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16 Sleep and Attachment Disorders in Children Chap-16:Sleep 10/12/2006 4:54 PM Page 219 16 Sleep and attachment disorders in children K H Brisch INTRODUCTION their disorders in children, and to strategize pre- vention measures that can help parents and infants An infant’s quiet night of sleep is a source of hap- establish sleep patterns and regulate sleep rhythms piness and empowerment for parents. In prenatal from the beginning.5–12 classes, many parents worry that their baby might develop a sleep disorder and that night-time could become an intense scene of crying and responses. ATTACHMENT THEORY AND DISORDERS Indeed, quite a percentage of infants and children develop sleep disorders, and nocturnal wakings Attachment is a fundamental human motivation and bed sharing are quite common during early that helps the infant to survive. During the first childhood. During infancy, the frequency of night- year, an infant develops a specific, exclusive attach- wakings increases with maturation of locomotion.1 ment relationship to an attachment figure that serves Nocturnal awakings have been reported in as a secure base for the infant and provides protec- 20–30% of 1- to 3-year-olds.2,3 These findings tion. Once the baby’s attachment system starts to appear despite the fact that methodologic prob- develop, which can be observed from 12 weeks lems exist in assessing sleep problems in infants, onward, the infant reacts on separation with attach- and it is well documented that maternal reports do ment behavior, such as crying to protest separation not objectively reflect the sleep pattern of their from the attachment figure followed by seeking infants.4 Although a sleep disorder does not neces- physical contact and reunion.13 We can distinguish sarily lead to an attachment disorder, an infant’s three different patterns of attachment quality. A crying through the night can be the start of a dis- securely attached infant will protest after separa- turbed parent–infant relationship that may conclude tion from his or her attachment figure with this result. Conversely, attachment disorders and will calm down quickly after reunion. An inse- in children are also associated with a range of curely avoidant attached infant will appear not to psychosomatic problems, one of which is sleep be stressed by separation and will not actively seek problems. If a sleep disorder and an attachment physical contact with the attachment figure after disorder are a baby’s predominant symptoms, then reunion, whereas an insecurely anxious–ambivalent the parent–infant and, later, parent–child relation- attached infant will react with extreme arousal and ship will be stressful and in the worst case can will take a long time to settle down after his or progress to a vicious circle of crying and physical her attachment figure has returned. It is typical abuse. Therefore, it is necessary to understand more that the attachment system of the infant, once about the association of sleep and attachment and activated, can be preferentially calmed by physical 219 Chap-16:Sleep 10/12/2006 4:54 PM Page 220 220 SLEEP AND PSYCHOSOMATIC MEDICINE contact with the attachment figure. Only if the pri - of the attachment system. Children with different mary attachment figure, for example the mother, is types of attachment disorders may have disturbed not present, does the infant allow a second ary sleep patterns or even sleep disorders. For example, attachment figure, such as the father, to soothe some attachment-disordered children cannot calm him or her.14–18 down easily at night or wake up often and suffer Attachment disorders are caused by an infant’s from nightmares and night walking. These dis - early experiences of repeated separation and orders may manifest through hyperactivity of their multiple traumas. Such disorders commonly evolve attachment system, or the children may have diffi- from traumatic events such as physical, sexual, or culty separating before sleep. Other children may emotional violence and severe deprivation, often suffer from an inhibited attachment disorder and perpetrated by attachment figures. In addition, if will anxiously lie in bed, and not cry at night to an attachment figure is sometimes a source of emo- seek the attachment figure. Caregivers of these lat- tional availability and protection for the child and ter children may thus think the infants are easily at other times a source of violence and anxiety, it cared for, whereas the babies are instead lying in will be difficult for the child to organize these bed in a state of hyperarousal. Their hyperarousal disparate experiences into a coherent internal and inhibition of showing attachment may cause working model of attachment.18,19 them to complain of stomach aches or headaches, On a behavioral level, attachment disorders may vomit, or develop an elevated temperature. If attach - emerge as strange patterns. Two forms of attach- ment figures do not understand these signals and ment disorders are included in the International prefer children who do not cry at night, children Classification of Diseases (ICD-10)20 and the Diag- may develop chronic psychosomatic symptoms. nostic and Statistical Manual of Mental Disorders, Still other children may suffer from undifferenti- 4th edition (DSM-IV).21 One pattern involves non- ated attachment disorders (as most foster infants selective, undifferentiated attachment behavior. do) and will be happy when anyone picks them up Children possessing this pattern exhibit promiscu- from bed. They might calm down for a short ous attachments, rapidly and seemingly randomly while, but will again cry until another person comes seeking physical contact with strangers. They are along. No secure attachment representation results indiscriminately friendly toward strangers, who by from this undifferentiated attachment behavior, so definition can never be real attachment figures. that while the children may receive physical con- Other children display a type of disorder charac - tact from various people, there is no decrease in the terized by inhibited attachment behavior: these level of arousal. children, although anxious, do not show their attach - Infants or children with hyperactivation of ment behavior, instead suppressing their attachment their attachment system normally cannot separate activities, which results in a continuous state of high until they fall asleep in close physical contact with arousal. Additional types of attachment disorders their parents in the children’s or the parents’ bed. have been classified, including attachment disorders It is important to note that many parents also have with psychosomatic symptoms (e.g., sleep prob- attachment problems and have difficulty separat- lems).18 Further types of attachment disorders (such ing, and sometimes it is not clear who is clinging as non-attachment behavior in attachment-relevant to whom. Some parents, especially those with prior situation, aggressive behavior, role reversal, aggres- trauma experiences, also have their own sleep sive symptoms, and a hyperactivation of attachment problems. Attachment anxiety has been associated behavior) also show pathologic behavior patterns in with self-reported sleep difficulties in men and attachment-relevant situations.22 women; even with depressed affect been included Separation at night for sleep is one of the as a control variable, the effect of attachment attachment-related situations leading to activation anxiety remained significant.23 If a mother has an Chap-16:Sleep 10/12/2006 4:54 PM Page 221 SLEEP AND ATTACHMENT DISORDERS IN CHILDREN 221 attachment disorder with role reversal, she may were home sleepers with their parents developed a carry her infant into her bed and take the infant as secure attachment relationship with their parents, a secure base to help herself fall asleep. Mothers while infants who slept in the group setting with- with panic disorders, when describing parenting out their parents available at night developed behaviors concerning infant sleep, reported less attachment relationships with their metapelet sensitivity toward their infants, who showed more (caregiver in the kibbutzim).29–32 ambivalent/resistant attachment, higher salivary cortisol levels, and more sleep problems.24 Mothers with high symptoms of depression and anxiety ATTACHMENT, SEPARATION, AND SLEEP more likely had ambivalent attached infants and used high levels of active physical comforting, and Looking at attachment behavior from an evolu- their infants developed high initial levels of sleep tionary point of view, most infants around the problems that continued in infant sleep distur- world have slept and continue to sleep in close bances over time.25 Benoit et al26 have shown that physical contact with their parents for the first a mother’s own insecure status of attachment is year of life and possibly longer, so these infants do strongly correlated with attachment and sleep dis- not experience separation at sleeping hours.33 turbances in her infant: every insecurely attached Thus, a crying baby at night is not a question in mother in their study had a child or children with most countries. Only in Western countries and sleep disturbances. Therefore, at the start of treat- especially in Europe and North America do par- ment, it is vital that the therapist learn something ents expect an infant to separate at night and sleep about the parents’ own histories of attachment and in his or her own bed or own room. This form of their experiences of unresolved loss and separation, separation between infants and attachment figures so that treatment can also address their needs – or during the night is not consistent with evolution- the therapy of the sleep-disordered child will not ary development. In former times, when human be successful. The importance of focusing on par- beings were nomads, survival required that an ents’ status of attachment when treating their infant remain in close contact with the attach- infant’s sleep problem cannot be overstated. ment figure, usually the biologic mother, during Finally, sleep disturbances and sleep disorders the daytime and even more so during night-time.
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