Putting Childhood Parasomnias to Rest

One of the most complex and intriguing facets of child and adolescent psychiatry is the study of parasomnias, according to Jess P. Shatkin, MD, MPH, New York University Child Study Center, who discussed the diagnosed and treatment of sleep disturbances in children during a presentation on Friday, Oct. 29, and the AACAP 57th Annual Meeting in New York, NY.

Parasomnias, defined as “inappropriate behaviors that intrude into sleep,” are organized into four types: arousal disorders, sleep/wake transition disorders, parasomnias associated with REM sleep, and miscellaneous parasomnias, which includes enuresis.

Commonly known as bed-wetting, enuresis is commonly seen in the clinical setting, impacting 30% of four-year-old children, 5% of 10 year-olds, and 1% of those 15 years and older, according to Shatkin. The condition, which is more common in males, is characterized by decreased arousability, decreased antidiuretic hormone levels during sleep, and inadequate bladder muscle control. Nocturnal enuresis is associated with poor self-image, diminished achievement in school and participation in activities, and increased time spent by families addressing the problem. Along with male gender, family history of enuresis and diagnoses of ADHD and autism are also risk factors.

Before establishing a treatment regimen, it is important to obtain a full history, including what behavioral methods were attempted, what medications were utilized and how successfully, said Shatkin. He advised discontinuing all caffeine in patients with enuresis, restricting late-night fluid intake, encouraging an afternoon nap, and attempting a brief awakening around midnight to use the toilet.

The most effective behavioral treatment involves putting a monitor on either the bed pad or the child’s underwear that triggers an alarm in the event of enuresis; this method, he said, takes about a month to work but has a very high cure rate. Other methods—for which there is little clinical data—include implementing cognitive and motivational therapy using a reward system; bladder training to increase capacity; and sphincter training exercises. Prescribed medications include: desmopressin acetate, imipramine (or amitriptylene), anticholinergic agents, combination treatment, and atomoxetine.

According to Shatkin, arousal disorders are characterized by brief episodes lasting around 1-30 minutes that occur during non-REM sleep. These “deep sleep phenomena” take place during the transition between sleep stages, which occur earlier in the night, and have a high potential for injury in children. They are associated with family history, and those who suffer from these episodes usually have no recollection of them occurring; attempts to awaken those in this state are not encouraged, he noted, adding that parents should try to gently guide the child back to bed.

The precipitating factors include dyssomnia, stress, sleep deprivation, taking medication, consuming drugs and alcohol, enuresis, and hormonal factors such as menses.

Characteristics of other arousal disorders are as follows:

• Sleep terrors (prevalent in 3-6% of children between the ages of 18 months and 10 years of age): short and intense episodes, complete amnesia
• Sleepwalking (prevalent in 15-20% of children, most common in ages 4-12 with a family history); children are generally docile during episodes and very confused. May engage in complex behavior, and tend to have complete amnesia
• Confusional arousal (although more data is needed on this, experts believe it is universal): poor judgment, disorientation, complete amnesia, and autonomic arousal

For these parasomnias, recommended psychosocial interventions included educating the family and patient; treating any primary disorders such as restless legs syndrome; avoiding possible precipitants such as fluids before bed; avoiding sleep disruptions; safeguarding the home; enforcing afternoon naps; and planning scheduled awakenings. Suggested medications include benzodiazepines with long half-lives such as clonazepam or diazepam, low-dose stimulants, and tricyclic antidepressants, said Shatkin.

Finally, he discussed parasomnias that occur during REM-sleep, including nightmare disorders. Interestingly, data has shown that up to 70% of children with repeated nightmares attribute the disorder to images seen in movies and television, providing a great reason to restrict putting television in children’s rooms, he noted. Nightmare disorders tend to correlate with stress and anxiety, and can be treated with cognitive behavioral therapy, hypnotherapy, and dream rescripting techniques.