widespread effects of persis-
influences may operate at different ages as the many tently disturbed sleep (especially inadequate or poor
changes during the course of development proceed. quality sleep) deserve to be more widely known by par-
ents and professionals alike.This alone would increase
Occurrence of sleep problems in children and the use of the various types of treatments that are avail-
adolescents, including high-risk groups able.
Estimates vary but,from the early years to adolescence, Emotional state and behavior
at least 30% of children in general have a sleep distur-
bance which is considered by parents,or the children “Overtired”children often become very difficult to han-
themselves,to be significant.However,the nature of the dle;they become irritable,distressed,and even aggres-
sleep problem varies considerably with age.Bedtime dif- sive,much to the exasperation of their parents.In some
ficulties and problems with night waking are common up children,such problems are frequent and seriously dis-
to about 3 years of age,whereas nightmares and sleep- rupt family life.Reference has been made to the fact that
walking,for example,feature more in older children,and certain young children said to have ADHD characterized
many adolescents suffer from the delayed sleep phase by overactivity,impulsiveness,and poor concentration,
syndrome mentioned earlier. are reported to have a primary sleep disorder.Stimulant
However common such problems are in children overall, drugs are not appropriate in this subgroup and might
certain groups have sleeping difficulties much more often make matters worse by increasing the sleeping difficulty.
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Especially in adolescence,persistent loss of sleep can waking during the night.In these circumstances,marital
have a depressing effect and lead to the problems at relationships may become seriously strained.
home and at school to which reference has also been Because of the changes of behavior that can result from
made. sleep disturbance,the affected child’s interpersonal prob-
Disturbed sleep can affect a child’s emotional state and lems may extend beyond his family.Irritable,difficult,or
behavior in various other ways.Bedtime can become a otherwise disturbed behavior is likely to affect friend-
source of distress if associated with frightening thoughts ships.Relationships with teachers can also easily suffer,
or experiences that are associated with various sleep dis- especially if they are unaware that behavioral problems
orders,including night-time fears. can be the result of inadequate or otherwise disturbed
sleep.
Intellectual function and education In view of these various potential complications to the
child’s life,it is essential that all concerned realize they
There is convincing evidence that insufficient sleep can can be at least partly the result of sleep disturbance for
cause impaired concentration,memory,decision-making, which effective treatment can be provided in most
and general ability to learn.Performance on tasks calling instances.
for sustained attention is particularly affected,and also
those requiring abstract thinking or creativity.Similarly, The distinction between sleep problems and
motor skills and reaction time can be impaired.Studies in their underlying causes (sleep disorders)
the USA have suggested that 80% of adolescents obtain
less than adequate sleep (ie,9 hours),25% less than 6 It is essential to distinguish between a sleep problem and
hours,and over 25% fall asleep in class.Students with a sleep disorder,although,in practice,this is often not
insufficient sleep generally achieve lower school grades.17 done.
Findings in other countries might well be similar. At any age,there are just three basic sleep problems(or
complaints)
Physical effects •Not sleeping well (“insomnia”or “sleeplessness”)
•Being excessively sleepy (“hypersomnia”)
As the production of growth hormone is closely linked • Behaving in unusual ways or having strange experi-
to deep NREM sleep,if sleep is seriously disrupted from ences in relation to sleep (“parasomnias”).
an early age,physical growth may be affected.As men- These sleep problems are not diagnoses or conditions in
tioned earlier,OSA can disrupt sleep from about the age their own right,no more than are “breathlessness”or
of 2,causing the child to “fail to thrive”and be smaller “pain.”In order for the correct advice or treatment to be
for his or her age than ideal. decided,it is necessary to identify the underlying cause,
In addition to this effect of OSA on growth,persistent ie,the sleep disorder.
sleep loss in particular is being increasingly associated in As mentioned earlier,nearly 100 sleep disorders are now
adults with physical ill-health such as impaired immunity, officially recognized,many relevant to children and ado-
obesity,hypertension,and diabetes.18There is no partic- lescents.Choice of advice and treatment rests essentially
ular reason to expect that children are free of at least on the patient’s sleep disorder.In a way that would be
some of these risks. unacceptable in many other areas of medical practice,
where the need to know the underlying cause of some-
Family and other social effects one’s symptoms is considered axiomatic,sleeping diffi-
culty is often treated (quite possibly doing more harm
There have been reports that relationships between par- than good) by means of medication without the cause of
ent and a child with a serious and persistent sleep prob- the problem being considered.
lem can be severely tested to the point of increased use The treatment of sleepless young children is an example
of physical punishment in extreme cases.19Parents may of the point just made.Many of those who do not settle
disagree with each other about ways of dealing with the to sleep at bedtime or who wake during the night
child’s refusal to go to sleep at the required time,or his demanding their parents’ attention are prescribed hyp-
or her insistence on joining them in their own bed after notic-sedative drugs,such as antihistamines,despite the
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evidence that they are usually ineffective and subject to syndrome (SIDS),should also be part of parental educa-
other drawbacks.15Despite its advocates’ claims,espe- tion about sleep.Main recommendations22include the
cially for children with a developmental disorder,some- following:
thing similar can be said about the use of melatonin.20 •Have the baby sleep on his or her back and on a firm
As the cause of the sleeping difficulty is often failure to mattress that will not obstruct breathing
have acquired good sleep habits,behavioral methods are •Use a safety-approved cot with narrow gaps between
much more appropriate for encouraging such habits or the rails
undoing bad habits.15,21Unfortunately,parents are rarely •Ensure that the baby's face cannot be covered during
taught ways of preventing or dealing with their children’s the night
sleep problems,with the result that many suffer needless •Do not allow the baby to become overheated at night
sleep loss and distress because the child does not sleep •Be sure the bedroom is smoke-free
well. •Do not sleep with the baby on a sofa or armchair
•Avoid cosleeping if either parent has consumed alco-
Changes in the pattern of sleep problems hol,or has taken medication or other substances with
and disorders during development a sedative affect.
Parents and professionals need to be familiar with the Preschool children
kinds of sleep disturbance that their child might develop
at different ages,and know that they are collectively com- The nature of the usual sleep disturbance,and the advice
mon and that they can be prevented or helped,for the required,is different after infancy into the toddler period
most part.Only the main forms of sleep disturbance are and beyond.Many children at this stage of development
mentioned here. recurrently resist going to bed at the required time,
and/or wake repeatedly at night,demanding their par-
Infancy ents’ attention,including coming into their bed.As at
other ages and with other sleep problems,medical fac-
It is important to encourage good sleep habits from an tors must be excluded but the usual explanations are
early stage to avoid bad sleep habits later on.The follow- behavioral,especially:
ing practices are recommended to help parents to •Anxiety about separating from parents at night
achieve this in infants: •Stimulating activities within the bedroom
•Establishing a consistent 24-hour routine,including a •Inadequate limit-setting on uncooperative bedtime or
bedtime routine that provides the baby with cues that night-time behavior
is time to go to sleep •Unhelpful associations with being in bed.If parents
•Not prolonging night-time feeding beyond the age lose their temper,or threaten or punish the child,he or
(about 6 months) when the baby’s body clock has she will come to associate bedtime with upset and fear
developed enough to allow feeding to be confined to •Having failed to acquire self-soothing ways of coping
daytime with night waking.
•Teaching the baby to fall asleep alone so that when he Behavioral treatment methods can be very effective in
or she wakes in the night (a natural occurrence at all these circumstances (sometimes in a surprisingly short
ages) he or she is able to fall asleep again without time).
requiring his or her parents’ attention (“self-sooth- Other possible contributory factors with which parents
ing”) need to be acquainted include:
•Establishing a clear difference between day and night •Inappropriate patterns of daytime napping,ie,too lit-
to help to develop the infant’s body clock which con- tle or too much daytime napping for the child’s age or,
trols sleep and wakefulness alternatively,a nap too near bedtime
•Ensuring the environment is conducive to sleep. •Putting the child to bed too early while he or she is in
Safety measures to reduce the risk of the infant coming the “forbidden zone”of maximal alertness and not yet
to harm at night from suffocation or other breathing physiologically capable of sleep.Bedtime should coin-
problems sometimes associated with sudden infant death cide with being “sleepy tired”
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•Night-time fears,which often begin at an early age,can reasons for not being able to sleep at this age.Nicotine,
cause difficulty getting off to sleep or disturbance dur- alcohol,and caffeine-containing drinks,as well as illicit
ing the night. drug use,are additional possible influences.
However,inability to get off to sleep and to wake up in
School-age children the morning is often part of DSPS,to which reference
was made earlier.This condition,which is reported to be
Again,the pattern of sleep disorders changes somewhat particularly common in adolescence,is potentially very
at this age.Certain causes of sleeplessness in preschool disruptive educationally and socially.As such,it deserves
children may still apply, but other causes of sleeping further discussion.DSPS is commonly misconstrued as
badly may begin to show themselves. something other than a sleep disorder.
•Night-time fears23 might intensify and become more The problem usually arises from the sleep phase delay at
complex.Such fears are usually transient and require puberty and habitually staying up late for social or other
only reassurance and comfort until they cease. reasons,especially at weekends or during holidays.The
Occasionally,however,they are so intense and persis- result is that it becomes impossible to go to sleep earlier
tent that they need special attention.In such instances by choice.
the content of the fear or accompanying nightmares The features of DSPS are persistently severe difficulty
might be revealing.Once more,behavioral treatment is getting to sleep (possibly until well into the night),unin-
reported to be very effective. terrupted sound sleep for just a few hours,but then great
Needless to say, the child’s reluctance to go to bed difficulty getting up for school,college,or work because
because he or she is genuinely afraid must be distin- of not having nearly enough sleep.This causes sleepiness
guished from pretending to be afraid as a delaying tactic. and underfunctioning,especially during the first part of
•Worry and anxiety about daytime matters may cause the day.The abnormal sleep pattern is maintained by
difficulty in getting to sleep or staying asleep.However, sleeping in very late when able to do so at weekends and
the original source of concern may no longer exist but during holidays.
the difficulty falling asleep may persist because the “Chronotherapy”includes gradually changing the sleep
child has developed the habit of lying awake in bed in phase to an appropriate time.Where the phase delay is
an agitated state (“conditioned insomnia”). about 3 hours or less,bedtime can be gradually brought
•Restless legs syndrome,which (as mentioned before) is forward.More severe forms of the disorder require pro-
now described in children,consists of disagreeable leg gressive sleep phase delay in 3-hour steps round the clock
sensations with an irresistible urge to move the legs until a satisfactory timing is achieved which then has to
causing difficulty getting to sleep.It is often accompa- be fixed.
nied by periodic limb movements.“Growing pains,” Additional measures to maintain the improved sleep
said to be a cause of sleep difficulties in otherwise schedule include early-morning exposure to bright light
healthy children,is an ill-defined condition.Where they and firm agreement with the adolescent to maintain a
occur around bedtime,the restless legs syndrome is a new pattern of social activities and sleep.Melatonin in
possibility.9 the evening might also help.
•In older children and later,early-morning wakening Difficulties achieving and maintaining an improved
may be part of an anxiety or depressive disorder. sleep–wake schedule by these means are compounded if
Otherwise,the child may have been woken too early by there is a vested interest in maintaining the abnormal sleep
noise or other environmental factors which intrude into pattern,for example,to avoid school (“motivated sleep
his or her sleep. phase delay”).Psychological problems,including depres-
sion,may well also make successful treatment less likely.
Adolescence The teenager’s reluctance to go to bed earlier and to get
up at the required time is often misinterpreted as “typi-
The generally very efficient sleep of prepubertal children cal difficult adolescent behavior”causing trouble in the
changes to less satisfactory sleep in adolescence for both family. Otherwise the condition might be mistakenly
physiological and psychosocial reasons. viewed as the usual form of school nonattendance,pri-
Worries,anxiety,and depression are commonly quoted mary depression,or substance misuse.
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Differential diagnosis of sleep-related epileptic seizures) as these often cause most
childhood parasomnias confusion and concern.Detailed accounts of these para-
somnias and others are provided elsewhere.24
Parasomnias are repetitive unusual behaviors or strange Often an accurate diagnosis can be made by means of a
experiences that occur just before,during,or arising out detailed account of the subjective and objective sequence
of sleep,or on waking.The many parasomnias (some pri- of events from the onset of the episode to its resolution,
mary sleep disorders,others secondary to medical or psy- and of the circumstances in which the episode occurred,
chiatric conditions) now officially recognized (over 30 in including its duration and timing.Audiovisual recording
ICSD-2) indicate how commonly and in many ways (including by means of home recording by parents) can
(some subtle,others dramatic) sleep can be disturbed by be very informative and often adds details that are
episodic events. missed in descriptions given in the clinic.
Confusion between the different parasomnias seems to For the most part (seizure disorders generally being a
be common.For example,in pediatric textbook accounts, main exception),physiological recordings are required
sleep terrors and nightmares (two very different types of only when clinical evaluation is inconclusive or where the
parasomnia) are mistaken for each other.Indeed,some- child might have more than one type of parasomnia.
times there is a tendency to call any dramatic parasom- Table I compares the main diagnostic features of the
nia a nightmare.Correct diagnosis is important because three chosen types of parasomnia.The meaning of the
different parasomnias each have their own significance three categories is as follows.
and call for contrasting types of advice and treatment. The term “arousal disorders”refers to childhood confu-
The following brief account is concerned with the main sional arousals,sleepwalking (calm and agitated forms of
features to be recognized in reaching the correct diagno- which are described) and sleep terrors.Used properly,
sis.Emphasis is placed on just some of the more dramatic nightmare is a straightforward term.As sleep-related
parasomnias (namely arousal disorders,nightmares,and epilepsy covers a number of seizure disorders of differ-
Arousal disorders Nightmares Sleep-related seizures *
Age of onset (y) 1-8 3-6 Any age
Gender Both Both Both
Family history Common Sometimes Variable
Prevalence Common Common Much less common
Usual stage of sleep Deep NREM REM Variable
Time of the night Usually first third of the night Middle to last third of the night Variable
Episodes at night Usually one Usually one One to many
Episodes/month Usually sporadic Usually sporadic Sporadic to many
Behavior Variable but usually dramatic with intense Little movement during dreams Variable, may be undirected
autonomic arousal (apart from calm but distressed on awakening, violence or distress during or
sleepwalking); often inaccessible and accessible and welcomes after attack in state of impaired
cannot be comforted; may resist intervention comforting; autonomic consciousness; autonomic
arousal usually marked arousal can be considerable
Level of consciousness Unaware during episode, confused if Asleep during episode, Variable, may be impaired
awakened or following episode fully awake afterwards during or after attack
Memory for events None or fragmentary Vivid recall Variable
Stereotyped Somewhat Somewhat Often
Likelihood of injury Moderate to high in agitated Low Overall low to moderate
sleepwalking and sleep terrors
Prognosis Good Good Good to poor
Table I. Comparison of the main features of arousal disorders, nightmares, and sleep-related seizures. REM, rapid eye movement *In view of the
wide range of types of epileptic seizures associated with sleep, the descriptions given are no more than generalizations, with certain clear
exceptions to the general rule (see text).
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ent types,permissible generalizations are limited. nosed mainly because the complicated motor manifes-
The following types of epilepsy are,to varying degrees, tations (eg kicking,hitting,rocking,thrashing,and cycling
related to sleep.The first four types have been classified or scissor movements of the legs) and vocalizations
as benign in the sense that,despite their focal origin in (from grunting, coughing, muttering or moaning to
the brain,they are not typically the result of a structural shouting,screaming,or roaring) which characterize many
abnormality and can be generally expected to remit attacks.As such, they are very different from other
spontaneously in time.25All five types can readily be con- seizure types.The abrupt onset and termination,short
fused with nonepileptic parasomnias as their clinical fea- duration of the attacks (different from seizures of tem-
tures can be complex and dramatic. poral lobe origin) and,sometimes,preservation of con-
•Benign partial epilepsy with centro-temporal spikes sciousness can also suggest a nonepileptic (even atten-
(Rolandic epilepsy) is a common form of childhood tion-seeking) basis for the attacks.
epilepsy in which about 75% of patients have their In the first instance,diagnosis rests on awareness of this
seizures exclusively during sleep.The seizures involve form of epilepsy and recognition of its clinical features.
distressing oropharyngeal-facial movements and sen- EEG recordings,even during the episodes,are of lim-
sations corresponding to the anatomical origin of the ited diagnostic value.
seizures.Actually,some doubt has been raised recently The distinction between epilepsy and other parasom-
about their entirely benign nature.26 nias can be difficult.Recently,the Bologna group of
•Apparent terror and screaming occur in benign epilepsy clinical researchers have attempted to set out clearly
with affective symptoms.27 the (mainly clinical) criteria for distinguishing between
•The child’s reactions to the complex visual experiences NFLE and other parasomnias.30
(including hallucinations) that can occur in benign
occipital epilepsycan involve dramatic behavior. Conclusion
•In the Panayiotopoulos syndrome seizures often
involve distressing vomiting and other autonomic Hopefully,this brief and highly selective account will
symptoms. have conveyed some of the special considerations and
•Nocturnal frontal lobe epilepsy(NFLE) deserves special points of emphasis that are relevant to sleep disorders in
mention because its clinical manifestations make it par- children and adolescents.As much is already known but
ticularly prone to misinterpretation as nonepileptic phe- little is practised,it is to be hoped that awareness will
nomena.Although mainly described in adults,it also increase about such developmental aspects which are
occurs in children.28It is now known that NFLE can take important for both clinical work and research in the field
a variety of forms,29but a usual variety is often misdiag- of sleep disturbance in young people. ❏
REFERENCES 9. Rajaram SS, Walters AS, England SJ, Mehta D, Nizam F. Some children
with growing pains may actually have restless legs syndrome. Sleep.
1. Aries P. Centuries of Childhood: a Social History of Family Life.New York, 2004;27:767-773.
NY: Vintage Books; 1962. 10. Chervin RD, Archbold KH, Dillon JE, et al. Associations between symp-
2. Orme N. Medieval Children. New Haven, CT; London, UK: Yale University toms of inattention, hyperactivity, restless legs and periodic limb move-
Press; 2001. ments. Sleep. 2002;25:213-218.
3. Still GF. The History of Paediatrics. London, UK: Oxford University Press; 11. Stores G. REM sleep behaviour disorder in children and adolescents.
1931. Dev Med Child Neurol. 2008;50:728-732.
4. Phaire T. The Boke of Chyldren(1545) Translated by Neale AV, Wallis HRE. 12. Stores G. Clinical diagnosis and misdiagnosis of sleep disorders. J Neurol
Edinburgh, UK: Livingstone; 1955. Neurosurg Psychiatry. 2007;78:1293-1297.
5. American Academy of Sleep Medicine. International Classification of Sleep 13. Stores G. The protean manifestations of childhood narcolepsy and their
Disorders, 2nd edition: Diagnostic and Coding Manual. Westchester, IL: American misinterpretation. Dev Med Child Neurol. 2006;48:307-310.
Academy of Sleep Medicine; 2005. 14. Wiggs L. Behavioural aspects of children’s sleep. Arch Dis Child.
6. Stores G. A Clinical Guide to Sleep Disorders in Children and Adolescents. 2009;94:59-62.
Cambridge, UK: Cambridge University Press; 2001. 15. Owens JA, Babcock D, Blumer J. et al. The use of pharmacotherapy in
7. Stores G. Sleep disorders. In: Gillberg C, Harrington R, Steinhausen H- the treatment of pediatric insomnia in primary care: rational approaches.
C, eds. A Clinician’s Handbook of Child and Adolescent Psychiatry. Cambridge, A consensus meeting summary. J Clin Sleep Med. 2005;1:49-59.
UK: Cambridge University Press; 2006:304-338. 16. Stores G, Wiggs L, eds. Sleep Disturbance in Children and Adolescents with
8. Stores G. Sleep Problems in Children and Adolescents: the Facts. Oxford, UK: Disorders of Developmen: its Significance and Management. London, UK:
Oxford University Press; 2008. MacKeith Press; 2001.
89
C l i n i c a l r e s e a r c h
Algunos aspectos de los trastornos del Aspects des troubles du sommeil chez
sueño en niños y adolescentes l’enfant et l’adolescent
Los trastornos del sueño en niños y adolescentes Les troubles du sommeil chez l’enfant et l’adoles-
constituyen un tópico que ha sido y continúa aban- cent ont été et restent un sujet négligé à la fois par
donado tanto en la educación de salud pública la politique éducative de la santé publique et par la
como en el entrenamiento profesional. Aunque se formation professionnelle. Malgré l’accumulation
ha acumulado bastante conocimiento en el último récentes de nombreuses connaissances, ces der-
tiempo, éste ha sido escasamente difundido y por nières ont été peu divulguées et donc faiblement
lo tanto es relativamente poco lo que se ha traspa- mises en pratique. Cet article n’envisage que
sado a la práctica. En este artículo sólo es posible quelques points de vue généraux, principalement
discutir algunos temas generales. Los aspectos ele- liés à la pratique clinique, mais qui peuvent être
gidos se relacionan principalmente con la práctica intéressants pour la recherche. Ils concernent plu-
clínica, pero ellos también tienen importancia para sieurs différences entre les troubles du sommeil de
la investigación. Estos se refieren a diversas diferen- l’enfant et ceux de l’adulte, leur apparition chez le
cias en los trastornos del sueño entre niños y adul- jeune, leurs effets sur le développement psycholo-
tos, a la ocurrencia de tales trastornos en gente gique et physique, la distinction essentielle (mais
joven, a sus repercusiones en el desarrollo psicoló- souvent ignorée) entre les perturbations du som-
gico y físico, a la distinción esencial (pero a menudo meil et leurs causes sous-jacentes (par exemple, les
ignorada) entre problemas del sueño y sus causas « troubles » du sommeil). L’article traite également
subyacentes (por ej. trastornos del sueño), a los des types de perturbation du sommeil selon les dif-
tipos de alteraciones del sueño encontrados en férents âges pendant le développement et du dia-
diferentes edades durante el desarrollo, y al diag- gnostic différentiel de certaines parasomnies qui
nóstico diferencial de ciertas parasomnias que fácil- peuvent être confondues entre elles.
mente pueden confundirse entre ellas.
17. Wolfson AR, Carskadon MA. Understanding adolescents’ sleep patterns 25. Panayiotopoulos CP, Michael M, Sanders S, Valeta T, Koutroumanidis
and school performance: a critical appraisal. Sleep Med Rev.2003;7:491-506. M. Benign childhood focal epilepsies: assessment of established and newly
18. Colten HR, Altevogt BM, eds. Sleep Disorders and Sleep Deprivation: an recognized syndromes. Brain. 2008;131:2264-2286.
Unmet Public Health Problem. Washington, DC: National Academies Press; 26. Perkins FF, Breier J, McManis MH, Benign rolandic epilepsy – perhaps
2006. not so benign: use of magnetic source imaging as a predictor of outcome.
19. Quine L. Severity of sleep problems in children with severe learning dif- J Child Neurol. 2008;23:389-393.
ficulties: description and correlates. J Community Appl Soc. 1992;2:247-268. 27. Dalla Bernadina B, Colamaria V, Chiamenti C, Capovilla G, Trevisan E,
20. Stores G. Medication for sleep-wake disorders. Arch Dis Child. Tassinari CA. Benign partial epilepsy with affective symptoms (‘benign psy-
2003;88:899-903. chomotor epilepsy’). In: Roger J, Bureau M, Dravet Ch, Dreifuss FE, Perret
21. Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A. Behavioral treat- A, Wolf P, eds. Epileptic Syndromes in Infancy, Childhood and Adolescence. 2nd
ment of bedtime problems and night wakings in infants and young chil- ed. London, UK: John Libbey;1992:219-223.
dren. Sleep. 2006;29:1263-1276. 28. Stores G, Zaiwalla Z, Bergel N. Frontal lobe complex partial seizures
22. Fleming P, Blair PS. Sudden infant death syndrome. Sleep Med Clin. in children: a form of epilepsy at particular risk of misdiagnosis. Dev Med
2007;2:463-476. Child Neurol. 1991;3:998-1009.
23. 23.Gordon J, King NJ, Gullone E, Muris P, Ollendick TH. Treatment of 29. Provini F, Plazzi G, Montagna P, Lugaresi E. The wide clinical spectrum
children's nighttime fears: the need for a modern andomized controlled of nocturnal frontal lobe epilepsy. Sleep Med Rev. 2000;4:375-386.
trial. Clin Psychol Rev. 2007;27:98-113. 30. Tinuper P, Provini F, Bisulli F et al. Movement disorders in sleep: guide-
24. Stores G. Parasomnias of childhood and adolescence. Sleep Med Clin. lines for differentiating epileptic from non-epileptic motor phenomena aris-
2007;2:405-417. ing from sleep. Sleep Med Rev. 2007;11:255-267.
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