SLEEP AND ITS DISORDERS IN INFANTS AND CHILDREN: A REVIEW

(1)

(

Received January 7; revision accepted for publication March 2, 1972.)

This work was supported by National Institute of Mental Health Research Development Award

Ki-MH-43340 (T.F.A. ) and by the W. T. Grant Foundation, Inc.

ADDRESS FOR REPRINTS: (T.F.A.

)

Children’s Hospital, 219 Bryant Street, Buffalo, New York

14222.

PEDIATRICS, Vol. 50, No. 2, August 1972

REVIEW

ARTICLE

SLEEP AND

ITS DISORDERS

IN INFANTS

AND

CHILDREN:

A REVIEW

Thomas F. Anders, M.D., and Pearl Weinstein, MS.

From the Infant Development Laboratory, Department of Psychiatry, Montofiore Hospital and Medical

Center, and The Rose F. Kennedy Center for Research in Mental Retardation and Human Development,

Albert Einstein College of Medicine

ABSTRACT. Recently the polygraphic study of

sleep has provided techniques for the assessment of

central nervous system (CNS ) functioning in new-born infants and the diagnosis of sleep disorders in

children. First, in this review, the normal

develop-mental course of the “active” and the “quiet” sleep

states from birth through childhood is described.

Then, within the context of these recent

electro-physiologic findings, the abnormalities of sleep state

organization during the neonatal period, the

physi-ologic disorders of sleep in older children, and

finally, the psychological disturbances manifested

through sleep are reviewed.

Pediatrics, 50:312, 1972, SLEEP, ENURESIS,

NIGHT-MARES, NARCOLEPSY, INSOMNIA.

I

N 1955 Aserinsky and Kleitman,1

observ-ing sleeping infants, described a

“rest-activity” cycle characterized by quiet

pen-ods of no body movements and no eye

movements and active periods of body

movements and rapid eye movements

(

REMs

)

under closed lids. Dement and

K.leitman2 first confirmed these observations

by electrophysiologic recording from

sleep-ing adults in 1957. More than 15 years later,

after a virtual explosion of investigative

in-terest into the functions and mechanisms of

sleep in man and other animals, it is well

recognized that sleep is not a unitary

physi-ologic state of restitution, but rather two

cycling states of differing physiologic

activ-ity. Several texts indicate the scope of this

work,3 and sleep studies during infancy

Abbreviations

CNS : Central nervous system

EEG: Electroencephalogram

NREM: Nonrapid eye movement

REM: Rapid eye movement

REMs : Rapid eye movements

SWs : Slow wave sleep

have recently been reviewed by Lenard.6

Although the sleep of infants and adults

differs in minor details, the basic alternation

of an “aroused” state with an “inhibited”

one is similar. An initial description of the

adult sleep cycle provides the background

for the understanding of developing sleep

patterns and sleep stage sequencing in the

infant and young child. Demerit and

Kleit-man2 described four stages of

electroence-phalogram

(

EEC

)

activity during adult

sleep: Stage 1 is typified by low voltage,

fast activity; Stage 2 by the presence of

sleep spindles and K-complexes against a

low voltage background; and Stages 3/4

by varying degrees of slow, high voltage

ac-tivity. Stages 3/4 have been called slow

wave sleep

(

SWS

)

. Rapid eye movement

(

REM

)

sleep is defined by the occurrence

of a Stage 1 EEC, binocularly synchronous

rapid eye movements, the suppression of

muscle tone as recorded from chin muscles,

and accelerated, irregular respiratory and

heart rates. The nonrapid eye movement

(

NREM

)

stages

(

1 to 4

)

of sleep lack

REMs and are accompanied by the

pres-ence of muscle tone, and slowed, regular

(2)

alternat-REVIEW ARTICLE

ing REM and NREM states, occurring

dur-ing sleep, define two distinct states of

neu-rophysiologic activity. The REM state is

highly activated; the NREM state is basal

and highly regulated. They follow each

other in a periodic fashion and together

they comprise the sleep cycle.

A typical adult sleep cycle starts (as does

sleep onset) with “descending” NREM

sleep stage shifts, moving from Stage 1 to 4,

then “emergent” shifts through Stages 3 and

2 to a REM period after which the cycle is

repeated. The typical night’s sleep involves

4 to 6 REM/NREM cycles. The REM

phase of the cycle is associated with what

typically has been defined as dreaming

though some mental activity does occur

during Stages 1 and 2 of NREM sleep.7’8

The present paper considers sleep and its

disorders in infants and children with

re-spect to recent findings emanating from

po-lygraphic studies of sleep. The

psychologi-cal disturbances of sleep, not associated

with abnormal polygraphic findings, are

differentiated from the physiologic

disor-ders. Three broad areas are reviewed : (1)

the development of normal and abnormal

sleep patterns in infancy, (2) physiologic

disorders of sleep and arousal in children,

and

(

3

)

psychological stresses manifested

by disturbances of sleep. Although these

areas differ slightly in their subject matter,

the role of sleep is central and the

poly-graphic recording of sleep parameters is

relevant to both development and

physio-logic studies. For the sake of completeness

they are included in this single review. It is

hoped that continuing investigation will

provide the links, if any, between early

de-velopmental deviations and the later

disor-dens of sleep and arousal. For the present, it

is possible only to review the three areas

in-dependently.

THE DEVELOPMENT

OF SLEEP

PATTERNS IN INFANCY

The changing electrophysiologic and

or-ganizational characteristics of infant sleep,

as maturation progresses, provide new

indi-ces for early developmental assessment.

Several of the differences between infant

and adult sleep patterns and sleep cycles

are worthy of note:

Organization

All of the sleep occurring during the

adult’s night sleep can readily be classified

as either REM or NREM sleep and staged

accordingly. During the newborn period, in

contrast, the physiologic and behavioral

ac-tivities routinely recorded during a sleep

period are not as readily classified into two

distinct sleep states. In a recent attempt at

standardization of terms and techniques, an

infant scoring manual has been published

which defines three sleep states : . . .

active-REM sleep, quiet sleep and indeterminate

sleep.9 Whereas active-REM sleep and

quiet sleep may be precursors of adult

REM and NREM sleep respectively and

seem, even in infancy, to share the

“acti-vated” and “basal” characteristics of the

two adult sleep states, indeterminate sleep

represents an “immature” state of poorly

or-ganized sleep, predominant in premature

infants but also present in young, term

in-fants and some abnormal infants. For more

precise definitions of these sleep states the

reader is referred to the infant scoring

man-ual.#{176}

Proportions

Sleep state proportions change with age.

Indeterminate sleep, predominant in the

premature infant of 34 weeks, diminishes

and most often disappears by 3 months of

age. At term, active-REM sleep occupies

45 to 50% of total sleep lime, indeterminate

sleep occupies 10 to 15%, and quiet sleep

occupies 35 to 45%. With increasing age,

the proportion of quiet sleep increases and

active-REM sleep decreases until late

childhood when young adult normative

amounts are achieved

(

20% REM sleep;

80% NREM sleep).b012 Furthermore, by 3

months of age, quiet sleep EEC patterns

can begin to be subclassified into NREM

sleep stages.13

The predominance of an activated state

(3)

led Roffwarg, et al.1 to put forward the

on-togenetic hypothesis which restated,

sug-gests, “the REM sleep mechanisms of the

brainstem constitute a CNS

auto-stimulat-lug system particularly important during

uterine development and early post-natal

life when the young organism is relatively

cut off from external stimulation. Since

growth and maintenance of neural tissue

are enhanced by stimulation, according to

this view, the cyclic excitatory activation

provided to much of the brain by REM

sleep serves to augment differentiation of

neunonal structures and lay down the

mdi-ments of neurophysiological discharge

pat-terns in the developing organism.”15

Periodicity and Sequencing

The length of the sleep cycle

(active-REM/quiet sleep) changes with age. The

cycle of normal infants at term has a

pen-odicity of 45 to 50 minutes. More immature

infants have shorter cycles and premature

infants of less than 34 weeks’ conceptual

age do not demonstrate sleep cycling.16 The

sleep cycle of adolescents and adults

ap-proximates 90 to 100 minutes.

The temporal patterning of individual

sleep states within a sleep period also

changes with age. Whereas adults enter

sleep with an initial sustained NREM

pe-nod and have most of their REM sleep

dun-ing the last third of the night, newborn

in-fants enter sleep initially through

active-REM sleep and cycle, at regular intervals,

with quiet sleep. Thus there is as much

ac-live-REM sleep in the first half of the

new-born’s sleep period as in the second half.

Day-Night Shifts

Diurnal patterning of sleep and

wakeful-ness develops with maturation. In adults,

wakefulness and sleep are associated most

commonly with light and dark respectively.

In newborn infants, daytime wakefulness

and night time sleep is evident by 3 months

of age, though indications of the diurnal

rhythm have been reported as early as the

first 10 days of life.17,18 These day-night

shifts occur while the overall 24-hour

amounts of sleep and wakefulness change

only minimally. Initial brief, individual

sleep and wake periods coalesce into longer

periods as the diurnal pattern develops. By

8 months of age a sustained period of

day-time wakefulness, interrupted by two brief

naps, and an uninterrupted period of night

time sleep are characteristic.19 This process

of “settling” or sleeping through the night is

discussed further in the section on

psycho-logical disturbances of sleep. It is unclear

what, if any, environmental influences retard

on enhance the progression of these

devel-opmental changes. On the one hand, early

adequate mother-infant regulation

includ-ing appropriate feeding procedures, diet,

absence of excessive anxiety, sufficient

han-dling, and so forth have been implicated;

on the other hand, maturation of the CNS

alone has been felt to be sufficient. Most

likely, the combination of a sensitive,

re-sponsive environment and normal

matuna-lion is optimal.

Miscellaneous

Several minor differences between adult

sleep and infant sleep have also been noted.

It is possible to deprive adult sleepers of a

single sleep state, such as REM sleep, for a

period of time and demonstrate a selective

“rebound” of that state during subsequent

uninterrupted recovery 2#{176}Neither

deprivation nor recovery of sleep states are

as clear cut in the newborn period. Rather,

the infant demonstrates a “tenacity” for his

ongoing sleep state, returning to it

immedi-ately following disturbance.15 Finally,

hon-mones such as human growth hormone and

cortisol have been associated with particulan

sleep stages in adults.Sl,22 These

relation-ships do not seem to exist during the first 3

months of life for the human infant.23’24

The assessment of sleep state

onganiza-tion, proportions and nhythmicity by the

polygraph has resulted in a new tool-the

sleep polygram-useful in the diagnosis of a

wide variety of developmental

abnormali-ties. The areas of clinical applicability can

(4)

Dreyfus-Brisac and Monod25 have

ne-ported a complete lack of cycling in the

sleep of severely brain damaged newborn

infants and unusually frequent and

irregu-Ian sleep state shifts in infants with lesser

degrees of neurological impairment. Infants

with mild degrees of birth trauma,2#{176} infants

born to diabetic mothers2 and to toxemic

mothers,25 and infants born to

heroin-ad-dicted mothers have all demonstrated

ab-normalities in their quiet sleep state

organi-zation and/or in the maturation of various

EEC wave forms. Abnormalities of

active-REM sleep have been reported in a variety

of pathological conditions including

chro-mosomal abnormalities,30 infantile autism,31

and nonspecific mental retardation.32 The

reversal of sleep EEC abnormalities

associ-ated with thyroid deficiency closely

paral-lels clinical improvement.33

More experience with the sleep polygram

during early development will provide the

basis for a much needed sensitive early

in-dicator of neurological integrity, especially

in the early detection and prognostic

deter-mination of children with minimal brain

damage. The efficacy of various therapeutic

regimens may prove to be another area in

which sleep studies will provide clinically

useful information.

DISORDERS OF SLEEP AND AROUSAL IN CHILDREN

In children older than 2 years, although

sleep stage proportions have not achieved

adult ratios, the characteristics of the

physi-ologic measures recorded during sleep have

by and large assumed adult forms.

There-fore, as in the adult, it is possible to define a

state of REM sleep alternating with a state

of NREM sleep which can be subdivided

further into Stages 1 to 4 according to

pre-viously described EEC criteria.2

Nocturnal enuresis, somnambulism,

somniloquy, pavor nocturnus

(

night

ten-rors

)

and narcolepsy are generally

consid-cred to be the most common physiologic

childhood disorders of sleep. In the past

they have been classified in a variety of

ways depending on their motor,

auto-nomic, or psychophysiologic components.34

Through the use of the sleep polygraph, the

widely held belief that these disorders wene

associated with seizure activity has not

been confirmed.3#{176} Rarely, teniporal lobe

seizures may mimic these disorders, but

ad-equate study in the sleep laboratory readily

differentiates epileptic disorders from sleep

disorders. Currently a helpful classification

has been with respect to their relationship

to the REM/NREM sleep cycle. After a

prolonged initial period of Stage 3/4

NREM sleep, the ascending or “emergent”

shifts to Stages 2, 1, and REM sleep

nepre-sent the “lightening” of sleep in the

dinec-lion of arousal. Accordingly bed wetting,

sleep walking, sleep talking, and night

ten-nors are all associated with emergence from

Stage 3/4 NREM sleep and consequently

are defined as disorders of arousal.

Nanco-lepsy, on the other hand, is associated with

the abnormal occurrence of REM sleep and

is thus regarded as a disorder of sleep.413

It is becoming increasingly evident that the

disorders of arousal are most often

associ-ated with signs of neurological immaturity

especially upon their initial occurrence in

younger children.

The various disorders of arousal often

ap-pear in the same penson at different times

and often with a family history of the

disor-ders.4446 They are further linked by

com-mon aspects of their symptomatology: They

are paroxysmal in nature and are

character-ized by nonresponsiveness to the

environ-ment, automatic appearance to actions, and

retrograde amnesia for the episode. Prior to

their study by sleep polygraphy, these

dis-orders were commonly regarded as dream

equivalents or “acting out” of dreams.7’8

Dissociating these disorders from REM or

“dreaming” sleep, however, are:

(

1

)

epi-sodes occur during REM periods in less

than 10% of polygraphic recordings; (2)

REM sleep is most abundant during the

last third of the night, whereas these

disor-dens occur mainly during the first 3 hours of

sleep;

(

3

)

dream recall is present after

awakening from REM sleep while there is

(5)

episodes, and (4) children suffering from

these disorders have normal REM sleep

patterns and proportions.36’4#{176}

Still poorly understood is the reason that

specific disorders occur in particular

mdi-viduals and in those individuals only at

cer-tam times. There is evidence that the

sus-ceptibility to particular sleep disorders is

related to individual physiologic differences

and possible genetic factors.40’49

Psycholog-ical anxiety and environmental stress are

also frequently recognized, particularly

where symptoms persist into late childhood

and early adulthood, suggesting multiple

interacting etiologies.

Nocturnal Enuresis

Bed wetting past the age of 3 is the most

prevalent childhood sleep disorder. Rarely

an organic etiology such as genitouninany

pathology, epilepsy, or diabetes may be

as-sociated with enuresis but more often it is

considered to be functional or idiopathic.

In the pediatric literature childhood

enune-sis has been classified in various ways :

Pni-mary enunesis refers to the enunesis of

chil-dren who have never developed bladder

control, whereas secondary enunesis refers

to children who have developed bladder

control and then lost it. This secondary loss

of control is often attributed to

psychologi-cal stresses on intervening organic

pathol-ogv. Nighttime enunesis has also been

differentiated from daytime enuresis. In

studies relating enunesis to sleep stage

pat-terns, these distinctions have not been

main-tamed and the results suggest that all

categories of enuresis share varying

propon-lions of a common physiological imbalance,

at least when the symptoms first occur.

Ritvo, et al.#{176}have suggested that the initial

psychophysiologic substrate for enuresis

may provide a basis for perpetuation of the

condition through later neurotic conflicts

especially where enunesis occurs during

Stages 1 and 2 NREM sleep in olden

chil-dren and adolescents.

Depending on the definition of enuresis

and the methods of sampling, 5 to 17% of

children between 3 and 15 years of age

cx-hibit the disorder. The condition, more

common in males, usually diminishes with

maturation, rarely persisting into adult-hood.445152

Bnoughton and Castaut,53 by polygraphic

monitoring, have defined an “enunetic

epi-sode” which generally occurs 1 to 3 hours

after falling asleep, as the child is arousing

from NREM Stage 3 or 4 sleep prior to

en-tening his first REM period. The sleep stage

change is often associated with body

move-ments and increased muscle tone followed

by tachycardia, tachypnea, erection in

males, and decreased skin resistance.

Mic-turition occurs ii to 4 minutes after the start

of the episode in a moment of relative

quiet. Immediately following micturition,

children are difficult to awaken and when

aroused indicate that they have not

dreamed. There is total amnesia for the

event. Adolescents and young adults ane

more likely to be enuretic when arousing

from NREM Stages 1 or

Bnoughton#{176} has suggested that the

arousal from slow wave sleep provides the

appropriate dissociative state in which

enu-resis may occur. Evidence has been

ob-tained that enureics have higher

intra-vesi-cal pressure, especially in Stage 4 NREM

sleep than controls, have more frequent and

intense spontaneous bladder contractions,

and have more secondary contractions in

response to naturally and artificially

occur-ring increases in pressure.55’56

Treatment has taken many forms

includ-ing drugs, conditioning techniques, and

psychotherapy. Presently the drug of choice

for severe enunesis is imipnamine which

ne-portedly increases Stage 2 NREM sleep and

decreases Stage 4 NREM sleep and REM

sleep. It is unclean whether the effects of

imipramine are due primarily to its

anticho-linengic properties effecting bladder control

on to its stimulant effect. A flexible dosage

and slow withdrawal schedule are

recom-mended.57’58 Ritvo, et al.#{176}noted that

imi-pramine was most effective for enuretic

epi-sodes that occurred during Stages 3 and 4

NREM sleep transitions.

(6)

con-ditioning techniques or psychotherapy have

met with mixed results.52,5963 Bakwin63

noted the lack of evidence for clear cut

be-havioral differences between enuretic and

normal subjects, but stressed the

psycholog-ical value of the physician’s supportive role.

When viewed as disorders of

developmen-tal immaturity, most cases

(

Stage 3/4

en-uresis

)

subside spontaneously; intractable

cases

(

Stage 1/2 enuresis

)

require more

vigorous intervention.

Somnambulism and Somniloquy

Perhaps 15% of all children between the

ages of 5 and 12 have walked in their sleep

at least once. Occurring in 1 to 6% of the

population, somnambulism or persistent

walking is a fairly common disorder

afflicting more males than females, more

children than adults, and often associated

with nocturnal enuresis.36’46’4#{176} Of enunetic

naval recruits, 34% reported a positive past

history, and 25% a family history of

sleep-walking.45 Monozygotic twins are

concon-dant for the disorder six limes as often as

dizygotic twins.’9 A typical somnambulistic

episode consists of the following behavioral

sequence: A body movement is followed by

the subject abruptly sitting upright in bed.

The eyes are open, glassy, and appear

“un-seeing.” The subject may or may not

actu-ally get up and leave the bed. Doors and

drawers may be opened, furniture skirted.

The movements are clumsy but collisions

and actual physical injury are generally

avoided. Efforts to communicate with the

sleepwalker may elicit mumbled and

slurred speech with monosyllabic answers

that are poorly related to the question.

Occa-sionally spontaneous somniloquy is

ob-served. The total duration of the episode

may range from 15 to 30 seconds when

sit-ting in bed, to 5 to 30 minutes, or more,

when actual walking occurs. Walking

gen-erally ends with the child returning to his

bed to sleep. There is amnesia for the event

upon awakening. Severe sleepwalkens may

have episodes 1 to 4 times weekly.

The majority of the somnambulistic

epi-sodes occur in the 1 to 3 hours immediately

317

following sleep onset. They appear, as do

enuretic episodes, to be associated with

transitions from Stages 3/4 NREM sleep

to lighter stages, prior to the first REM

pe-nod. Kales, et al.,64 recording

polygraphi-cally during somnambulistic episodes,

never found sleepwalking to arise during

REM sleep. In this same report,

sleepwalk-ing could be induced in 7 of 38

sleepwalk-ens by standing them up during Stage 3 or

4 NREM sleep but not in REM sleep.

Nor-mal controls could not be induced to walk

during any stage of sleep. When restricted

from walking, somnambulists, compared to

controls, tend to make many niovements of

a complex nature during slow wave sleep.34

They also exhibit longer than normal

confu-sional episodes following forced

awaken-ings from these stages.4#{176}

The sleep EEC of somnambulists reveal

the presence of rhythmic, paroxysmal, high

voltage, slow frequency delta bursts

(

1-3

Hz) preceding each event.65 These

paroxys-mal bursts also occur in somnambulists at

times unassociated with the event. Gibbs

and Gibbs66 have described these bursts as

present in 85% of normal 6- to 11-month-old

infants, decreasing to 3% in 7- to

9-year-olds. Their continued presence in

somnam-bulists has suggested to Kales, et al.65 an

organic index of CNS immaturity in such

patients.

Administration of a wide variety of

psy-chological and personality tests has shown

no single constellation of traits

chanacteris-tic of somnambulists. A wide range of

per-sonality traits, emotional responsiveness

and heterogeneous psychopathology marks

these patients.#{176}7 Somnambulists in the

mili-tary, on the other hand, exhibit greater

psy-chopathology than controls.46 Sleep-walking

incidents, despite their distinctive

physio-logical signs and lack of specific

psycho-logical symptoms, are not divorced from

psychological and environmental factors.

In-vestigators report less sleep-walking in the

laboratory than in the home.40’65

Individu-als who have had long periods without

sleer-walking may revert under stress.#{176}7

(7)

somnambulistic episodes. When it occurs

alone it is most often associated with

emen-gent stage transitions during NREM sleep.

In these instances, speech content is related

to immediately preceding experience.68

As with enunesis, the therapy of

somnam-bulism has included drugs, situational

ma-nipulalion, and psychotherapy. The drug of

choice for intractable, frequent occurrences

is diazepam (Valium) which significantly

reduces Stage 4 NREM sleep and also may

reduce the number and intensity of

emer-gent sleep stage shifts.69 As CNS maturation

progresses, somnambulistic episodes usually

diminish and disappear spontaneously.

Pavor Nocturnus

Attacks of childhood night terror must be

differentiated from the more common

nightmare on anxiety dream. In pavor

noc-turnus, the child suddenly sits upright in

bed and screams. He appears to be staring

at an imaginary object, breathes heavily,

of-ten perspires, and is in obvious distress. He

is usually inconsolable for 10 minutes or

more, then finally relaxes and returns to

sleep. Immediate dream recall is

fragmen-tary,

if

present at all, and in the morning

there is amnesia for the attack. Though seen

in older children and adults, night terrors are

most common in the preschool age group.

Gastaut and Broughton34 polygraphically

recorded seven episodes of night terror in

seven children. In all cases, the attack

oc-curned during intense and sudden arousal

from slow wave sleep. It was further noted

that these children had relative tachycardia

during slow wave sleep and hyperactive

heart rates during arousal episodes. Fisher

et al.69 have confirmed these

electnophysio-logic findings in young adults.

For severe cases, the drug of choice, as in

somnambulism, is diazepam. Most episodes

in children occur so infrequently, however,

that no medication is indicated.

Nightmares and anxiety dreams, which

will be discussed more fully in the next

see-tion, are not considered disorders of

arousal. Rather, they occur during REM

sleep, are associated with vivid

recollec-lions, and often make the child fearful of

going to bed.

Narcolepsy

Narcolepsy, in contrast to disorders of

arousal, has been defined as a disorder of

sleep. The characteristic symptom is

recur-rent daytime episodes of irresistable

drow-siness and sleep. These sleep attacks may or

may not be associated with the three

auxillary symptoms of cataplexy, sleep

paralysis, and hypnagogic hallucinations to

form the “narcoleptic tetrad.”39’7#{176} Cataplexy

is the sudden loss of muscle tone resulting in

falling to the ground while consciousness is

maintained. Sleep paralysis is the sudden

awareness, while falling asleep or during

sleep, that one can not move or cry out.

Hypnagogic hallucinations consist of vivid

visual or auditory imagery occurring at

sleep onset. Sleep attacks are associated

with cataplexy about 75% of the time and

with sleep paralysis and hypnagogic

hallu-cinations 20 to 30% of the time. The full

blown narcoleptic tetrad occurs about 10%

of the time.7#{176}A genetic factor is suggested

by the higher familial incidence of the

dis-order.70’”

While most sufferers are brought to a

physician in their teens on early adult years,

it is probable that childhood symptoms of

recurrent drowsiness are present but not

considered remarkable. The interval

be-tween the first sleep attack and the

occur-rence of the other symptoms may vary

from hours to years.39 The symptoms,

them-selves, also may vary between attacks and

do not always occur together. Partial

nemis-sions have been reported, but complete

remission is doubtful.

Electrophysiologic studies of the

narco-leptic tetrad confirm its relationship to

REM sleep.4143’72 In patients with a history

of cataplexy on other auxillany narcoleptic

symptoms, sleep attacks during the daytime

are episodes of REM sleep intruding upon

wakefulness. Cataplectic attacks during the

day and sleep paralysis at sleep onset

repre-sent the loss of peripheral muscle tone, a

(8)

refers to extreme confusion and drowsiness,

lasting for 1 to 2 hours, upon awakening.76

The nocturnal sleep of hypersomniacs

cx-hibits normal REM/NREM sleep cycles

and patterns. The hypersomniac episodes

generally represent periods of Stages 1 and

2 NREM sleep. The incidence, etiology,

and management of this disturbance

ne-mains unclear, but it is generally felt to be

largely associated with psychological

con-flicts.

PSYCHOLOGICAL DISTURBANCES OF SLEEP

“A sleepless baby is a reproach to his

guardians” wrote Sundell in 1922

suggest-ing that the full responsibility for sleep

dis-turhance belonged to parents. Anna Freud,3

on the other hand, suggesting cultural

sources of sleep disturbances, has pointed

otit that the human infant is perhaps the

only creature among mammals who sleeps

without the direct contact and warmth of

another’s skin. Regardless of their source,

virtually all parents anticipate some sleep

disturbances in their children.

Prior to sleep polygnaphy, many of the

previously described disorders were

con-sidered psychological in etiology. Indeed,

many of them are associated with or

in-duced by psychological conflicts or

situa-tions of heightened anxiety. All are a source

of psychological suffering. The disorders to

be described in this section, however, are

those characterized by normal sleep

poly-grams. They are more common, often are

reflections of normal phases of development,

and have been loosely labeled by parents

and pediatricians as “insomnia” and

“night-manes.” By far the majority are transient

and, though a source of irritation, are

in-consequential. Sometimes when bizarre or

fixed, however, they may be indicators of

more serious psychopathology. Medication,

by and large, is not indicated though the

short-term use of chloral hydrate has been

advocated to promote peace and quiet in

the family and prevent the sleep

distur-bance from becoming ingrained by

“posi-live” reinforcement. Understanding the

REVIEW ARTICLE

The vivid imagery of the hypnagogic

hallu-cinations resembles dreams recounted after

REM sleep awakenings. In contrast to

nor-mat adults who enter sleep through a

prolonged NREM period, sufferers of

cata-plexy, sleep paralysis and hypnagogic

hal-lucinations exhibit a prolonged initial REM

period, both in daytime attacks and in

noc-turnal sleep, reminiscent of newborn sleep.

Individuals who have only sleep attacks

without a history of any auxillary symptoms

may not demonstrate this unusual transition

to REM sleep, but rather the normal

de-scending pattern from wakefulness to

NREM sleep in both daytime attacks and,

nocturnal 47 That is, all daytime

sleep attacks are not episodes of REM

sleep. This has led Dement, et to

pro-ROSe a compelling argument to limit the

definition of narcolepsy to those disorders

characterized by attacks of REM sleep and

relegate other episodes of involuntary sleep

to another diagnostic category.

The etiology of the disorder remains

oh-scure but emotional experience and

in-creases in tension and anxiety are known to

precipitate attacks. Treatment with

analep-tic drugs has proved effective. The

amphet-amines, which reduce REM sleep while

minimally interfering with other sleep

stages are most commonly used.39’2

Me-thylphenidate hydrochloride

(

Ritalin

)

has

also been tried.” Although numerous

inves-tigators have confirmed the nonepileptic

form of narcolepsy, the anticonvulsant

phe-nacemide

(

Phenurone

)

has achieved some

success.74 Most recently the use of the REM

suppressing MAO inhibitors have had

marked

Hypersomnia refers to an excessive

amount of sleep. It generally starts during

adolescence. Though often confused with

narcolepsy, it is not a disorder of REM

sleep. Hypersomniacs fall into three

catego-lies : Daytime hypersomnia refers to

exces-sive sleepiness during daylight hours when

wakefulness is desired; nocturnal

hypen-somnia is characterized by excessively long

nocturnal sleep periods with difficulty in

(9)

source of the child’s anxiety, the parental

concerns, and the current family situation

are most often sufficient to enable the

pedi-atnician to provide supportive guidance

un-til the disturbance subsides.

Sleep disturbances may occur from the

imminent approach of bedtime to the time

of awakening. Nagera79 has extensively

re-viewed these disturbances and classified

them according to the most common age of

appearance. This system of classification

af-fords optimal understanding of the

distur-bance within the context of the child’s

de-velopmental stage.

The First Year of Life

Two major concerns of the infant’s family

during the first year of life are sleeping

through the night (“settling”) and night

awakenings. Settling, most comprehensively

studied by Moore and Ucko,8#{176} refers to

sleeping from around midnight to early

morning. These authors report that 70% of

babies settle by 3 months, and another 13%

have settled by 6 months. Ten percent

never sleep uninterruptedly during the first

year. The factors which promote settling

are unknown though it is generally felt that

it is related to the process of CNS

matura-tion. Infants who have suffered some

peri-natal insult, such as anoxia, settle later.81

Sex, birth weight, and weight at 6 months

do not seem related. Environmental

condi-lions such as feeding schedule, sleeping

ar-rangement, minor illness, and so forth, also

do not seem related though high levels of

maternal anxiety, reflected by inconsistent

handling or insufficient nonfeeding play

does seem to delay settling. Interestingly, 3

months of age

(

the age at which most

in-fants are settling) is the time when infants’

sleep polygrams assume more adult

charac-tenistics. At that time infants enter sleep via

a sustained NREM period and the NREM

EEC begins to be differentiated into

NREM sleep stages.’3 A study of the

nela-tionship between the age of settling and the

maturity of the sleep polygram would be of

interest.

Once the process of settling has occurred,

waking normally recurs in 50% of infants

between 5 and 9 months. During the

see-ond half of the first year environmental

fac-tons such as changed sleeping

arrange-ments, separations, minor trauma, and new

family members have been reported to be

associated with wakenings. These

disrup-lions are usually transient, though severe

trauma may result in more prolonged

dis-turbances. After 6 months of age parental

concern and anger over poor sleeping

hab-its may frequently compound the existing

difficulty.82 Thus during the first year, if the

babies’ physiological needs are met

ade-quately, empathetic understanding and

guidance from the pediatrician to allay

cx-cessive parental anxiety should lead to a

rapid resolution of the sleep disturbance.

The

Second Year of Life

During the second year of life, sleep

dis-turbances often reflect infantile anxiety

stemming from either developmental

im-maturity or neurotic conflict. At this age,

psychological and cognitive components are

added to the physiological requirements of

sleep. With the strengthening of the child’s

ties to significant people and to the

happen-ings of the external world, he clings all the

more tenaciously to 78 A

preva-lent disturbance of this age, therefore, is

re-luctance to go to sleep.83 During the first

half of the second year, the child’s ego is

still immature and can offer little comfort

during times of separation. Since the child

lacks the capacity to differentiate between

absence and total disappearance of an

ob-ject, he attempts to hold onto his important

ties to avoid the fear of loss. Substitute

ob-jects, such as teddy bear or blankets, often

tide him oven these difficult times. By the

end of the second year, with the acquisition

of language and the development of a sense

of object permanence, these difficulties

of-ten disappear.

Children in this age group are also easily

overexcited by parents or upset by

frighten-ing daytime experiences. The resulting

in-creased tension may lead to a second

(10)

night-REVIEW ARTICLE

mares. Polygraphic studies have confirmed

the presence of dream reports following

REM sleep awakenings in 2-yean-olds.84

. . Latency

Most often these elicited dream reports are

re-enactments of daytime experiences,

though the characters are frequently

ani-mals or monsters. Since the child, at this

age, cannot distinguish between dreams

and reality, fear of going to sleep because

of bad dreams may develop. With an

in-crease in ego development and the

estab-lishment of a clear-cut distinction between

dreams and reality, this type of disturbance disappears.

To allay the anxiety associated with

go-ing to sleep, presleep habits or rituals

de-velop during the second year. These

in-elude repetitive bedtime stories, last

good-nights, and so forth. In a minority of cases,

the rituals seem to stem from additional

conflicts and become excessive,

represent-ing early precursors of more serious

psycho-pathology. These instances are most often

associated with overzealous attempts at

early discipline (e.g. toilet training, limit

setting, and so forth) . It has been

hypothe-sized that the anger generated by these

par-ent-child power struggles is reduced by the

child’s presleep rituals. The youngster who

repeatedly needs to kiss his parents

good-night, and so forth, indicates his love for

them and in turn verifies their love for him.

The Third to Fifth Year of Life

It is rare to find a child in the 3- to 5-year

age group who is not experiencing some

difficulty over sleep, whether it be tardiness

in falling asleep, night wakening,

night-mares, projective fears of ghosts and wild

animals, inability to sleep alone or in the

dark, or ritualistic presleep behavior. Most

of these disturbances are transient and

re-sponsive to minimal environmental

manip-ulation. If refractive, the sleep disturbance

most often represents only one symptom of

a more profound conflict. Such conflicts in

this age group most commonly are

attnibut-able to parental disturbances or reflect the

child’s inability to enter into the wider

world of social relationships. Enlightened

family counselling or psychotherapy for the

child and family may be indicated.

During latency there usually is

ameliona-lion of most sleep disturbances. Reading

before going to sleep often replaces other

presleep rituals. This avoids engaging in

fantasies, mostly erotic, and the resulting

secondary conflicts over masturbation. On

occasion, however, the previous sleep

dis-turbance may carry oven, on even arise de

novo. It may then persist through

adoles-cence into adulthood.

SUMMARY

Recent electrophysiologic techniques

have added considerably to the

understand-ing of sleep and its disorders. Persistent

nocturnal enuresis, somnambulism,

somni-loquy, and night terrors have been

associ-ated with emergent sleep stage transitions

from Stage 4 to Stage 1 NREM sleep and

have thus been classified as disorders of

arousal. Narcolepsy, on the other hand, has

been associated with the abnormal

transi-tion from wakefulness directly into REM

sleep and has been termed a disorder of

sleep. Though these disorders may be

asso-ciated with psychological factors,

psycho-physiological factors have been

demon-strated and specific pharmacologic agents

have proven most effective in treatment.

The stresses and conflicts of growth and

normal development may be expressed,

from time to time, in various manifestations

of disturbed sleep. Many complaints of

“in-somnia” and nightmares fall into this

cate-gory and are misunderstood in terms of the

developmental problem that the child and

family face. Most often patience, support,

and guidance are sufficient to alleviate the

symptoms. Rarer, pathological disturbances

must be differentiated from the more

com-mon developmental manifestations.

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Acknowledgment

Doctors M. Cohen, L. Finberg, M. Gersch, and

H. Cordon graciously reviewed earlier versions of

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1972;50;312

Pediatrics

Thomas F. Anders and Pearl Weinstein