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Behavioral Sleep Problems in Children


Just as sleep is important for adults, sleep is also extremely important for children. Sleep is a vital part of brain and body development, and those in their adolescence need more of it in order to develop properly. Oftentimes, “bedtime resistance and night waking are common sleep problems throughout childhood, especially in the early years” [1]. Children will resist going to bed “because they wish to engage in other preferred activities, because they do not feel tired, because they have nighttime fears that make them frightened of going to sleep alone, etc.” [1]. For whatever reason it is, they find themselves losing sleep. Night waking is also a common problem for children, as it is hard for them to fall back asleep once waking up in the middle of the night.


Normal sleep patterns in children are as follows [2]:


● 0-2 months = 16-18 hours of sleep

● 2-12 months = 12-16 hours of sleep

● 1-3 years = 10-16 hours of sleep

● 3-5 years = 11-15 hours of sleep

● 5-14 years = 9-13 hours of sleep


You can often tell if your child isn’t sleeping through the night if they are falling asleep during the daytime. It is shown that “sleepiness in children commonly manifests as irritability, behavioral problems, learning difficulties, motor vehicle crashes in teenagers, and poor academic performance” [2].


Children that have pre-existing behavioral problems, such as “attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD)” may have more problems going to sleep and staying asleep compared to children without them [1]. There has also been a correlation seen between parents with sleep problems and their children developing “attention problems, hyperactivity, oppositional and aggressive behavior, mood problems, and anxiety” as a result [1].


Let’s go into some common sleep disorders that affect children. These include obstructive sleep apnea, parasomnias, confusional arousals, sleep terrors, nightmares, behavioral insomnia, delayed sleep phase disorder, and restless leg syndrome.


Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is when there is an “upper airway obstruction, despite respiratory effort, that disrupts normal sleep patterns and ventilation” [2]. This will usually start to occur around 8 years old, and, in children, this is usually caused by “enlarged tonsils and adenoids” [2]. The most common symptom is snoring, but some other symptoms include: “unusual sleeping positions (e.g., hyperextended neck, seated with open mouth), sleep-related paradoxical breathing, nighttime diaphoresis or enuresis, morning headaches, and excessive daytime sleepiness” [2]. OSA in children can cause the child to become depressed, develop behavior issues, or have a shortened attention span. If untreated, OSA can lead to serious behavioral and neurological problems.


If you suspect that your child is suffering from OSA, it is important to have a specialist diagnose your child through a screening.


Parasomnias

Parasomnias include a few different “undesirable events” that can happen while asleep, including “sleepwalking (somnambulism), sleep talking (somniloquy), confusional arousals, sleep terrors, and nightmares” [2]. Although these are not common, they are considered very dangerous.


Let’s talk about nightmares. We can get them as adults, but we don’t often talk about monsters in the closet in our waking hours. Why is that? Disturbances in children's sleep is often caused by “psychopathological symptoms in children and adolescents, including elevated anxiety traits, difficult temperament, and emotional and behavioral problems” [3]. Adults who suffer from nightmares often developed these terrors as children. This can be both “environmental and genetic contribution” [3]. Unfortunately, there still isn’t too much information on how nightmares manifest in children, but it is speculated that nightmares can be comorbid. Most of the time, these other conditions are psychological and manifest differently for each person.


Nocturnal seizures can occur during parasomniac behavior. If you believe that your child might be experiencing parasomnias that are severe, it is recommended to have them evaluated.


Behavioral Insomnia

Behavioral insomnia can be described as “a learned inability to fall and/or stay asleep” [2]. There are two different types of behavioral insomnia, which include limit-setting and sleep-onset association types. The sleep-onset association type is when a child cannot or will refuse to fall asleep unless certain conditions are met, e.g. being rocked to sleep by their parent. The limit-setting type is when the parent does not set up certain rules for the child to fall asleep. This can look like a child refusing to sleep, so the parent allows the child to sleep in their bed instead of putting the child back into their own bed.


The best way to prevent this is to stick to a certain schedule at night. A consistent bedtime routine can help children to go to sleep and stay asleep through the night. Parents should also make the effort to educate themselves on “normal sleep patterns, good sleep hygiene, realistic expectations, setting boundaries, and sleep plans” [2].


Delayed Sleep Phase Disorder

This disorder is when a child’s circadian rhythm is off due to lighting. For example, exposing a child to a lot of light before bedtime will lead their brain to not feel sleepy, and they may fall asleep an hour or two after they are supposed to. In order to set the cycle back on track, it is important to avoid exposing the child to any bright lights/loud noises before bedtime. It is recommended to have this quiet time so that the child can transition into sleep time. It may also help to implement a small melatonin supplementation before bed. Melatonin is natural.


Restless Leg Syndrome

Restless leg syndrome can be described as “an unpleasant sensation in the legs, with the urge to move the legs starting in the evening” [2]. Unfortunately, with children that have this syndrome, rest only makes the symptoms worse. Thus, sleep is very difficult for the child to achieve. This condition can be caused by “dopamine dysfunction, genetics, and iron deficiency” [2]. If you notice that your child could have restless leg syndrome, it is important to get them diagnosed in order to start preventative measures (such as taking iron supplements).


How to Prevent Behavioral Sleep Problems

So now that we’re familiar with these common sleep disorders, how can they be prevented? The best option is to set up a specific bedtime routine. This can be tricky because the routine has to be consistent in order to work, which means parents must “always be ready to be firm if their child acts up around bedtime” [4]. Try to precede the bedtime routine with quiet time. This means keeping your child away from technology, or anything else too stimulating, as well as turning down the overall noise in the house.


It may also help, if your child is a bit older, to let them sleep without you. If they do not self-settle, they will “wake you or come to your bed to seek your help to go back to sleep” [4]. In order to practice self-settling, “you need to go out of the room with the lights out” [4]. It is better if they are awake, as they have to learn how to fall asleep on their own. Explain and reassure them that they will be able to sleep without you in the room, and if they come out of their room to wake you up, lay them back into bed before leaving the room again. It will be a process, but, ultimately, it’s worth it!


References:

1. Kathryn Turnbull, MSc, Graham J. Reid, PhD, J. Bruce Morton, PhD, Behavioral Sleep Problems and their Potential Impact on Developing Executive Function in Children, Sleep, Volume 36, Issue 7, 1 July 2013, Pages 1077–1084, https://doi.org/10.5665/sleep.2814


2. Carter, K. A., Hathaway, N. E., & Lettieri, C. F. (2014, March 1). Common sleep disorders in children. American Family Physician. Retrieved March 2, 2023, from https://www.aafp.org/pubs/afp/issues/2014/0301/p368.html


3. Shirley Xin Li, MA, Mandy Wai Man Yu, MPH, RPSGT, Siu Ping Lam, MRCPsych, FHKAM (Psych), Jihui Zhang, MD, Albert Martin Li, MRCP, MD, Kelly Yee Ching Lai, MRCPsych, FHKAM (Psych), Yun Kwok Wing, FRCPsych, FHKAM (Psych), Frequent Nightmares in Children: Familial Aggregation and Associations with Parent-Reported Behavioral and Mood Problems, Sleep, Volume 34, Issue 4, April 2011, Pages 487–493, https://doi.org/10.1093/sleep/34.4.487


4. Sleep Health Foundation. (2011). Behavioural sleep problems in school aged children - the sleep health ... Www.sleephealthfoundation.org.au. Retrieved March 2, 2023, from https://www.sleephealthfoundation.org.au/pdfs/Behavioural-Sleep-Problems-Children.pdf


 

Contributors:

Author: Kayjah Taylor

Editor: Lauryn Agron

Health scientist: Joanna Gudino


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