Sleep disorders in children and teens
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As many as 30% of children have a sleep disorder at some time in their childhood (1,2), and the impact on patients and families can be enormous. Thorough history taking is the single most important step in identifying the type and source of the problem.
A nonthreatening, parent-cued way to uncover events that can affect sleep is to complete a 24-hour sleep-history questionnaire. Parents are asked to start with the evening meal and describe what happens during the next 24 hours. The bedtime routine is brimming with important details. It is not unusual to hear accounts of struggles or tensions, vigorous sports practices, or viewing of energizing or scary TV shows or videos before bedtime.
A 24-hour history also chronicles the typical delay between going to bed and going to sleep, the total sleep time per night, the number and duration of nocturnal arousals, day-night reversal patterns, time of morning awakening, and whether morning awaking is spontaneous or aided by a parent. Continuing history taking throughout the course of the day uncovers napping patterns, unusual daytime sleepiness, impairment of school performance, and changes in behavior or mood. Asking families to complete a sleep log (see box below) that documents sleep-wake patterns for at least 2 weeks before coming to the clinic is often extremely helpful in identifying the sleep problem.
The sleep-environment history is another important tool in sorting out sleep complaints. Sleep environment plays a role from cradle to college--from the infant who falls asleep nursing to the teen who slumbers in a dungeonlike basement. Reports of transitional objects (eg, a special blanket or stuffed animal) that are necessary for sleep and of the amount of ambient light and noise (eg, TV, computer) are often enlightening parts of the history.
A review of systems is critical to identifying sleep disorders in children and teens and primarily involves cardiorespiratory and neurologic features of sleep. Breathing disorders (eg, obstructive sleep apnea) and primary snoring occur in asmany as 11% of pediatric patients (3). Specific medical conditions (eg, craniofacial disorders, tracheomalacia, bronchomalacia, prematurity, reactive airways disease) may predispose children to sleep-disordered breathing.
Sleep quality is often disrupted in children with neurologic impairment and, in many cases, interferes with the family's ability to continue caring for the child at home. Thorough developmental and behavioral history taking may uncover a range of issues affecting sleep, including separation anxiety and attention-deficit disorder. These diagnoses are discussed in further detail in the following text, according to age-group.
Infancy through preschool
Common sleep problems found in infants, toddlers, and preschoolers are sleep-onset association disorder (sometimes accompanied by issues of parent and child sleeping together) and night terrors (a parasomnia that should be differentiated from nocturnal seizures).
Sleep-onset association disorder
A common presentation of sleep-onset association disorder is an infant or toddler who, parents report, just doesn'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, during normal nocturnal arousals, 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. Waldo is an example of a child who has learned such behavior.
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