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Parasomnias

Parasomnias are unusual things that happen at night
like screaming, peeing, talking, and walking.

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Chris's Story
Introduction & Screening Evaluation & Diagnosis Treatment & Referral Results

Chris's Story

Let’s catch up with Chris, the 9 year old who is wandering around the house at night. Is this sleepwalking or something else?

Chris’s mom recently called the pediatrician with concerns that Chris appears to be wandering out of his room at night. This used to happen once in awhile but now happens as frequently as 2-3 times a week.

He will go to sleep and then later can be heard walking around inside or outside his room. He seems dazed or confused and doesn’t interact in his usual “awake” behavior. He’s yelled out a "couple of times" and has been noted to be walking around. Mother doesn’t think he is awake since he acts differently than he does during the day.

If his mom leads him to the bathroom, he may urinate. Otherwise, she leads him back to his room and he doesn’t usually remember anything in the morning.

Expert Insights
Expert Insights

Sleepwalking, as well as the other NREM related parasomnias, occur, out of slow wave sleep. Slow wave sleep—also referred to as deep sleep/N3 sleep, or delta sleep—occurs in cycles with the highest percentage of slow wave sleep occurring within the first third of the night. Sleep cycles alternate between NREM and REM sleep occuring about 90 to 120 minutes, though sleep cycles change across development stages. Slow wave sleep percentage usually decreases across puberty so often NREM parasomnias (specifically sleepwalking) decreases across puberty.

Triggers

Sleep deprivation or not acquiring adequate sleep results in a rebound of slow wave sleep. Anything that contributes to sleep disruption could lead to a trigger of more sleepwalking.

Specific Triggers can include:

  • Inadequate sleep (either acute or chronic)
  • Irregular sleep schedule or inappropriate bedtime routine
  • Sleep apnea - contributing to sleep disruption and poor quality sleep
  • Periodic limb movements or restless legs - again contributing to poor sleep quality
  • Fever or illness
  • Medications
  • Caffeine
  • Stress and anxiety
  • Sleeping in a new place

BEARS Screening for Sleepwalking or Night Terrors

As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Chris and his mother.

Bedtime Problems

No bedtime problems are reported. Chris falls asleep fine.

Expert Insights

A child who has sleepwalking or night terrors may not have bedtime problems, but it often can occur. Sleep deprivation and irregular sleep schedule can be primary causes of sleepwalking. Additionally, if a patient describes restless leg symptoms (uncomfortable feelings in the legs or arms that affect the ability to fall asleep) or significantly restless sleep, then please refer to the section on restless legs as a sleep disorder. This disorder can also cause sleep deprivation contributing to sleepwalking.

For many families without a regular bedtime routine, it can be difficult to determine if irregular bedtimes are one of the issues contributing to sleepwalking. A sleep diary can be beneficial in tracking sleep pattern and events at night.

Excessive Daytime Sleepiness

Chris shows minor signs of daytime sleepiness – having a hard time getting up some mornings, and some yawning and inattentiveness reported at school.

Expert Insights

Usually, daytime sleepiness is not frequently seen unless a child is having daily or weekly sleepwalking. A child with sleepwalking could be sleepy during the day if they are not getting enough sleep, which can be a factor in having more sleepwalking events.

Awakenings

Chris has been seen sleepwalking at night. He goes back to sleep easily and doesn’t remember. Other types of nighttime awakenings are not reported. However, it is important to discuss all types of awakenings at night that a patient could be having including watching TV, snacking, going to caregivers’ room, using the restroom, or other events.

Expert Insights

One of the primary features of sleepwalking is that a child leaves the room or at least gets out of bed at night but may not be aware that they are getting up.

Signs & Symptoms Related to Sleepwalking:
  • Sleepwalking is a cause for awakening at night
  • Often there is a family history of sleepwalking or night terrors
  • Child may not remember what happened
  • May act clumsy or disoriented or wander in unusual areas
  • Awakenings may be triggered by sound, touch, or other stimuli
  • Can be related to stress or anxiety
  • Usually can go back to sleep well, unless caregiver tries to fully awaken
  • Should occur at a fairly predictable time of the night - usually within 30 minutes to 2 hours after falling asleep
  • Multiple events per night is unusual but could happen - the timing of these multiple events is important in the overall history taking
Regularity & Duration

Chris has an inconsistent bedtime schedule, going to bed later some nights during the week when he has sports activities and staying up and sleeping in on weekends. Aside from the sleepwalking events, he seems to get enough sleep at night.

Expert Insights

This is an important component of the history since it will directly relate to overall sleep quantity. It’s also helpful to track the regularity of sleep in relationship to the known times of sleepwalking. Also, if there is significant difference in total sleep amount on the weekdays versus the weekends, this can be a contributing factor to sleepwalking. For example, a child that goes to bed late on the weekends may have a sleepwalking event on Sunday night, related to not enough sleep on the prior night.

Sleep-Disordered Breathing / Snoring

Chris does not show signs of snoring or sleep apnea.

Expert Insights

Screening for obstructive sleep apnea is important. Obstructive sleep apnea (OSA) may be related to sleepwalking but usually is not the primary cause. However, if OSA (obstructive sleep apena) is causing poor sleep quality as well as arousals at night, sleepwalking can be noted in these cases.

Questions to ask in regards to obstructive sleep apnea include frequency of snoring, dry mouth on awakening, mouth breathing, appearing to struggle to breath, witnessed apneas or snorting or gasping at night if observed.

Chris's Evaluation & Diagnosis

What evaluation & diagnostic protocol should the medical provider use to diagnose Chris’s nighttime behaviors?
Check all that apply:

The evaluation protocol strategies we recommend for Chris’s case are:

  • Determine elements of the child’s sleep history
  • Complete a sleep diary

History is the primary source of information for this case. Sleep diary and tracking of sleep pattern is also important.



Determine elements of Chris's sleep history

Sleep History Case Specific Questions Chris's Evaluation Results

What the child does at night

Have there been any injuries?
Do you find food wrappers in the room? Has he ever eaten “unusual” things at night? (Patients can also have sleep eating as a component to sleepwalking and often eat items that they normally do not eat during the day.)

The medical provider interviews Chris and his parents to fill in the details for sleep history, and this is what they share:
Parents have found a couple of food wrappers in his room for granola bars and candy bars. Chris denies eating them so parents are unsure if he does this during the night without remembering.

Anything out of place in the morning?

Yes - food wrappers as mentioned above. Sometimes his toys and stuffed animals are moved into a different area of his room. They have not found his things out of his room.

What does the patient remember?

Chris rarely remembers what happened the night before. However, he sometimes worries that he will do something weird at night.

Have you ever found him unusual places?

Yes, mother has found him on the couch in the morning and Chris does not remember coming in there. He has also wandered into mother’s bedroom and will just stand at the end of the bed. If he does say something, it is difficult to understand.

Review timing of events at night (bedtime/waketime)

How often does this happen at night?

Usually only once within the first 3 hours of the night. It has not happened after 2 am.
 

Mother thinks it started in the last couple of years. At first, it happened only once every couple of months. However, now in the last 6 months, he has been sleepwalking 2-3 times a week.

When Chris was younger, he did have a couple of episodes of possible night terrors. Mother describes that she thinks he was still in his crib or toddler bed and she found him sitting up and screaming. It was very difficult to calm him down after those episodes. She thinks they happened a couple hours after going to sleep but she can’t exactly remember. He was too young to tell mother if he remembered the events the next morning.

Screen for other sleep issues (OSA, restless leg syndrome)

  

Chris denies any growing pains or restless leg symptoms.
No reported snoring.
No nocturnal cough of history of asthma.
He has not had bedwetting associated with sleepwalking.

Safety concerns

  

Mother finally put a bell on his bedroom door so that she could hear him if he wandered out of his room.
She always makes sure to lock the front and back doors.
She added a hook and eye type lock high on the door frame to make it even more difficult for Chris to wander out of the house.
He does not sleep in a bunk bed.

Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep)

  

Chris is not currently taking any medications.

Assess for family history of sleep disorders

Any family history of sleepwalking or night terrors

Mother thinks that she might have had a couple episodes of sleepwalking when she was younger and she knows that Chris’s maternal uncle has had sleepwalking. Unknown history on father’s side of the family.

Complete a Sleep Diary

Information to obtain includes: Case Evaluation Results

Usually involves recording a child's sleep schedule, any sleepwalking episodes during the night, and how the child feels during the day.
Information that is helpful from the sleep diary is the regularity and duration of sleep on a night to night basis. Parents or caregivers record the estimated time the child goes to sleep and wakes up on each night. Additionally, it is helpful to write down when sleepwalking occurred within that night as well as any other times the child woke up or got out of bed.

Mother decided to track Chris’s sleep pattern over the course of 2 weeks.
Download and review his sleep diary

Review of sleep diary:

In review of Chris’s sleep diary, it appears that he likely needs about 10 hours of sleep for adequate rest. This is assumed by looking at days when he is not having to be awoken by his mother on school days. Weekends or holidays are times when assessment of optimal sleep amount may occur. Additional resources on recommended normal sleep amounts are available in the Sleep Health module.
Also, the pattern of sleepwalking tends to occur on the nights that he has either gone to bed later or after a night when he had very little sleep (after a sleepover for example).

Options that are Not Recommended

Order Labs/Other Diagnostic Tests

There is no need to order other labs or diagnostic tests.

Sleep Study

A sleep study is not recommended in this case.

Refer to a Specialist

A referral to a specialist is not recommended in this case.

Red Flags


  • Try to have caregivers give as much detail of the events as possible. If there are stereotyped movements or rhythmic movements, this raises a concern of seizures.
  • Timing of events – events that occur right after falling asleep, in the early morning hours close to the time of awakening, or at irregular times are concerning.
  • Daytime sleepiness, which is not explained by lack of sleep or another sleep disorder.
  • Family history of epilepsy.
  • Multiple events per night.

When evaluating a child for possible parasomnias,
consider how other health care providers may also need to be involved.



Expert Insights:
Triggers for Sleepwalking



Evaluation & Diagnosis

What is the most likely Diagnosis for Chris’s nighttime behaviors?
Check all that apply:

Chris’s signs and symptoms are consistent with:

  • Sleepwalking

In this case, Chris's symptoms are not normal for his age, but they're not considered Night Terrors, Confusional Arousals or Nocturnal seizures.

Chris has a history typical for sleepwalking in which he usually has an awakening within the first one third of the night. Slow wave sleep (also referred to as deep wave sleep or N3 sleep) is more concentrated in the first several hours of sleep. The transition from deep sleep to lighter sleep is often the time of the night when a sleepwalking event can occur. The beginning of the event may be characterized by confusion or vocalization although for Chris, he primarily wanders around - either in his room or to another part of the house.

As a reminder, sleepwalking as well as other NREM parasomnias can be associated with another primary sleep disorder such as obstructive sleep apnea, restless leg syndrome, or insomnia. Screening for comorbid sleep disorders is important to accurately diagnose but especially in treating NREM parasomnias.

Chris's Treatment & Referrals

Now it’s time to recommend treatment options for Chris’s sleepwalking.
Check all that apply:

The following treatment strategies are recommended for Chris’s sleepwalking:

  • Ensure adequate hours of sleep
  • Screen for other sleep disorders that could be contributing to sleep disruption
  • Minimize stress and anxiety
  • Ensure safety measures

Treatment Strategies for Sleepwalking/Night-terrors
  • Often the initial intervention is to ensure adequate hours of sleep by stabilizing bedtimes and ensuring adequate hours of sleep on a daily basis - minimizing significant differences between weekdays and weekends is important.
  • Screening for other sleep disorders that could be contributing to sleep disruption, specifically OSA (snoring) and PLMD.
  • Minimizing stress and anxiety especially about the events around sleepwalking. “Demystifying” sleepwalking for the family.
  • Ensuring safety measures - no sharp objects around, no bunk beds, alarms on doors or at least locks on doors and windows, precautions also in new environments (hotels, sleepovers).

Addressing any of the other triggers listed below may also be helpful.
  • Medications are rarely indicated. However, if there are frequent events especially associated with any injury or significant patient / family distress. One could consider a benzodiazepine or tricyclic antidepressant. If sleepwalking is not improving and medications are being considered, consult a sleep specialist.
  • Try not to fully awaken the child since it may be difficult and actually cause more distress. Additionally, it may be difficult for the child to go back to sleep. However, safety is of the utmost importance so if they are going to harm themselves or walk outside, it IS important to wake them.
  • Decrease fluid intake at bedtime since a full bladder can be a trigger.
  • Avoid caffeine, especially after 12PM since this can make it difficult to fall asleep.
  • Discuss the effects of alcohol with sleepwalking for teenage patients - alcohol can be sedating and can precipitate a sleepwalking episode especially for people who are prone to sleepwalking.

Chris's Results:

Good news! Chris’s sleepwalking episodes have decreased since putting the treatment strategies to use.

Treatment strategies for Chris’s Sleepwalking:
  • Keep a sleep diary to track episodes.
    Through the diary, they saw a pattern of him waking 2 hours after going to bed, so they could be ready to lead him back to his room if needed. They also saw that staying up late one night often lead to sleepwalking two nights later.
  • Follow a regular bedtime schedule & consistently getting enough sleep.
    This seemed to help Chris the most to have solid night sleep without sleepwalking awakenings.
  • Decrease anxiety.
    The family stopped talking about (and teasing!) Chris for sleepwalking, and he is able to go to sleep without feeling stressed that it might happen.
  • Improve safety.
    His parents installed some extra precautions to keep Chris safe. A bell on his door (so they could hear him get up), extra lock on the doors of the house, and door knob cover on the basement door.

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