Parasomnias are unpleasant or undesirable events that intrude into sleep. The common parasomnias in children are nightmares, confusional arousals, sleep terrors and sleepwalking.
With the exception of nightmares, parasomnias usually occur in slow wave sleep (within the first few hours of the night after the child falls asleep), and there is often no recollection of the event the next morning.
These events can occur in otherwise healthy children, but may occur more frequently during episodes of acute illness and/or fever, stress, sleep deprivation or in association with any disorder that disrupts sleep.
This section will focus on some of these parasomnias in more detail:
Confusional arousals consist of confused behaviour during and following arousals from sleep in the night, and/or upon attempted awakening from deep sleep in the morning.
Confusional arousals are present in five to 15 percent of children and are usually benign in nature. They usually start before five years of age and peak in frequency during mid-childhood before spontaneous remission. There may be a family history of confusional arousals or sleepwalking.
Episodes of confusional arousals are usually sudden and may be startling. The child may appear to be awake but is disorientated and will be slow in speech and mentation, responding poorly to commands. The child may sit up in bed, moan or whimper inconsolably, and say words like ‘Go away!’, ‘No!’ or may be even more bizarre, such as talking to a lamp. The episode usually lasts for a few minutes to half an hour, and sometimes longer.
Sleepwalking consists of a series of complex behaviours. It is usually initiated during arousal from sleep, and culminates in walking around with an altered state of consciousness and impaired judgement.
The onset of sleepwalking is usually between four to six years of age. About 15 to 40 percent of children have sleepwalked on at least one occasion, with three to four percent having frequent (weekly or monthly) episodes. Episodes usually decrease during adolescence. In children who sleepwalk, a third of them continue to sleepwalk for five years, while 12 percent continue to do so for 10 years. There may be a family history of sleepwalking.
Episodes of sleepwalking usually begin with the child sitting up in bed and looking around confused, before walking. It can involve routine behaviours (e.g. unlocking the door, walking out of the room) or more inappropriate behaviour (e.g. urinating into a waste paper basket). The child may sometimes speak but the speech is usually meaningless. The child usually appears to be awake with the eyes open with a confused ‘glassy’ stare.
The child may then return to sleep on his/her bed, or lie down at an inappropriate site to sleep. The child is usually very difficult to arouse during an episode of sleepwalking and will appear confused and disorientated if awoken.
Sleep terrors are characterised by sudden arousals from sleep with behavioural manifestations of intense fear.
The typical onset of sleep terrors is between two to four years of age, and tends to decrease in frequency as the child grows older. It rarely persists beyond puberty.
Usually more males than females are affected, and a history of sleep terrors in family members may be present. It is estimated to affect three percent of prepubertal children, and one percent of adults.
The event is often of sudden onset. The child sits up in bed and screams in fear, looking tensed with symptoms of flushing, sweating, fast breathing and an increased heart rate. The child is often inconsolable and attempts to pacify him/her may worsen the reaction.
If awoken, the child will appear disorientated and confused. Episodes usually last for a few to five minutes, with the child returning to sleep on his/her own thereafter.
Sleep terrors may be confused with another more common parasomnia – nightmares. In contrast to night terrors, nightmares tend to occur in the last one-third of the night (during a sleep stage known as ‘rapid eye movement sleep’ or ‘dream sleep’), and if awoken, the child is orientated and able to recall events vividly.
In the majority of cases, a reassurance and education of the child and parents will suffice.
Parents should be encouraged to maintain good sleep hygiene and practices, specifically a consistent bedtime routine and schedule for the child.
The prevention of physical injuries is important in sleepwalking (e.g. installing gates at the top of the stairway, locking of windows and the main door). Parents should be advised to guide the child slowly and calmly back to the bed during a sleepwalking episode, without waking him/her. In children where these episodes are recurrent, a scheduled awakening just before the usual time of the first episode, on a nightly basis for a few weeks, may be effective.
Causes of fragmented sleep (e.g. obstructive sleep apnoea, periodic leg movement disorder) may worsen parasomnias, and if suspected, should be identified and treated. Medications are rarely needed.
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