Sleep Disorders in Children

Many children at some point in their young lives will have problems with sleeping. There’s nothing more frustrating for a parent than a child who won’t sleep or sleeps irregularly. Is there anything you can do? You bet! The most common sleep problem with infants, toddlers, and preschoolers is sleep-onset association disorder sometimes accompanied by issues of parent and child sleeping together.

Children who have this type of disorder just don’t sleep. Parents often describe a child who insists on being nursed to sleep or on having a parent lie alongside until he or she falls asleep. Parents are often unaware that their well-meaning habits have created the difficulty.

The problem occurs when the child awakens fully if the parent or other condition he or she has learned to associate with falling asleep is not present. The child has learned to rely on the parent to fall asleep and may lack the self-soothing skills necessary to settle back into sleep independently. Sleep-onset association disorder can lead to frequent nightly arousals for both child and parent.

Management of sleep-onset association disorder involves two critical elements. First, you must gain an understanding of your child’s “brain clock” or typical time of sleep onset and morning awakening. It might be helpful for you to keep a sleep log to accomplish this.

Then, you must undertake a period of training the child to shift from wake to sleep independently. Making this transition requires that parents put the child to bed when he or she is drowsy but still awake-- in other words, at a time that coincides with natural sleep onset rather than at an arbitrary hour they have chosen as bedtime.

Even when timing is optimal, most children protest when their bedtime routine is changed. Parents vary in their ability or willingness to allow their child to cry for brief intervals during this period of training. Simply allowing infants to cry themselves to sleep is unnecessary and potentially harmful, particularly in babies with daytime symptoms of separation anxiety.

Try also using a delayed-intervention method. This only works in children older than ten months. This method gradually increases the time parents remain away from a crying child at bedtime--from several seconds to 2 minutes on the first night depending on the child and parent comfort level and up to 5 minutes on subsequent nights. When they return to the room after each interval away, parents are advised to reassure the child over the crib rail or at their bedside, without picking him or her up, and without turning on the light.

Talking in a slow, quiet voice to a child who is distressed or angry can help calm both the parent and the child. After comforting the baby for a minute or two with endearments (e.g., "I am right here with you, you are okay, sleepy baby, slow down"), the parent may need to again step out of the room while the child is still crying. Many parents find looking at a watch with a second hand during these intervals helpful, because listening to their baby cry for just 1 minute feels like an eternity to many parents.

The goals are to offer nurturance, comfort, and safety; to enhance the baby's self-soothing skills; and to set a clear, consistent limit regarding sleep location, assuming the parents choose not to have the child sleep with them.

For many cultures around the globe and for many families in the United States, parents sharing their bed with their infants and children are the norm and a strongly felt personal preference. This is a sound option when both parents are agreeable to it and commonsense safety precautions are observed. Whatever the sleep location, supine sleep positioning is recommended in babies.

Nighttime snacks and drinks, with the exception of water, should be avoided, because these can exacerbate nocturnal arousals from a physiologic standpoint and negatively affect dental health.

During the middle-childhood years, short sleep requirement, sleep-onset anxiety, and obstructive sleep apnea are commonly encountered problems. In these cases, making a sleep chart is very helpful both for parent and doctors if the problem becomes persistent.

When dealing with sleep-onset insomnia caused by anxiety, physicians will ask about daytime complaints, fears, or worries, which may suggest a more pervasive anxiety problem warranting referral to a children's mental health professional. Exposure to frightening media events and a history of stressful events such as a death in the family or the arrival of a new sibling should be explored.

More severe stressors, such as enduring sexual abuse or witnessing family violence, are considerations in some cases. A simple but common cause of sleep-onset insomnia in children is rumination on issues of the day at bedtime. This problem can often be settled with a small amount of extra attention and conversation with a parent at bedtime.

Anxious children are best treated with a combination of therapies, including a cognitive-behavioral approach that empowers them to generate solutions and gain mastery over their worries. For example, the physician might say to the child, "Adults sometimes feel nervous, too. Let's make a list of the things that could make you feel safe and brave and strong."

In persistent and difficult cases, a 1- to 3-month trial of the short-acting benzodiazepine alprazolam (Xanax) may be indicated, along with referral to a mental health professional. Obstructive sleep apnea is seen in as many as 3% of preschool and school-age children. Parents often complain that the child snores nightly in all positions, perhaps worse when lying on their backs.

Parents may also observe choking spells or what they refer to as breath holding or a halting pattern in the snoring. Children may assume a position of neck hyperextension during sleep. Sleep fragmentation caused by obstructive sleep apnea may lead to daytime sleepiness, manifested as increased napping or falling asleep at school or while watching TV.

Alternatively, children may show changes in daytime behavior, including hyperactivity, distractibility, and mood changes. Common childhood causes of sleep apnea are inflammation of the tonsils or adenoids. These can usually be removed in a simple operation and give your child some relief.

Sleep disorders to watch for in adolescents are delayed sleepphase syndrome - a disorder of circadian rhythm and narcolepsy. Delayed sleep-phase syndrome is common among teenagers, although some delay in sleep phase is considered normal in this agegroup. These teens often describe feeling wide awake in the lateevening hours, with a delay in sleep onset until 3 or 4 AM.

When they manage to drag themselves to school, their performance is impaired, and they may fall asleep in morning classes. Accordingly, the young person often presents with academic failure, truancy, or tardiness. Their sleep debt accumulates until the weekend, when they may sleep until early afternoon, further disturbing their circadian clock.

Changing a delayed sleep cycle is usually a challenge. It consists of setting the morning wake-up time 15 minutes earlier each successive day until the desired target is reached. This procedure is accompanied by exposure to bright natural light or use of a highintensity (2,500-lux) light box in the morning.

Other measures that may be beneficial in resetting the brain clock are minimizing exposure to evening light, a trial of melatonin 4 to 5 hours before desired sleep onset, and a short course of sedative medication in the evening. Strict adherence to the new sleep schedule, even on weekends and holidays, is usually necessary to prevent relapse to previous patterns.