Specific sleep problems may occur at different ages, and it would be useful to read the earlier sections to determine whether your child's sleep pattern is appropriate for his age. Some specific sleep problems, such as sleepwalking, sleep talking, or night terrors, appear to occur more frequently when children have abnormal sleep schedules. Most of these common problems are bothersome to the family but are not harmful to the child.
However, one problem, severe and chronic snoring, may be hazardous to a child's health. Please read the section on poor-quality breathing even if your child has no specific sleep problems or you think he does not snore. Snoring is sometimes not appreciated as a problem because the child has always snored, or because allergies developed when the child was older—an older child is usually in his own bedroom and the parents are unaware of how much snoring is occurring every night because they do not go into his bedroom after he has fallen asleep.
Sleepwalking
Between the ages of six and sixteen, sleepwalking occurs about three to twelve times each year among 5 percent of children. An additional 5 to 10 percent of children walk in their sleep once or twice a year. When it starts under age ten and ends by age fifteen, sleepwalking is not associated with any emotional stress, negative personality types, or behavioral problems. Research has shown that there is a substantial genetic factor to sleepwalking, as it was found that the behavior is more common among identical twins than fraternal twins.
Sleepwalking episodes usually occur within the first two to three hours after falling asleep. The sleepwalk itself may last up to thirty minutes. Usually the sleepwalker appears to be little concerned about his environment. His gait is not fluid and his movement not purposeful. In addition to walking, other behaviors such as eating, dressing, and opening doors often occur.
Treatment consists only of safety measures to prevent sleepwalkers from falling down stairs or out of open windows. Try to remove toys or furniture from your child's path, but don't expect to be able to wake him. Rousing him won't hurt, but usually the child wakes spontaneously without any memory of the walk.
Sleep Talking
Sleep talkers do not make good conversationalists! They seem to talk to themselves and respond to questions with single-syllable answers. Adults appear annoyed or preoccupied. Children often repeat simple phrases like “get down” or “no more,” as if they were remembering important stressful events that had occurred that day.
Between the ages of three and ten years, about half of all children will talk in their sleep once a year. Older studies have suggested that sleepwalking and sleep talking tended to occur together and were more common in boys; however, newer studies do not support this association.
Night Terrors
Your child utters a piercing scream, and you rush into his room. He appears wild-eyed, anxious, frightened. His pupils are dilated, sweat is covering his forehead, and as you pick him up to hug him you notice his heart is pounding and his chest heaving. He is inconsolable. Your heart is full of dread, and it almost seems as if some evil spirit has gripped your child. After five to fifteen minutes, the agitation and confused state finally subside. This is night terror.
Night terrors, sleepwalking, and sleep talking all occur mainly during non-REM sleep and usually within two hours of going to sleep. They usually do not occur when we dream (during REM sleep); they are not bad dreams. In fact, children have no memory of them once they are awake.
Night terrors usually start between four and twelve years of age. When they start before puberty, they are not associated with any emotional or personality problems. Night terrors have nothing to do with seizures, convulsions, or epilepsy. Night terrors appear more often when a child has a fever or when sleep patterns are disrupted naturally, such as on long trips, during school vacations, during holidays, or when relatives come to visit. Recurrent night terrors are also often associated with chronically abnormal sleep schedules.
Enabling them to get more sleep is the way of treating overtired children who have frequent night terrors. I have observed that night terrors disappear when the parents moved the bedtime earlier by only thirty minutes.
Drug therapy is not warranted for most children with night terrors, sleepwalking, or sleep talking problems. Most children should be allowed to outgrow these problems without complex tests (such as CT scans), drug treatments, or psychotherapy.
Nightmares
In old English mythology, a nightmare was thought to be a female spirit or monster that beset people and animals at night, coming upon them when they are asleep and producing a feeling of suffocation.
I myself have had nightmares of suffocation, strangulation, breathlessness, choking, being crushed or trapped, drowning, entrapment, and being buried alive—but only when I sleep on my back or have an alcoholic drink before going to bed. My wife says that at these times my breathing sounds like a diesel truck with a bad motor. When she pokes me to get me up, the nightmare ends, and I breathe normally again. You see, my nightmares occur when my upper airway is partially blocked, and this obstruction happens only when I sleep on my back or drink alcohol before bedtime. Occasionally, I have less dramatic dreams of breathlessness while running, flying (without a plane, of course), or being chased. If my wife does not awaken me, I wake up to breathe, but I have no dream recall. Maybe some children have similar nightmares when they have bad colds or throat infections that partially obstruct their upper airway.
The child with a nightmare can be awakened and consoled, in contrast to the child with a night terror, which spontaneously subsides. About 30 percent of high school students have one nightmare a month. Adults who have more frequent nightmares (more than two per week) often have other sleep problems: frequent night awakenings, increased time required to fall asleep, and decreased sleep duration. They appear more anxious and distrustful, and experience fatigue in the morning.
But nightmares in most young children do not seem to be associated with any specific emotional or personality problems. However, two recent reports in children, one for five to eight years of age, and the other for six to ten years of age, concluded that anxiety issues or other psychological problems are associated with nightmares. Analysis—guesswork, really—of dream content in disturbed children who have been referred to psychologists or psychiatrists should not be generalized to normal populations of children with the assumption that normal anxieties or fears represent a mental or emotional problem. We really do not know the exact value or limitations of dream interpretation. If you think your child is having a nightmare, shower him with hugs and kisses and try to awaken him.
What do you do if the child comes into the parents’ room, sometimes several times a night, complaining of nightmares? If you strongly suspect that your child is not feigning nightmares just to get extra attention at night, consider consulting with a child psychologist or psychiatrist.
Head Banging and Body Rocking
My third son banged his head against the crib every night after we moved into a new house. Actually, he struck his shoulder blades more than his head against the headboard of his crib. My solution was to use soft cushions to pad both ends and both sides completely. Now when he banged away there was no racket, no pain, and no parental attention. After a few days he stopped. Other parents are not so lucky.
About 5 to 10 percent of children will bang or roll their heads before falling asleep during their first few years. This usually starts at about eight months of age. Boys behave this way more than girls. No behavioral or emotional problems are seen in these children as they develop, and they certainly have no neurological problems. Body rocking before falling asleep also occurs in normal children.
All this rhythmic behavior usually stops before the fourth year if there are no underlying neurological diseases. Your pediatrician can diagnose these uncommon conditions if they are present.
Bruxism
Teeth grinding, or bruxism, during sleep is common in children. At the Laboratory School at the University of Chicago, about 15 percent of the students were reported by their parents to have a history of bruxism. In the age range of three to seven years, the percentage of bruxists was about 11 percent; between eight and twelve years, it was 6 percent, and between thirteen and seventeen years, the percentage dropped to about 2 percent.
Teeth grinding does not occur during dreams or nightmares. Furthermore, there is no association between emotional or personality disturbances and teeth grinding. No treatment is needed for bruxism in children.
Narcolepsy
The major characteristic of narcolepsy is excessive abnormal sleepiness. It appears as if the child has a sudden sleep attack while engaged in ordinary activities such as reading or watching television. The child with a mild form of narcolepsy may drift into a state of excessive drowsiness; the child with a more severe form might fall stone asleep in the middle of a conversation.
Narcolepsy is less common under the age of ten. When it begins in older children it may be mistaken for lack of concentration or inattentiveness.
Other features of narcolepsy seen in older children are cataplexy, a muscular weakness triggered by emotional stress; sleep paralysis, a passing sensation of inability to move when drifting off to sleep; and hypnagogic hallucinations, visual or auditory experiences that occur as sleep begins.
Poor-Quality Breathing
(Allergies and Snoring)
If you've ever suffered through a head cold, I'm sure you'll agree that when you can't breathe easily during sleep, you can't sleep easily either. In turn, this makes you sleepy during the day, which can affect your mood and performance. When the cold finally disappears, you feel like your old self again, and your mood improves, as does your performance. Some children experience the same type of disrupted sleep every night because of allergies or snoring. Let's look at them both.
Allergies
Allergies frequently are suggested as a cause of the typical signs and symptoms characterizing snorers. Here's a list of symptoms from one study of children with difficulty breathing during sleep, conducted at the Children's Memorial Hospital in Chicago.
Snoring
Difficulty breathing during sleep
Stopping breathing during sleep
Restless sleep
Chronic runny nose
Breathing through mouth when awake
Frequent common colds
Frequent nausea/vomiting
Difficulty swallowing
Sweating when asleep
Hearing problem
Excessive daytime sleepiness
Poor appetite
Recurrent middle-ear disease
Perhaps the “chronic runny nose” and the “frequent common colds” are due to allergies.
Allergists have long associated food sensitivities or sensitivity to environmental allergens with behavioral problems, such as poor ability to concentrate, hyperactivity, tension, or irritability. Terms such as “tension-fatigue” syndrome or “allergic-irritability” syndrome are used by allergists to describe children who exhibit nasal or respiratory allergies, food allergies, and behavioral problems. It is possible that allergy causes behavioral problems in children by producing swollen respiratory membranes, large adenoids, or large tonsils, which partially obstruct breathing during sleep. The difficulty these children experience in breathing during sleep causes them to lose sleep and thus directly causes fatigue, irritability, and tension.
Also perhaps due to allergies, large adenoids or tonsils can partially or completely obstruct breathing during sleep as well as cause hearing problems or recurrent ear infections. So, either because of the actual enlargement of the tonsils or because of the underlying allergies that cause swelling of the membranes in the nose and throat, these children suffer from frequent “colds”—runny nose, sneezing, coughing, and ear problems.
Snoring
Two of the world's leading sleep researchers, Dr. Christian Guilleminault and Dr. William C. Dement, published a landmark paper in 1976 that was the first careful study of how impaired breathing during sleep destroys good-quality sleep in children. At Stanford University School of Medicine, they studied eight children (seven boys and one girl, ages five to fourteen years), all of whom snored. All eight children snored loudly every night, and snoring had been present for several years. Snoring started in one child at six months, and while the snoring in most children was originally intermittent, it eventually became continuous. Here's how their symptoms were described.
Daytime drowsiness: Five of the eight children experienced excessive daytime sleepiness. The report noted that “the children, particularly at school, tried desperately to fight it off, usually with success. To avoid falling asleep, the children tended to move about and gave the appearance of hyperactivity.”
Bed-wetting: All the children had been completely toilet trained, but seven started to wet their beds again.
Decreased school performance: Only five of the eight children had learning difficulties, but all the teachers reported lack of attention, hyperactivity, and a general decrease in intellectual performance, particularly in the older children.
Morning headaches: Five of the eight children had headaches only when they awoke in the morning; the headaches lessened or disappeared completely by late morning.
Mood and personality changes: Half the children had received professional counseling or family psychotherapy for “emotional” problems. The report noted that “three children were particularly disturbed at bedtime; they consistently avoided going to bed, fighting desperately against sleepiness. They refused to be left alone in their rooms while falling asleep and, if allowed, would go to sleep on the floor in the living room.”
Weight problems: Five of the children were underweight, and two were overweight.
Overall, we have a picture here of impaired mood and school performance, which deteriorated as the children grew older or as the snoring became more continuous or severe. Sleep is definitely not bliss for these children!
But was this a new discovery? Not really. As I will discuss further, most snoring children have enlarged adenoids, which medical texts written as early as 1914 acknowledged can disrupt sleep and cause behavior problems. As one early textbook noted:
Restlessness during the night is a prominent symptom; the patient often throws the covers off during the unconscious rolling and tossing which is so characteristic. … Daytime restlessness is also a characteristic sign. The child is fretful and peevish, or is inclined to turn from one amusement to another … the mental faculties are often much impaired … difficult attention is very often present. The child is listless and has difficulty in applying himself continuously to his play, studies, or other tasks, of which he soon tires. He has fits of abstraction.
Interestingly, increased motor activity or physical restlessness during sleep, distractibility, and reduced attention span are also characteristic features of children who have been diagnosed as “hyperactive.”
Another study, this one done in 1925, showed enlarged adenoids and tonsils as a physical cause of poor sleep. Even a major pediatric professional journal cited “difficulty in breathing, such as seen with extreme enlargement of the adenoids” as a common cause of “infantile insomnia” as far back as 1951. In truly severe cases of enlarged adenoids and tonsils, affected children appear to be mentally retarded, have impaired growth, and suffer from heart disease.
In one study of children who had documented difficulty breathing during sleep, the following problems were observed in addition to snoring:
“Breath holding,” “stopping breathing” during sleep
Frequent nighttime awakening
Breathing through an open mouth
Sleeping sitting up
Excessive daytime sleepiness
Difficulty concentrating
Bed-wetting
Decreased energy, poor eating, weight loss
Morning headaches
Hyperactivity
Some parents have also described to me their child's apparent “forgetting to breathe” during sleep. Their child's chest is heaving, but during those moments of complete airway obstruction airflow is stopped. These periods are called “apnea.” With only partial airway obstruction, though, excessively loud snoring throughout the night is the result. In either case, it's the poor-quality sleeping that's the culprit, causing daytime sleepiness, difficulties in concentration, school and behavioral problems, decreased energy, and hyperactivity … even though the total sleep time may be normal!
Why, then, has kids’ snoring particularly been ignored? Are there more snorers around today? Perhaps yes, because although surgical removal of tonsils and adenoids is much less common today, it was for years a very popular procedure for recurrent throat infections; it also happened to “cure” snoring in children. And perhaps yes, because the air we breathe is increasingly polluted and our processed foods increasingly allergenic; this may cause reactive enlargement of adenoids or tonsils in more children.
Whatever the causes of snoring, we've seen so far that children who snore aren't getting the best-quality sleep. Now we see that generally they aren't getting the best quantity either. One study of snorers at Children's Memorial Hospital in Chicago also showed that children with documented obstruction of breathing generally slept less than normal children. At about age four, average night-sleep duration was only eight and a half hours in affected children, compared to ten and a quarter hours in normal children.
In another study I performed, also at Children's Memorial, the affected snoring children were somewhat older, about six years of age, and their total sleep duration was about half an hour less than that of normal kids. They also had night wakings that lasted longer, went to bed later, and took longer to fall asleep after going to bed. These affected children exhibited snoring, difficult or labored breathing, or mouth-breathing when asleep. Parents described problems such as overactivity, hyperactivity, a short attention span, an inability to sit still, learning disabilities, or other academic difficulties in their snoring children. And as we have seen, a chronic sleep deficit of only half an hour per night might cause impaired intellectual development.
Even in infants, snoring might be a problem. I studied a group of 141 normal infants between four and eight months of age. In these infants, 12 percent exhibited snoring and 10 percent exhibited mouth-breathing when asleep. These snoring infants slept one and a half hours less and awoke twice as often as infants who did not snore.
In another study of infants about four months of age, cow's milk allergy was thought to be the cause of brief night-sleep durations and frequent awakenings. Other studies have suggested that an allergy to cow's milk protein can cause respiratory congestion.
PRACTICAL POINT
Although snoring reflects difficulty breathing during sleep, it is not related to sudden infant death syndrome (“crib death”).
The night waking in these snoring infants and the restless light sleep in older children probably represent protective arousals from sleep. As we learned earlier, these arousals mean that the child awakens or sleeps lightly in order to breathe better. When awake, the child breathes well, but the brain's control over breathing is blunted during sleep stages. So, to prevent asphyxiation, the child awakens frequently, cries out at night, and has trouble maintaining prolonged, consolidated deep-sleep states. Here, the crying and waking at night and resistance to falling asleep are caused by a valid medical problem, not a behavioral problem, not nightmares, not a parenting problem.
Not all children who snore a lot have all of the problems listed above. Differences among snorers can probably be explained by differences in severity and duration of the underlying problems. Also, I have encountered many monster snorers with minimal problems because they habitually take very long naps or have been able to go to bed much earlier than their peers. In other words, there are snorers and there are snorers! Some, like myself, have never been studied, and except for occasional nightmares—like the ones of asphyxiation, drowning, or strangulation I have when sleeping on my back—do not suffer adversely from snoring. Other snorers are not so fortunate because their snoring is more severe, a result of enlarged adenoids or tonsils.
PRACTICAL POINT
All children snore a little, and frequent colds or a bad hay fever season might cause more snoring, which usually does no harm. Consider snoring a problem when it gets progressively worse, is chronic or continuous, disrupts your child's sleep, and affects daytime mood or performance. About 10 to 20 percent of children snore frequently.
The reason attention has been focused on the problem of enlarged adenoids and tonsils is that sleep researchers have proven that breathing is actually disordered during sleep. This is an important point, because when the child opens his mouth, the tonsils do not necessarily look enlarged. In fact, the adenoids and tonsils may cause partial airway obstruction in some children during sleep only because the neck muscles naturally relax and the airway thus narrows. In other words, the real problem in some children might not be enlarged adenoids or tonsils, but rather too much relaxation in the neck region during sleep. This relaxation of the muscles in the neck may permit enlarged tonsils or adenoids to swing toward the midline, causing a partial or complete blockage of the flow of air. If snoring appears to be disrupting your child's sleep, consult with your physician. Your child's doctor may have to do some tests to determine how serious the problem really is.
The term “sleep-related breathing disorders,” or SRBDs, was coined to describe those children who had snoring or heavy or loud breathing while sleeping, or who appear to have trouble struggling to breathe while sleeping, or who make a snorting sound and wake up. One research study conducted in 1997 directly connected SRBDs to attention deficit hyperactivity disorder (ADHD). They calculated that about 25 percent of children with ADHD would have their symptoms eliminated by correcting their habitual snoring or SRBD. In 1998, two studies showed that SRBD was associated with extremely poor academic performance in first grade (improvement occurred upon removal of tonsils and adenoids) and also that SRBD was associated with difficulties with behavioral sleep disorders such as fighting sleep at night or bedtime battles. By 2002, the terminology had changed to “sleep-disordered breathing,” or SDB, but the message was the same. Inattention, hyperactivity, behavioral, and emotional difficulties are more common in children with SDB. Again, surgical intervention helped these children.
Locating the Problem
Try to suck through a wet paper soda straw. You can't; it collapses. When we inhale, active neuromuscular forces keep our neck from collapsing like a wet straw. Sometimes things don't work well during sleep and the neck muscles lose their tone. Sometimes the major problem involves the tongue, which may not stay in its proper position during sleep and flops backward, causing upper-airway obstruction.
Think of this as a neurological problem involving the brain's control over our muscles while we sleep. The result is that the airway is not kept open during sleep. If it's a neurological problem, then consider the possibility that there are other associated problems involving the brain: difficulty concentrating, poor school performance, excessive daytime sleepiness, or hyperactivity. If the major problem involves the tongue or neck muscles, removing the tonsils or adenoids might not help. So it is obviously important to determine the cause of the problem before considering surgery.
Children who snore and have many of those problems associated with poor breathing during sleep often have abnormal X-rays of the neck when viewed from the side. The most common abnormality is enlargement of the adenoids or tonsils. A simple X-ray might tell the entire story. But some children who snore might have normal X-rays and will require studies designed to document airway obstruction; it is important to pursue this before clinical problems develop.
Studies that have been used to document obstructive breathing problems during sleep include actual measurements of respiratory flow through the nose, skin oxygen levels, and the carbon dioxide concentration in the air exhaled during sleep. Another type of sleep study, using fluoroscopy, may visualize the level of obstruction. CT scans during sleep also have been used to measure the cross-sectional area at different levels of the airway to determine the anatomical location of the airway narrowing.
Electrocardiograms are useful because, in severe instances, the right side of the heart shows signs of strain. This strain can lead to pulmonary hypertension in long-standing cases.
Pulmonary hypertension also occurs with massive obesity, as in Pickwickian syndrome. This is named after Dickens's The Pickwick Papers, in which an extremely fat boy is pictured as standing motionless, barely awake, and feebly snoring. Massive obesity itself apparently causes difficulty breathing.
Finding the Answers
If the tonsils or adenoids are causing significant airway obstruction, they should be removed. Sometimes a surgical procedure to correct an abnormal nasal septum solves the airway problem. Tracheostomy, or creating a breathing hole in the neck, is occasionally needed when the obstruction is due to airway closure or narrowing not caused by enlarged adenoids or tonsils. During the day, the hole is closed and covered by a collar. Oral devices are now available that keep the tongue from flopping backward, when that's the major problem.
OBSTRUCTIVE SLEEP APNEA
SNORING, DIFFICULT BREATHING, OR
MOUTH-BREATHING WHEN ASLEEP
DISTURBED SLEEP
ABNORMAL SLEEP SCHEDULE
BRIEF SLEEP DURATIONS
SLEEP FRAGMENTATION (PROTECTIVE AROUSALS)
NAP DEPRIVATION
PROLONGED LATENCY TO SLEEP
BEHAVIORAL, DEVELOPMENTAL,
AND ACADEMIC PROBLEMS
REVERSIBLE
FIGURE 8: POOR-QUALITY BREATHING CAUSES PROBLEMS
Weight reduction to correct obesity and management of allergies may be crucial nonsurgical treatments in some children. The management of allergies might include a trial of a diet without cow's milk, making the bedroom dust-free by using efficient air purifiers, reducing the level of mold spores in the air by using dehumidifiers, or getting rid of pets. Nightly administration of decongestants or antihistamines are sometimes needed to reduce the allergy symptoms. Often, intranasal steroid sprays are used to keep the nasal airway open; this treatment avoids the side effects of oral decongestants. A “snore ball,” which is a small glass marble or half of a small rubber ball sewn to the pajamas or attached with a Velcro strap in the midback region, will prevent a back snorer from sleeping on his back.
Enjoying the Cure
When treatment restores normal breathing during sleep, the loud snoring, daytime sleepiness, morning headaches, and other problems either disappear or are greatly reduced. Sleep patterns return to normal, and electrocardiogram abnormalities disappear. These changes are rapid and dramatic. For example, in one report, a thirteen-month-old boy was assessed as having the developmental level of an eleven-month-old baby before surgery, but five months after surgery, his developmental level had jumped past his real age, to the level of a twenty-month-old!
Remember, sleep deficits may directly cause behavioral, developmental, or academic problems. These problems are reversible when the sleep deficits are corrected (see Figure 8).
One word of caution: If the problem has been long-standing, then once children are cured of their snoring or their allergies are under control, bad social or academic habits or chronic stresses in the family or school will still require the continuous attention of professionals, such as psychologists, tutors, or family therapists. The treated child is now a more rested child, however, and is in a better position to respond to this extra effort.
Hyperactive Behavior
Educators and parents have used different terms to describe children with hyperactive behavior, but the current popular diagnosis is attention deficit hyperactivity disorder, commonly called “hyperactivity.” Hyperactivity in children is not usually thought to be related to snoring or severe allergies, although children suffering from ADHD, snoring problems, or allergies all have similar academic problems and characteristically poor sleep patterns.
Yet restless sleep, or increased amounts of movement during sleep, has been documented in hyperactive children. Could these turned-on school-age children be cranked up from chronically poor sleep habits that started in infancy?
I studied a group of boys whose ages were between four and eight months. Only boys were included, because most hyperactive school-age children are boys. The infant boys in my study also had active sleep patterns—they moved throughout the night in a restless fashion, with many small movements of the hands, feet, or eyes. They also had difficult to manage temperaments: They were irregular and withdrawing, had high intensity, were slow to adapt, and were moody. This temperamental cluster is thought to be common among hyperactive children as well. The results of my study showed that infant boys with more difficult temperaments and active sleep patterns also had briefer attention spans. Perhaps their motors were racing so fast, day and night, that they couldn't sleep quietly at night or concentrate for prolonged periods when awake during the day.
Another study I did involved preschool children at age three. It also showed that children who had increased motor activity when awake had a physically active sleep pattern. A child with active sleep patterns was more likely to be described in the following terms, taken from a questionnaire used to help diagnose hyperactivity:
Restless or overactive
Excitable, impulsive
Disturbs other children
Fails to finish things he starts—short attention span
Constantly fidgeting
Inattentive, easily distracted
Demands must be met immediately—easily frustrated
Cries often and easily
Mood changes quickly and drastically
Temper outbursts, explosive and unpredictable behavior
Figure 9 summarizes my research suggesting how a transformation could take place from an extremely fussy/colicky/difficult temperament baby with brief sleep durations to a hyperactive school-age child. The upward-pointing arrows before certain terms mean that high ratings for rhythmicity signify irregularity and high ratings for persistence signify short attention spans. These infant traits are replaced by hyperactivity and increased intensity as the child becomes more fatigued. As an infant, the child would have been negative in mood and less easily adaptable due to brief sleep durations, and would have remained so at three years.
Such children never learned how to fall asleep unassisted and had accumulated a chronic sleep loss, which caused chronic fatigue. As discussed in Chapter 3, this long-lasting fatigue turned such children “on,” making them more active night and day, and interfered with learning.
Learning may suffer, then, in kids who do not sleep well because they breathe poorly during sleep or sleep too little, and who in turn suffer from chronic fatigue that causes hyperactivity. Figure 10 summarizes this entire cycle. It shows how crying and sleeping problems present at birth can trigger parental mismanagement. Parental mismanagement or breathing problems during sleep can in turn cause disturbed sleep, elevated levels of neurotransmitters, and a more aroused, alert, wakeful, irritable child. This turned-on state directly causes even more disturbed sleep because of heightened arousal levels. It also may indirectly cause parents to misperceive their child as not needing much sleep: “Johnny just won't quit—he certainly doesn't seem to be running out of gas.”
All of these factors in combination—the fatigued child who is too alert to sleep well, plus irregular, inconsistent parents who also are tired and anxious—conspire to produce a child who may find it difficult to concentrate, may seem hyperactive, or may have behavioral problems that make him difficult to manage. These school and behavioral problems make the parents even more anxious, and the cycle continues on and on. Of course, there may be other causes for school problems or hyper activity, but disturbed sleep appears to be one that is both preventable and treatable.
FIGURE 9: TRANSFORMATION OF TEMPERAMENT CHARACTERISTICS ASSOCIATED WITH BRIEF SLEEP DURATIONS
FIGURE 10: DISTURBED SLEEP
Seasonal Affective Disorder
Seasonal affective disorder (SAD) is commonly known as winter depression. Symptoms of depression include feeling blue or sad; decreased interest or pleasure in activities; dramatic weight gain or weight loss, or failure to gain weight normally; sleeping too little or too much; behaving very restlessly or in a very slowed-down manner; fatigue or loss of energy; feelings of worthlessness; indecisiveness or difficulty in concentrating; and recurrent thoughts of death or suicide. Not all of these symptoms need to be present, but when many occur daily for extended periods of time, the diagnosis of depression has to be considered. When these symptoms tend to occur only or mainly during the months of October and November, then seasonal affective disorder may be the problem.
The reduced amount of daylight during winter, with its short days and long nights, seems to cause the depressive symptoms, and treatment may include using a bank of special fluorescent lamps behind a plastic diffusing screen. The intensity of light needed, the duration of the light treatment, and the risks bright-light treatment may pose for the eyes are currently being investigated. Light therapy has been shown to be effective in children, but it's not like taking penicillin for a strep throat, so if you think your child might have SAD, your best bet is to contact a sleep disorders center for evaluation and treatment.
Survey studies have shown that between 2 and 5 percent of children between the ages of nine and nineteen fulfill diagnostic criteria for SAD. More symptoms appear in northern regions, where days are significantly shorter in winter, compared to southern regions. So if you have an older child who seems not to be doing well after the first few months of the school year, consider the possibility that it is not the teacher, the coach, or the increased homework load, but winter depression.
Bed-wetting
Bed-wetting during sleep occurs in about 20 percent of children at age four and 10 percent at age five. By the age often, it occurs in about 5 percent of children. The exact cause of bed-wetting is not known. It is not caused by emotional problems. It tends to occur more often in boys and has a tendency to be inherited. Pediatricians or pediatric urologists may offer bladder-training strategies or other treatments, but it is difficult to prove that one treatment works best, as most children outgrow the problem. Restricting fluids before bedtime does not work.
I find that moisture alarms are an effective treatment for bed-wetting. These alarms wake the child as he begins to urinate. This seems to disturb the sleeping brain, and so to prevent such an abrupt arousal from the alarm in the future, the brain controls the bladder better and prevents urination.
Sometimes the alarm does not rouse the child, so the parent has to be able to hear the alarm in order to wake the child. The reason the child might sleep through the alarm is that bed-wetters appear to have very deep sleep. Even though older research suggests that bed-wetters are not more difficult to awaken than children who are not bed-wetters, this deep sleep may be a major part of the problem for some children.
In my experience, some children with too-late bedtimes or severe allergies causing difficulty breathing through the nose appear to be overtired during the day and wet at night. When they are helped to sleep better, they often appear to be better rested during the day and drier at night. The most dramatic “cures” of bed-wetting sometimes occur when enlarged adenoids or tonsils are removed. Now the child breathes easier during sleep, sleeps better, and becomes drier.