The term "parasomnia" refers to a wide variety of behaviors that occur during sleep. The most common type of parasomnia is the "disorder of partial arousal," which includes confusional arousals, sleepwalking, and sleep terrors. Experts believe these types of arousal disorders are related and share some symptoms. Essentially, they arise when the child is in a mixed state, being both asleep and awake, generally coming from the deepest stage of nondreaming sleep. The child is awake enough to act out complex behaviors, but asleep enough not to be aware of or remember them. These events are usually infrequent and mild. However, they may occur often enough or be sufficiently severe enough to require medical attention.
Confusional arousals usually begin with crying and thrashing around in the crib
or bed. Your child will appear awake and may look confused or upset. She may
moan or cry out for you, but if you try to comfort her, she may resist you and not allow
you to console her. You will realize that she is half-asleep, and she will be
difficult to awaken. These episodes may last up to half an hour. They usually end
with your child calming down and returning to a deep sleep. Sometimes a child will
awaken briefly from a confusional arousal, only to return to sleep quickly.
Most infants and toddlers have at least one confusional arousal. It may have happened to
your child without your even realizing it. It may just seem to you that your child
seemed to wake up, fuss for a while, and then fall back to sleep. As stated before,
most children have confusional arousals. They are extremely common and primarily
occur in children under the age of three.
Sleepwalking is often seen in older children, peaking between the ages of four and eight. Almost half of all children have at least one episode of sleepwalking. Some children will simply get up out of bed and walk around the room, whereas other children may sleepwalk for a long period and may go to another part of the house or even outside to the yard or the garage. The sleepwalker may return to bed or awaken in the morning in a different part of the house, such as in a closet or someone else's room. Sleepwalkers can even carry on conversations, which are difficult to understand and make little or no sense. Children who are sleepwalking are capable of acting out complicated behaviors, such as rearranging furniture, but usually the activities make little sense. It is quite common for children to urinate in closets or other strange places while sleepwalking. When your child sleepwalks, his eyes will be open, but they may appear "glassy." Injuries during sleepwalking are uncommon because your child is able to see when sleepwalking.
Sleep terrors, or night terrors as they are often called, are the most extreme and dramatic form of partial arousal disorders. They are also the most distressing to witness. Sleep terrors almost always begin with a "bloodcurdling" scream or shout. During one of these events your child will look as though she is experiencing extreme terror. Her pupils may be dilated, she will breathe rapidly, her heart will be racing, and she may be sweating. Overall, she will look extremely agitated. During a sleep terror a child may bolt out of bed and run around the room or even out of the house. During the frenzied event, children may hurt themselves or someone trying to calm them. As disturbing and frightening as these events appear to the observer, children having them usually are totally unaware of what they are doing and do not remember the incident in the morning. In fact, sleep terrors are much worse to watch than to experience. For the child, a sleep terror is less traumatic than a typical nightmare or bad dream. An easy way to distinguish between sleep terrors and nightmares is to determine who is more upset the next morning. If your child is more upset, then it was a nightmare. If you are more upset, then it was a sleep terror.
About five percent of children have sleep terrors, with most sleep terrors occurring when the child is between five and seven years, although younger children can also have them. And sleep terrors run in families. Studies find that 96 percent of children who have sleep terrors have another family member who has experienced a disorder of partial arousal.
While the term "parasomnia" refers to a wide range of sleep disorders, for the rest of this article parasomnia will refer to the disorders of partial arousal: confusional arousals, sleepwalking, and sleep terrors.
Confusional arousals, sleepwalking, and sleep terrors all have a number of things in common that distinguish them from other sleep disorders. Once you know about these features, these disorders are relatively easy to identify.
Time of night. Parasomnias usually occur within one to two hours of falling asleep. They also occur like clockwork. That is, you may be able to predict almost to the minute what time your child is going to have one.
Amnesia. Another feature of parasomnias is that your child will have no memory of these events. In the morning, to them, it will be as if it had never happened. Some children, if they have them often enough, may have some fuzzy recollection of being up but no more than that.
Avoid comfort. Children who are upset usually cling to their parents. Children having a parasomnia do not. They may not appear to even notice you. They are likely to scream more if you pick them up or try to hold them. They may get more upset if you talk to them and try to calm them down. Just leave them alone. Watch them, but don't interfere.
We don't know exactly what parasomnias are, but we do know some things about them. All parasomnias occur out of non-REM sleep. They occur during transitions from one sleep stage to another. They usually occur coming out of stage three or four sleep, what is referred to as deep sleep. The person is basically stuck halfway between being asleep and awake. He is not fully asleep nor fully awake.
Some children sleepwalk or have a sleep terror every night. For other children, it will wax and wane, with "good" weeks and "bad" ones. Every child is different. Some children may have only one episode in their lifetime.
We also know that parasomnias are not any of the following:
Not a nightmare. Sleep terrors are not nightmares. Your child is not dreaming during these events, although it may look like it. Nightmares occur during REM sleep. Most of REM sleep occurs at the end of the sleep period, usually early in the morning. This means that nightmares are also more likely during the second half of the night. One of the defining characteristics of REM sleep is that you are basically paralyzed. Your eyes move, your heart pumps, and you are able to breathe, but you are not able to move. So you cannot yell, cannot sit up in bed, and definitely cannot walk. Sleepwalking, confusional arousals, and sleep terrors occur in non-REM sleep when you are not dreaming and are not paralyzed.
Not a psychological problem. Many parents become worried that sleep terrors and sleepwalking indicate that their child has some serious psychological problem. The children look terrified and frightened. It may appear to somethat they are acting out some concern or problem that occurred during daytime hours, but this is not so. Many studies have been done, and the consensus is that parasomnias are not related to psychological problems. The children do not have problems with anxiety and are not depressed, and they are certainly not psychotic or having hallucinations. They are simply stuck halfway between awake and asleep.
Not possessed. Some parents say that their child looks possessed or is speaking "in tongues." Obviously, this can't be true. Your child just looks and acts strange during a night terror.
Nightmares. It is very easy to distinguish parasomnias from nightmares if you know what to look for. Look on the following table and compare the sleep disorders covered here with nightmares on several key components.
Seizures. Parasomnias can also be confused with seizures that occur during sleep. It is very unlikely that your child is having a seizure because they are quite rare, but you should be aware of what to look for. Seizures can occur at any time of the night but often happen shortly after a child falls asleep. The behavior is repetitive and steroetypic, meaning that your child will always move the same way over and over. You will not be able to arouse your child, and your child will not recall the event in the morning, similar to parasomnias. If your child is having seizures during sleep, then he may also be sleepy during the day. Again, seizures in sleep are very rare compared to common parasomnias and nightmares. If you have any concern that your child is having seizures, contact your pediatrician immediately.
| Parasomnias | Nightmares | |
| Time of night | First 1/3 of night | Mid to last 1/3 |
| Behavior | Variable | Very little motor |
| Level of consciousness | Unarousable or very confused if awakened | Fully awake |
| Memory of event | Amnesia | Vivid recall |
| Family history | Yes | No |
| Potential for injury | High | Low |
| Frequency | Common | Very common |
| Stage of sleep | Deep non-REM | REM |
| Daytime sleepiness | Little or none | None |
Just as we don't know exactly what parasomnias are, we don't know exactly what causes them. We do know that they run in families. If a two-year-old has them, it is likely that one of his parents had them, although maybe not as severely. In some families every one of the children has them to some degree. They also appear to be a developmental phenomenon, with children most likely to have them at certain ages.
There are certain factors that cause these sleep disorders to be worse or more likely to occur.
Sleep deprivation. Not getting enough sleep is the number one reason that a child has a sleep terror or walks in his sleep. If your child doesn't get enough sleep on Wednesday night, he is more likely to have a sleep terror on Thursday night. This is because confusional arousals, sleepwalking, and sleep terrors occur during deep sleep. When deprived of sleep, the body demands more deep sleep and gets more than usual on a normal night. So the more deep sleep that your child gets, the more likely that he is going to have an episode.
Medications. Some medications can cause parasomnias. Lithium, Prolixin, and desipramine can induce or exacerbate one of these parasomnias.
Fevers or illness. A high fever or being sick can cause confusional arousals and sleep terrors. The higher the fever, the more likely an event will occur. For some children, this is the only time they will ever have one. If you have never observed one in your child before, it can be very scary especially when your child is sick.
Strange places. Sleeping at Grandma's house, a friend's house, or any strange place can lead to a sleep terror or sleepwalking.
Stressful times. Parasomnias often occur during periods of stress. It is not the stress itself that causes the sleep problems but the sleep deprivation that often goes along with it. If you are moving or going through a divorce, or there has been a death in the family, your child may not be getting to bed as early as you would like and may not be getting enough sleep. If your child is worrying before falling asleep, he may not be getting the sleep he needs. Whenever this happens, unusual sleep behaviors are more likely to occur.
Other sleep disorders. Some children's parasomnias are made worse by another underlying sleep disrupter. For example, if your child has sleep apnea, it may be causing her to wake more frequently. This waking is causing her to have more sleep transitions. As these parasomnias occur during sleep transitions, the apnea may be triggering a sleep terror. Therefore, it is important to know whether your child is having other sleep problems. If you have any concerns, contact your pediatrician or a sleep disorders center in your area.
People can easily get injured sleepwalking when sleeping in an unfamiliar place, whether it is at a grandparent's house or at a friend's place. If your child has sleep terrors or is a known sleepwalker, be sure to use safety precautions both at home and at other places.
The most common injuries occur when a child falls out of a second-story window or walks outside. Surprisingly, although your child is asleep, he can still see. This is why he doesn't bump into furniture and is unlikey to fall down the stairs. In the dark or in a strange place, however, accidents can happen. And even for children who sleepwalk regularly without incident, it is possible for their sleepwalking patterns to suddenly change. Children have been found at a neighbor's house, down the street, and in driveways. Often they walk out, go somewhere, lie down, and fall back to sleep, waking in the morning unsure of where they are.
The most important thing you can do is make sure your child is safe. Just because your child has not sleepwalked in the past, doesn't mean that she won't begin next week. It is therefore better to be safe than sorry, especially if your child has ever had a parasomnia event. Here are some things you can do to make sure your child is safe.
Gates. Put up gates at the door of your child's bedroom and at the top of the stairs. For younger children, the gates will stop them from leaving their room or going downstairs. For older children, the gate may not stop them, but perhaps it will slow them down enough for someone to hear them.
Alarms. An alarm can be very helpful in making sure your child doesn't leave the house. An alarm is not intended to wake your child, but to wake you. Any type of alarm will do, from the fancy and expensive burgler alarm to a simple and more econimcal option. For instance, hang a bell or other jangling item from a string in front of your child's doorway so that when the door opens, it will make noise. The sound doesn't have to wake your child, but it should be loud enough to wake you. There are also inexpensive burglar alarms available that hang on doorknobs. If the doorknob gets touched or turned, a loud alarm goes off. There are even fancy electric eye systems that you can install in your child's room, even over her bed, that will trigger when your child gets up and starts moving about. A word of caution, though: If you are relying on an in-home alarm system, especially one that has motion sensors, be careful that the police don't get called simply because your child is sleepwalking.
Lock windows. Ensure that windows, especially second-story or higher, do not open enough that your child can jump out of them. There are devices available thta prevent windows from opening more than a few inches.
Rearrange furniture. Rearrange the furniture in your child's room so that he won't bump into anything in the dark and get hurt. A low table in the middle of the room may be perfect for drawing on during the day but can be dangerous if your child is sleepwalking in the middle of the night.
Remove things that are in the way. If your child walks in his sleep, clear away anything that he can step on or trip over during the night. Don't leave piles of blocks lying on the floor near the bedroom door, and be sure to pick up scattered toys.
Sleeping on the first floor. If your child is in real danger of going out a second-story window, consider having your child sleep on the first floor. If you live in a fifth-floor apartment, obviously you can't do this. But in other cases, this may be possible.
Following are suggestions of things you can do to deal with your child's parasomnias:
Don't wake your child. Waking your child will not harm your child--that is an old wives' tale--but it will prolong the event.
Guide your child back to bed. Your child is asleep during these events, although he may not look it. He will eventually, and sometimes abruptly, return to normal sleep. To encourage this, guide your child gently back to bed. If he resists, let him be.
Try not to interfere too much. The normal response of parents is to try to comfort their child during a parasomnia episode. Try to resist doing this. Most children will just get more agitated; this is especially true if you try to hold a child who already appears upset. If your child is about to come to harm, though, be sure to keep her safe even if she fights you.
Increase amount of sleep. Try to increase the length of time that your child is asleep in order to avoid his becoming sleep-deprived. This is because confusional arousals, sleepwalking, and sleep terrors all occur during transitions from deep sleep. If your child is not getting enough sleep, he will have more deep sleep and will be more likely to have an event.
Maintain a regular sleep schedule. Parasomnias are more likely to occur on nights that your child goes to sleep at a time that is different from his usual time.
Don't discuss the event the next day. The morning after an event, don't discuss the problem with your child. Discussing the event is likely to worry him. This can lead to your child's becoming anxious about sleeping, because he is scared about what he may do. If he is anxious, he is less likely to fall asleep at night and then may become even more sleep-deprived. This, unfortunately, can lead to even more events. In addition, discussing parasomnias may lead older brothers and sisters to tease a younger child about how "weird" he was last night. Older children are also likely to ask if they acted strange during the night.
Allay your child's fears. Although this article is geared towards infants and toddlers, you may have an older child who has parasomnias. For older children, it may be helpful to discuss how common these behaviors are and to allay your child's fears or concerns that she is different or that something is wrong with her. Many older children become worried that they are crazy. Such a discussion should occur as part of everyday conversation. It is still recommended, even with older children, that you do not discuss whether such an event occurred the previous night. Again, it can make a child self-concious and lead to the avoidance of sleep.
In most cases parasomnias require no treatment other than the above suggestions. After all, these events rarely indicate any serious underlying medical or psychiatric problem. Furthermore, the number of events tends to decrease in children as they get older; most children do not have them anymore after puberty. In some cases, however, medicatoin or scheduled awakenings may be prescribed.
In severe cases, when parasomnias involve injury, violence, or disruption of the sleep of others, treatment may be necessary. This treatment may include medical intervention with prescription drugs or behavior modification techniques.
Doctors usually try to avoid giving drugs to a child who has parasomnias. However, in certain instances, when the sleep terrors are extreme or the child is in danger of hurting himself or someone else, medication may be recommended.
The most common types of medications given are benzodizepines, such as Restoril or Klonopin. These drugs have a sedative effect and are often prescribed for anxiety. For parasomnias, though, they are prescribed not for their effect on anxiety but because they depress deep sleep--which is when sleep terrors are most likely to occur. These drugs will also help your child fall asleep, an asset if your child is scared to go to sleep. Usually a very short-acting medication is prescribed because all that is needed is to suppress deep sleep during the first few hours when sleep terrors occur. You also don't want a medication that stays in the system any longer than a few hours because you don't want your child to be groggy and feeling sluggish the next day.
A treatment technique known as scheduled awakenings is available to treat parasomnias. This techniques has been utilized by many with success, but there are no empirical data stating that scheduled awakenings definitely work. (While this technique can be used for confusional arousals or sleepwalking, sleep terrors will be used for ease of discussion.)
This technique involves waking your child about ten to fifteen minutes before he normally has a sleep terror. Ususally you will need to repeat this process for about a week to ten days, and then the sleep terrors will stop. To use this intervention, your child will need to be having sleep terrors on a regular basis, at least two to three times per week, and have them at a consistent time of night. To figure out whether scheduled awakenings could be effective for your child, keep a nightly log in which you record the time that your child falls asleep and the time that he has a sleep terror (or sleepwalks, or whatever the case may be). Keep this log for at least one to two weeks, until a pattern emerges. You are looking for how often your child has sleep terrors and what time of the night they occur.
Once you have figured out the pattern of your child's sleep terror. you can begin scheduled awakenings. For the next ten days, wake your child fifteen minutes before he normally has a sleep terror. So if your child falls asleep at 8:30 every night and usually has a sleep terror at 9:45, wake him up at 9:30. If your child has a sleep terror sixty-five minutes after he falls asleep, then wake him fifty minutes after he falls asleep. The exact time you wake him will depend on what time he falls asleep on a given night. When you wake him, you don't need to totally get him up. You need only wake him to the point that he mumbles or moves, or rolls over. You may need to set an alarm for yourself to remind you to wake your child. This way you won't have to watch the clock, and you won't have to worry about missing the time that you are supposed to wake him.
This technique sounds much more straightforward than it actually is. There are several things that can occur or go wrong. On a given night, your child may have a sleep terror before you get a chance to wake him. If this happens, move your scheduled awakening for the next night, and all subsequent nights, to an earlier time. If you were supposed to wake your child at 9:30 and he had a sleep terror at 9:20, then move your scheduled awakening to 9:15. Your waking him might also trigger a sleep terror. Again, if this happens, move your scheduled awakening earlier in the night. The scheduled awakenings can also move the sleep terrors back later in the night. This is the trickiest problem to deal with. What you will need to do is slowly begin moving the scheduled awakenings later in the night. If you were waking your son at 9:45, do so for about five days. Then start moving the wakings later by fifteen and thirty minutes. So for three days, wake him at 10:15, and then for another three days, wake him at 10:45. And so on. Keep doing this until the sleep terrors end.
If the sleep terrors persist after ten days of scheduled awakenings, continue waking your child for another week. If the scheduled awakenings are effective, stop after the ten days. For many children, no more sleep terrors will occur.If they return when you stop the wakings, fo back to waking your child for another week. Try stopping again. If they still continue but no sleep terrors occur on the nights that you do wake your child, then go ahead and keep up the scheduled awakenings.
While we are not totally sure why scheduled awakenings work, there are several possible reasons for their effectiveness. Remember that sleep terrors, and other similar parasomnias, occur at the same point in the sleep cycle and happen when your child is making the transition from deep sleep to either awake or to another sleep stage. Scheduled awakenings may give your child practice in making the transition from deep sleep. That practice may allow the body's mechanism to learn how to do this effectively without getting stuck and having a sleep terror. Another reason they may work is that they are forcing the body to bypass that point in the sleep cycle when a sleep terror is likely to happen. A last reason they may work is that scheduled awakenings may lead to a new learned behavior. Rather than having a sleep terror, your child may learn to wake at that point in the sleep cycle, and thus a sleep terror doesn't have a chance of occurring. For whatever reason it works, for some children scheduled awakenings can be extremely effective in treating sleep terrors and other similar parasomnias.
Scheduled awakenings aren't for every child, however. If your child's sleep terrors are affecting others or put your child in danger of hurting himself, a more intensive intervention may be warranted. Also, if your child's sleep terrors are infrequent, then scheduled awakenings are difficult to do. They also shouldn't preclude you from instituting safety precautions. No matter what treatment you choose--including doing nothing--make sure that your child is always safe and can't hurt himself.
This article was excerpted from a book called "Sleeping Through the Night--How Infants, Toddlers, and Their Parents Can Get A Good Night's Sleep," by Jodi A. Mindell, Ph. D.