Sleep difficulties in children and adolescents

The majority of children and adolescents experience sleep problems at some stage. Although these may not attract formal diagnoses, these problems nonetheless are often the source of considerable distress for both the child and their family, resulting in diminished functioning and well-being for all concerned. Sleep disorders are classified into two major categories, dyssomnias and parasomnias. The following discussion of sleep difficulties will be presented within the context of these two categories. Finally, a number of treatment approaches for sleep disturbances will be outlined.

The  Sleep Cycle

Pineal gland
Pineal gland

The alternation between sleeping and waking typically follows a 24- hour cycle, which is synchronised to the person's physiology and their social and physical environment. This reflects the spontaneous rhythm of the endogenous circadian pacemaker, commonly referred to as the biological clock and is regulated by the pineal gland in the brain which produces and secretes the hormone melatonin,  which helps regulate biological rhythms such as sleep and wake cycles. The secretion of melatonin is inhibited by light and triggered by darkness.

Sleep occurs in a rhythmic pattern that is characterised by five distinct physiological stages, that are cycled through several times during the course of a night's sleep. Of these stages, the most important appear to be rapid eye movement (REM) and slow wave sleep (SWS), as they are believed to support a number of important functions. Although far from conclusive, evidence suggests that SWS may serve restorative and regenerative functions in regions of the brain and cerebellum.

While it does appear probable that sleep involves restorative and information storage processes, a comprehensive and unequivocal explanation to the question of why we sleep is still yet to be provided. Nevertheless, the debilitating effects of inadequate sleep are a sound indication that inadequate sleep, at the very least, has secondary effects that are not conducive to optimal functioning and wellbeing, and at worst, may have primary effects that impede physical and cognitive development.

The Normal Sequence of Sleep

The stages of sleep
Stages of sleep

Although sleep is controlled by the same neural mechanisms for all people, the structure and pattern of sleep varies across different age groups. Children are born with a multiphasic sleep pattern that does not develop into an adult-like monophasic sleep pattern for a number of years. The emergence of a mature sleep-wake rhythm is a developmental process, which entails the child learning to adapt his or her sleep to comply with the 24-hour environment. Gradually the child’s sleep-wake pattern will consist of progressively shorter and fewer nap’s during the day, and a longer more sustained sleep episode at night. A monophasic pattern of sleep, synchronised to the environment, commonly emerges between the ages of 2 and 5, when the child completely abandons the daytime nap. The total amount of sleep required each 24-hour period, and the total amount of sleep time spent in rapid eye movement (REM) sleep, also follows a developmental time course. It steadily decreases with age, from approximately 16 hours per day in newborn babies, to approximately 8 hours per day in 17 year old adolescents. Thus, the normal range of sleep duration in children varies enormously with age.

In addition to considerable differences in the sleep of children at different ages, there is considerable variation in the sleep patterns of children of the some ages. For example, the parameters for normal sleep in a typical 5 year old ranges from about 8 to 13 hours of sleep, with or without daytime naps. Because of this enormous natural variance that exists within sleep, it is difficult to definitively pinpoint where normal sleep finishes and abnormal sleep begins.

Parasomnias

Parasomnias are disorders of arousal, partial arousal and sleep stage transitions, that is, the activation of the physiological systems at inappropriate times during the sleep cycle. The systems involved are the autonomic nervous system, motor system and the cognitive processes. People who suffer from a parasomnia usually present with complaints of unusual behaviours during sleep.

  1. Nightmare Disorder
  2. Sleep Terror Disorder
  3. Sleepwalking Disorder
  4. Parasomnia not otherwise specified

 

(1) NIGHTMARES - connected to the REM sleep cycle

Diagnostic Criteria

  • essential feature is the repeated occurrence of frightening dreams that lead to awakenings from sleep;
  • become fully awake, oriented and alert
  • significant distress or occupational functioning
  • occur during REM (rapid eye movement) sleep stage;
  • nightmares are not part of another disorder

 

Differential Diagnosis

  • during middle and latter portions of the night during REM sleep;
  • vivid dream imagery;
  • any verbalisations are subdued;
  • moderate physiological arousal;
  • slight or no movements;
  • easy to arouse and responsive to environment;
  • episodes are frequently remembered; (APA, 1994; Wicks-Nelson & Israel, 1997)

    (2) SLEEPWALKING - connected to DELTA (slow wave sleep)

     

    Diagnostic Criteria

    • Repeated episodes of rising from bed during sleep and walking about;
    • Child leaves bed and walks around; can be like an automaton
    • Occurs during stages of SWS;
    • No memory of it the next day
    • Within several minutes after awakening, no impairment of mental activity/behaviour (could be confused)
    • Distress or impairment in social/ occupational other areas
    • Not the result of other physiological
    • disorders

     

    Differential Diagnosis

    • child sits upright in bed; eyes are open but appear ‘unseeing';
      tend to move in a confused and clumsy manner that becomes more coordinated;
    • stays in bedroom, generally, looking for something specific;
    • it is impossible to catch their attention- if left alone go back to their bed;
    • navigation around room through memory of the room layout (which seems to be heightened while asleep)
    • (if blindfolded and did a similar route when awake will not have the same navigational success and will more likely bump into things);
    • sometimes injuries occur
    • sometimes adventurous activities occur-going to the fridge, dressing; note: if the activity becomes more complex-dress then ride a bike this is less likely to be sleepwalking and more a confusional arousal into true wakefulness;
    • disturbing mental events can occur.

    (3) NIGHT TERRORS - connected to Delta (SWS) sleep cycle

    Baby with nightmares
    Baby with nightmares

    Diagnostic Criteria

    1. Recurrent episodes of abrupt awakening from sleep, during first third of night, child wakes with screaming or crying;
    2. Intense physiological arousal (increased heart rate, profuse sweating, pupils dilated) and fear; occurs during non-REM sleep, that is DElTA SWS ; and so, can be associated with sleepwalking;
    3. Difficult to comfort the child;
    4. Very limited or no memory of the episode;
    5. Episodes cause significant distress/ impairment in social/occupational functioning;
    6. The disturbance is not due to direct physiological effects of a substance;

     

    Differential Diagnosis

    1. individuals can suffer isolated episodes of sleep terror, but a disorder is diagnosed on above criteria;
    2. after the fright the child can awaken a little but can be disoriented and confused;
    3. there is motor activity, agitation, child is difficult to arouse and unresponsive to the environment;
    4. verbalisations usually present;
    5. sudden, horrifying sensations with images that shock the sleeper into wakefulness;

     

    Dyssomnias

    Dyssomnias are noted in DSM as disorders of initiating or maintaining sleep, or of excessive sleepiness, which result in a disturbance in the quality, amount, or timing of sleep. Problems of sleep quality are expressed as not feeling rested after sleep, sleep amount problems are characterised as being unable to maintain sleep or excessive sleeping, and sleep timing problems are noted as an inability to fall asleep during conventional sleep times.

    Problems of sleep timing contain reference to the inability to sleep during conventional sleep times, which highlights the social construction that is inherent with the sleep disorders and should be considered during discussion of these disorders.

    Factors involved in sleep disorders

    Childhood sleep disorders have been viewed as manifestations of a child’s neurophysiological development and have been considered to remit with increasing development. However, parental and environmental factors play a role in the development of sleep disorders. Poor sleepers are less able or unwilling to return to sleep and tend to wake their parents. Good sleepers are able to return to sleep adopting behaviours such as looking around or self-quieting by hugging a toy or sucking a thumb. This observation, supported by studies suggest that poor sleepers are less able to self soothe and may be lacking serotonin and/or melatonin neuromodulation.In our experience in the clinic using QEEG to examine the neurophysiology of over 6000 children, these children have low delta power levels and low Alpha power levels. Both of which can be treated with dietary changes and nutrient supplementation. 

    Difficulties going to sleep

    Sleep-onset association disorder is an impairment or absence of sleep-onset in the absence of a particular set of circumstances or objects, for example, a pacifier or bottle, being rocked to sleep, or the presence of a parent (dcsc, 1990). Sleep initiation problems are not encountered when the objects or circumstances are present, although problems of sleep initiation and maintenance (night awakenings) can occur in their absence (dcsc, 1990). Similarly to Limit-setting sleep disorder, this disorder is thought to be an environmentally related problem and is thought to occur in approximately 15-20% of children between the ages of six months and three years, although it may persist after this time (Mindell, 1993).

    Milk-intolerance

    Although this disorder is listed in the icsd (dcsc, 1990) very little is known about the disorder beyond the fact that milk-intolerance can lead to sleep initiation and maintenance problems. The disorder was highlighted in a study that examined a clinical sample of 147 children referred for sleep problems (Kahn, Mozin, Rebuffat, Sottiaux, & Muller, 1989). Of the 147 children 58% were diagnosed with inappropriate sleep habits, 10% had minor problems (the majority of these being parental anxiety), 5% suffered a poor sleeping environment, and 15% were diagnosed with various parasomnias. The remaining 12%, despite symptoms of an average duration of 13 months, particularly frequent night awakenings, did not receive a diagnosis. An intolerance to cow’s milk was suspected as the cause for these children’s symptoms and all (n=17) were placed on a diet that excluded diary products. For 15 of the 17 children sleep was normalised within five weeks of commencing the diet. Subsequently, children were given a double blind milk challenge with symptoms recurring in 14 of 15 children. The milk challenge was again performed at 1-year follow-up with 10 children. All but one child reacted as before with the initial challenge.

    Intestinal Dysbiosis

    Intestinal Dysbiosis is the term used to describe a disordered ecology of the bacteria that normally reside in the gut. Some bacteria populations can become overgrown for a variety of reasons, at the expense of other varieties. Some of these bacteria produce toxic by-products that trigger the brain to function over actively, keeping the person awake and causing anxiety and sometimes panic attacks. If the bowel function is not normal in form and regularity, or if the child frequently complains of tummy aches, contact the clinic for advice. An overgrowth of Streptococcus has been associated with anxiety, panic attacks, restless sleep and night terrors in some children. A diet high in sugars and refined carbohydrates from bread, pasta and cereal grains causes the gut to become acidic and promotes an overgrowth of Strptococcus.

    Night-time feeding

    Night feeds

    It is difficult to distinguish between what is abnormal and normal night-time feeding. It is generally thought that by around the age of six months an infant should be able to acquire all of its food needs during the day. Hence while it may be normal for a 6 month old or so to wake once or twice at night for a feed,  it would be considered abnormal for infants of that age waking more than three to four times per night for substantial feeds.  Consider whether the infant is getting enough nutrients from the diet. Remember food intake is not necessarily the same as nutrient intake. The best food is not processed, but cooked from scratch with unprocessed foodstuffs, such as legumes, vegetables fish and meat. All flour based foods are highly processed and low on nutrients.

    Sleep-wake rhythm disorder

    The timing of sleep is under the control of the circadian timing of our sleep-wake cycle and can become disordered. Some individuals are unable to fall asleep until around 3-5 a.m. after which sleep is of good quality but is not sufficient in quantity due to societal demands to rise. The course of the disorder may be chronic, lasting anywhere between one year or decades, although cases where the disorder has spontaneously corrected itself have been reported. If you have a child with an abnormal sleep-wake cycle, please call the clinic for help.

    Sleep apnea

    Sleep apnea has been associated with excessive daytime sleepiness and involves an obstruction of the airways during sleep that leads to a decreased oxygen saturation of the blood. The decreased oxygen saturation causes the sufferer to awaken briefly and to be frequently aroused many times throughout the night. Sleep apnea is associated with heavy snoring and is thought to be most commonly caused by enlarged tonsils in children, although some have excessive mucous production. Other causes of sleep apnea include a small oropharynx, obesity (especially of the neck), micrognathia (an unusually small jaw), chronic upper airway infection, rhinitis (an inflammation of the mucous membranes of the nose), and hayfever. In such cases, an examination by a paediatric Respiratory Physician or sleep specialist is indicated.

    Treatment

    Nightmares and Night Terrors

    Because there seems to be multiple causality of nightmares (eg. Developmental, physiological, and environmental factors), no single treatment formula can be considered the most effective. Anxiety is generally considered to form the basis of nightmares, however, and individual assessment is necessary, so that appropriate treatment can be instigated. For example, family stresses such as home orschool disharmony may be identified as needing to be targeted, in the treatment of the child's nightmares.

    Consistent with anxiety being viewed as the basis of nightmares, the majority of treatments tend to be anxiety reduction techniques such as relaxation training and parent counselling. Tranquillisers or melatonin supplementation are considered helpful only as a stopgap measure.It would depend on the extent of the problem, as to whether treatment is in fact indicated for night terrors. In many cases, treatment may not be indicated because the episodes disappear spontaneously. However, should intervention be needed, similar treatment approaches are often taken for night terrors, as for nightmares. A combination of medication such as imipramine, education regarding the nature of the disorder, dietary changes, relaxation techniques and parent counselling have been reported as highly effective. While this might be a useful component to treatment, on it’s own it doesn't treat possible underlying causes such as daytime stresses and anxiety. Perhaps a combined approach would produce positive outcomes.

    Sleep Walking

    Child sleepwalking
    Child sleepwalking

    Professor Barry Sterman at UCLA discovered in the late 1960s that there is an alpha rhythm in the brain, called sleep spindles, that is lacking in people who have restless sleep, restless legs and sleep walk. He improved sleep patterns using EEG biofeedback (Neurotherapy) and has published extensively on the subject to this day. Because episodes of sleepwalking may also be triggered by anxiety, one other common treatments is reassurance of the parents, as the more worried they become, the more it will be sensed by the child, resulting in increased anxiety and more sleepwalking. Sleepwalking can also be, at times, a benign habit that can be broken by altering the child's sleeping circumstances, for example, by changing bedroom for a few days. It is considered unwise to try waking up a sleepwalking child as this may result in distress for the child. It is best to guide or carry them back to bed.

    Difficulty Going to Sleep

    Behavioural approaches are considered more successful than sleeping tablets, however before behavioural techniques are applied, causes such as colic, milk intolerance or real fears of sleep or nightmares need to be ruled out and treated appropriately.  Provided the child experiences feelings of safety and security during waking hours, the most effective behavioural technique involves tucking the child in at bedtime, and then leaving the bedroom without going back in until the child is asleep, or failing that, only briefly entering the bedroom for reassurance that the child has no physical complaint, and then leaving immediately. The first night or so is usually quite traumatic for all concerned, but if implemented consistently and correctly, progress is rapid. We don't believe that controlled crying is useful in the long term, as the practice teaches the child Learned Helplessness. Half way measures, such as the parents allowing the child to cry for twenty minutes, and then intervening, are counter-productive as the child's crying behaviour is positively reinforced.

    Dairy intolerance

    Where cows milk intolerance is suspected, the obvious treatment is to withdraw milk products from the baby's diet. In one study , sleep was normalised within 5 weeks in 15 out of 17 subjects and follow-ups involving reintroduction of milk induced the reappearance of sleep difficulties for most of the babies.

    Night time feeding

    Because large night time feeds can create or compound sleep-wake problems, through wet nappies, or discomfort, for infants over 6 months, it is recommended that such feeds be minimised or stopped. The best method for this is gradual reduction over a 2 week period; decreasing the milk available, and increasing the acceptable time between feeds. Success is usually marked, and parents often surprised by how quickly the infant adapts (Horne, 1992).

     

    Sleep-wake rhythm disorders

    Some children presenting with free-running 25 hour sleep-wake rhythms, can benefit from bright light treatment which blocks the drift and resynchronises the sleep-wake rhythm. The recommended treatment, is to wake the child early, say around 7.00am, and exposing the child to sunlight or to bright "daylight lamps",  in the evening avoid bright white lights, use warm lighting and avoid TV or computer screens.