Night terrors, or sleep terrors, represent a sudden partial arousal (parasomnia) associated with disorientation, emotional outburst, and often the appearance of fear, motor activity (eg, walking, running in sleep), and profound autonomic discharge (eg, flushing, sweating, tachycardia). Night terrors classically occur in the first half of the night during deep non-rapid eye movement (non-REM) sleep. This characteristic separates night terrors from nightmares, which usually, but not exclusively, occur in the second half of the night during REM or light non-REM sleep. Children usually have no memory of night terrors, whereas they often can recall the content of dreams and nightmares.

Therefore, night terrors may be more worrisome to the parents than the children and can be inadvertently prolonged when an understandably anxious parent attempts to awaken the frightened-appearing youngster. Carmen is an example of a child with neurodevelopmental disability who experiences night terrors.

Parents should be questioned regarding a history of daytime seizures or staring spells, unusual posturing, limb jerking, and changes in skin color during episodes. If there is doubt, formal testing for nocturnal seizures, particularly in a child with underlying neurodevelopmental disability, should be considered. When nocturnal seizures have been ruled out, frequent or dramatic night terrors may, on rare occasions, warrant medication, such as low-dose clonazepam (Klonopin), at bedtime. Typically, youngsters outgrow these parasomnias.

Middle childhood

During the middle-childhood years, short sleep requirement, sleep-onset anxiety, and obstructive sleep apnea are commonly encountered problems.

Short sleep requirement and sleep-onset anxiety

Taking a 24-hour sleep history helps differentiate the constitutional delays in sleep onset and relatively short sleep requirement (exemplified by Tamika in the case report that follows) from anxiety-related sleep-onset insomnia (seen in Patrick in the case report below). Children's behaviors at sleep onset are rarely exclusive to bedtime. Therefore, it is not surprising to learn that Tamika is a spirited, high-eergy youngster and that Patrick expresses other worries during the day. Although both children have bedtime struggles, the treatment approach is very different for the two.

When dealing with sleep-onset insomnia caused by anxiety, physicians should 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 (eg, a death in the family, 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

Obstructive sleep apnea is seen in as many as 3% of preschool and school-age children (5). Parents often complain that the child snores nightly in all positions, perhaps worse when supine. 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.

By: John Garcia, MD; Laurel Wills, MD

Related Articles