Sleep Refusal

Toddlers often resist going to bed when their parents want them to go. Parents may have difficulty recognizing whether the resistance is related to true needs and fears or whether it is attention seeking or oppositional. The resistance often takes the form of repeated requests for a snack, a drink, or a trip to the toilet and may include fears of noises, shadows, or imaginary monsters.

A sleep diary can be helpful to sort out the etiology for the sleep refusal and direct management efforts. The parents record bedtimes and waking times for 2 weeks and indicate specific problem behaviors and their responses to each situation. Parents are often able to recognize patterns and problems themselves as they review the diary.

Many common refusal patterns can be addressed by focusing on the problem aspects of good sleep hygiene (Box 24-1). If the problem seems to be oppositional, the best approach is for parents to ignore it. If the child gets out of bed, a parent should place the child back in bed without conversation other than a firm, “It’s time for bed.” When the parents actively ignore their child’s efforts to get attention, the behaviors often get worse before they improve. However, even persistent children eventually respond (Blum and Carey, 1996). If standard ignoring is too stressful on the family, a “gradual ignoring” technique is also effective (Reid et al., 1999) (SOR: B). This involves briefly checking on the child every few minutes until they are asleep and gradually lengthening the interval between checks.

For a child who is fearful, having parents ignore them may make the fears worse. A gradual withdrawal of the parent’s presence after the bedtime routine works better. The parent may sit in the room while the child falls to sleep but should avoid lengthy discussion of the child’s fears. Once the child is able to get to sleep without fear, the parent begins to move their chair closer to the child’s door and eventually outside the bedroom. Fearful children who do not respond to this technique should be considered for referral for more intensive treatment similar to that applied toward phobias.

Night Waking

Most children wake up in the night but are able to get back to sleep without arousing their parents. The exceptions can have a serious impact on the entire family, as previously noted. As with sleep refusal, a sleep diary can help, and parent education regarding good sleep hygiene is beneficial. However, two common problems deserve particular attention: night terrors and nightmares (Table 24-1).

Table 24-1 Diagnostic Features of Night Terrors vs. Nightmares

Night terrors come about as a sudden partial arousal from the deepest non-REM sleep. Essentially, part of the brain snaps into wakefulness, but part remains soundly asleep. Because deep non-REM sleep predominates in the first four hours of sleep, night terrors usually happen during the early part of the night. The child bolts upright in bed, screaming, sweating, tachycardic, and tachypneic. The episodes usually last only a few minutes, ending as abruptly as they began, with the child falling back to sleep quickly unless fully awakened by the parents. Not fully awake, these children do not respond to the parents’ efforts to comfort them. The child appears disoriented and confused, often with a blank stare, and has no recall of the event the next morning. Night terrors usually occur in children ages 2 to 6 years and are more common during times of illness, stress, or sleep deprivation. A nocturnal seizure should be considered in the differential diagnosis if the events are more likely right at sleep onset or if there is a personal or family history of seizures (Dahl, 1998).

Nightmares, on the other hand, are frightening dreams that awaken the child from REM sleep. Therefore, they tend to occur during the second half of the night, leaving the child upset or scared with a vivid recall of the dream. The child responds to comforting efforts by the parent but may be slow to go back to sleep because of fear. As with night terrors, nightmares occur most often during the toddler to preschool years and are more common during stressful times.

Management

In general, sedative medications are not indicated for night waking. Instead, behavior management techniques similar to those outlined for sleep refusal are appropriate for most cases.

There is no specific treatment for night terrors. Parents should be reassured with the explanation that the problem is common and self-limited. They should not try to wake the child up because this may only frighten the child or slow the child’s return to sleep. For children who thrash violently, the parent should take precautions to provide protection for them. If the child sleepwalks into potentially dangerous situations, the parents can hang a bell or electronic movement alarm on the child’s bedroom door to warn them. Because overtiredness is a major factor in the tendency to have night terrors, increasing the total amount of sleep and keeping a consistent sleep-wake cycle should be emphasized.

Because nightmares tend to occur at times of emotional stress, the focus of treatment should be on assisting parents with effective ways to manage the underlying stress. When a nightmare has occurred, the child is awake and frightened. The parent should comfort the child without a detailed review of the nightmare contents or “flashlight searches for monsters” (Blum and Carey, 1996) which can further increase the child’s fears.

Obstructive Sleep Apnea Syndrome

Habitual snoring occurs in 3% to 12% of preschool-age children. The childhood incidence of obstructive sleep apnea syndrome (OSAS) is estimated to be 2%. The American Academy of Pediatrics has published an evidence-based guideline for the diagnosis and management of OSAS (AAP, 2002).

In children, OSAS is most often associated with large adenoids and/or tonsils, as well as specific facial features such as micrognathia, macroglossia, and Down syndrome. Unlike adults with sleep apnea, children can be affected without large drops in blood oxygen levels, because children can have frequent brief awakenings to quickly reestablish their airway. Thus, the primary clinical issue may be sleep fragmentation. In the context of a child with snoring and restless sleep, OSAS should be considered any time there are symptoms or signs suggesting sleep deprivation, such as difficulty paying attention, emotional lability, partial arousals during the night (night terrors, sleepwalking), or difficulty waking up in the morning (Dahl, 1998).

Because only a portion of children with snoring and adenotonsillar hypertrophy have OSAS, a sleep study is recommended to avoid unnecessary surgery. A caution, however, is that sleep studies in children require special expertise that may not be available at an adult sleep center.

Treatment of a child with OSAS on the basis of adenotonsillar hypertrophy is surgery. Continuous positive airway pressure (CPAP) is effective in children but is reserved for when adenotonsillectomy is contraindicated or unsuccessful (AAP, 2002) (SOR: A).

Sleep Deprivation and Delayed Sleep-Phase Syndrome

Sleep deprivation and delayed sleep-phase syndrome are common problems in adolescents for several reasons. The total sleep requirement is as much or more in adolescence as in pre-adolescence (Carskadon and Roth, 2000), but adolescents tend to receive less sleep for both biologic and cultural reasons. School-age children are more likely to be “larks,” preferring to wake up early even if they are up late at night. At puberty, a circadian rhythm change occurs that results in a switch from larks to “owls,” the preference for a late-night bedtime and late-morning awakening. This biologic tendency is encouraged by the availability of stimulating activities late into the night, whether social events, part-time jobs, or technologic advances (e.g., TV, Internet). Stimulants such as caffeine and tobacco also act to delay sleep. Despite these factors that act to delay sleep, school schedules often require the adolescent to awaken early. Thus, sleep deprivation develops. Also, jet lag–like shifts often develop between the weekday and weekend or holiday schedule. These schedule shifts probably play a role in the most common adolescent sleep problem, delayed sleep-phase syndrome (Dahl, 1998).

The assessment is by history. The main differential diagnosis to consider from delayed sleep-phase syndrome is the teenager who is choosing a late-night schedule for some secondary gain. This person is not distressed by the dysfunctional sleep pattern and is unmotivated to change it. Therefore, the adolescent with secondary gain requires treatment directed at the underlying school or family issues rather than the sleep disturbance.

Treatment of the cooperative adolescent involves attempting a schedule shift and consistently maintaining it. Those with marked difficulty initiating timely sleep may respond to staying awake through an entire night, then reestablishing a regular schedule. Mindell and Owens (2009) provide a practical clinical guide for pediatric sleep.

Narcolepsy

Although rare, narcolepsy is an important cause of daytime sleepiness because it can affect personal safety and school performance but is readily treatable. Normally, REM sleep only occurs when a person has been asleep for 60 to 90 minutes and follows all four stages of non-REM sleep. Narcoleptic patients, on the other hand, experience sudden episodes of REM sleep in the middle of a wakeful state or immediately after falling asleep.

The key feature of narcolepsy is recurrent sleep attacks: sudden, unintentional, irresistible bouts of sleep that occur in inappropriate situations, such as during conversations or while driving. Other common findings include cataplexy (sudden bilateral loss of muscle tone without loss of consciousness), hypnagogic hallucinations (vivid dreamlike imagery just before falling asleep), and sleep paralysis (inability to move or speak just after morning awakening). Any child or adolescent with unexplained daytime sleepiness who does not respond to initial management with good sleep hygiene, or who has a family history of narcolepsy, should be considered for evaluation. A sleep study is required to make the diagnosis.

Narcolepsy treatment combines behavioral approaches with medications. The patient should adhere to good sleep hygiene. Therapeutic naps enhance daytime alertness and reduce the necessary dose of stimulants. Stimulant medications, such as methylphenidate, dextroamphetamine, or modafinil are very helpful for daytime sleepiness (Vgontzas and Kale, 1999) (SOR: A). The antidepressants are REM suppressants that help prevent cataplexy or hypnagogic hallucinations. The nonsedating antidepressants, especially the selective serotonin reuptake inhibitors (SSRIs), work synergistically when combined with stimulants (Vgontzas and Kale, 1999) (SOR: B).

Assessment

Developmental screening should be part of each well-child examination. The Denver Developmental Screening tools have often been used for this purpose but they lack sensitivity and specificity for autism. The AAP provides a thorough examination of screening instruments for autism (Johnson and Myers, 2007). A variety of screening tools aimed specifically at autism are available but also lack sensitivity (Bryson et al., 2003). Therefore, physicians should take parental concerns about delayed speech and language development seriously, especially beyond 18 months of age, even in the context of normal screening. In addition to delayed speech development, the other common presenting symptom is challenging behavior. The behaviors may include a violent reaction to minor changes in the environment or routine, stereotypic movements such as clapping or rocking, and preoccupation with narrow interests or inanimate objects.

When autism is suspected, a thorough evaluation should be performed, including appropriate intellectual testing, speech-language assessment, Autism Diagnostic Interview–Revised (ADI-R) (Western Psychological Services [WPS], 2003) and the Autism Diagnostic Observation Schedule (ADOS) (WPS, 2001). Because hearing loss can mimic autism, the evaluation should also include formal audiologic testing. Common comorbidities include anxiety, depression, and obsessional behavior (Prater and Zylstra, 2002). Many autistic patients develop infantile spasms in the first year of life, a severe seizure disorder.

Management

Early intervention is important because the younger children are treated, the better the outcome. The most successful programs utilize a multidisciplinary approach that includes behavior modification, development of social communication, active involvement of parents and families, and use of psychotropic medications for dangerous behaviors that do not respond to behavior modification (Myers et al., 2007). Referral to an established program is recommended. Despite anecdotal reports of efficacy of alternative and complementary treatments, none of these has shown benefit in clinically controlled trials. Less than 5% of autistic people become self-sufficient adults, although one-third achieve some degree of independent living (Prater and Zylstra, 2002). Clear gain in language is the most important predictor of adult outcomes (Bryson et al., 2003)

Assessment

There is no independent valid test to determine that a child has ADHD. The diagnosis can only be obtained reliably by using well-established diagnostic assessment methods. This involves using the standardized diagnostic criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; Box 24-2), rather than the clinical description of the World Health Organization’s International Classification of Diseases (ICD-9) (AHCPR, 1999). Unfortunately, only 30% of family physicians routinely use the DSM criteria (Rushton et al., 2004). This must be part of a comprehensive diagnostic evaluation that involves obtaining information from the parents, child, and teacher. The baseline assessment of target ADHD symptoms can be assisted by using standardized behavior reports, such as the Conners Rating Scales (1997 revision), NICHQ Vanderbilt forms, or the SNAP checklist. Broadband behavioral rating scales, such as the Child Behavior Check List (CBCL, Achenbach), do not effectively discriminate between ADHD and non-ADHD children but do assist in identifying comorbid disorders (AAP, 2000). Because of the significant prevalence of comorbid psychiatric disorders, the assessment should include inquiring about these conditions (AHCPR, 1999). In addition to psychiatric symptoms, the ability of the child to function normally in different domains must also be assessed. These domains include family relationships with adults, sibling relationships, peer social relationships, community behavior, school academic performance, school behavior, interests and play activities, and subjective psychological distress.

The physician should conduct a medical screening examination, including hearing and vision tests, if this has not already been done. Other diagnostic tests, including laboratory screening tests for lead intoxication, abnormal thyroid function, neuroimaging for brain tumor, or seizure disorder, should be conducted when indicated by the history and physical examination (AHCPR, 1999). Computerized continuous performance tests should not be used as a clinical screening or diagnostic tool for ADHD.