Chapter 16

Sleep-Wake Disorders in Children  

•   Sleep-Wake Disorders in Children

– DSM-5: Sleep-Wake Disorders

–  Characterized by disruptions in a person’s sleep patterns or dissatisfaction regarding the quality, timing, or amount of sleep.

–  

– DSM-5: 20 Sleep-Wake Disorders

– About 25% children experience a sleep problem

Pediatric Insomnia

•   Pediatric Insomnia

– Sleep problems resulting in distress or impairment with the quantity and quality of sleep

–  One (or more) of the following:

–  

– Difficulty maintaining sleep

– Early-morning waking, inability to fall back to sleep 

–  Distress or impairment can be reported by the child or caregiver

–  At least 3 nights per week for 3 months

– Less duration: acute (less 1 month), subacute (1-3 months)

–    

– Most common sleep problem experienced by youth  

•   Pediatric Insomnia

– Prevalence

–  Sleep Problems and Disorders

–  

– Sleep disorders: more prevalent in early childhood and decline with age 

–  Sleep Problems

– More common among youth with:

–  Intellectual disability

–  Autism spectrum disorder

–  Chronic health problems

•   Pediatric Insomnia: Risk Factors 

– Difficulty Falling Asleep Alone

– Issue:

– Co-sleeping

– Condition children to fall asleep when being held, rocked, carried, cuddled, or fed

–  Learn to associate sleep with external stimuli and are unable to fall asleep without them      

– These behaviors increase problems with:

– Fall asleep independently

– Nighttime waking

– Reduced sleep quality

•   Pediatric Insomnia: Risk Factors 

– Night Waking

– Issue: conditioned to fall asleep only with the help of their parents

– Wake parents to assist in returning the sleep

– Sleep loss: child and parent

•   Pediatric Insomnia: Risk Factors 

– Bedtime Resistance or Struggles

–   

– Children: positively reinforced for behavior

– Caregivers: negatively reinforced for behavior 

–  Inconsistent bedtime schedules and routines exacerbate bedtime refusal

– Inadvertent training of children to delay or refuse bedtime

•   Pediatric Insomnia: Risk Factors 

– Anxiety or Impulsivity

–  

– Try to force self to sleep or distract self

–  Issues: increased frustration and tension or increase arousal  and prolong sleep onset

– Issue: broader social and cultural context

– Physical sleep environment

– Family structure and resources

– Social-cultural beliefs and values

– Issue: impulsivity may contribute to sleep problems

– Falling asleep and staying asleep 

Other Sleep-Wake Disorders in Children

•   Other Sleep-Wake Disorders in Children

– Circadian Rhythm Sleep-Wake Disorder

– Recurrent inability to fall asleep and wake at conventionally appropriate times.

– Contributes to:

–  Insomnia and/or daytime sleepiness

–  Impairment in daytime functioning 

– Prevalence:

–  

•   Other Sleep-Wake Disorders in Children

– Sleep Arousal Disorders

– Recurrent episodes of “incompletely awakening” from non-REM sleep; occur at the transition from non-REM sleep to REM sleep

– Sleepwalking and Sleep Terrors

– Common Characteristics

–  About 60 to 90 minutes after sleep onset

–  Occur during non-REM sleep

–  Generally unresponsive

–  Relatively brief (10-30 minutes)

–  Fall back to sleep after the episode

–  No memory

–  Prevalence

–  

–   

•   Other Sleep-Wake Disorders in Children

– Sleep Arousal Disorders

–  Sleepwalking

– Common: 4 to 8 years

– Average: 10 to 20 minutes

–  Sleep Terrors

– About 3% of children

– Average: 10 to 30 minutes

–  Risk Factors

– Heredity

– Immature neural networks

– Environmental stressors

–   

•   Other Sleep-Wake Disorders in Children

– Nightmare Disorder

– Criteria:

–  

– Content reflects threats to survival or well-being

– Cause significant distress and impairment

– Nightmare disorder – not common

– Nightmares

–  Occur during REM sleep

–  Can be awakened from a nightmare

–  Can recall nightmare content

–  Recurrent nightmares may be associated with psychosocial stress or trauma 

•     Nightmare Distress as a Mediator between Frequent Nightmares and Depressive Symptoms in Chinese Adolescents (Yang et al., 2022)

–  Method

–  Participants:

–  Data from the Shandong Adolescent Behavior and Health Cohort

–  11,831 youth, M = 14.97, 50.9% male 

–  Cross-sectional and correlational

–  Method of Observation:

–  Demographic questionnaire: youth report

–  Nightmare frequency: youth report

–  Nightmare Distress Questionnaire: youth report

–  Center for Epidemiologic Studies Depression Scale: youth report

–  Insomnia Scale: youth report

–  Sleep Duration: youth report

–  Results

–  Frequent nightmares compared to no frequent nightmares:

–  Greater nightmare distress

–  Greater depressive symptoms

–  Nightmares and Depression

–  Frequent nightmares and nightmare distress was associated with depressive symptoms

–  Nightmare distress mediated the relation between frequent nightmares and depressive symptoms

–  Message

–   

•   Other Sleep-Wake Disorders in Children

– Obstructive Sleep Apnea Hypopnea

– Airway is constricted or blocked during sleep

–  Apnea: temporary cessation of breathing

–  Hypopnea: slow or shallow breathing

– Children wake to increase oxygen intake, reducing sleep quality

–  Causes: physical conditions

–  

Sleep-Wake Disorders: Assessment

•   Sleep-Wake Disorders: Assessment

– Assessment Tools

– Parental report in interviews or questionnaires

–  

– Actometer

– Attaches to the arm or leg, measure of nighttime activity 

– Polysomnogram (PSG; “sleep study”): hospital setting

– Monitor:

–  Brain activity

–  Eye movements

–  Muscle activation

–  Heart rhythm 

– Asses

–  Sleep duration and quality

–  Abnormalities in sleep architecture

–  Breathing-related sleep problems

Sleep-Wake Disorders: Intervention

•   Sleep-Wake Disorders: Intervention 

– Pediatric Insomnia: Infants and Younger Children

–  

– Consistent bedtime routine

– Put to bed when still awake 

– Extinction - if developmentally appropriate

–  Placing the child in the bed without the stimuli associated with sleep

–  Planned ignoring

–  Graduated ignoring

–  Bedtime fading 

– Behavioral approaches demonstrate efficacy

•   Sleep-Wake Disorders: Intervention 

– Pediatric Insomnia: Older Children and Adolescents

–  

– Treatment: target the behaviors and thoughts that elicit anxiety

– Components:

–  Establish sleep hygiene – behaviors and environments that prompt quality sleep 

–  Relaxation training

–  Stimulus control

–  Sleep restriction

–  Cognitive restructuring

•   Sleep-Wake Disorders: Intervention 

– Pediatric Insomnia: Children and Adolescents

–  

– Most commonly used intervention

– Note:

–  No medications approved to treat insomnia in youth

–  Very little research on the efficacy

•   Sleep-Wake Disorders: Intervention

– Circadian Rhythm Sleep-Wake Disorder

– Intervention goal: match the adolescents’ internal sleep-wake cycle to the expectations of the social environment

– Approaches:

–   

–  Supplements: synthetic melatonin and light therapy

–  Chronotherapy: effective; Supplements: mixed effectiveness 

•   Sleep-Wake Disorders: Intervention 

– Sleep Arousal Disorders

– Sleepwalking and Sleep Terrors    

–  

– Intervention may not be necessary

•   Sleep-Wake Disorders: Intervention

– Nightmare Disorder

– Interventions may involve:

– Assessing possible psychosocial stressors that elicit the nightmares

–  

– Teach relaxation and coping skills

•   Sleep-Wake Disorders: Intervention

– Obstructive Sleep Apnea Hypopnea

– Interventions

– Removal of the adenoids or tonsils

–  

Arginine vasopressin (AVP): A naturally occurring hormone that increases urine concentration and reduces its total volume.

Benzodiazepines: medications that augment GABA and produce marked sedation; can cause tolerance and withdrawal symptoms.

Chronotherapy: a behavior treatment for circadian rhythm sleep-wake disorder; involves gradually advancing or delaying bedtime until the person’s sleep-wake cycle is aligned with their schedule.

Circadian rhythms sleep-wake disorder: a DSM-5 disorder characterized by a persistent or recurring patterns of sleep problems caused by a mismatch between the person’s typically sleep-wake cycle and the scheduled require by the person’s school or work.

Cleanliness training: a version of over correction used to treat nocturnal enuresis; children much wake, change their pajamas and bedding, and reactivate the urine alarm prior to going to bed.

Consultation: In the field of pediatric psychology, providing professional recommendations or assist to a medical professional regarding an aspect of a child’s behavior that interferes with treatment.

Continuous positive be pressure PA) device: A small mask connected to a tube and ventilator that provides constant air pressure to keep the individuals airway open during sleep.

Desmopressin (DDAVP): The most commonly prescribed medication for nocturnal enuresis; a synthetic version of vasopressin, the hormone that reduces nighttime urine production.

Encoresis: A DSM-5 disorder characterized by the repeated passage of feces into inappropriate places whether involuntary or intentional; the individual must be at least 4 years of age, and the act must occur at last once per month for 3 months and cause distress or impairment.

Enresis: A DSM-5 disorder characterized by the repeated voiding of urine into the bed or clothes whether voluntary or intentional; the individual must be at least 5 years of age and the act must occur at least twice per week for 3 months and cause distress or impairment.

Fall spectrum home training (FSHT): Comprehensive behavior treatment of nocturnal enuresis; includes (1) education ad behavioral contracting, (2) urine alarm training, (3) cleanliness training, (4) retention control training, and (5) over learning.

Insomnia disorder: A DSM-5 disorder characterized by predominant difficulty or dissatisfaction with sleep quantity or quality associated with problems going to sleep, remaining asleep, or returning to sleep; occurs at least 3 nights per week for 3 months and causes distress or impairment.

Kegel exercises: Contracting and relaxing pelvic floor muscles in order to stop and start the flow of urine during voiding; used to treat daytime enuresis.

Liaisons: In the field of pediatric psychology, mental health professionals who help members of an interdisciplinary health care team coordinate treatment and communicate with each other and the child's family or school.

Monosymptomatic primary enuresis IMPEl: A term used to describe children who wet only at night, have never been able to stay dry each night for longer than 6 months, and have no known medical cause for their wetting.

Nightmare disorder: A DSM-5 disorder characterized by repeated, extended, and upsetting dreams that occur during REM sleep, typically involve threats to personal security, and cause distress or impairment; the person can be easily awakened and has a vivid memory of the dream.

Nightmare imagery rehearsal therapy: A cognitive treatment for nightmare disorder; children rewrite the nightmare in a manner that emphasizes mastery or resilience and then mentally rehearse the dream daily.

Obstructive sleep apnea hypopnea: A DSM-5 sleep-wake disorder characterized by recurrent breathing disruptions (apneas) or episodes of shallow breathing (hypopneas) during sleep that leads to breathing disturbance (e.g., gasping, snoring) or daytime sleepiness.

Overlearning: A component of full spectrum home training, after remaining dry at night for 24 consecutive nights, a child continues to drink large amounts of fluids and delay voiding to prevent the return of nocturnal enuresis.

Pediatric psychology: An interdisciplinary field concerned with the application of psychology to the domain of children's health.

Polysomnogram (PSG): Assessment of a child's sleep architecture during the course of the night; involves the monitoring of brain activity (EEG), eye movements (EOG), muscle activation (EMG), and heart rhythm (ECG).

Polysymptomatic nocturnal enuresis (PSNE): A term used to describe children who wet throughout the night, void small amounts of urine, and wake after wetting; these children also frequently experience sudden urges to urinate during the day.

Primary encopresis: A term used to describe encopresis exhibited by a child who has no history of bowel control.

Primary enuresis: A term used to describe enuresis exhibited by a child who has never been able to stay dry at night.

Retention control training: A component of full spectrum home training; children with enuresis drink increasing larger amounts of fluids and delay voiding for longer periods of time to become sensitive to a full bladder and to increase functional bladder capacity.

Secondary encopresis: A term used to describe encopresis exhibited by a child who formerly showed appropriate toilet use.

Secondary enuresis: A term used to describe enuresis exhibited by a child who was previously toilet trained for at least 6 months and then began to show enuresis.

Sleep architecture: Activity of the central nervous system during sleep; consists of a series of stages of non-REM sleep usually followed by a REM episode when repeated over the course of the night.

Sleep arousal disorders: DSM-5 disorders characterized by recurrent episodes of incomplete awakening during non-REM sleep resulting in either (1) sleepwalking or (2) sleep terrors; the child experiences no dreams during the episode and has no memory of the episode the next day.

Sleep hygiene: Developmentally appropriate behaviors and environmental conditions that promote restful sleep.

Sleep terrors: A type of sleep arousal disorder characterized by recurrent episodes of abrupt panic and autonomic arousal during non-REM sleep; the child typically lacks responsiveness and is unable to be consoled during the episode; causes distress or impairment during the day.

Sleep-wake disorders: A class of DSM-5 disorders characterized by disruptions in a person's sleep patterns or dissatisfaction regarding the quality, timing, or amount of sleep; causes distress or impairment.

Sleepwalking: A type of sleep arousal disorder characterized by the tendency to leave the bed and walk during non-REM sleep; the person usually has reduced responsiveness to others and is difficult to wake.

Urine alarm: A small mechanical device worn in children's underpants or placed in bedding that detects urine and wakes the child with a noise and/or vibration.

Voiding postponement: A cause of daytime wetting in young children; children avoid voiding in the toilet because they are engrossed in other activities.