He Sleepwalking in children Is characterized by a sequence of more or less complex behaviors that occur during slow-wave sleep, occurs between phases 3 and 4 of non-REM sleep, usually in the first third of the night.
It is classified within the sleep disorders And is a problem that falls within the parasomnias, in the disorders of the awakening.
Parasomnias are characterized by abnormal events or behaviors associated with sleep, their specific phases or the moments of sleep-wake transition.
Other parasomnias other than somnambulism are nightmares, night terrors or other unspecified parasomnias ( sleep paralysis , REM sleep behavior disorder).
An episode of sleepwalking begins with body movements that can get the subject to sit up in bed abruptly or can also get up and start wandering.
It may be associated with other sleep disorders. In this way, we frequently find that the same individual presents somnambulism, somnioquio, which indicates that there could be some kind of relationship.
In addition, in children, many episodes of sleepwalking are preceded by night terrors, as well as children With enuresis Are more likely to experience somnambulism throughout adolescence.
With awakening disorders we refer to the manifestations of partial awakening that occur throughout the dream. They are primary disorders of the mechanisms of normal awakening.
Classification and diagnosis of sonámbulismo
Sleepwalking is included within the parasomnias. They are not serious disorders in childhood, although they can become annoying and draw the attention of the family by being stubborn.
In addition, excessive tiredness, febrile processes or anxiety can increase them.
The diagnosis of a parasomnia should be made with a detailed medical history and in some cases a Polysomnography To differentiate it from some types of epilepsy.
During the episode, the child can respond with questions to the questions but not always, since he usually will not understand the meaning of the words.
Also, it is difficult to wake him up because he is deeply asleep and if he does, he will be insecure and will appear strange, since he will not recognize the situation.
Sleepwalking is within the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), within the parasomnias and disorders of non-REM sleep awakening.
In it, it is diagnosed when the person has repeated episodes in which the individual gets up from bed and walks during sleep.
During this episode, he has his eyes fixed and blank and is relatively insensitive to the efforts that other people make to communicate with him, waking up only after much difficulty.
Symptomatology and characteristics of sleepwalking
Sleepwalking would consist of a dissociated state of consciousness, since the phenomenon of sleep (neurophysiological state) is combined with that of waking (appearance, behavior). It would be considered an arousal disorder.
As we have seen, it is observed in the first half of the night, when it is more frequent that phases 3 and 4 of non-REM sleep occur.
Due to the characteristics of the disorder it would be expected to consider REM sleep , Where rapid encephalographic activity occurs and there is high brain activation.
However, in the records it is observed that it appears in non-REM sleep, where the Cortex Is progressively deactivated and slow waves appear, in addition to a decrease in muscle tone, lower cerebral blood flow and heart rate or metabolism of the glucose .
The symptoms of the sleepwalking person are the body movements that he performs, which can lead him to get out of bed, to wander, to sit in it, and so on.
Also, keep your eyes open and fixed, being able to go inspecting the environment and thus avoiding the various objects that may be hindering your step.
However, there are different risks, such as stumbling or falling or falling down stairs or a window.
The sleepwalker can perform different actions: he can dress, open doors, windows, leave the house, feed himself, do personal hygiene tasks, etc.
Occasionally he can speak, although the articulation he presents is very poor and limited to gossip, usually.
In addition, a false responsiveness occurs throughout the episode, the end of which can occur in multiple ways. In this way, getting the person's attention or waking him up does not usually work.
The duration of the sleepwalking episode is variable, as it can range from about 1 minute to over 30 minutes. And usually a single episode takes place in one night.
The frequency with which it can occur can be even of several episodes within the same week and can last even several years.
In addition, the person with sleepwalking does not have to have any alteration in the behavior during the day, since the problem occurs exclusively during the dream. Nor does it have to predispose to other pathologies.
However, the occurrence of frequent sleepwalking episodes is of concern to the family and may lead to an alteration in relationships with other people.
Sleepwalking implies that the child automatically repeats during sleep behaviors he has learned in waking periods. The child is deeply asleep when he does it.
The episode usually appears when the child has slept between 2 and 4 hours. Usually, the episode ends when the child returns to bed. Also, the child forgets the episode the next day.
A typical succession of events may be for the child to get out of bed, asleep even if his eyes are open, go to the wash and pee on the floor and go back to bed, for example.
In addition, the most frequent form of onset of somnambulism is that which appears in childhood, presents a family predisposition and disappears at puberty.
However, there is another less common form that is when it appears in preadolescence and had not been present previously. In this case they are usually"reactive"? And is common to be comorbid to other psychopathological manifestations.
In children with somnambulism there is the?? amnesia of the episode?? Or a"fragmentary memory".
Etiology
Sleepwalking may have a hereditary basis, since it usually occurs more in children whose parents were also somnambulists in their childhood than in normal population.
In addition, in Monozygotic twins (Identical) is greater agreement than in Dizygotic (Twins), which would also support this claim.
On the other hand, we could indicate that there is a genetic predisposition in children that in times of stress (for example, school stress or exams) would awaken these episodes.
Somnambulism in children does not indicate that there are affective alterations, what seems to be related is that stressful episodes exacerbate their appearance.
Sleep deprivation can also affect sleepwalking episodes.
Different hypotheses have been described about the etiology of somnambulism. Emotional factors such as delayed maturation have been included, for example.
Other studies have shown, through the polygraph , That it is an awakening disorder, where the subject, after phases III and IV of the dream passes abruptly to the first two phases, so that a superficial dream is given.
According to a University of Washington study published in the journal"Neurology", a flaw in chromosome 20 could help to make somnambulism manifest.
According to other studies, the risk of a child being a sleepwalker is seven times greater if their parents were also. For example, 25% of the children had parents who had not been sleepwalkers, compared to 47% who had a father who had been sleepwalking or 62% where both had been sleepwalkers.
We could conclude that this alert disorder is due to an interaction between genetic, maturative, organic and psychological causes and that usually occurs in stages of the key to child development.
Epidemiology
Sleepwalking begins between the ages of 4 and 8, being more frequent in males than in females.
In addition, it is common to disappear throughout adolescence, so it is a disorder more often given in childhood.
About 15% of the children have at some point an episode of sleepwalking. It usually disappears spontaneously at 15 years and after this age only 0.5% of adults conserve these episodes of sleepwalking.
Also, several studies have shown that about 25% of children present one episode per year and 10% at least once per week.
When episodes are very frequent or persist with age, it is advisable to perform the differential diagnosis with temporal lobe epilepsy.
It is important to emphasize that the prevalence of somnambulism increases when nap is suppressed prematurely.
In children under five years of age who are abruptly removed from the nap period, an increase in episodes of parasomnias associated with deep sleep has been observed, including somnambulism.
It happens because there is a"sleep deprivation", so that when you start the sleep at night the children quickly enter the 3-4 phase of sleep.
Evaluation and treatment
Sleep disorders in the child should be evaluated considering their age, since there are pathological behaviors that at certain ages can be considered normal or vice versa. And also wonder if there really is a problem or are expectations of parents.
The parents should be informed and reassured, since these sleep problems are benign and their evolution favorable.
The evaluation should take into account the Anamnesis And physical examination (if it is a transient or chronic problem, etc.), sleep diaries and questionnaires, psychophysiological techniques, etc. can be used.
In the case of somnambulism, a detailed history of sleep, episode time after sleep onset, family history of parasomnias, and even episodes with camera may be recorded.
Some sleep disorders, such as somnambulism, in which the professional must perform the differential diagnosis with other neurological diseases, usually with the Epileptic seizures .
In most cases, the diagnosis can be made through EEG and polysomnography techniques. He EEG record During sleepwalking shows a combination of alpha, theta and delta frequencies, without a typical waking pattern.
In sleepwalking episodes there is no evidence that there is a complete awakening even though the person's behavior may be complex. The child shows a behavior of absence of response to stimuli and different levels of autonomic activation.
There is no specific treatment, although the episodes usually decrease with the age of the child. Usually, since it is a benign sleep disorder, no special treatment is usually necessary.
In the treatment of somnambulism, parents should take care that the child is not harmed during the episode.
It is advisable to take into account access to windows, to avoid dangerous objects inside the room, to lock dangerous places like windows or doors, to avoid having high beds or bunk beds, to block stairs, etc.
Caution also includes avoiding all the factors that can trigger the episodes: tiredness, anxiety , etc. And you should follow a good hygiene Of sleep .
In addition, if it is an intense problem and anguish to the parents, the specialist can be asked for an evaluation to deal with pharmacotherapy, with Diazepam In a short period of time.
Another technique that is also used in the treatment of sleepwalking episodes is to wake the child about 15 minutes before it occurs.
It is most appropriate to attend to environmental control measures to avoid accidents and also to use behavioral procedures that are less intrusive and with fewer side effects than medication.
Some authors propose that a practice based on therapeutic nested and controlled naps may mitigate or reduce the frequency with which episodes of sleepwalking have their effects on deep sleep.
Another alternative that could be valued is to put some kind of alarm that can help the child not get hurt when he gets up during the night.
How to act before the episode? During these, it is advisable to take the child back to his bed by talking to him in a relaxed manner. In addition, you should talk to short and very simple sentences.
Sleepwalking is not a serious health problem for the child or affects his brain development. However, it can affect your nocturnal rest and can worry the family a lot, so prevention in this case is the most appropriate measure.
References
- Alberola, S. Sleep disorders in children: identification and tools for their management. Pediatric forum.
- American Psychiatric Association. DSM-5. Diagnostic and Statistical Manual of Mental Disorders.
- Amaro, F. Sleep disorders in childhood and adolescence. Autonomous University of Barcelona.
- American Academy of Pediatrics (2007). Sleep Problems in Children.
- Belloch, A. (2008). Manual of psychopathology. Volume I. McGraw-Hill Interamericana of Spain.
- Choliz, M. (1999). Anxiety and sleep disorders. In E. G. Gernández-Abascal and F. Palmero (Eds.): Emotions and Health (Pp. 159-182). Ariel.
- Espinar, J., Ramos, J. (1991). Sleep disorders in children. Revista Asoc Esp Neuropsiq, Vol XI, 38.
- Estivill, E., Segarra, F. (2003). Parasomnias in childhood.
- Hernández Guillén, R., Rodrigo Alfageme, M. Sleep disorders.
- Hernández Rodríguez, M. (2005). Monographic number: Paroxysmal episodes in pediatrics. Revista Española de Pediatría Clínica e Investigación , 61, 9-80.Infirmus (2015). Sleepwalking can be hereditary. Jama Pediatrics. In: www.infirmus.es
- Navarro, J. F., Espert, R. (1994). Somnambulism. Behavioral Psychology , 2 (3), 363-368.
- Schiemann, J., Salgado, I. Sleep disorders.
- Childhood sleepwalking: life is a dream. Consumer.
- Venebra, A., García, J. S., García, F. (2006). Sleep disorders. Medical Journal of the University of Veracruz, 6 (2), 18-28.
- Zolten, K., Long, N. Sleepwalking. Center for Effective Parenting. University of Arkansas, Department of Pediatrics.