A 5-year-old boy has been receiving mental health services to address separation anxiety and generalized worrying. His mother brings up something new:
It is the same thing each time. I hear his ear-piercing scream, and I run upstairs to find him drenched in sweat, pacing around his room and muttering phrases like “don't make me do it.” I try to comfort him, but it does not help. After 5 minutes, he lays back down and goes to sleep. When I ask him about his bad dream the next day, he has no memory of any of it.
Clinical Features and Diagnosis of Sleep Terrors
Mental health providers working with youth commonly hear sleep-related complaints. Sleep initiation and maintenance insomnia are the most commonly reported concern, but a wide array of sleep disorders are prevalent in youth (Ivanenko & Johnson, 2016). The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders classifies the sleep–wake disorders into 10 conditions, each with the core feature of disrupted sleep with impaired daytime functioning (American Psychiatric Association [APA], 2013). Similarly, the third edition of the International Classification of Sleep Disorders recognizes six conditions (American Academy of Sleep Medicine, 2014). Both classifications include parasomnias, which are abnormal behavioral, experiential, or physiological happenings during sleep or sleep–wake transitions (APA, 2013).
The most common forms of parasomnias are non–rapid eye movement (NREM) sleep arousal and rapid eye movement (REM) sleep behavior disorders (APA, 2013). NREM sleep arousal disorders are most common in youth and include repeated episodes of partial awakening, manifesting as either sleepwalking or sleep terrors (APA, 2013). Sleep terrors are characterized by abrupt, frightful awakenings from sleep in which the youth is mostly unresponsive to comfort from others (APA, 2013). The event typically starts with a sudden scream and includes dilated pupils, sweating, tachycardia, and rapid breathing (Ivanenko & Johnson, 2016).
The episodes occur during slow wave sleep in the first one third of the night with startling disruptions in electroencephalogram patterns compared to moments before the episode (Golbin, Guseva, & Shepovalnikov, 2013). Diagnosis does not require polysomnography (PSG); rather, it is typically based on clinical history gathered from the caregiver (Ekambaram & Maski, 2017). There are no reliable PSG indicators for those who will experience sleep terrors (APA, 2013). Sleep terror events last 1 to 10 minutes on average, and typically, only one event occurs per night and rarely occurs during naptime (APA, 2013). If the child wakes, there is complete amnesia for the episode or only fragmented memories, contrary to the story-like recall seen with nightmares (APA, 2013).
Although many youths may experience sleep terror events, to be diagnosed with a sleep disorder, the episodes must cause clinically significant distress or functional impairment (APA, 2013). Determining diagnosis based on impairment takes into consideration the frequency of episodes, potential for harm to self or others, embarrassment, and impact on the family (Ivanenko & Johnson, 2016). Sleep terrors should not be diagnosed if the events are better explained by the use of a medication or substance, or if they are caused by another medical or mental health disorder (APA, 2013). For example, nocturnal frontal lobe seizures are similar in presentation to NREM sleep arousal disorders but typically occur in an earlier stage of NREM; misdiagnosis may also result in delayed treatment of seizures (Ekambaram & Maski, 2017). Other medical conditions that commonly affect sleep are obstructive sleep apnea, asthma, eczema, and gastroesophageal reflux (Davey, 2009).
Most children experience sleep terrors as a benign and transient disruption; however, for children with sleep terror disorders, these episodes are frequent and result in lack of restorative sleep that causes daytime fatigue (Laberge, Tremblay, Vitaro, & Montplaisir, 2000). In addition, parental sleep disruption can be significant (Petit et al., 2015). Embarrassment in social settings (e.g., sleepovers) can occur, causing impairment in social relationships, and in rare cases, injury to the child or parent who is offering comfort may occur (Ivanenko & Johnson, 2016).
Prevalence and Etiology
Sleep terror episodes are considered common among children. An estimated 20% to 40% of children younger than 3 are reported to experience sleep terrors (APA, 2013; Nguyen et al., 2008), whereas 3% to 14% of school-age children have sleep terrors (Gupta et al., 2016; Ivanenko & Johnson, 2016; Laberge et al., 2000; Ozgun, Sonmez, Topbas, Can, & Goker, 2016). Accurate prevalence rates have been difficult to determine due to variability in research methods, which prompted a large prospective longitudinal study—Petit et al. (2015) found 34.4% of children experienced sleep terrors at 18 months of age, 13.4% at age 5, and 5.3% at age 13. Petit et al.'s (2015) study provided greater support for previous reports of prevalence and demonstrated how sleep terrors are more common in young children and decrease as they age. Only 2% of adolescents and adults experience sleep terrors (APA, 2013).
The pathophysiology of sleep terrors is somewhat unknown. For some children, the transition from one stage of sleep to another results in experiencing features of being awake and asleep simultaneously (Davey, 2009). Sleep terrors have long been associated with genetic vulnerability, as children experience sleep terrors at a higher rate if one or both parents have a similar sleep history (Petit et al., 2015). Twin studies offer additional support for genetic factors by showing higher concordance rates for sleep terrors in monozygotic compared to dizygotic twins ages birth to 3 years (Nguyen et al., 2008) and ages 3 to 8 (Abe, Oda, Ckenaga, & Yamada, 1993). Parental history of sleepwalking has also been shown to increase risk for sleep terrors, suggesting similar pathophysiological conditions (Petit et al., 2015). As many as one third of children who had early childhood sleep terrors developed sleepwalking later in childhood, also indicating that there are etiological similarities among the parasomnias (Petit et al., 2015).
Mental Health Comorbidities
Socioeconomic status, family structure, and parental characteristics (including age, education level, and occupation) are not significantly correlated with parasomnias; however, psychological issues have been associated with parasomnias and sleep problems in youth (Laberge et al., 2000). When children present with inattention, poor impulse control, academic difficulties, mood changes, daytime fatigue, or sleepiness, they should have a thorough evaluation of their sleep (Ivanenko & Johnson, 2016; Silvestri et al., 2009).
In general, youth with psychiatric conditions have a higher prevalence of sleep disorders, including parasomnia in general and sleep terrors specifically (Ivanenko & Johnson, 2016). In a study of sleep disorders in children with attention-deficit/hyperactivity disorder, 38% were found to have sleep terrors based on a structured sleep interview and overnight video-PSG (Silvestri et al., 2009). Children who experience sleep terrors have been found to have high anxiety scores, which was not found in children experiencing sleepwalking, another form of NREM sleep arousal disorder (Laberge et al., 2000). Children with affective disorders, including bipolar disorder, have been reported as having increased risk for sleep terrors (Murphy, Frei, & Papolos, 2014). In addition, sleep terrors in youth have been associated with higher risk for psychotic symptoms in adolescence (Fisher et al., 2014) and adulthood (Thompson et al., 2015) when adjusted for possible confounders.
Parents whose children have autism spectrum disorder (ASD) commonly report sleep problems. Salazar et al. (2015) found 4.9% of children with ASD experience sleep terrors, which is associated with parental psychological distress. Ming, Sun, Nachajon, Brimacombe, and Walters (2009), using a questionnaire and PSG, found high rates of parasomnias, predominantly disorders of partial arousal (e.g., sleep terrors, arousal confusion) in children with ASD compared to a control group. Of the 23 children with ASD in the study, 14 had PSG evidence of parasomnia (60.8%), and 11 of these 14 children had positive reports of parasomnia on the parental questionnaire; history of parasomnia may be a reliable diagnostic approach for those who cannot be evaluated using PSG (Ming et al., 2009).
In addition to psychiatric disorders, psychosocial factors can play a role in the development of sleep terrors. After adjusting for pre-existing or confounding variables, Wolke and Lereya (2014) found 9.3% of elementary students who experience bullying will develop sleep terrors years later; those who were chronically victimized had higher rates. In addition, children who refuse to go to school have been found to have high rates of sleep disturbances, including sleep terrors (Hochadel, Frölich, Wiater, Lehmkuhl, & Fricke-Oerkermann, 2014).
Assessment and Interventions
Mental health evaluation for all children should include basic screening for sleep-related problems. A simple, 5-item tool that can be included in all initial evaluations is the BEARS: B = bedtime issues, E = excessive daytime sleepiness, A = night awakenings, R = regularity and duration of sleep, S = snoring; screening questions can be tailored to the age of the child and directed to the parent or child (Owens & Dalzell, 2005). If concerns are reported, a 2-week, 24-hour sleep diary is recommended to provide an overall picture of sleep patterns as well as frequency and timing of sleep terror events (Davey, 2009). Specific questioning for parents reporting sleep terrors during the evaluation can include: What time does your child fall asleep? What time of night do the events occur? How often do the events occur and how long do they last? What are your child's behaviors during the event? Is your child responsive to you during the event? Can your child recall the event the next day? (Davey, 2009).
Treatment for parasomnias is often unnecessary; however, education and support for parents are imperative. If safety concerns exist, harm reduction measures should be initiated, specifically the use of gates, alarms, locking doors or windows to the outside, and removing sharp or dangerous objects from the room (Ekambaram & Maski, 2017; Ivanenko & Johnson, 2016). Parents should also minimize situational triggers for sleep terrors, including sleep deprivation, withdrawal of slow-wave sleep-suppressing medications, and environmental stimuli that cause arousal from sleep (Ekambaram & Maski, 2017). Limiting stressful situations and strict adherence to sleep hygiene efforts are also recommended (Ivanenko & Johnson, 2016).
Some evidence exists for scheduled awakenings each night at the common time of the episode; however, this is needed only for those with nightly episodes and may only move the episodes later into the night (Ekambaram & Maski, 2017; Ivanenko & Johnson, 2016). Treatment for other sleep problems and mental health disorders will help decrease the frequency and severity of sleep terrors (Ivanenko & Johnson, 2016). Currently, there are no U.S. Food and Drug Administration–approved medications for patients experiencing sleep terrors or other parasomnias. When pharmacological interventions are indicated, providers must make risk–benefit clinical decisions based on the frequency and severity of the sleep terrors. Suggested considerations include clonazepam (0.01 mg/kg), diazepam (0.04 mg/kg to 0.25 mg/kg), or lorazepam (0.05 mg/kg) (Ivanenko & Johnson, 2016).
Nurses need to have a strong knowledge base regarding sleep terrors and be prepared to provide supportive intervention. When youth are identified as having sleep terrors, an important role for the psychiatric nurse is to provide psychoeducation. Tips for parents include the importance of staying calm; not touching the child unless needed for safety; not discussing the event until the next day; maintaining a regular sleep routine; and being aware of the child's physical health, as episodes may precipitate a fever or illness (Davey, 2009).
Although the anxious 5-year-old boy in the beginning scenario appears to be highly troubled during these episodes, his mother can rest assured that sleep terrors are common and typically benign and self-limiting.
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