As parents, we all look forward to the peace and quiet which occurs when our children are finally tucked quietly into their beds. However, sometimes kids get up at night and do weird stuff. In a new series, I want to explore some of these weird and wonderful behaviors which we call parasomnias. Quite simply, parasomnias are events which occur out of sleep and contain both characteristics of sleep and wake. For example, children who sleepwalk are walking(duh) but not acting in a logical manner. Today, I’m going to be talking about some of the most common parasomnias which come out of non-REM sleep, usually very deep sleep. Specifically, sleepwalking, night terrors, confusional arousals, and sleep talking in children. These events all have several characteristics in common:

• They usually (but not always) occur in the first half of the night, most commonly a few hours after bedtime. This is because they emerge from the deepest kind of sleep, slow-wave or Stage 3 sleep.
• During these events, children may be agitated and seem confused; they are usually difficult to console, and if you try to talk with them, the conversation are usually non-sensical.
• Children usually do not have difficult going back to sleep after these events (although you may).
• Generally, your child will not remember these events the next day. I have seen children in clinic who have nightly events who never recall any of them.
• There is often a family history of similar events in up to 60% of in first degree relatives (parents and siblings) of affected children.
• Usually (but not always) these events resolve by early adolescence for most kids
• Events occurring in teenagers and adults tend to be longer and more severe.

Night Terrors

Night terrors are one of those things that really freak you out as a parent. All of a sudden, you hear your child screaming at the top of his lungs. You rush to your room to see what’s wrong, and your child doesn’t seem to see you. He may scream your name, but any effort to comfort him is in vain, and actually seems to agitate him further. Eventually (usually in about ten minutes), the screams become sobs, and your child eventually falls back to sleep. He doesn’t remember it the next morning but you sure do. The events are relatively uncommon, occurring in about six percent of children. Evidence of the fight or flight response, (sweating, heart pounding, dilated pupils) are common.

Here’s a good example of one:

My older son used to have these about once a month between the ages of three and four. Even though I knew what it was, it was still pretty unpleasant. His events would last for about 3–4 minutes, but it felt A LOT longer. These events are typically brief (~5 minutes) but can feel a lot longer. If we tried to wake him up, it seemed to prolong the events. Once he was in a bed, I would just sit in the room as he thrashed about to make sure he didn’t hurt himself. Although I knew exactly what was going on, I still found it stressful.

Younger kids with night terrors tend to stay put, but older kids may pop out of bed and run around in an agitated manner. Night terrors are thus a close cousin of sleepwalking.

Sleepwalking

Sleepwalking, or somnambulism is the act of walking around out of slow wave sleep. Children usually seem calm, to the point where a casual observer may think that the child is awake. Rarely, children may get up and urinate in places other than the toilet. (I know, it certainly sounds funny until you are cleaning up a puddle of urine in the middle of the night). One of the most common manifestation is your child wordlessly materializing at your bedside in the middle of the night, but not really seeming “all there.” Less commonly, children may be agitated, running around and yelling in a way analogous to a night terror. It’s important to remember that sleepwalkers can perform complex tasks such as unlocking doors and turning on the stove. Sleepwalkers can get injured if they get out of the house. This can be especially perilous if you are on vacation or, say, camping by a cliff.

Sleepwalking occurs in 15% of kids; a much smaller proportion (1–6%) will have events at least once per week.

Here’s a video of a child sleepwalking:

Confusional Arousals

Confusional arousals are the less interesting, milder mannered version of night terrors and sleepwalking. The timing is similar to the events above, and these events will usually present as some moaning, talking, and maybe a little light thrashing in bed. They typically last longer than night terrors but are milder– a 5–15 minute duration is common.

Sleep Talking

Sleep talking  (or somniloquy) is really common– so common, in fact, that I’m not convinced that it is a disorder per se. However, like all of these parasomnias, it can occur more commonly in children with disorders of sleep fragmentation such as obstructive sleep apnea.

Here’s a video of a baby waking herself up sleeptalking.

Assessment

Like pretty much all sleep disorders, the most important way to assess these problems is by reviewing a detailed history of the events. How frequently do they occur? How severe are the events? When in the night do they occur? Does anything seem to trigger them? Especially in these scenarios, a video captured on a smartphone can be invaluable. (Here’s my article on how to get the most out of your doctor’s visit).

Rarely, further testing is necessary:

• A history of snoring or very frequent events may prompt an overnight sleep test (polysomnogram) to look for disorders which could trigger these events. Any disorder which fragments sleep (including medical disorders such as asthma) can trigger these events. The most common disorder we are looking for is obstructive sleep apnea (OSA). OSA does not cause night terrors or sleep walking, but it can trigger it. In our standard sleep study, we record video. If we are lucky, we’ll capture one of the events you had at home. If we don’t, however, it is OK because the primary purpose is to look for a sleep problem.
• Rarely, I may order an electroencephalogram (EEG) to rule out seizure activity. Seizures are usually stereotyped, meaning that each event (seizure) is the same in terms of movement, etc. Rhythmic or repetitive movements are common.

How To Treat

As you can infer from above, these problems are pretty common in childhood. If events are rare, or infrequent, they are little cause for concern. However, events that are frequent or severe may require first assessment or treatment.

• Careful attention to adequate sleep is critical. Sleep deprivation is a clear trigger. This is why these events often occur when families are on vacation or after special occasions. Here’s an article on how much sleep kids need.
• It’s critical to ensure a safe sleeping environment. At home having double locked doors (where you need a key to get out) or deadbolts out of children’s reach are important. Travel can be a challenging time as the disruption to routine and schedule can make events more likely, and also more perilous. A portable door alarm such as this one(affiliate link) may be a usual addition to your travel toolkit.
• Sedating medications are reserved for severe (children are getting hurt, hurting others, or getting into risky situations such as getting out of the house) or very frequent cases. Most commonly, benzodiazepines are prescribed and are quite effective. In intermediate cases, I will prescribe them for vacations, sleep overs, or other situations where sleepwalking would be dangerous (e.g. sleeping in a tent by a cliff).
• Scheduled awakenings are a technique where parents wake children up nightly, usually about 30 minutes prior to the typical time where the night terror or sleep walking episodes occur. Doing this nightly for a month seems to reduce the frequency and severity of these events. You need to wake your child up to the point where he or she is able to have a conversation with you. The downside is that a) doing these events may rarely trigger an event b) the awakenings can contribute to sleep deprivation.

Have your children had any unusual, alarming, or amusing behaviors in their sleep? Let me know in the comments.