Identifying Sleep Disturbances

View the Sleep chart for more information about how much sleep children of different ages need. It is important to keep in mind that all children are different, so just because your child sleeps a little more or less than average does not mean that he or she is "abnormal." Almost all children and adolescents have an occasional sleepless night. Kids also occasionally have difficulty with bedtime routines (e.g., not wanting to go to bed or stay in bed or becoming upset when bedtime routines change or parents set limits). More

Sleep Problems in Children and Adolescents

Sleep disturbances among children and adolescents are the second most frequently encountered behavioral problem encountered by primary care providers. It is estimated that 42% of children of various ages experience sleep-related difficulties.¹ Between 35 and 45% of children age 2-18 suffer from a Sleep Disorder at some point in their lives.² Children experience a number of sleep-related difficulties. Examples include:

• Insomnia: problems falling or staying asleep, or failure to get restorative sleep
• Refusing to go to bed or stay in bed
• Nightmares
• Sleepwalking
• Shouting or talking during sleep
• Overly tired during the day
• Enuresis: bedwetting

A child who goes to bed unwillingly or wakes frequently during the night can be highly disruptive to a family. Sleep disorders in children, if confirmed by reproducible findings in a sleep laboratory, are not appreciably different from those occurring in adults. However, sleep problems, defined as a sleep pattern that is unsatisfactory to the parents, child or physician, are far more common. More

Children will sometimes get out of bed and seek your comfort if they are frightened, sick, or have soiled themselves. It is normal if this happens every once in awhile. However, if your child is having difficulty going to bed or staying asleep on a consistent basis it may be time to take action.

According to the Diagnostic and Statistic Manual of Mental Disorders-IV, Primary Sleep Disorders are diagnosed when sleep problems cannot be attributed to another mental disorder, a general medical condition, or use of a substance. Secondary Sleep Disorders are sleep problems that are associated with medical, neurological,or substance misuse disorders. There are two categories of Primary Sleep Disorders listed in the DSM-IV: Dyssomnias and Parasomnias.

• Dyssomnias involve difficulty initiating sleep (falling asleep) or maintaining sleep (staying asleep). These disorders cause disruptions in the amount, quality, or time of sleep. Types of Dyssomnias:
  • Primary Insomnia
  • Primary Hypersomnia
  • Narcolepsy
  • Breathing-Related Sleep Disorder
  • Circadian Rhythm Sleep Disorder
• Parasomnias involve abnormal behavioral or physiological events that occur in association with sleep, specific sleep stages, or sleep-wake transitions. Specifically, the autonomic nervous system (system that controls involuntary actions of internal organs), motor system, or cognitive processes are activated at inappropriate times during the sleep-wake cycle. People with these disorders usually complain of unusual behavior during sleep rather than insomnia or sleepiness during the day. Types of Parasomnias:
  • Nightmare Disorder
  • Sleep Terror Disorder
  • Sleepwalking Disorder

For a description of each of these disorders

Enuresis(bedwetting) is classified in the DSM-IV as an Elimination Disorder, not as a Sleep Disorder. However, Nocturnal Enuresis (bedwetting at night) impacts the young person's ability to sleep. For instance, when a child wets the bed in the middle of the night, he or she usually wakes up. Sheets and clothing have to be changed before returning to bed. Children can become anxious about going to sleep, for fear of having additional accidents. These issues combined impact the child's ability to fall asleep and stay asleep. According to the DSM-IV, in order to meet diagnostic criteria for Enuresis the young person must:

• Repeatedly urinate into bed or clothes
• Repeated urination must occur twice a week for at least three consecutive months, and/or must cause clinically significant distress or impairment in social, academic, or other important areas of functioning
• The young person must be at least five years old
• The behavior cannot be attributed exclusively to the direct physiological effects of a medication or a medical condition

Sleep problems can also be symptoms of other disorders, such as Anxiety and Depressive Disorders. Young people do experience a number of sleep-related difficulties that do not meet diagnostic criteria for a mental disorder. For instance, bedtime refusal or resistance is not classified as a mental disorder, but it is recognized as an important problem that may cause significant impairment in the lives of children and their parents.

The International Classification of Sleep Disorders lists more than 80 different Sleep Disorders, some of which are classified in the DSM as mental disorders and some are not. Not all Sleep Disorders are attributed to psychiatric or behavior causes. Medical and biological factors can also cause Sleep Disorders. Possible causes or contributing factors include:³

• Stress or anxiety
• Depression
• Parenting
• Poor sleep hygiene
• Obstructed airways
• Pain
• Medication side-effects (e.g., stimulant medications)
• Poor sleeping environment (e.g., excessive light or noise)
• Sleep deprivation
• Allergies/asthma
• Gastrointestinal esophageal reflux

Although sleep problems tend to decrease with age, once sleep disturbances have taken hold and become significant problems, children or adolescents are not likely to simply "outgrow" them.³ This is particularly true if young people and their parents have adopted poor sleep habits that cause or contribute to the difficulties. Like many habits, once they are well formed they can be hard, but not impossible, to break. Symptoms are likely to improve over time as young people and their families receive treatment or develop tools to cope with sleep disturbances.

Take the Sleep IQ Quiz to find out how much you know about children and sleep.

¹Moore, B. (in press).Pediatric insomnia.In J. E. Fisher & W. O'Donohue (Eds.). Practitioner's guidelines for evidence based psychotherapy. New York: Kluwer.

²Connelly, K. P. (2006). Sleep disorder: Nightmares. Accessed 4/24/06.

³Durand, V. M., Mindell, J., Mapstone, E., & Gernert-Dott, P. (1998). Sleep problems. In T. S. Watson & F. M. Gresham (Eds.). Handbook of child behavior therapy (pp. 203-219). New York: Plenum Press.