These are primary sleep disorders, sleep disorders related to another mental disorder, sleep disorders due to a general medical condition, and substance-induced sleep disorders. Primary sleep disorders are subdivided into dyssomnias, which are characterized by abnormalities in the amount, quality, or timing of sleep, and parasomnias, which are characterized by abnormal behavioral or physiological events that occur in association with sleep stages or sleep-wake transitions. Key history areas are as follows:
- When evaluating a child or adolescent for a sleep disorder, obtaining a thorough sleep history cannot be overemphasized. A sleep diary usually kept for about 2 weeks provides information regarding night-to-night variability over time. Sleep diaries also are helpful in tracking patient compliance with behavioral interventions and response to treatment. Rating scales have been developed to quantify subjective sleepiness of patients. The Epstein Sleepiness Scale and Stanford Sleepiness Scale are examples.
- Temporal history
- When the problem began
- Predisposing, precipitating, and perpetuating factors
- Review of evening activities and bedtime rituals
- Sleep environment
- Latency to sleep onset
- Arousals – When, duration, frequency, behavior during awakening, and ease with which child returns to sleep
- History of snoring, breathing pauses, sleepwalking, talking, enuresis, and nocturia
- Sleep position
- Nightmares and sleep terrors
- Seizure symptoms – Tongue biting, chewing, blood on bed clothes, and encopresis
- Time of morning awakening, sleep paralysis, and early-morning headache
- Total sleep time
- Restorative sleep
- Daytime sleepiness, fatigue, and school performance
- Questions about depression, anxiety, worries or concerns, hyperactivity, and irritability
- Frequency and duration of naps
- Existing comorbid disorders
- Substance use
- Use of caffeine, alcohol, drugs, medications (prescription or over-the-counter [OTC]), and herbal preparations
- Family history of sleep disorder or metabolic disorder
- Parents’ sleep habits
- Efforts made to control symptoms
- Overall impact of sleep disturbance on family
- Primary insomnia: Insomnia is defined as the subjective symptom of inadequate sleep quantity and quality. Patients with primary insomnia report difficulty falling asleep or maintaining sleep. Chronic insomnia may produce poor concentration and a low level of energy. Other symptoms include a decreased sensation of well-being and poor productivity. Some patients with primary insomnia feel that the sleep was not restorative. Distress due to inability to sleep may lead to a vicious cycle of frustration and insomnia.
- Primary hypersomnia: Patients with primary hypersomnia require more sleep despite long and good sleep (about 12 h), usually require naps in the daytime, and are not refreshed by short naps.
- Narcolepsy: Patients with narcolepsy may experience (1) excessive daytime sleepiness with irresistible daytime sleep attacks; (2) sleep paralysis, in which the individual awakens unable to move; (3) cataplexy, which may be subtle initially (eg, wobbly knees, dizziness) but may progress to sudden falls following a strongly experienced emotion; (4) hypnagogic hallucinations; and (5) feeling of refreshment after a sleep attack.
- OSAS: Children with OSAS have a history significant for loud snoring, breathing pauses, mouth breathing, restless sleep, and increased perspiration at night. Snoring is the most common presenting symptom. Hyperactivity and failure to thrive are more common symptoms of childhood obstructive apnea. Other symptoms in children with OSAS include excessive daytime sleepiness, morning headaches, and behavioral changes (paradoxical hyperactivity as children try to stay awake). These children also experience emotional lability, changes in school performance, and cardiac failure.
- Delayed sleep phase syndrome (DSPS): Of the circadian rhythm sleep disorders, DSPS is the most common, with a prevalence of about 7% for adolescents. It is characterized by early insomnia, little or no difficulty maintaining sleep, and difficulty waking in the morning.
- Nightmare disorder: Nightmares affect 10-50% of children aged 3-6 years. Nightmares occur during REM sleep usually in the second half of the night. After a nightmare, the child is alert and can clearly describe in detail scenes and frightening images. Nightmares are common during stressful times or after frightening events, such as frightening movies. Nightmares are well remembered in the morning. If nightmares are severe and frequent, they may affect daytime functioning. In posttraumatic stress disorder (PTSD), nightmares may be associated with flashbacks, numbing, reenacting the events, and avoidance.
- Night terrors (pavor nocturnus): This form of sleep disturbance occurs in the first 3 hours of sleep. The child is not awake but appears agitated. Abrupt, usually agitated, arousal from slow-wave sleep takes place. Night terrors are associated with autonomic arousal (eg, tachypnea, tachycardia, diaphoresis) and screaming. The child is often inconsolable during the episode. The episode terminates spontaneously after about 3-5 minutes and the child quickly returns to sleep. Recall of the event in the morning is poor. This type of disturbance may be associated with an ongoing illness or fever.
- Sleepwalking disorder (somnambulism): The sleepwalker is difficult to arouse and usually has no recollection of the event in the morning. Actions taking place during sleepwalking frequently vary.
- Bed-wetting (enuresis): In primary enuresis, no period of nighttime dryness occurs for more than 6 months. In secondary enuresis, a relapse of bed-wetting occurs after a period of at least 6 months of dryness. This sleep disturbance may be associated with shame and low self-esteem.
- Sleep disorders related to medical and psychiatric conditions: A wide variety of medical and psychiatric disorders may result in sleep disruption. The clinician must first establish the presence of a general medical condition. Furthermore, the clinician must determine whether the sleep disturbance is causally related to the medical illness through a physiological mechanism. Cluster headaches occur more frequently during the night than in the daytime. Sleep-related headaches usually awaken the patient and fragment sleep.
- Insomnia related to another mental disorder is characterized by reports of difficulty falling asleep, frequent awakenings during the night, or a marked feeling of nonrestorative sleep that has lasted for at least 1 month and is associated with daytime fatigue or impaired daytime functioning.
- Hypersomnia related to another mental disorder is characterized by reports of either prolonged nighttime sleep or repeated daytime sleep episodes for at least 1 month. In both insomnia and hypersomnia related to another mental disorder, the sleep symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.
- Diagnostic criteria for sleep disorders caused by a general medical condition include the following:
- A prominent disturbance in sleep that is sufficiently severe to warrant independent clinical attention
- Evidence from the history, physical examination, or laboratory findings that the sleep disturbance is the direct physiological consequence of a general medical condition
- Disturbance that is not better accounted for by another mental disorder (eg, an adjustment disorder in which the stressor is a serious medical illness)
- Disturbance that does not occur exclusively during the course of a delirium
- Disturbance that does not meet the criteria for breathing-related sleep disorder or narcolepsy
- Sleep disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The following medical conditions fragment sleep, lead to excessive sleepiness during the day, and affect the individual’s concentration and performance in the day to various degrees. In pediatric populations, epilepsies occurring during sleep account for 30% of seizure disorders. Epilepsy appears to fragment sleep and causes impairment in daytime functioning. The sleep disturbances associated with developmental CNS disorders generally reflect fragmentation with frequent awakenings, difficulty in initiating sleep, and early morning awakenings. The physical abnormalities associated with Down syndrome and Prader-Willi syndrome that occlude the upper airway often lead to OSAS. Blind individuals experience cyclic disorders because of the lack of cues that continually reset the internal clock to fit the 24-hour day/night cycle.
- Klein-Levin syndrome: Klein-Levin syndrome refers to a constellation of symptoms that include episodes of excessive somnolence, overeating, and sexual disinhibition. Behavioral disturbances, such as irritability and confusion, are associated with Klein-Levin syndrome. Occasional hallucinations have been reported. Klein-Levin syndrome is 3 times more frequent in boys than in girls. Symptoms typically begin during adolescence, either gradually or abruptly. Onset follows a flu-like illness or injury with loss of consciousness in half the cases. Klein-Levin syndrome has a course that remits and relapses, with relapses occurring at intervals of weeks to months. Symptoms may last from 12 hours to 3 weeks. Klein-Levin syndrome usually resolves spontaneously during late adolescence or early adulthood.
- Down syndrome: Airway hypotonia leads to obstructive apnea that is not associated with obesity, age, or congenital heart disease. Central apnea also is common and is associated with significant desaturation.
- ADHD: Paradoxical hyperactivity in children with ADHD encourages them to stay awake. Emotional lability may be observed. Children with ADHD tend to have fewer arousals and shorter arousals than adults. These children also tend to have obstructive hypopnea with relatively few complete apneic events. Children with ADHD have a strong tendency to fall asleep during the day. Children with ADHD have high rates of RLS and PLMS, and they have a higher prevalence rate for OSAS comorbidity.
- Tourette syndrome: Approximately 50% of children with Tourette syndrome have sleep disturbances. Nocturnal awakenings and movements increase when tics persist into sleep. Comorbidity exists with obsessive-compulsive signs, traits associated with increased sleep latency, decreased REM sleep, and deceased REM sleep latency. Children and adolescents with this movement disorder are at risk for parasomnias. Patients with Tourette syndrome have a higher incidence of enuresis.
- Rett syndrome: This is associated with prolonged sleep latency. Short and fragmented sleep results in low sleep efficiency.
- Prader-Willi syndrome: Obesity, hyperphagia, and developmental delay are the most common features. Obesity can cause obstructive sleep apnea. An increased frequency of apneas, decreased nadir of oxygen saturation, increased maximum heart rate, and blunted respiratory response to hypercapnia during NREM sleep all may occur in patients with Prader-Willi syndrome. Sleep time and slow-wave sleep increase during the day and at night.
- Upper airway resistance syndrome: This results in REM fragmentation and extra daytime sleep (EDS).
- Menstrual-associated periodic hypersomnia: This is another cyclic sleep disorder, noted during the first few years after menarche. Attacks generally last 1-2 weeks after ovulation, with sudden resolution occurring at the time of menses.
- Sleep-related GERD: This is characterized by regurgitation of stomach contents into the esophagus during sleep. It is very common in patients using theophylline as a respiratory stimulant for apnea of prematurity or asthma.
- Nighttime exacerbations of childhood asthma: These are common and may lead to significant sleep disruption.
- Atopic dermatitis: Children with atopic dermatitis tend to have increased sleep-onset difficulty, night awakenings, and decreased sleep duration due to pruritus and medications, such as antihistamines and corticosteroids.
- Chronic illness: Children with chronic illnesses, such as juvenile rheumatoid arthritis (JRA) or sickle cell disease, can experience sleep difficulties.
- Insomnia related to another mental disorder is the most frequent diagnosis (35-50%) among individuals who present to sleep disorder facilities for evaluation of chronic insomnia. In young children, separation anxiety, stress, and trauma may result in nighttime awakening, nightmares, or resistance to going to bed.
- Patients who have major depressive disorder or dysthymic disorder often report difficulty falling asleep or staying asleep or early morning awakening with inability to return to sleep. Hypersomnia can be a feature of depression, especially major depression with atypical features. Children and adolescents with major depressive disorder generally present with less subjective sleep disturbance and fewer polysomnographic changes than do older adults with a similar degree of depression.
- Prepubertal children with depression are more likely to experience insomnia (75%) than hypersomnia (25%); after puberty, hypersomnias predominate. Hypersomnia is a common feature of depressive disorders in adolescents and young adults, and insomnia is more common in older adults.
- Individuals with generalized anxiety disorder often report difficulty falling asleep and may awaken with anxious thoughts in the middle of the night. Panic attacks can arouse patients and cause insomnia. Significant insomnia is often observed during exacerbations of schizophrenia and other psychotic disorders but rarely is a predominant symptom. Other mental disorders that may be related to insomnia include adjustment disorders, somatoform disorders, and personality disorders.
- Substance-induced sleep disorder most commonly occurs during intoxication with substances, such as alcohol, amphetamine and related substances, caffeine, cocaine, opioids and sedatives, hypnotics, or anxiolytics. Substance-induced sleep disorder can also occur in association with withdrawal from these same classes of substances.
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