The frequent occurrence of sleep disorders in children and adolescents has often led to the trivialization of these manifestations, or even to their integration in “normal” development and to underestimating the existence of real disorders, dyssomnias or parasomnias.
Recent advances in the understanding of the physiopathology of sleep and wake mechanisms, particularly through the use of polysomnographic recording techniques, have led to the authentication of these disorders in children.
In the absence of a child-specific classification, the International Classification of Sleep Disorders (ICSD, 1990), based on clinical, epidemiological and electrophysiological criteria, leads to an international consensus. Child and adolescent disorders are integrated as a continuum with those of the adult, from a developmental perspective and from the maturation of the central nervous system.
For the clinician and researcher, the ICSD is an instrument of choice, allowing many diagnostic categories, particularly in young children, not available in other classification systems (DSM III-R, DSM IV, ICD 10 ) Because they are still considered insufficiently established by their authors.
In this chapter we shall see successively the primary disorders of dyssomnia and parasomnia, and secondary disorders to a psychiatric or medical cause. Far from being exhaustive, this chapter aims to provide the reader with an up-to-date overview of the approach to sleep disorders in children and adolescents.
We have deliberately chosen to conform to the terminology of the ICSD, particularly concerning dyssomnia and its subdivision into intrinsic
Insomnia and hypersomnia belong to the nosographic framework of dyssomnia.
These are based on the notion of subjective complaint on the part of the subject, insufficiency or an excess of sleep. In the young child, the complaint is essentially that of the entourage (parents, pediatric nurses …). We distinguish dyssomnias called intrinsic dyssomnias, in which there is supposed to exist a primary dysfunction of the centers of regulation of wakefulness and sleep and the dyssomnies created or maintained by environmental factors, called extrinsic. The younger the child is, the more he is subject to the rules laid down by those around him. It is therefore necessary to distinguish between early childhood disorders and those of the older child or adolescent.
Insomnia of infants and young children:
Still called insomnia with childhood-onset insomnia by Anglo-Saxon authors, because of its early childhood, it is the main cause of insomnia intrinsic in this age group. ‘age. It can manifest itself from the first months of life, or even from birth by an inability to produce a sleep of normal quality. These children suffer from difficulties of falling asleep and of frequent nocturnal awakenings. This insomnia would be related to a neurological abnormality of the sleep / wake control system that would involve either a hyperactivity of the arousal system or a hypoactivity of the sleep regulation system. This disorder, rare in its pure form, persists into adulthood and affects these subjects throughout their life. Polysomnographic investigations reveal abnormalities in the sleep microstructure that would support the hypothesis of primitive involvement of sleep regulation systems.
The so-called extrinsic disorders are by far the most frequent in young children and are closely related to environmental or behavioral factors. The sleep recordings of these children do not show any specific abnormalities when they are performed under the conditions usually required to obtain sleep.
These disorders are most often reversible by a change in the environmental conditions that created and sustain them.
Associated disorders in sleeping:
It results in difficulty falling asleep and nocturnal awakening, and would involve 15 to 20% of children between 6 months and 3 years. This is not a disturbance of sleep regulation mechanisms (intrinsic disorder), but rather a consequence of poor learning during the sleep / wake transition period.
Sleep is quickly obtained in the presence of the conditions usually associated with it, and supposedly learned by the child (parents’ arm, rocking, bottle, shared bed ..). However, these conditions require the intervention and active participation of the adult and do not allow the young child to learn to manage the period of sleep / sleep transition and to discriminate sleep stimuli. The difficulties present at bedtime are repeated during the nocturnal awakings.
However, the hypothesis that poor early learning predisposes to the onset of a specific sleep disorder in adolescence or adulthood remains to be demonstrated.
Rare prospective longitudinal studies have shown a low predictive value of the items “night sleep duration”, “intrasommeil awakening” and “shared bed”.
Nocturnal food intake syndrome:
This syndrome is characterized by iterative nocturnal arousal and the impossibility for the child to regain sleep without food or fluid intake. In these children who wake up at night, the parental response consists in systematically proposing a bottle of water, milk or fruit juice. This disorder affects about 5% of children aged between 6 months and 3 years in the general population. It is similar to the previous disorder but is liable to self-maintenance due to the importance of fluid intake likely to induce or aggravate an organic pathology (gastroesophageal reflux, ENT infectious pathology …).
Inadequate limitations or inappropriate educational rules:
This disorder is the consequence of an absence or incoherence of the sleeping routines proposed to the child, and results in a refusal and opposition on the part of the child at bedtime and more rarely during the nocturnal awakings. The adult is confronted with the refusal of the child to respect the schedules of bed that it wishes to impose to him. The child uses multiple requests to delay or avoid being put to bed; Drinking, going to the bathroom, being rocked or taken in the arms, having light, watching television, being comforted by fears …
From the psychoanalytic point of view, falling asleep is a phase of regression, a return to primary narcissism, implying the need for the child to disinvest the surrounding world and to withdraw into oneself. This transition to fulfillment requires an affective climate that is both secure and borrowed from firmness. Indeed, falling asleep can be a trying experience, because to fall asleep is to separate, to be confronted with fantasy and dream life. The creation of a transitional and aconflictual space therefore becomes necessary for the proper realization of sleep and its fulfillment. This transitional space, created by the mother during the first months of life, will progressively become a space, or it will be absent to allow her child to
To abandon oneself to sleep. This space is an opportunity for the child to arrange, where the investment of certain objects (fluff, cloth diapers) is privileged. Some repetitive rituals or behaviors help prepare for bedtime. The rhythms of suction of the thumb, of covers, allow a transition from the quiet watch to the sleep.
When this space is not realized, or realized in an uncertain way, the excitation is not able to yield and to leave a place to favorable conditions of falling asleep.
The prevalence of the disorder is estimated to be between 5 and 10% of the children in the general population and mainly concerns children from the age of 2 years.
Frequently used in extrinsic disorders, psychotropic products are mainly derived from phenothiazine (phenothiazine antihistamine or neuroleptic phenothiazine) and are likely to present side effects undesirable neuroleptics (acute dyskinesias, paradoxical excitation, sedation, extrapyramidal syndromes …). On the other hand, the effects of long-term intake of these products on sleep and cerebral maturation are not demonstrated.
Therefore, the use of drug prescriptions in extrinsic disorders can not be regarded as a satisfactory therapeutic response in the absence of associated psychoeducational measures. The aim is to modify the response behavior of parents during the night-time iterations, using techniques that are often behavioral.
Aside, cow’s milk protein allergy insomnia (IPLV):
This is a rebel insomnia that can occur as soon as cow’s milk is introduced in the first two years of life. Insomnia is often an isolated symptom. Other allergic phenomena can be associated such as respiratory, cutaneous or gastroenterological disorders. Treatment involves the removal of the allergen present in cow’s milk.
Insomnia of the school-aged child and the adolescent:
It begins with the adolescent or the young adult and involves learned behaviors of prevention of sleep. The complaint is that of an insomnia and an alteration of the diurnal functioning. Non-sleep behaviors are underestimated by cognitive factors (inability to fall asleep when the subject decides despite his efforts, erroneous thoughts about the restorative function of sleep …) and somatic (agitation, muscular tension , Vasoconstriction …). Negative conditioning to environmental factors (bedroom, bed) is also reported.
This insomnia “learned” then evolves for its own account, aggravated by a possible long-term taking of hypnotics likely to modify the architecture of sleep.
Behavioral and cognitive therapies have been studied in the treatment of adult insomnia. The effectiveness of certain techniques in the management of cognitive awakening (cognitive therapies, cessation of thinking), somatic arousal (“training” autogenous, “biofeedback”) or behaviors not conducive to falling asleep Of Bootzin stimuli) was emphasized by different authors. Little used in children and adolescents, they are nonetheless rich in promise, because it allows to intervene early on factors likely to maintain a dysfunction whose trigger is certainly not univocal (stress, disease Intercurrent, dreams of anxiety, family conflicts …).
Inadequate sleep hygiene:
It is frequent in the adolescent, in whom the respect of the rhythms of sleep is sometimes not very compatible with the social and educational constraints imposed at an age where the needs of sleep are great. Irregular sleep schedules, late bedtime and early rising times, combined with sometimes rough sleeping conditions, often lead to chronic sleep deprivation responsible for daytime sleepiness. Morrison et al show that in a population of 15-year-olds, 33% report long-term sleep difficulties. Among these subjects, the most frequently reported complaint is sleeping insufficiency (25%), even before the difficulty of falling asleep (9.6%).
Insomnia related to circadian rhythm disorder: Sleep Phase Syndrome (SRPS):
Described by Weitzman and Czeisler in 1981, it results from an incompatibility between the sleep / wake rhythms of a subject and the schedules imposed by life in society. SRPS mainly affects the adolescent or young adult, but has also been described in infants and young children. Typically, sleep is normal in quantity and quality, but can not be obtained at conventional schedules and delayed by 2 to 3 hours compared with normal subjects of the same age.
The complaint consists of an insomnia of falling asleep and an inability to rise at the desired times, associated with a certain degree of daytime somnolence mainly morning, the whole may jeopardize the pursuit of a normal schooling. The treatment is based on a progressive resynchronization of the rhythms by chronotherapy, gradually delaying the time of bedtime. The use of strong synchronizers such as light has also been proposed. Phase retardation syndrome would account for nearly 10% of cases of chronic insomnia and especially in adolescents or young adults.
Most of the pathologies responsible for excess sleep begin in adolescence. In addition, the effect of puberty is associated with a significant decrease in vigilance in normal subjects.
In the prepubertal child, excess sleep is sometimes difficult to understand and must be defined in relation to the average of the total sleep time for age. The role of the entourage appears decisive (teachers, school doctors) in the detection of a symptomatology sometimes misleading.
This syndrome is characterized in its complete form by the association of excessive diurnal somnolence (SDE), invincible diurnal sleep episodes, cataplectic attacks, hypnagogic hallucinations and sleep paralysis. If the diagnosis remains essentially clinically, the nocturnal polygraphic recording followed by iterative tests of delay of sleep (TILE) allow to objectify more than two sleepings in REM sleep and a very short sleep latency. Very strong binding to the human leukocyte antigen (HLA) system DR2-DQ1 is reported.
The frequency of this syndrome is 0.03 to 0.16% in the general population, but is unknown in children. The onset of the disease is most often during the second decade with a peak around 14 years. The complete form is rarely present at the beginning. Early forms of prepubertal children are rare and characterized by longer narcoleptic bouts than adults, daytime sleepiness masked by hyperactivity or behavioral disorders. The treatment of drowsiness is essentially symptomatic, based on psychostimulants such as methylphenidate or modafinil. Early in life, combined with sleep hygiene measures (naps, sleeping time), it provides a better chance for these children to pursue normal schooling. The planning of sleep and activity periods must be done in accordance with the family and school environment.
For a long time confused with narcolepsy, it also begins readily during cataplexies, hypnagogic hallucinations and sleep paralysis. In addition, TILE-coupled polysomnographic studies typically show slow sleep asleep (NREM). The prevalence of the disease is 0.01 to 0.02%. Treatment is only symptomatic to restore normal daytime vigilance (see above). There is no known association with the HLA system.
It is characterized by bouts of drowsiness lasting 3 to 10 days on average, which when combined with hyperphagia and instinctual disinhibition with hypersexuality realize the complete form of Kleine-Levin-Critchley syndrome.
These episodes are spaced apart at good intervals of good quality in which the subject presents no alertness disorder. During access the subject can sleep 18 to 20 hours a day, rising only to eat. Thymic manifestations or behavioral disorders are frequently associated, which can take the aspect of various psychiatric pathologies. This form of hypersomnia is more rare than the previous two. The evolution is generally favorable and is done over several years. Prophylactic treatment of access by lithium could be proposed by some authors.
Obstructive sleep apnea syndrome (OSAS):
The first cause of excessive sleep in children in the Stanford study, this syndrome is characterized by repetitive episodes of partial or complete obstruction of the upper airways during sleep, usually leading to a decrease in saturation Of the blood in oxygen. In children, OSA is frequently the result of an increase in tonsil or vegetation volume. Anomalies of craniofacial morphology also appear to play an important role in the genesis of SAOS, underpinned by genetic and developmental factors.
This syndrome can be accompanied by numerous nocturnal manifestations (snoring, buccal breathing, waking reactions, unusual postures of sleep, enuresis) but also diurnal (difficulties in school, attention and concentration disorders, EDS).
Apnea occurring during sleep is responsible for repeated arousal reactions and a fragmentation of sleep that can affect the quality of the sleep and are responsible for daytime sleepiness. Only a polysomnographic investigation makes it possible to make the diagnosis of SAOS and to determine its severity. Treatment is primarily surgical, based on the removal of the obstacle in the upper airways (tonsillectomy, adenoidectomy). The use of continuous positive pressure therapy (CPAP) is indicated in some cases of severe OSA.
Parasomnias correspond to disorders that intrude during sleep and which the subject usually does not remember. The complaint then comes from the entourage, as is the case in somnambulism or nocturnal terrors. Parasomnias are the translation of an activation of the central nervous system through the skeletal muscular system or the vegetative nervous system.
The parasomnias are classified according to their occurrence during the sleep cycle.
These can occur during the sleep / wake transition, slow sleep (NREM sleep) or REM sleep (REM sleep).
Parasomnia associated with an Awareness Disorder:
The concept of awakening disorder corresponds to the occurrence of motor and / or vegetative activity during partial arousal occurring during slow wave sleep.
Night terrors (pavor nocturnus) are characterized by a sudden arousal in slow wave sleep (NREM), manifested by crying or piercing crying, accompanied by behavioral and neurovegetative manifestations of intense fear.
The distribution of the slow-wave sleep in the first third of the night explains the time of preferential occurrence of the night terror, on average 2 to 3 hours after bedtime. The nocturnal terror mainly concerns the prepubertal child, between 4 and 12 years. The development of the disorder is usually favorable tending to resolve spontaneously in adolescence.
Triggering or promoting factors have been reported causing certain episodes such as sleep deprivation, fever, certain psychotropic medications.
The prevalence of the disorder is about 3% of children and less than 1% of adults. Nocturnal terror appears more frequently in the boy than in the girl and can be demonstrated in several members of the same family.
Like sleep terror, somnambulism is considered to be a disorder of arousal occurring during sleep NREM, resulting in a series of behaviors more or less complex. The child may be calm, sitting on his bed, strolling around his room or in the apartment, urinating in a closet, trying to get out of the apartment by the door or window. Somnambulism can be associated with a nocturnal terror, generating behaviors of fear, flight, or even self- or heteroaggressiveness. The amnesia of the episode is classic, as is the preferential schedule of occurrence in the early night.
The evolution of somnambulism is usually spontaneously favorable, confirming the hypothesis of a developmental process.
Its incidence in children aged 5 to 12 years is estimated to be 15% (one episode) and 3-6% (more than one episode). The disorder rarely persists in adults (1%). Family history is reported in 10-20% of subjects, highlighting the hypothesis of a genetic susceptibility factor.
In some cases, polysomnographic recording may be critical to differential diagnosis with a behavioral disorder occurring during REM sleep or sleep-related epilepsy. It shows the occurrence of the episode during slow sleep and the normality of the intercritical tracing. Behavioral techniques using relaxation have shown some efficacy in mild to moderate forms. Drug treatment is reserved for severe forms (frequency and intensity of seizures). Imipraminic tricyclic antidepressants have been proposed as well as dopaminergic antidepressants (amineptine).
Parasomnia associated with a sleep / wake transition disorder:
Producing in the quiet vigil, during the falling asleep, and being able to persist in light sluggish sleep.
These rhythms most often involve the head by “head-banging” or “head-rolling” movements, but also a member or limb segment (“arm banging”, “leg banging”, “arm rolling” “,” Leg rolling “) or the body as a whole (” body rocking “,” body rolling “).
The age of onset is most often in the first year of life, with rhythmic activity occurring in 66% of normal children aged 9 months.
This activity would affect only 8% of children after the age of 4, but may persist in some cases in adolescents, even in adults. It is more frequent in the boy (4/1). Complications are rare but sometimes severe (skin lesions, retinal lesions, subdural hematomas).
A behavioral approach can be proposed (relaxation). Benzodiazepines have sometimes been successful.
Parasomnias usually associated with paradoxical sleep:
Nightmares differ from nocturnal terrors in their occurrence during REM sleep, absence of intense neurovegetative phenomena or associated body movements, a mnesic remnant during spontaneous or induced awakening. Nightmares in children are frequent and their prevalence is estimated to be 75% for occasional nightmares. More rarely, the nightmare belongs to a syndromic entity as in the post-traumatic stress state, for which treatment with clomipramine has been proposed and whose suppressive effect on REM sleep is demonstrated.
REM sleep behavior disorder:
As these dissociative states occur in the course of paradoxical sleep, these “waking dream” type manifestations that can result in dangerous, complex, even extremely violent behaviors that cause bruises, lacerations, fractures have recently been Described in adults. They may also occur in children with the problem of differential diagnosis with epilepsy or NREM-dependent parasomnias.
Numerous parasomnias are described. Among the most frequently found in children, somniloquia (speaking in sleep), which usually does not require treatment, and bruxism (squeaking of teeth due to sleep), which in certain severe cases may require preventive Setting up during the sleep of a dental appliance, or a behavioral therapy using relaxation.
SLEEP DISORDERS ASSOCIATED WITH ORGANIC OR PSYCHIATRIC DISEASE:
Disorders associated with a psychiatric cause:
Most psychiatric disorders in the adolescent or prepubertal child are likely to cause sleep disturbances. Of these, particular attention should be paid to an anxiety disorder or a mood disorder.
Many authors have emphasized the relationship between sleep and anxiety during development. From the third month, the mother, acting as organizer and stimulator of the maturative processes, acts on sleep by playing a role in the processes of adjustment between waking and sleeping moments and alternating day.
From the second year, the small child is very ambivalent compared to the bed.
He is divided between his desire for empowerment and his needs for dependence, which are still very marked. According to Kreisler, “it is both an excited and a worried”; Excited by his avidity to explore everything and everywhere, to master what surrounds him, worried because his needs for independence go against his main object of attachment, his mother.
Separation anxiety is therefore inherent in this phase of development.
In the forms of anxiety insomnia, one frequently finds an element contributing to cause a feeling of insecurity in the child: excessive parental anxiety, but also sometimes an ambivalence where emotional feelings and hostility, even rejection . Anxiety is then generated by the lack of coherence in the line of conduct, the paradoxical aspect of certain messages addressed to the child, and reactivated by the situation of separation from bedtime. The alternation of over-stimulation and neglect behavior confronts the child with a state of “affective vacuum”, where the success of the “narcissistic regression” necessary for falling asleep is compromised.
Thus it is necessary for the clinician to take the part between the behaviors of opposition to bedtime and the anxieties related to sleep.
Sleep, in addition to an obvious need, becomes a communicative value and becomes, at the center of an interrelational system between the child and the mother, a means of dialogue or a personal expression of the child during development Of his anxiety. During this phase in which the sleep cycle takes place, exogenous or conflicting causes can disrupt its functioning.
In addition, various child anxiety disorders (separation anxiety, generalized anxiety, phobias, post-traumatic stress disorder) can be accompanied by night-time manifestations, such as opposition to bedtime, a phobia of the dark, a recrudescence Anxiety during the separation of bedtime, difficulty falling asleep, anxious awakenings, even genuine nocturnal panic attacks (APN).
The AFN would be a dependent NREM phenomenon that would occur preferentially during the transition from stage 2 to stage 3 of slow sleep and whose relationship with other parasomnias and in particular night terror remains to be specified.
Sleep disorders can be integrated into a depressive symptomatology in both children and adolescents.
The total sleep time is either decreased (difficulties of sleep, nocturnal awakening, early morning awakening) or elongated (late withdrawal, iterative naps, diurnal somnolence). The architecture of sleep is disturbed with reworking cycles and different stages. A decrease in paradoxical sleep latency has sometimes been found, but this parameter, proposed by some as a “biological marker” in major depressive states of adults, appears in children with developmental First sleep period NREM. Kupfer et al., Proposed the hypothesis of two distinct mechanisms responsible for the shortening of REM latency, one of which would be NREM-dependent and could be linked to genetic and maturation factors.
Aside from this, the case of depressions of a seasonal nature in the adolescent which can be treated with “luxtherapy”, the effectiveness of which has been demonstrated on the endogenous rhythms.
Among children with Attention Deficit Hyperactivity Disorder (ADHD), many have agitated or disturbed sleep, reporting difficulty falling asleep, awakening to sleep, early morning awakening. The polygraph patterns of sleep of these children appear disturbed in the sense of a lack of control of the physiological wakefulness threshold. The effect on sleep of psychostimulating treatments such as methylphenidate, is undoubtedly not currently completely elucidated.
Disorders associated with a medical cause:
Sleep disorders in children and adolescents may be associated with a medical cause, in particular epilepsy with nocturnal seizures, which should be distinguished from parasomnia, gastroesophageal reflux, which promotes nocturnal arousal in children. Infant, asthma with nocturnal seizures or any infectious or algal pathology likely to sound on sleep. In all cases, a thorough clinical examination, supported if necessary by specialized investigations, will allow the diagnosis and the implementation of an adapted treatment.
To devote a chapter to sleep disorders of child and adolescent in a treatise on psychiatry, shows how much sleep medicine has progressed in the last ten years. The contribution of this new discipline to the understanding of the psychopathology of children and adolescents appears fundamental, since one wishes to advance in the knowledge of developmental processes and cerebral maturation. Probably this stage is necessary before attempting to interpret the “macroscopic” changes provided by the polygraphic recordings of children and adolescents suffering from psychopathological disorders. The crucial role of the developmental process is emphasized by Feinberg, for whom no known cerebral disease, consistent with life, alters sleep as much as normal development and cerebral aging.
The approach to sleep disorders in children and adolescents must be conceived from a multidimensional perspective in which learning factors and neurodevelopmental factors appear to be determinant.
The establishment of specific clinical and electrophysiological assessment tools should allow a better knowledge of these disorders, their evolution and their becoming in adulthood.