Interruptions During Sleep
Partial Wakings: Sleep Talking, Sleepwalking, Confusional Arousals, and Sleep Terrors
I. What They Are and
Why They Happen
Marcy, age four, often moaned, babbled semicoherently, and moved about her bed restlessly about two hours after falling asleep, but she always went back to sleep on her own after a few minutes. Lisa, eighteen months old, was a happy baby; yet every night, a few hours after falling asleep, she began crying and rolling about in her crib, seemingly unable to be comforted. Noah, nearly three, would sleep peacefully for two or three hours and then begin thrashing and yelling bizarrely, calming down only after fifteen to twenty minutes. Christopher began to walk in his sleep at age six, quietly and calmly, with a blank expression on his face; by the age of eight, he had also begun sitting up in bed and screaming in apparent fright. Maria, a twelve-year-old, jumped out of bed and ran around her room or thrashed frantically on the floor. David, seventeen, would suddenly leap out of bed after two or three hours and run around as if terrified, so wildly that he actually injured himself.
Despite the apparent differences in their behaviors at night, all of these children were experiencing variations of the same kind of event: incomplete wakings from deep, dreamless non-REM sleep. The characteristics and significance of such arousals vary with age and certain physiological, behavioral, habitual, and psychological factors. While sleep talking (like Marcy’s) is so common that it can hardly be considered abnormal or even a problem, the less common phenomenon of sleepwalking has always been seen as a disorder, worrisome to parents and fascinating to sleep specialists and poets. Sleep terrors—episodes like those exhibited by David—are perhaps the most dramatic of all sleep disorders; they are certainly the most frightening to family members who witness them. Most people know little about sleep terrors, even though they are fairly common. Less intense than sleep terrors, but even more common and often longer in duration, are confusional arousals, which take the form of periods of confused thrashing (like Noah’s) and can appear equally frightening.
We will return to these children and their stories at the end of the chapter—once we’ve explained the nature of partial wakings like theirs—and then discuss how each child was treated.
Parents often misinterpret these partial wakings, or “confusional events,” as bad dreams or even as epileptic seizures. In fact, not only are they unrelated to dreams and seizures (see Chapter 14 for more information on distinguishing confusional events from nightmares), but they are also quite different from full wakings and call for a different response from the parent, at least during the event itself. In a typical full waking, a child might ask for a pacifier or a back rub; if that behavior becomes a problem, the appropriate response is usually to set limits and teach the child new habits and expectations. By contrast, a child experiencing a confusional event is not truly awake or fully conscious of her actions. Firm parental responses during the event will be of no benefit: there is no point in enforcing limits on a child who is unaware that limits are being set. (If the child wakes fully afterward, then the confusional event is over, and parents may handle problems at this time as they would at any other nighttime waking.)
Thus, the causes and treatments of the sleep problems discussed in this chapter often differ from those involved with habits, associations, limits, and fears. Surprisingly, however, there is also sometimes a considerable overlap: what happens during a child’s full wakings may actually be responsible for some of her partial wakings, or the full and partial wakings may have similar causes, and in these cases they ultimately require similar treatments.
The Normal Transition from Deep (Stage IV)
Sleep Toward Waking
We know with certainty that episodes like those described in this chapter could not possibly occur during dreams. Because of the near-paralysis of REM sleep, you cannot sit up, thrash about, walk, scream, run around, or otherwise act out your dreams; instead you remain safely in bed. But in non-REM sleep you can move, and in fact you usually do, at least a little bit, especially during the transitions between sleep cycles. Ordinarily these movements are minor and brief, but even when they are more dramatic, violent, or extended, they are still examples of the same phenomenon. Thrashing, sleepwalking, and screaming are closely related to the quieter behaviors that occur normally at the end of a period of deep sleep—they are just more intense, complex, and long-lasting.
Stage IV is the deepest stage of sleep. In this state the body is on autopilot, with heart rate, respiration, and other functions controlled in a stable and regular manner. People wakened from Stage IV report no dreams and have little or no memory of ongoing thoughts. Generally it is difficult to wake someone from this stage, even with words (“Fire!” “Help!”) or noises (crying, crashes) that will produce a swift, powerful reaction in just about any other state. This is particularly true for children, who often can’t be wakened from Stage IV sleep even with vigorous stimulation. As we saw in Chapter 2, a child who has fallen deeply asleep in the car or at a neighbor’s house can often be carried back home, undressed, and put to bed with only a slight arousal and no memory of being moved.
As you will also recall from Chapter 2, sleep begins with a descent into Stage IV. This transition happens rapidly in children, more gradually in adults. At the end of the first sleep cycle, usually sixty to ninety minutes after falling asleep, the sleeper shifts to a lighter stage of sleep and perhaps even wakes briefly. In children, this arousal is usually followed quickly by another rapid descent into Stage IV sleep as the second sleep cycle begins (adults may have a brief and unremarkable dream first). The second sleep cycle ends much like the first, and the rest of the night is mostly spent alternating between lighter non-REM and REM sleep. Before waking for good in the morning, children often descend once more into Stage III or Stage IV sleep; although deep, this sleep is still easier to wake from than are the Stage IV periods earlier in the night.
The transition from deep Stage IV sleep back toward waking begins suddenly. Even when we observe a child in the laboratory, we see no indication that a change in state is about to occur. Suddenly and without warning, the child moves. She may turn over in bed, and often she will briefly open and close her eyes before descending again into deeper sleep and beginning the next sleep cycle. Typically she won’t wake completely, and if she does, the waking will be brief and the child will not become fully alert. During the transition out of deep sleep, the child’s brain waves show a mixture of patterns including some from deep sleep, some more specific to the transition toward waking itself, and even some from the drowsy and waking states.
Although the state transition starts suddenly, the full change from one state to the next takes time to complete, especially in children. During this transitional phase, a child is in a state of partial waking, somewhere between deep sleep and full waking, with some of the characteristics of both. Usually this phase is brief: the child wakes slightly, turns over, pulls up the blanket, and goes back to sleep with little or no awareness of waking or nearly waking. But sometimes it does not go so smoothly. She may begin to wake, then start to walk, thrash, scream, or run. It is these “confusional events” that parents so often find alarming.
More Intense Transitions:
A Spectrum of Confusional Events
Confusional events happen most frequently at the end of the first or second sleep cycle, between one and four hours after falling asleep. They always occur during a partial waking from non-REM sleep. Most of these episodes—certainly the more intense and long-lasting ones—arise from Stage IV, but mild episodes in young children can arise out of lighter sleep, even from Stage II, which is still fairly deep sleep throughout the toddler years.
In young children, up to age five or six, confusional events are so common that most are typically considered “developmental,” meaning that the events only reflect the normal maturation of a child’s sleep systems. Probably all toddlers at least occasionally have fairly intense episodes. It is hard to be sure how often these events occur because their characteristics are so varied, and because they probably often go unrecognized in children that young (particularly if the events are mild or brief, with only a few minutes of confused restlessness or perhaps a single momentary shout).
Although all the confusional events discussed here usually end with a quick return to sleep, they sometimes recur only a little while later. Several confusional events can follow in succession, separated by a mere few minutes of sleep, before calm, sustained sleep finally returns.
In a very mild period of confusion, a child may moan, mumble incomprehensibly, and move about restlessly for several minutes, as Marcy did each night. She may also lift her head, grind her teeth, and even sit up briefly and look around in a confused manner before returning to sleep. Most sleep talking occurs during this kind of mild partial non-REM arousal rather than during a dream.
If the arousal is a bit more intense (see Figure 14), there may be an episode of calm sleepwalking: your child may begin to crawl about the bed as if in search of something, or she may even get out of bed and walk around quietly. Although her eyes are open and she can make her way around the room or house, she has little actual awareness of the world about her. She may come to you, wherever you are, but she probably won’t seem to recognize you. She may stop and stare, but “through” you, not at you. She may seem to be looking for something, and she may mumble phrases that are difficult to understand. She may walk downstairs and even try to leave the house. If she is very calm, she may respond to simple questions (“Are you okay?”) with one-word answers. If you tell her to go back to bed she may comply on her own, or she may let you guide her back to bed. Once back in bed, younger children usually return to sleep without ever becoming completely awake. Older children and adolescents may become alert briefly—possibly to their embarrassment, if they find themselves in unexpected places with people staring at them—but they, too, usually return to sleep promptly.
If an older child’s partial arousal is still more pronounced, she may jump out of bed and hurry about the room or house. Perhaps she will feel along the wall for the doorway leading out of her bedroom, almost as if she can’t see. She may appear upset, confused, and disoriented, perhaps even frantic. She may yell alarming things, such as “No, no! Stop it,” but although she may seem very upset, she will not seem to be really terrified. During such episodes of agitated sleepwalking, your child is unlikely to respond to your questions. She will not recognize you, and if you try to hold her she will only become more upset and push you away. You won’t be able to wake her, but after a period of usually not more than forty minutes (typically between five and twenty minutes) she’ll calm down, wake briefly, and go back to bed on her own or let you lead her there. She will remember little or nothing of the episode, and she certainly won’t report having had a dream.
Toddlers and young children are unlikely to sleepwalk in this agitated way, but the more intense of their confusional arousals can seem even stranger and are often quite frightening for parents. If your child shows this kind of behavior, she may moan, then begin to cry, sob, or even scream. She may then thrash wildly around the bed with her eyes open and her heart pounding. These disturbances can continue as long as forty minutes, even an hour on rare occasions. The thrashing and rolling may be unlike anything you have ever seen her do during the day or in her other nighttime wakings. You might think at first that she is having (or has just awakened from) a bad dream, but she doesn’t calm down when you enter the room and she might even seem unaware that you’re there. She isn’t comforted when you try to hold her, and she may arch, twist, and push you away. If you try to wake her by shaking her or putting cold water on her face, the thrashing may only get worse. Many parents say that during these episodes their child seems “possessed,” because of her strange facial expression, wild thrashing, and unresponsiveness to their attempts to help. Some parents become so alarmed, perhaps believing their child is very sick or possibly having a seizure, that they rush their child to the hospital, only to have the episode end before they get there.
These episodes of screaming and thrashing are commonly referred to as “night terrors” or “sleep terrors” by families and some physicians. But since the child does not really appear terrified so much as agitated, confused, and upset during these episodes, the term “confusional arousal” is more appropriate. The label “sleep terrors” should be reserved for those even more intense events where the child appears and acts extremely frightened, as described below.
As the confusional arousal nears its end, your child will most likely stretch, yawn, and lie down again or let you tuck her back into bed. If she wakes more fully at this point, she will be perfectly calm and will just want to go back to sleep, which she will do quickly if you don’t insist on keeping her awake. She will have no memory of the episode, either then or when she wakes in the morning. If she does wake fully when the event ends, she will, of course, not remember dreaming. You may be upset, but she will be fine.
Infants at least as young as six months of age can experience similar partial wakings in the form of long periods of crying during which they cannot be comforted or calmed. These episodes don’t seem so strange to parents, partly because any thrashing is less intense than it would be in an older child, and partly because they are difficult to tell apart from the occasional periods of uncontrollable wakeful crying that are commonplace in infants. Many parents simply assume their baby has had a bad dream. It’s an easy mistake to make, especially if the child is too young to say otherwise.
An interesting variant sometimes seen in toddlers and school-age children resembles a temper tantrum. It is not, of course, a real tantrum (since those begin when a child is awake), and it may well occur even in children who are not prone to temper tantrums in the daytime. Once such an event is under way, however, it may be difficult to distinguish from a waking tantrum. Your child may stomp around angrily, seeming upset and confused, and run away from you. She may make demands, but she will seem unsure of what she wants; for instance, she might request an object and then throw it away as soon as you give it to her. These events last from ten to forty-five minutes before ending as peacefully as the other kinds of partial wakings.
The most pronounced confusional events, less common but more intense than those we’ve covered so far, are the aforementioned “sleep terrors.” These arousals occur most often in adolescents and preadolescents, although younger children can have episodes with many of the same features. Generally, a full sleep terror event, unlike a more typical confusional arousal, starts very suddenly without a gradual buildup. The child lets out a bloodcurdling scream and sits bolt upright in bed. She is sweating and her heart is racing, as in a confusional arousal, but in this case she looks truly terrified. She may yell phrases that suggest fear or danger: “It’s gonna get me!,” “Leave me alone!,” “Stop it!,” or, most commonly (as in confusional arousals), “No! No!” These episodes often end within one to five minutes, without the extended thrashing shown by younger children; afterward, the child wakes briefly and quickly returns to sleep. If she wakes fully, she is unlikely to remember anything frightening, although she might report a vague memory that may or may not fit the words she uttered during the episode itself. She might say, “Something was going to get me,” but she will not be able to describe the memory in any of the detail that you would expect if she had actually been dreaming.
SPECTRUM OF BEHAVIOR IN CHILDREN AT THE END OF A PERIOD OF STAGE IV SLEEP
Listed in order of increasing intensity*
Normal termination of Stage IV (brief body movements; perhaps eye opening, mumbling, chewing)
Calmly sitting up in bed, looking about, blank expression
Calm sleepwalking (semipurposeful; child may appear to be looking for something and/or may walk towards parents or light; actions may seem to be aimed at fulfilling a need such as hunger or the urge to urinate)
Agitated sleepwalking (confused, jumpy, and upset; child appears to be trying to get out of the room or away from something)
Confusional arousal (extended period of confused wild thrashing, moaning, yelling, kicking, screaming; may be prolonged, child may act bizarrely or seem “possessed”)
Sleep terror (screaming with appearance of fear or panic; child may leap out of bed and run wildly, as if away from something; increased chance of accidental injury)
In the most extreme sleep terrors, which are fortunately quite rare, a child may jump out of bed and run wildly, as if trying to get away from someone or something. She appears to be in a real panic. She may knock over furniture or even people, break lamps or windows, or fall and injure herself. This phase usually lasts less than a minute, though the child may remain confused for some minutes longer.
What a Confusional Event Feels Like
When you watch a confusional event unfold, you are seeing the simultaneous functioning of your child’s waking and sleep systems. The waking system is trying to activate, and the sleep system does not “want” to yield control. Both processes are going on at the same time, so the child shows elements both of being awake and of being asleep at the same time.
This phenomenon is not really as strange as it may seem at first. Consider a similar event in a more familiar context: suppose that an hour after you fall asleep you are awakened by a loud crash. You “wake up” instantly, your heart racing, but for a few seconds you will still be partially asleep and not thinking clearly, unable to figure out what’s happening or whether you need to do anything. The feeling of those first few seconds, in which you are agitated but still confused and not fully alert, is probably more or less what children experience during a confusional arousal or sleep terror. (However, you will be closer to full waking than your child is during a real confusional event, so there are differences: you might be genuinely frightened; your behavior, while possibly comical, won’t be truly bizarre; and you will probably remember the episode in the morning.)
To take a milder example, suppose you set an alarm to wake you in the middle of the night to give your child medicine. When the alarm goes off, you get up and automatically walk into the bathroom, but instead of getting the medicine, you use the toilet, start to return to your bedroom, and then stop, vaguely aware that there’s something else you’re supposed to be doing. If somebody were watching you at this point, they would see you look about with a blank or dazed expression, unsure what you are looking for, where to look, or why you are even out of bed in the first place. This experience is probably similar to what a child experiences during a quiet sleepwalking episode.
Adults don’t ordinarily have true confusional events, largely because their Stage IV sleep is lighter than a child’s, so they wake more easily in the middle of the night. But in each of these examples, if it was more difficult than normal for you to wake up—perhaps because you hadn’t slept the night before, or because you had taken a sleeping pill or had some alcohol before bed—the loud noise could conceivably trigger a full confusional event: that is, you might behave especially bizarrely and might not remember the event in the morning.
Why Confusional Events Happen:
The Balance Between Sleep and Waking
Given the confused and often upset appearance of a child during a confusional event, it would be easy to assume that scary thoughts of some sort were the cause. In fact, some theories, particularly from the older psychoanalytic literature, maintain that the initial cause of confusional events is a frightening idea, urge, or image that suddenly intrudes into “consciousness” during the deep sleep state, when the child’s emotional defenses are down, and that the thought triggers the arousal. These theories broadly explain the appearance of a sleep terror, but they have some serious weaknesses. They do not explain how such thoughts can appear in nondreaming sleep. They do not explain why a sleep terror can be triggered by a common, unthreatening sound or why most confusional events are mild and have no appearance of terror. They do not explain why spontaneous confusional events arise near the end of a deep sleep phase, rather than in the middle. And, most important, they do not explain why (unlike after a nightmare) the child has no terrifying memory upon awakening fully, only a desire to go back to sleep. (Supporters of these theories may argue that there was a momentarily frightening thought at the onset, but one that then was immediately forgotten. However, evidence based on studies of sleep terrors induced by external stimuli suggests that this possibility is extremely unlikely.)
Actually, all the characteristics of confusional events can be more easily explained if they are viewed as primarily physiological events that just produce the physical appearance of agitation, and (sometimes) even of terror, without any preceding or accompanying scary thoughts. The physiological changes that create this appearance of upset (increased heart rate and blood pressure, bulging eyes, perhaps even screaming) are responses to activity generated deep in the nervous system, without any conscious emotion or thought being involved. That explains why in less intense confusional events such as calm sleepwalking there is often no appearance of fear at all. It also explains why confusional events typically occur when the first or second sleep cycle is coming to an end (when an arousal is due anyway), why the child doesn’t remember any clear thoughts when she finally wakes, and why she no longer seems afraid or upset as the event ends, the transition toward waking is completed, and bodily functions return to normal.
To understand why confusional events occur at all, the most important thing to remember is that partial wakings are a normal, inherent part of the way our sleep systems function. Everyone has these partial arousals several times every night—specifically, periods of semiwaking confusion that occur at the end of each cycle of deep non-REM sleep—though ordinarily they consist only of brief movements without vocalizations. Confusional events occur when these partial wakings don’t go smoothly. Even the most dramatic episodes are only exaggerations of normal behavior.
As you remember from Chapter 9, the main factors controlling sleepiness and alertness are homeostatic (based on how long you’ve been awake or asleep) and circadian (based on the current time and the setting of your biological clock). These factors can be strengthened, weakened, or otherwise modulated by other important biological factors as well as by various environmental and psychological ones. Understanding how these factors interact is key to understanding why confusional events, rather than normal partial wakings, sometimes occur.
What a child does when waking from sleep is determined by the activity of her sleep and wake systems at that time. Partly, that depends on what kind of sleep she is waking from—deep or light, REM or non-REM. It also depends on the relative strengths of her drive to sleep and her drive to wake: that is, how sleepy she is at the time of the arousal, how strong the arousal signals are (whether generated internally or externally), and how urgently she feels she must wake.
It may seem strange to talk about a child’s drive to sleep or how “sleepy” she is when she’s already asleep, but in fact the drive to sleep waxes and wanes during sleep just as it does during the waking hours. During the day this drive affects how easily you can fall asleep; at night, it affects how hard it would be to wake you up. While you sleep, the strength of this drive depends on several things: how long you were awake before bed, how long you have been asleep, how well you have been sleeping, how sleep deprived you are, what drugs or medication you have taken, and where your biological clock is in its daily cycle. The drive is particularly strong early in the night, after you have been up all day and before you have had a chance to sleep very long.
While you sleep, there are also forces that push you toward waking up, which I refer to collectively as the “drive to wake.” This drive can be strong or weak at different times, depending on (again) where your biological clock is in its cycle, as well as on levels of external stimulation and psychological factors. In the morning and at the end of each sleep cycle, internal signals from your biological clock strengthen the drive to wake. External stimulation (an alarm clock or someone shaking you, for example) also strengthens the drive to wake, and the more intense the stimulation is (the louder the alarm clock, or the more vigorous the shaking), the greater its effect. The meaning you give to the stimulus makes a difference: a cry of “Fire!” will probably affect you more strongly than “It’s your turn to feed the baby.” The drive to wake also increases if you have some important reason to wake up—to check on your child in the middle of the night, say, or to get to work on time in the morning.
When there is a proper balance among the forces controlling sleep and waking, you will sleep well at night, move smoothly from one sleep cycle to the next, wake easily in the morning, and generally be alert during the day. During deep (Stage IV) sleep early in the night, your drive to sleep should be strong and your drive to wake should be weak, so that your sleep will be uninterrupted. Toward morning, when your sleep is lighter, the drive to sleep should be weaker and the drive to wake should be stronger, making it easy for you to wake up. But if the balance is not as it should be—if one of these drives is strong when it should be weak, or weak when it should be strong, or if your sleep is light when it should be deep, or deep when it should be light—you can be left awake and unable to sleep soundly (insomnia) or asleep and unable to wake fully. The latter is, as we will see, the condition in which confusional events occur: that is, when a child is strongly driven to stay asleep and to wake up at the same time.
At the end of a cycle of light sleep (Stage II, or REM), it’s relatively easy for a child to wake up, so confusional events at these times are unlikely. But consider what happens at the natural arousal that follows a cycle of deep (Stage IV) sleep. Since these cycles tend to come early in the night when the child hasn’t been asleep for very long yet, her drive to sleep will be strong. If her drive to wake is weak at that moment, as it should be, she will move quietly into the next sleep cycle, stirring, perhaps, but hardly waking, and all will be well. But if the drive to wake is strong for some reason, then her waking and sleeping systems will fight for control: she will struggle to emerge from sleep but won’t be able to wake completely. The same thing can happen if something disturbs her in the middle of a deep sleep cycle. In either case, confusional events become much more likely.
Understanding how these forces work is the key to finding the causes of a child’s confusional events: we look for things that affect the depth of her sleep, her need or drive to sleep, and her drive to wake up. When a child receives a signal to wake up—typically the internal signal that comes at the end of a sleep cycle, but possibly an external one, such as a noise or someone touching her—then anything that deepens her sleep or strengthens her drive to sleep will make it harder for her to wake fully, increasing the chances of a confusional event. Similarly, when her sleep is deep and her drive to sleep is strong, anything that strengthens her drive to wake will also make confusional events more likely.
A variety of factors influence the depth of sleep and the drives to stay asleep and wake. Some of them can affect both drives, even simultaneously. Let’s look each of these factors in turn.
Factors That Make Sleep Deeper and
Strengthen the Drive to Stay Asleep
The fact that young children naturally sleep very deeply explains why confusional events are so common among them. Their Stage IV non-REM sleep is deeper than that of older children, and much deeper than that of adults. For that reason alone, even when the normal internal mechanisms that trigger an arousal at the end of a cycle of deep sleep are strong, they sometimes fail to entirely break the grip of the sleep state, leaving the child half asleep and half awake.
Being Overtired or Behind in Sleep
In a young child who experiences confusional arousals only occasionally, the best predictor of such episodes is whether the child is overtired, and, if so, how badly. The cause could be an early waking, a missed nap, or a late bedtime; increased daytime activity and inappropriate schedules can lead to overtiredness, too. When young children are overtired, their sleep drive, already strong at the start of the night, is strengthened further: sleep is less “willing” to give way to wakefulness, and wakefulness less able to wrest control back from sleep.
Factors That Strengthen the Drive to Wake
A Job to Do
Ordinarily, when we wake slightly between sleep cycles, there is no reason for us to wake up all the way or for any length of time. We need only get back into a comfortable position, adjust the pillow and blanket, and return to sleep. But if there’s anything else we need to do first—such as check the environment for unwanted changes, reestablish the conditions we associate with falling asleep, or get control of our thoughts and emotions—we may have to wake completely to take care of it; thus the drive to wake is strengthened, and confusional events become more likely. Children are particularly prone to this problem.
This concept, of having a “job” to do causing an increased effort to wake, is so important in understanding and treating confusional events in children that we will return to it in more detail shortly.
Noises, lights, and other kinds of sensory stimulation can easily strengthen the drive to wake, since they signal a change in the environment that might warrant investigation. If they disturb a child during or at the end of a period of Stage IV sleep, the additional drive to wake up can lead to a confusional event—in the laboratory, a loud buzzer set off an hour after sleep begins can trigger a sleep terror in susceptible children. Lower levels of stimulation can have the same effect at home: your child may sit up and scream when you make noise climbing the stairs, for instance, or if you cover her with a blanket near the end of her cycle of deep sleep. Even children who don’t ordinarily sleepwalk often can be induced to do so at the end of a Stage IV period simply by lifting them up and setting them on their feet.
Factors That Can Strengthen Either Drive
Inconsistent and Chaotic Sleep/Wake Schedules
The drives to stay asleep and to wake are controlled in large part by our biological rhythms (see Chapter 9). When we travel, jet lag can cause our bodies to get confused: these rhythms are no longer rising and falling together at predictable times, and the relative timing of the sleep and wake drives may be affected. As a result, our bodies get mixed messages from different physiological systems, some saying to wake and others saying to sleep.
The same thing can happen to a child on a variable schedule. As a cause of partial wakings at night, this phenomenon is particularly important in young children. Day-to-day changes in bedtimes, waking times, or the number or timing of naps can throw a child’s underlying biological rhythms out of sync. Her drive to wake may be increased at a time when she should be sleeping, or her drive to sleep may be increased when she should be awake. Thus, for example, the internal signal to wake and end the night’s first sleep cycle may come before that cycle is really done—while the drive to sleep is still very strong—and a confusional event becomes more likely.
Sleep Disruption, Illness, and Medication
Illness and medication affect the waking and sleeping drives in complex ways. Many illnesses, and the side effects of some medications, directly affect the body in ways that increase sleepiness. On the other hand, the side effects of other medications stimulate the drive to wake up, and some illnesses and sleep disorders (like sleep apnea) do the same, either directly or by causing pain or discomfort that wakes the child. (For instance, a sick child may wake at night because of throat pain or a dry mouth.) This extra tendency toward waking leaves a child’s sleep disrupted, broken, or fragmented, and that loss of sleep in turn increases her drive to sleep as well. Not surprisingly, some children experience confusional events only when running a fever, when sick (with or without a fever), or when taking medication that affects sleep or the ability to wake.
Other Causes of Confusional Events
Some children who experience confusional events at night have close relatives with a similar history. We do not know what traits these children inherited; it may be that family members simply tend to sleep more deeply than most, or that they have a stronger inherent biological drive to wake between sleep cycles. In some children, inherited characteristics by themselves appear to account completely for the confusional events. In others, they may only be predisposing factors. These characteristics might explain why only some children with jobs to do during the night walk, thrash, talk, or yell in their sleep. Genetic factors may also partially determine the specific type of arousals shown by a child—that is, where on the spectrum of intensity they occur, from sleep talking to terrors.
Other Biological Factors
In a small group of children, frequent arousal events persist at night even after we have dealt with all identifiable causes. In some of these youngsters non-REM sleep is continually broken by small arousals that are identifiable only with special monitoring, like that done during an overnight study in a sleep laboratory. (You would not see them just by watching your child sleep at home.) These children’s sleep patterns seem to be inherently unstable, although we do not yet know the biological factors responsible. Although their nighttime arousals may be resistant to behavioral treatments, they still usually respond well to medication.
The Significance of Having a Job to Do at Night
The problems facing a child with a “job” to do at night should be largely familiar to you from the chapters on associations, feedings, limits, and fears. For example, if a child starting to wake after a sleep cycle finds that the conditions associated with falling asleep have changed, or she has learned that they frequently do, she will try to wake fully to check and, if necessary, to try to get the previous conditions reestablished. She may find she is in a different room, that her parents are no longer sitting on her bed, that the rocking has stopped or the pacifier fallen out, or that it is time for her to change to another bed. If she starts to wake during the night at a time when she is used to eating, she will try to wake fully to ask to be fed. If she spends an hour testing limits by repeatedly calling and coming out of her room before she falls asleep, she will pick up where she left off and start doing the same thing when she starts to wake.
In each of these scenarios, the child has a job of some kind to do—some situation that requires her full attention—and she must wake up to do it. She can’t simply slide into the next sleep cycle after a brief brush with the waking state, as she should. You may well have experienced this kind of thing yourself: if you have to get up early but your alarm clock is broken, for instance, you may find that you awaken completely several times during the night to check the time, whereas ordinarily you would just stir slightly and go right back to sleep. Having jobs to do during the night is not good for sleep. They greatly strengthen a child’s drive to wake and, as we’ve seen, that may lead to confusional events.
Consider a child who will only go to sleep at bedtime if her father is sitting in the room. Instead of falling asleep quickly, she keeps checking to be sure he is still there and to go and find him if he isn’t. Suppose she wakes every night at two in the morning, checks for her father, and, finding him gone, goes after him; then she gets into her parents’ bed, where she sleeps the rest of the night. She can switch rooms without trouble because at that hour she is waking from fairly light sleep.
Now suppose that one night she tries to do the same thing when she starts to wake at the end of her first sleep cycle, at eleven o’clock, after only two hours of sleep. The pattern of room switching may have become so automatic that she tries to leave her bed and head for her parents’ room before she is fully awake. Her habitual response is to try to become more alert and switch rooms—that is, her drive to wake is strong. But at this time of night her sleep is very deep, much deeper than at her usual two o’clock waking. It may be so deep that she cannot wake fully enough even to realize why she is struggling to get up. The conflict between her waking and sleeping systems produces a partial arousal, a confusional event.
Exactly what she does may depend upon the strength of the sleep system when she tries to wake. If she is almost able to wake, she may still get to her parents’ room, but now by walking in her sleep. It may be even be hard to tell if she is asleep but almost awake, or awake but almost asleep (although this distinction is probably meaningless anyway, since in both cases sleep and wake systems are active simultaneously). If the balance is closer to sleep, she may remain in bed but cry and thrash about; or, she may be able to get out of bed and sleepwalk, but in an upset or very confused manner, heading off in the wrong direction. She is too asleep to know why she is trying to get up. If she did not have this job to do during the night, she would simply slide back into sleep and the confusional event would not happen.
As this example illustrates, confusional events commonly occur only at a child’s first or second waking at night; later in the night she will be waking from lighter sleep, so those wakings are likely to be more complete. However, patterns and habits learned at these later, fuller wakings, like this girl’s need to check for her father, or another child’s habit of calling to have her back rubbed, are often behind the confusional arousals that occur earlier in the night, especially in toddlers and young children of school age. In these situations, a single problem (that of improper behavior patterns and habits) shows up in different ways at different times of night: as full wakings with specific requests or demands in the middle and end of the night, and as confusional events early on.
At the end of a confusional event triggered in this way, the child’s job remains undone, so it is not uncommon for both types of behavior to appear in a single waking. The waking starts as a confusional event—recognizable because the child’s thrashing about seems to have no purpose, and because she doesn’t respond well to attempts to help—but when she wakes at the end of the episode, she does not go right back to sleep, as most children do after even intense events. Instead, because she still has the job to do, she may force herself into fuller alertness. From that point forward she is completely awake, and her behavior may now clearly reflect learned habits and associations of the kind discussed in earlier chapters.
The specific jobs a child can have to do at night vary with age and with factors such as sleeping arrangements, patterns of parental response, recent events, and current concerns. School-age children typically have different jobs to do than do toddlers. An eight-year-old child who is trying not to wet the bed may have a strong impulse to wake fully, get up, and use the bathroom each time she stirs. And a ten-year-old girl who frequently hears her parents fighting at night may feel the need to wake and listen to be sure they are okay. Also, an older child who is frequently carried to bed after falling asleep in the living room may need to check which room she is in each time she starts to wake—in the same way that a toddler often must do.
Once a behavior pattern of this sort has been established, it can persist out of habit in sleep even after it ceases to serve a purpose and is no longer reinforced by full waking behavior. A child who no longer moves to her parents’ room at night when she is fully awake may still walk there (or elsewhere) in her sleep, effectively on autopilot. In a sense, this habit still functions as a job to do, even though the job no longer really needs doing—she just can’t wake fully enough to remember that.
During middle childhood and into adolescence, children may develop another type of job to do at night, that of controlling their own urges and thoughts. Many people find it easy to keep unpleasant feelings in check during the day, when they are wide awake and fully alert, but not so easy when they are asleep and dreaming, drowsy and daydreaming, or just waking up. As you wake from deep sleep, you are not in full control of your thoughts and behavior. If, for any reason, it is important to you to regain control quickly, then you may try to become fully alert as soon as possible. As we have seen, that struggle can, at least in a child, be enough to trigger a confusional event.
For example, some children keep their behavior carefully controlled during the day. When such well-behaved children start to wake at night, they may instinctively work to regain the self-control they gave up during sleep. This task requires the child’s attention and effectively strengthens the drive to wake, which, in turn, also makes partial arousal events more likely.
(Such well-controlled children are typically pleasant to be with and easy for a teacher to have in class. This tendency toward control is often just a personality style, but it can become a problem if carried to excess. Some children, for example, choose to keep any feelings they might consider negative, such as anger, jealousy, and guilt, inside and unexpressed. Others do so only in class, but feel freer to show their emotions at home. Most children put extra checks on their behavior at the start of a school year, particularly if they have a new teacher; probably for this reason, confusional events are especially common in September and October. Interestingly, whereas school-age children who frequently sleepwalk or have confusional arousals tend to be the well-behaved type, children with frequent nightmares are more likely to be ones who act out their feelings and have trouble controlling their behavior during the day.)
Anxieties and other concerns may also be associated with a need for control and an attempt to wake fully during the night. If you go to sleep after lying awake for a long time troubled by anxieties, for example, you may wake fully and start worrying again whenever you stir at night, instead of just turning over and returning to sleep. Similarly, if an anxious child lies in bed frightened for a long time at bedtime, struggling to avoid certain thoughts or behaviors as she goes to sleep, she may try to wake fully enough to get the same control over those thoughts and actions whenever she stirs during the night. If this occurs on waking from deep sleep, then, despite her efforts, she may be unable to wake fully.
Children may also find themselves reacting to situations outside of their control: a move to a new neighborhood, a transfer to a new school, or especially a personal loss such as a divorce, separation, or death in the family. Even an intact family can lack warmth, love, and nurturance: parents may be rigid, demanding, and uncompromising, setting unrealistically high expectations for their child’s behavior, school performance, and athletic success. Older children in such situations are often angry, but, unlike most toddlers, they may choose to keep their anger locked up, probably in the belief that expressing their feelings would only lead to more unpleasantness. A child may blame herself for her parents’ separation or for other family problems, and she may carefully avoid giving her parents any reason for displeasure. Such a child is likely to act extremely pleasant and well behaved—if anything, too well behaved. Occasionally her anger will show in passive ways that seem safer to her: she may stay in her room after school and keep silent at mealtimes, or she may not do as well in school as she could. She expends enormous quantities of energy during the day guarding her emotions and keeping them in check. But at night, in sleep, these defenses must be relaxed. Whenever she starts to wake, she senses this loss of control and tries to wake more fully to get it back. This job can easily be enough to cause a confusional event.
To get a better idea of how a child’s emotional state at bedtime can alter her reaction to a normal partial arousal, and turn a routine end-of-sleep-cycle waking into a confusional event, think about how your own state of mind can affect your reaction to a stimulus while you’re awake. Imagine that you are nervously walking through an old cemetery alone on a dark night, when suddenly you hear a twig snap. You will probably jump or cry out in fear—you might even run away without ever learning whether there was really anything to be afraid of. If you heard the same twig break at home in the light of day, it might not startle you at all. But alone in the cemetery, you are already jumpy and on your guard: your state of mind determined your response to the noise.
The analogy isn’t perfect, because in this example you are awake and (relatively) clearheaded. But the same idea applies during sleep. If a twig breaks outside your window while you’re comfortably asleep in your own bed, you probably won’t be aware of it, and if it wakes you at all, you will not consider the noise important and you’ll immediately return to sleep. But if for some reason you were sleeping in that cemetery, or on a battlefield where an attack could come at any time, the same sound of a snapping twig might awaken you instantly in a panic. Confused and terrified, you might jump up and even cry out (as a child having a sleep terror does). But it’s not the noise of the twig that made you scream, or even finding yourself in the cemetery or on the battlefield, since you reacted before you had a chance to see or remember where you were. Rather, it was the anxieties that you went to sleep with in the first place that gave the snapping twig significance and caused you to have an increased need to wake to check to see that you were still safe. Going to sleep in the cemetery or on the battlefield, you knew you were letting down your guard in threatening surroundings, and as a result your drive to wake, and thus your response to the noise, is much greater. Your psychological state at the time of falling asleep made the difference.
The causes of calm sleepwalking are similar to those of sleep terrors, but the need to wake may not be so urgent. Think of going to sleep with the window open on a night when thunderstorms are predicted. If a storm starts, the sounds of thunder and rain—which ordinarily would barely interrupt your sleep—will trigger a strong impulse to wake up, but only because you knew the window was open. If you are deeply asleep at that moment, you won’t be able to wake fully right away, and you may be too confused at first to remember what exactly you needed to do. For a short while, wandering about befuddled and unsure why you are up, you will be feeling something much like what your child feels when she walks in her sleep.
The same phenomenon is true for children. Any child who goes to bed at night knowing she will have to try to wake later because she has a “job” to do, whether to check for change or danger or to complete a simple habit or task, may be prone to sleepwalking, confusional arousals, and sleep terrors. The solution for these children is (if possible) to take away the jobs that are driving these children to wake up and to help them learn to relax their guard when they go to sleep so that they can take normal nighttime arousals in stride. We will return to this idea later in this chapter when we consider treatment methods.
The Variability of Arousals over Time
The intensity of confusional events can be mild (restlessness, sleep talking, mumbling), moderate (thrashing in bed, sleepwalking, yelling), or severe (wild screaming, appearance of panic or marked agitation, running). They can be very brief in duration (several minutes at most), short (five to twenty minutes), or long (up to an hour), and they can occur only occasionally (no more than once every few weeks), commonly (up to once a week), or frequently (several times per week, even nightly).
A child’s nighttime arousals may differ from night to night, month to month, or year to year. They may progress in either direction along the continuum ranging from quiet arousals to major sleep terrors (Figure 14), becoming either more or less severe. But day-to-day changes in a child’s life can be subtle and difficult to recognize, and the occurrence and intensity of arousals may change from night to night without any apparent changes in the child’s daytime activities or stresses; in fact, symptoms usually wax and wane over weeks and months without any evident psychological or physiological reasons. Therefore, it’s not easy to predict on which nights a child’s confusional events will occur based only on knowledge of what is currently happening in her life, even when that includes major events such as an upcoming examination, an operation, a soccer game, or a separation from the family. (The main exception is that confusional events are much more common in toddlers when they are overtired.)
It’s also possible for daytime changes to affect the pattern of confusional arousals in unexpected ways. For example, if your child’s partial arousals are caused in part by a need to keep her thoughts and behavior tightly controlled, then an apparent change for the worse in her daytime behavior may actually be associated with a reduction in the frequency of these nighttime arousals. Because she is allowing herself to express more of her feelings in the daytime, even if inappropriately, she might feel less of a need to guard against them at night.
Evaluating Confusional Events:
When to Take Action
In deciding how significant your child’s partial wakings are and whether you should do anything about them, there are several factors to think about: your child’s age; the frequency, length, and intensity of the episodes; the extent to which they disrupt other family members’ sleep, including yours; what social consequences they may have (at camp or sleepovers, for example); the risk of injury; any identifiable triggers (such as being overtired or starting a new school year); and any self-imposed or external psychological stressors. As you evaluate your child’s symptoms, consider the possible causes described in this chapter, but remember that you may well be unable to find a good explanation for any particular episode.
Without any treatment, the typical confusional arousals of a toddler will usually be outgrown by age five or six. Emotional factors are rarely the cause during these early years, but if they seem to be—for example, if the episodes’ onset coincides with a significant event such as a divorce, a death in the family, or a family member’s hospitalization—then you may want to consider professional consultation. However, other causes of partial wakings are more common at these ages (jobs to do at night, a regular schedule becoming irregular, being overtired), and these are most often straightforward to treat. When partial waking episodes begin in or persist into middle childhood or adolescence, their significance, causes, and course may be different. For example, psychological style and other emotional factors are more likely to be relevant in an older child, especially if the partial waking events are frequent. Partial wakings with these causes usually can also be treated successfully; but, if left untreated, it’s impossible to say when they will stop.
Events that are mild and brief are probably of little importance, even if they happen frequently, and they generally need no treatment. Even moderately intense events, regardless of whether they are short or long lasting, are probably unimportant if they occur only occasionally. But moderately intense events that happen more frequently should be considered significant enough to at least consider treatment. So should more severe events, even if they happen only occasionally. You should also consider treating any events an older child finds embarrassing, particularly if social decisions—such as attending sleepovers and camp—are affected. Keep the context in mind: if confusional episodes happen only when your child is overtired or febrile, they are probably of little concern, especially if the child is young and the episodes are relatively mild. In older children, episodes that happen only at times of temporary anxiety, such as exams or the start of the school year, should probably not worry you either.
If the problem does appear to require treatment and you cannot solve it yourself, you should consult your doctor. You should probably also discuss with your doctor any events that are extremely frequent, very long lasting, or very intense, especially if they pose any danger to your child or other family members. Don’t hesitate to contact your doctor even if you are simply feeling uncertain or worried about what is happening.
In very rare cases, medical or neurological problems may be involved: for example, pain from heartburn or ear disease may be triggering the events, or seizures may be causing them or being mistaken for them. Be particularly suspicious and always seek medical advice if your child’s episodes are significantly different in character from those described in this chapter—for example, if they occur near morning instead of closer to bedtime; if the episodes are always exactly the same; if your child wakes fully just before the beginning of the episode, rather than only at the end, and knows that something unpleasant is about to occur; if she clearly remembers the entire event or its beginning; if her body stiffens and consistently takes on an asymmetrical posture (such as with her left arm extended and her head turned to the left); or if her body jerks prominently and repetitively during the episodes.
Keep in mind that most normal toddlers occasionally have confusional arousals of varying intensity. It is not known how many children have extended thrashing spells, sleepwalking, and full sleep terrors, but at least 15 percent of all children sleepwalk at least once, and extended confusional arousals probably occur in far more children than that. Of course, the number of these children whose episodes are very frequent and intense is smaller, but occasional wild sleep terrors—where the child runs about in apparent panic—are by no means rare.
If your child is a toddler, you may want to see if you can eliminate her confusional events using the methods described below, even if the events are not particularly troublesome or worrisome; it is often easy to identify and treat the causes in toddlers. With older children, you need to consider psychological factors as well as the actual symptoms in deciding whether or not to seek treatment, but take care not to be too quick to ascribe a serious psychological significance to your child’s particular nighttime partial arousals. In a happy, socially active, academically successful youngster, the episodes may only reflect the child’s style of controlled behavior and thought, which is not necessarily a sign of trouble. If nothing else points to an ongoing problem, there is probably no need to seek psychological counseling. The best guide is to assess your child’s psychological well-being in the daytime. If she is having emotional problems in general, she may benefit from psychological help, and if she is also sleepwalking or having sleep terrors at night, it may help with those too. Bear in mind, however, that significant progress in psychotherapy may not produce an immediate improvement at night. Don’t judge therapeutic success by, say, how far your child walks in her sleep at night.
As you judge your child’s emotional condition, don’t place too much weight on things she says while sleep talking or during other confusional events. The things children say during agitated partial arousals—most commonly “No, no!”—are automatic vocalizations triggered in low-level areas of the brain, not in the areas that control waking thought. Don’t let them worry you: they do not reflect subconscious or deep-seated fears or urges. You can even ignore violent or alarming speech (such as “Kill him!” or “I want to die”), if she is mostly asleep when she says such things. Do, however, pay attention to what she says when awake. If she is truly depressed, anxious, or suffering from another emotional disturbance, it will show in her waking life, not just when she’s in a semiwaking confused state.
Because often neither parents nor children discuss these sleep episodes with friends, they are likely to think of the episodes (and the child herself) as strange or abnormal. You should recognize by now that these behaviors are, in fact, common, and that, even without help, preschoolers, at least, will probably outgrow them on their own.
What You Should Do and
What Else to Consider
Most treatment approaches used with young children are not only benign in themselves but also good sleep hygiene practices in general. Applying them is a good idea even if they don’t entirely solve the problem of partial wakings
As you begin to determine what to do about your child’s partial arousals, first try to identify any factors that make it harder for her to wake out of deep sleep or that make a full waking more urgent. Then eliminate these factors, if possible, or at least minimize them. Having done that, you will probably find that the arousals disappear or at least become milder, shorter, and less frequent. Even if they continue, you have at least prepared the way for other techniques.
Depending upon your youngster’s age and the details of her problem, you will likely need to use one or more of the following approaches. Specific techniques for dealing with many of these individual issues are also discussed in depth in other chapters.
Ensure Adequate Sleep
As we saw earlier, an overtired child will have more, not fewer, partial arousals, because her increased need for deep sleep interferes with her ability to wake at the end of the first or second sleep cycle. For youngsters up to about age six, and sometimes older children as well, simply ensuring that the child gets enough sleep at night may be the only intervention needed. For children younger than three and a half or four years of age, continuing regular naps may be similarly important.
Keep to a Regular Schedule
Try to keep bedtimes and nap times consistent and predictable. That will allow your child’s biological rhythms to stabilize and work in harmony so that the arousals at the end of the first and second sleep cycles will be timed appropriately, when deep sleep is “ready” to give way to a lighter state.
Eliminate Nighttime Jobs and Habits
Your child should have no need to wake fully between sleep cycles before going back to sleep. She should not have to call for something (to be rocked, have her back rubbed, or get fed), look for something (a parent or a pacifier), or check on her surroundings (to determine what room she is in, for instance). She should not have to get out of bed (to switch rooms, change beds, walk around, or check that you are home). Methods to accomplish these changes are discussed in Chapters 4 through 7.
Provide a Pleasant Structured Bedtime; Avoid Bedtime Activities That Your Child May Try to Resume on Waking
When we wake during the night, we tend to feel and act as if it were still bedtime. If your child is occupied by any tasks at bedtime other than falling asleep, she may try to continue these activities as soon as she begins to wake up. Thus, it’s important that bedtime be a happy time without demands and struggles. A child should not start the night by fighting to stay awake or testing limits; nor should she have to check that you are still rocking her and have not put her in bed or left the room. Otherwise, she will have an increased drive to wake up during the night.
Set an Appropriate Bedtime, Late Enough for Your Child to Fall Asleep Quickly
Setting bedtime at an appropriate time is important for the same reason. If a child has too much time to think, worry, or make demands before she falls asleep, then when she starts to wake she may try to continue where she left off. If your initially chosen bedtime turns out to be too late, and you always have to wake her in the morning, you can gradually move the bedtime earlier as long as she continues to fall asleep quickly.
Make Any Necessary Changes to Keep Your Child Safe
Children moving around at night may not be fully aware of their surroundings. Most negotiate stairways without trouble, but if your child sleepwalks, don’t leave anything on the floor or stairs that she could slip on. If your child is young, you may need to install a gate at the top of the stairs, in the hall, or in her bedroom doorway. If she sleeps in a bunk bed, put her in the lower bunk. If she tries to leave the house while sleepwalking, put an extra chain lock high up on the outside doors. If necessary, you can buy inexpensive alarms to alert you if doors are opened during the night. If your child walks to places other than your bedroom, you may want to attach a bell to her bedroom door or gate to notify you that she is up. Even a child who is old enough to open a gate by herself may benefit from one, if she wants to stop sleepwalking: in order to open the gate she has to stop and wake more fully, giving her a chance to realize what she is doing and to return to bed. Occasionally you might have to lock windows, and in extreme cases glass windows can be replaced with plastic.
Other Treatments to Consider
Try Relaxation Exercises
Progressive relaxation exercises have been used successfully by some children seven years and older. Books on these techniques are readily available. In bed, before going to sleep, children practice relaxing the different regions of their body one part after the other. Concentrating on relaxation rather than on active behavior at bedtime may diminish a child’s drive to wake fully during nighttime arousals since, again, at nighttime wakings people tend to pick up what they were doing when they fell asleep. This practice will help her get right back to sleep instead of trying to wake up completely during the night.
Consider Counseling for Emotional Issues
A decision about counseling should be based on several factors. As explained above, it’s important to base your assessment mostly on the child’s behavior during the day. Even frequent arousal events do not necessarily mean a child needs psychotherapy, but keep an open mind. If you are unsure, consultation with a mental health professional may help you decide.
Bear in mind, too, that therapy is a means to identify and treat certain psychological problems, not a specific treatment for arousal events. Improvement in sleep often follows progress in therapy very slowly. It may take your child some time to learn new ways of dealing with difficult feelings so that she can go to bed without worrying about relaxing her emotional defenses in sleep.
Try Medication if Necessary
Partial arousals in school-age children and adolescents are usually easy to control with medication. Its effect in younger children is less predictable. A small bedtime dose of clonazepam (Klonopin), a drug similar to diazepam (Valium), often works quite well, as do other related agents. If a small dose decreases the frequency and intensity of episodes, a slightly higher dose will probably eliminate them. However, nightly use of such agents in young children is generally not warranted. Even though the dose required is usually small, and thus the side effects are usually mild to nonexistent, I typically recommend medication for children only if they seem at risk of injuring themselves (unlikely in younger children) or if their partial arousals are particularly frequent, long-lasting, intense, and disruptive, and only if other treatment measures were unsuccessful. Sometimes, once we have determined a dose that works satisfactorily, the child reserves its use for sleepovers, travel, and camp. A few children must use medication nightly for several years.
It is not known just why this class of drugs is so effective, but they suppress physiological changes that usually accompany arousal (such as increases in heart rate and blood pressure), and they likely reduce the cognitive drive to wake as well by making a child less anxious or concerned about any job to do. Medication treats the symptom of partial wakings, but it usually does not cure the underlying problem, if there is one. However, occasionally a treatment course of several weeks seems to interrupt a pattern and the events do not restart when the drug is stopped.
What to Do During an Event
Let Arousal Episodes Run Their Course
Once an arousal episode has begun, keep your distance, wait it out, and intervene as little as possible; when the arousal subsides, let your child return to sleep. During a partial arousal, parents often (and understandably) feel that they should “do something.” Unfortunately, except in very calm events, you will usually only make matters worse if you try to hold your child, restrain her, or even touch her while the episode progresses. She will not recognize you, even though she may be calling for you, and she is likely to react to any intervention as a threat or attack. If she squirms, twists away, pushes you, or hits you, your attempts to help will only make her more upset. Generally, no amount of stimulation will bring your child to full wakefulness, at least during a major confusional event. A parent who shakes a child and yells at her until she wakes fully may think he has finally succeeded in awakening her, but the truth is that the child woke on her own when the episode was over, and the extra stimulation may only have prolonged it. It is much better simply to watch your child, ensuring that she is safe but otherwise letting the episode run its course.
All episodes eventually end on their own fairly suddenly. You can learn to tell when your child reaches this point: she will begin to relax, then typically stretch and yawn. Soon she will be ready to return to sleep. You can help her back into bed, or lay her back down, but don’t do anything else. Remember, she is awake now, and you do not want to encourage full extended wakings by playing with her or engaging in long conversations, or it could become a habit.
Even fully developed sleep terrors should be allowed to run their course, though you may have to step in if your child is about to hurt herself or others, or if she might damage the furniture or walls. If you must intervene, do so as gently as possible, and use as little physical restraint as you can. An attempt to restrain an agitated seventeen-year-old could end up with both of you getting hurt.
A child who is less agitated during a partial waking may be easier to handle. This is especially true of a calm sleepwalker, who can often be redirected or even led back to bed (in contrast to an agitated sleepwalker, who does not like to be touched and must calm down before you can direct her anywhere). Often parents lead a sleepwalking child to the bathroom before directing her back to bed, on the (typically inaccurate) assumption that it was a need to urinate that got her up in the first place. That is not always wise: the frequent act of getting up to use the bathroom, even when there is no great need, may only further condition the child to try to wake up at that time. This attempt to wake can develop into such a habit that it actually becomes the cause of sleepwalking; in fact, sometimes a boy—less frequently, a girl—will even get up on his own to urinate, but do so in the wrong place, most likely in the corner of the room or into a wastebasket or closet, as if he knows generally what he is trying to do but is not fully aware of the specifics. Since most children past the age of toilet training do not need to use the bathroom at all during the night, consider not taking her to the bathroom unless she specifically asks to go, or unless you find that she inevitably wets the bed later if you don’t.
Keep Calm: Control Your Own Worries and Curiosity
If you attempt to help your child through a confusional event and she pushes you aside, it may make you angry. If she thrashes wildly as if “possessed,” you may be frightened. Try to avoid these reactions. By now you understand what is happening during a partial waking, and you should be able to watch it without misinterpreting your child’s actions or mistaking it for something more serious. Do your best not to overreact, and control the impulse to try to wake your child. When she wakes after the episode ends, don’t question her about it—she will not remember the event, anyway. Just let her go back to sleep. If she sees you upset at this time, she may only become upset herself, which can further disrupt her sleep: she may have difficulty returning to sleep and start to worry about having similar events in the future.
She may also be embarrassed: she has been acting in a way that she has no control over and that her family may regard as bizarre. If so, she might become angry if you ask about it. If her personality is of the tightly self-controlled type, she may already worry about losing control during the day, and the knowledge that she has been quite out of her own control during the night could cause her even more anxiety, increasing her worries at bedtime and possibly even leading to more arousal events. As a result, it’s usually best simply to let your child’s episodes pass without comment, unless she asks about them or is old enough to participate in decisions concerning psychotherapy and medication.
How We Helped the Children
Now that we’ve covered the spectrum of nighttime arousals and seen how to understand and treat them, we can go back to the children described at the beginning of the chapter to take a closer look and see how their problems were resolved.
Marcy was the four-year-old girl who talked in her sleep and moved restlessly early in the night. She did not really have a significant problem, but her parents were worried that her sleep was not calm enough; they wanted to know for certain whether they should be doing something about it. Once I explained that Marcy’s behavior was completely normal and just part of the pattern of sleep cycling across the night, they relaxed. There was nothing they needed to do.
Lisa, one and a half, went to sleep easily at bedtime in her crib with her pacifier, but she would seem to wake several hours later, crying and thrashing. She looked more uncomfortable or frustrated than frightened. Her mother or father would pick her up and try to comfort her to no avail, and she wouldn’t take her pacifier. Instead, she thrashed still more strongly, arching her back and kicking. At various times her parents tried walking her, talking to her, and shaking her in an attempt to wake her. On a few occasions they tried cold compresses or even screamed at her. Eventually, after ten to thirty minutes, Lisa would begin to quiet down, stretch, and yawn, and her parents would find that they could finally wake her fully and reassure themselves that she was all right. At this point she would take her pacifier and go back to sleep, usually until morning. Her parents would hear her stir several more times, but they would only have to go to her when she needed their help to find the pacifier.
I explained to Lisa’s parents that Lisa was not awake during these episodes, nor was she frightened or in pain; if she were, she would want to be held and would allow herself to be comforted. I told them to keep an eye on her during these spells, but not to do anything else unless she was awake and clearly wanted something. Once she stopped crying, they could help her lie down and cover her, but there was no need to wake her fully or to replace the pacifier if she hadn’t missed it. They soon grew accustomed to letting her get through the episodes without intervening and without feeling guilty.
I also suggested that they stop letting Lisa sleep with the pacifier in the first place. Even though she was better able than most children her age to replace it by herself in the middle of the night, she did have to wake enough to look for it, and that need was probably contributing to her partial arousals. She got used to the change within three nights, by which time she had even stopped asking for it at bedtime.
Lisa’s parents noticed two improvements almost immediately: her partial wakings became shorter, and she began going right back to sleep after each episode now that her parents were not trying to wake her. By the second week, the wakings had ceased to be a problem. Most of the remaining ones were mild, with only a little whining and thrashing, and her parents didn’t even find it necessary to go into her room. Most nights, they were no longer sure whether she even woke at all. After a few weeks more, the wakings had completely stopped.
Noah, almost three, was happy and well behaved during the day, but he had been waking frequently at night for a year. At his 7:30 bedtime he always stalled, running off, demanding extra stories, and running off again. Once it got late enough, he stayed in bed and fell asleep easily, but that usually didn’t happen until nine or ten o’clock. Two to three hours later he would begin moaning and moving around, then screaming, crying, and sweating profusely. He would toss, turn, and thrash wildly, get caught in the sheets, and bump into the wall. He appeared confused or, as his parents described him, “out of it.” He sometimes muttered intelligible phrases—“I don’t want to,” “Go away”—but much of his speech could not be understood. To his parents’ dismay, they were unable to comfort him: he did not seem to recognize them, and he would push them away, which sometimes made them angry.
Still, they would keep calling his name and shaking him until the episode finally ended after fifteen to twenty minutes. Then he would relax, stretch, yawn, and start returning to sleep. Sometimes he had another episode an hour or two later, but it was almost always shorter and less intense than the first. The rest of the night was usually quiet. Shortly before bringing Noah to see me, his parents had tried eliminating his nap in hopes of improving his nighttime sleep, but that had only made the wakings worse.
Noah’s partial wakings were similar to Lisa’s, just more intense: he was bigger than Lisa, so his thrashing could be more violent, and as he was nearly three his failure to respond or to talk clearly during these events seemed stranger and more worrisome to his parents than it would have if he were younger. I explained the partial arousals to Noah’s parents and gave them the same advice I gave Lisa’s parents, recommending that they keep their distance during the arousals and let him go back to sleep without questioning him—although I suggested that they go into his room when he was having an episode, just to be sure he didn’t hurt himself. Now that they understood the events better, they got less upset, and his apparent rebuffs of their efforts to help no longer bothered them.
There was room for improvement in other ways as well. It seemed to me that Noah was not getting enough sleep: he was falling asleep too late, at least on some nights, and the loss of his nap was not helping. If he was overtired, it would make partial arousals more likely. I was also concerned by his constant attempts to find new ways of putting off going to bed, because I suspected that he was trying to resume that behavior when he began to wake, worsening the problem.
At my suggestion, his parents reinstated the nap and put him on a later—but firmly controlled—bedtime schedule. We set 8:45 as the time for a story, and they were to say good night at 9:00. I helped them learn strategies for setting limits and enforcing the new rules (see Chapter 5). Once Noah began falling asleep quickly and easily, moving his bedtime earlier again would be an option.
Noah’s parents were successful on all counts. Bedtime began to go smoothly (soon they moved it thirty minutes earlier), and Noah fell asleep quickly; he was napping again, and he was now getting enough sleep on a regular and predictable schedule. He had stopped testing limits at bedtime, and when he started to wake at night he was no longer being over-stimulated by his parents’ well-meaning attempts to help. His nighttime partial wakings soon grew much rarer and milder, and over the next month or so they disappeared almost completely.
Christopher, eight, had been having abnormal nighttime wakings for almost two years. His sleep problems had started two months after his father’s death, when he and his mother moved to a new neighborhood. He began walking in his sleep two or three times a week, calmly and quietly, without crying, talking, or showing any signs of agitation. He would have what his mother described as a “strange look” on his face, and he wouldn’t always respond to her questions. Usually he appeared to be wandering aimlessly, but sometimes he seemed to be looking for something. Although he seemed not to recognize his mother, he would allow her to lead him back to bed, usually after a stop in the bathroom to urinate. On two occasions he urinated in his room, once into the wastebasket and once into his closet. Twice he walked out of the house and was led back home by neighbors. These episodes continued unchanged for a year, through several stressful periods: his mother was away for two weeks for emergency surgery, and shortly after that she remarried and his family moved again.
Then his mother became pregnant. Shortly before the birth of his sister, Christopher’s nighttime episodes changed. They now occurred several times a night, and they followed a new pattern. About an hour after falling asleep, Christopher would sit up suddenly and cry out briefly, appearing frightened. He would not respond to his mother; he resisted being touched, and he muttered incoherently off and on throughout the episodes. He would calm down in a few minutes, at which point he could be coaxed to lie back down in bed and would fall asleep rapidly. The episode would repeat itself an hour later, and again an hour after that. After the third episode he would begin to walk about the house in his sleep as he had when he was younger, but now in a more agitated manner. His mother and stepfather couldn’t understand why these things were happening, and since their own sleep was constantly being interrupted, they were resentful and angry about his behavior.
Christopher was a quiet, pleasant youngster, but he seemed tense and anxious. I learned that both his late father and his stepfather were alcoholics and that his family had some trouble with domestic violence. He was angry at the people around him, but he was afraid to express those feelings. He was also frightened by his lack of control over the world around him, and he was no doubt distraught that his parents could not control themselves. He devoted much of his energy to rigid self-control, worried that if he did not control his feelings, his parents would become even angrier and possibly increase his punishments.
Christopher and his mother both needed counseling, which they began separately on my recommendation. In the meantime, I explained the details of nighttime arousals to his mother and stepfather so that they wouldn’t be so angry at him. To keep him from leaving the house again in his sleep, I suggested a lock high up on the front door.
Given Christopher’s ability to hurt himself while sleepwalking, and because his mother and stepfather were not yet able to be supportive, I also chose to prescribe medication to control his partial arousals, at least until his counseling had progressed. With a small dose of clonazepam taken before bed, his nighttime arousals disappeared almost completely. Meanwhile, in counseling he was allowed to express his fears and concerns in a safe and supportive setting, and his mother began to learn how to listen to him in a sympathetic, non-judgmental way. He became happier, more relaxed, and less fearful.
After six months, Christopher and his mother had made real progress in therapy and tensions had eased at home, so we gradually stopped his medication. Some nighttime arousals returned, but they were milder now. His sleepwalking was no longer agitated, and often, instead of sleepwalking at all, he merely sat up in bed; instead of screaming, he would only talk softly. The episodes were much less frequent than before, never happening more than once a night, and his mother now knew how to deal with them without getting angry. They diminished even further over the next several months, and by the time he was nine they occurred only occasionally.
Maria’s nighttime arousals were still more dramatic than Christopher’s, falling somewhere between angry, agitated sleepwalking and full sleep terrors. At age twelve, she had been having them for just over three years. About an hour and a half after going to sleep, she would sit up and let out a single long, guttural scream. Then she would get out of bed and run about frantically, fumbling along walls and furniture as if trying blindly to escape a burning room. Sometimes she would fall to the floor and thrash, kick, and roll around. Occasionally she ran wildly out of her room and even down the stairs.
Although weeks sometimes passed between Maria’s episodes, more often they happened once or twice a week. Sometimes she seemed frightened; other times she seemed angry, frantic, and confused. She pushed people away when they tried to restrain her, and when spoken to she responded with apparent anger, replying, “Go away” or “Leave me alone.” Once or twice she tried unsuccessfully to leave the house. Occasionally she had milder episodes, during which she sat up in bed talking and showed few signs of agitation. Her mother had discovered that she could trigger an episode by disturbing Maria’s sleep in any way between sixty and ninety minutes after Maria had fallen asleep; she had learned to stay out of Maria’s room at those times, not even trying to cover her with a blanket. Maria had not had any major problems during sleepovers at friends’ homes, but the possibility worried her mother.
When Maria was nine her confusional episodes had lasted as long as half an hour, but now, at age twelve, most of them ended within five or ten minutes. As an episode ended she would grow calm, wake up enough to use the bathroom, and go back to sleep. Her parents often let her spend the rest of the night in their room. Some mornings they found her sleeping in their room, but neither they nor Maria knew when she had come in. Maria herself had no memory of any of the events, either immediately after they occurred or in the morning.
Maria’s family tried to be supportive, but her parents were preoccupied with their own marital problems, which they were working on with the help of a marriage counselor. Maria had recently started seeing a psychologist, too. She did not seem to have any striking emotional problems, and she was extremely well-behaved, at least away from home. However, she was not an outgoing youngster. She was angry at her parents over the strained mood at home and what she experienced as a lack of warmth and nurturance. She had difficulty expressing these feelings, and she was afraid that if she did express them it would only make matters worse.
I was able to reassure Maria’s parents that she was physically normal—as are most children who have confusional events at night—and that arousals like hers were common. They were relieved to learn that we could stop the episodes with medication, but since the episodes were brief and occurred early in the night while they were still awake, we decided not to put Maria on a regular prescription. It would always be available when she was sleeping away from home, or if the episodes worsened. I also suggested that Maria sleep in her own room all night, every night. If she never found it necessary to change rooms and always knew where she was when she woke up, some of the causes of the arousals would likely go away. Her parents put a chair by their door so that if she came into their room they would hear her and could guide her back to her own bed.
Our hope was that as Maria continued to work with her psychologist, as she got out of the habit of switching rooms, and as her parents continued to resolve their own problems, her wakings would gradually become rarer and less severe. In fact, they did diminish significantly over the next several months.
David was seventeen; over the eight years before I met him, his parents had divorced and both had remarried. Before their separation, David was known to talk in his sleep frequently. That was the extent of his nighttime arousals until he was twelve, when his father remarried; then they started to show more severe variations. About once a month, around midnight, he would suddenly leap out of bed and begin yelling. His mother would find him standing in his room, apparently upset and looking, she said, “as if he was worried that something was going to happen to him.” He did not seem to be actually frightened, although he occasionally mumbled cryptic phrases like “I’ve got to get him.”
When David was fifteen his mother remarried as well, and his arousals became even more intense. Now they began with what his mother described as a bloodcurdling scream, after which David would jump out of bed, knock over furniture, and run about as if trying to escape from something. In these episodes he appeared truly terrified. He injured himself a few times; although mostly he got away with minor scrapes and bruises, once he broke a window-pane and cut his hand. On another occasion, he leaned dangerously out an open window in his room on the second floor. He woke fully at the end of each episode, embarrassed to find himself in a room in disarray with his family staring at him.
David’s parents described him as “very controlled,” with a tendency to “hold things in” and “handle things too well.” He seemed not to be working to the best of his ability in school. I found him pleasant and cooperative, but he seemed somewhat depressed. He was easy to talk to and, in fact, he was able to express many of his feelings, though he was clearly not fully aware of all of them, particularly those involving sadness and anger.
Although David’s partial arousals were infrequent, they were so severe that I feared he might seriously injured himself. I have treated adolescents who have jumped out of windows during episodes like his. I placed David on medication that effectively stopped the arousals, but that was only a stopgap to ensure his safety. We wanted him sleeping calmly and safely without drugs. Even apart from any impact on his sleep, his mild depression, suppressed anger, and unsatisfactory school performance all needed attention. For these reasons, I recommended psychotherapy.
David and his family followed through on this suggestion, and he profited enormously. Over time I watched him emerge from his shell and become a happier young man and a more successful student. After several months, we considered stopping the medication. Because his nighttime arousals had been potentially dangerous, I reduced his prescription slowly and carefully, watching for recurrences at each step. By the time he left for college, he had been off medication altogether for several months, but I asked his family to be sure he had a roommate to report the recurrence of any problems. The medication would always be available if it became necessary again.
FIGURE 15. PARTIAL WAKINGS: A SUMMARY OF THE MAJOR PATTERNS ACROSS CHILDHOOD AND GENERAL RECOMMENDATIONS FOR MANAGEMENT
*The confusional arousal, common in young children, does not fit neatly into one place in this table, since it has its own severity spectrum and can vary from mild to intense and from brief to long-lasting, with the child anywhere from semiresponsive to completely unresponsive.