Parasomnias in children

Parasomnias in children are common and may consist of abnormal movements, behaviours, emotions, dream perception, and autonomic activity during transitions between sleep states. They occur from sleep to wakefulness, or during arousals from sleep.

Non-rapid eye movement (NREM) parasomnias occur most commonly in the first half of the night and include sleepwalking, night terrors, and confusional arousals.

Rapid eye movement (REM) parasomnias occur later during the night and consist of nightmare disorder, recurrent isolated sleep paralysis, and REM sleep behaviour disorder (RBD). The latter is extremely rare in children.

The most common modifiable triggers for parasomnias in children include sleep deprivation and comorbid sleep disorders. Treatment of these disorders may significantly reduce or resolve parasomnias in affected children.

Parasomnias are diagnosed on clinical grounds, based on descriptions from an observer, such as a parent or sibling who may share the bedroom. Ordinarily, a sleep study (diagnostic polysomnogram) is not necessary to establish the diagnosis. However, this test may be ordered when other comorbid primary sleep disorders, such as sleep apnoea, are suspected, and it is required for the diagnosis of RBD.

Management usually consists of treatment of the underlying cause of the parasomnia, reassurance, modification of the sleep environment, and, in adolescents, avoidance of substances such as caffeine and alcohol. When parasomnias become frequent and more problematic, occasionally pharmacotherapy may be helpful.

The home environment needs to be modified to increase safety. This includes removal of any potentially dangerous items and sharp objects, locking doors, arranging for a sleeping space on the ground floor, and installation of door alarms.

Parasomnias are undesirable events or experiences that occur during sleep, sleep-wake transitions, or arousals from sleep, involving abnormal movements, behaviours, emotions, perceptions, or dreams.[1]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders Although parasomnias can present at any age, they are especially common in childhood, with many cases resolving spontaneously by adolescence.[2]Deshpande P, Salcedo B, Haq C. Common sleep disorders in children. Am Fam Physician. 2022 Feb 1;105(2):168-76. https://www.aafp.org/pubs/afp/issues/2022/0200/p168.html http://www.ncbi.nlm.nih.gov/pubmed/35166510?tool=bestpractice.com

These events are considered clinical disorders due to their potential to cause injury, disrupt sleep, and contribute to adverse health, behavioural, and psychosocial outcomes.[1]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders [3]Fulfs T, Poulain T, Vogel M, et al. Associations between sleep problems and emotional/behavioural difficulties in healthy children and adolescents. BMC Pediatr. 2024 Jan 5;24(1):15. https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-023-04487-z http://www.ncbi.nlm.nih.gov/pubmed/38183087?tool=bestpractice.com [4]Laganière C, Gaudreau H, Pokhvisneva I, et al. Sleep terrors in early childhood and associated emotional-behavioral problems. J Clin Sleep Med. 2022 Sep 1;18(9):2253-60. https://jcsm.aasm.org/doi/10.5664/jcsm.10080 http://www.ncbi.nlm.nih.gov/pubmed/35686369?tool=bestpractice.com

​Parasomnias are classified according to the sleep stage in which they occur.[1]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders [5]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022[6]Bruni O, DelRosso LM, Melegari MG, et al. The parasomnias. Child Adolesc Psychiatr Clin N Am. 2021 Jan;30(1):131-42. http://www.ncbi.nlm.nih.gov/pubmed/33223057?tool=bestpractice.com ​​ Parasomnias occurring in NREM sleep include disorders of arousal such as confusional arousals, sleepwalking, sleep terrors, and sleep-related eating disorder. REM-related parasomnias include RBD, recurrent isolated sleep paralysis, and nightmare disorder. A final category of ‘other parasomnias’ include exploding head syndrome, sleep-related hallucinations, sleep enuresis, and parasomnias secondary to medical disorders or substance use.[1]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders ​[6]Bruni O, DelRosso LM, Melegari MG, et al. The parasomnias. Child Adolesc Psychiatr Clin N Am. 2021 Jan;30(1):131-42. http://www.ncbi.nlm.nih.gov/pubmed/33223057?tool=bestpractice.com ​​

The term 'disorder of arousal' is used to imply incomplete arousal from NREM sleep, manifesting with parasomnias. Confusional arousals are characterised by mental confusion or confused behaviour that occurs while the patient is in bed. There is an absence of terror or ambulation outside the bed. When the patient leaves the bed, this is classified as 'sleepwalking'.[1]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders

This topic will cover confusional arousals, sleepwalking, sleep terrors, nightmares, recurrent isolated sleep paralysis, and RBD.