CHALLENGING CASE: BEHAVIORAL CHANGES

Recent Onset of Sleepwalking in Early Adolescence*

CASE Martin T. Stein, MD A healthy 13-year-old boy experienced two sleep- Professor of Pediatrics walking episodes during the last 3 months. Both School of Medicine University of California, San Diego occurred away from home, after he went to bed later San Diego, California than usual (about midnight), and occurred approxi- mately 2 hours after going to sleep (about 2 a.m.). Dr. Richard Ferber During the first episode, he fell down some stairs at Sleepwalking consists of movements related to camp, inflicting minor trauma that awoke him. The ambulation (sitting, walking, running) occurring second episode occurred at a friend’s home, when he during a partial arousal from (usually) stage IV non- walked outside the house and could not get back in. REM sleep.1–4 The behavior actually takes place dur- He has no previous history or family history of sleep- ing a transition from deep sleep to waking, usually at walking. He has no history of night terrors. the end of a sleep cycle, ends when the arousal is complete and full wakefulness is reached, and gen- erally is followed by rapid return to sleep. Electro- Dr. Martin T. Stein physiologically, such transitions represent no more For most behavioral conditions of children and than somewhat exaggerated versions of normal tran- adolescents, a distinct biological marker has not been sitions that occur nightly in everyone. Typically, discovered. An area of behavioral pediatrics, how- there is full amnesia for the event itself, although the ever, in which our understanding of the biology of child may remember finding himself in an unusual specific behaviors is at least partially evident, consti- location upon waking. Events usually occur early in tutes a group of sleep disorders known as parasom- the night (typically, 1–3 hr after sleep onset, when the nias. Sleepwalking, confusional arousals, and sleep first or second cycle of deep sleep is ending). The terrors are different clinical phenomena that share a somnambulistic child may be quite calm or very common alteration or exaggeration of a normal elec- upset and agitated. “Sleepwalking may be associated trophysiological sleep pattern. These disorders of with falls, injuries and...walking out of a door into arousal (or partial arousal states) were discovered the street.”5 A noise, or even just the act of covering over 30 years ago by the use of electroencephalo- a child, may act as a precipitant; in fact, sleepwalking graphic measurements during sleep. The neurologi- can be induced in most young children simply by cal event in the brain that has been associated with standing them up 1 to 2 hours after they fall asleep.4 parasomnia is, in fact, an exaggeration of the physi- Probably the single factor most commonly associated ological arousal state that is known to occur period- with arousal parasomnias in childhood is that of ically through the night between deep (non-rapid being “overtired,” typically from a late bedtime or an eye movement [non-REM]) and lighter (REM) sleep. unusually active day. Although “arousal events” For clinicians, the important questions are the fol- tend to occur more commonly at home (child is lowing: Why are partial arousal events seen in many relaxed and sleeps deeply) than in other environ- children but not all? What is the interaction between ments, it is also true that they are common in situa- a constitutional predisposition to these events and tions that require behavioral control at times of anx- experiences in a child’s environment associated with iety (e.g., start of school term or camp), whether the internalizing and externalizing behaviors? When are child is home or not. Occasional sleepwalking is therapeutic interventions indicated and which treat- reported to occur in about 15% of children (even ments are most effective? more in children with strong family histories).6,7 In Dr. Richard Ferber, a pioneer in the clinical study reality, most children probably have wandered to the of sleep disorders in children and adolescents, com- bathroom or to their parents’ room at night without ments on a diagnostic and management approach to fully waking. an early adolescent with a recent onset of sleepwalk- Because sleepwalking and other partial arousal ing described in this challenging case. Dr. Ferber is symptomatology (sleep terrors, confusional arousals) an Associate Professor of Clinical Neurology at Har- occur so commonly in children, evaluation beyond vard Medical School and Director of the Center for careful history and physical examination generally is Pediatric Sleep Disorders at the Boston Children’s neither required nor realistic. As described in a re- Hospital. cent American Sleep Disorders Association practice parameters article,8 the main indications for obtain- ing polysomnographic (or electroencephalographic)

* Originally published in J Dev Behav Pediatr. 1998;19(4) study are, as follows: (1) the events are likely to be PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad- ictal in nature (e.g., tonic-clonic movements, postictal emy of Pediatrics and Lippincott Williams & Wilkins. states); (2) they are violent or potentially injurious to

842 PEDIATRICS Vol.Downloaded 107 No. 4from April www.aappublications.org/news 2001 by guest on September 24, 2021 the patient or others (whether suggestive of an ictal and Practice of Sleep Medicine in the Child. Philadelphia, WB Saunders, etiology or not); (3) they include features atypical for 1995, pp 99–106 4. Fisher C, Kahn E, Edwards A, Davis DM: A psychophysiological study usual arousal parasomnias (this could mean the pres- of nightmares and night terrors, I: Physiological aspects of the stage 4 ence of stereotypical, repetitive, or otherwise un- night terror. J Nerv Ment Dis 157:75–98, 1973 usual motor patterns features, or that the events 5. Diagnostic Classification Steering Committee: International Classifica- occur only towards morning, are very long lasting, or tion of Sleep Disorders: Diagnostic and Coding Manual. Rochester, MN, American Sleep Disorders Association, 1990 recur with unusual frequency); (4) there is failure of 6. Kales A, Soldatos CR, Bixler EO, Ladda RL, Charney DS, Weber G: conventional therapy (assuming therapy is even re- Hereditary factors in sleep walking and night terrors. Br J Psychiatry quired); or (5) forensic evaluation is required. 137:111–118, 1980 In the case of the 13-year-old boy described here, 7. Klackenberg G: Incidence of parasomnias in children in a general pop- an ictal explanation is extremely unlikely. The events ulation, in Guilleminault C (ed): Sleep and Its Disorders in Children. New York, Raven Press, 1987, pp 99–113 as reported are apparently typical of sleepwalking in 8. Indications for Polysomnography Task Force: American Sleep Disor- all respects (time of night, behavioral characteristics, ders Association Standards of Practice Committee: Practice parameters precipitating conditions). For typical sleepwalking for the indications for polysomnography and related procedures. Sleep events that have occurred only twice, generally no 20:406–422, 1997 9. Fisher C, Kahn E, Edwards A, Davis DM: The psychophysiological further evaluation is required. Although falling study of nightmares and night terrors, II: The suppression of stage 4 down the stairs and getting locked out of a house are night terrors with diazepam. Arch Gen Psychiatry 28:252–259, 1973 potentially injurious conditions, in this case they seem to have been accidental and are unlikely to be repeated if proper safeguards are taken (as opposed Dr. Martin T. Stein to arousals with wild running, knocking over furni- The diagnosis of sleepwalking was not difficult in ture, swinging at people, or jumping through win- this case. A detailed history from the parent (or other dows). Thus, only if there were litigation pending witness) who is asked to describe the event without (since he fell down at camp and sustained minor interruption and in their own words is the first step. injuries) would polysomnography be indicated. Focused questions about frequency, duration, asso- Two episodes of (apparently calm) sleepwalking ciated events during the day, and circumstances sur- during a 3-month period should not be considered rounding sleep are usually helpful. The characteris- an indication to start pharmacological (or, for that tics of the two episodes in this case are consistent matter, any other) treatment. In fact, this youngster with the criteria for sleepwalking as defined by Dr. has had no known episodes except for two nights out Ferber.1 of 13 years. The most important consideration is to When a parent describes an unusual event during provide explanation and reassurance to the family. sleep associated with motor activity, vocalization, or An extra lock could be placed high on the door of the autonomic responses, in addition to sleepwalking, it house to make it unlikely for him to simply wander is reasonable to consider a nocturnal seizure. Repet- out to the street without making enough noise to itive, stereotypical, or violent behaviors may suggest alert family members. The stairs need to be kept clear a partial complex seizure. This should be differenti- of obstacles. Although a gate could be added to block ated from the agitated form of sleepwalking during the stairs, this is probably not necessary for this which speech is garbled or unintelligible, and the teenager (calm sleepwalkers rarely fall down famil- child recoils with greater agitation when touched or iar stairs, and he has never walked in his sleep at held. Nocturnal seizures may occur anytime during home). For future sleep-overs, the camp and other sleep, but they are more likely to occur during tran- parents need to be alerted that the boy should not sition states, at the onset of sleep, or just before sleep by the door to the cabin at camp, and he should awakening in the morning. Because seizures at night probably not be assigned an upper bunk. Avoiding disturb restful sleep, daytime somnolence may oc- even occasional late bedtimes is nice in principle but cur. There are many similarities, however, between difficult to enforce. If the events should recur when nocturnal seizures and sleepwalking.2 In both condi- he is away from home, covering such nights with tions, the patient is unarousable during the event. low-dose benzodiazepene treatment (e.g., 0.25–0.5 With a seizure at night, there is confusion followed mg of clonazepam at bedtime) might be considered by wakefulness. During sleepwalking, similar to (especially if patient or family concerns are great).3,9 other partial arousal disorders, the patient is un- arousable or very confused if awakened. In both, Richard Ferber, MD amnesia for the event is characteristic. A standard Associate Professor of Clinical Neurology electroencephalogram is not a diagnostic tool for Harvard Medical School sleepwalking but may be useful when the descrip- Director of the Center for Pediatric Sleep Disorders Boston Children’s Hospital tion of the event is ambiguous and suggests a sei- Boston, Massachusetts zure. Sleepwalking can be conceptualized as a constitu- tional predisposition to a particular form of a partial REFERENCES arousal state that is most often a spontaneous event 1. Broughton R: Sleep disorders: Disorders of arousal? Science 159: and unrelated to precipitating factors. At other times, 1070–1078, 1968 it is precipitated by an environmental stressor asso- 2. Gastaut H, Broughton R: A clinical and polygraphic study of episodic phenomena during sleep. Biol Psychiatry 7:197–223, 1965 ciated with anxiety or a significant life-event change. 3. Rosen G, Mahowald MW, Ferber R: Sleepwalking, confusional arousals, Parents of susceptible children often report that and sleep terrors in the child, in Ferber R, Kryger M (eds): Principles sleepwalking occurs when their child is overtired

Downloaded from www.aappublications.org/news by guest on September 24, 2021 SUPPLEMENT 843 and when daytime schedules are irregular. Major by Dr. Ferber, imipramine is also effective before psychological factors are usually not found in these bedtime.3 cases. As children approach adolescence, stressors Two other approaches may be helpful. Self-regu- around home life (marital discord, separation/di- lation techniques that teach children relaxation and vorce, family moves), in school (impending test, mental imagery during wakeful states have been competitive sport event), interpersonal issues (dat- used to control nocturnal behaviors. Although stud- ing, relationships), and changes in sleep environ- ied more extensively in children with sleep terrors,4 ment (sleep-over and camp, as in the challenging relaxation and mental imagery has been used with case presentation) may precipitate sleepwalking. success in sleepwalking children.5 These techniques An understanding of the constitutional and pre- require special training that can be applied in a pe- cipitating components of sleepwalking guides a rea- diatric setting.6 Finally, scheduled awakening for at soned clinical approach. When the events are infre- least 5 minutes approximately 30 minutes before the quent, typical of a partial arousal event in timing and anticipated sleepwalking has been shown to be ef- motor patterns, associated with overtired periods, fective in some cases.7,8 and without major psychological stress, then educa- tion, reassurance, and attention to the child’s safety, as described by Dr. Ferber, is sufficient. When a REFERENCES developmental or psychosocial history reveals unex- 1. Wolraich ML, Felice ME, Drotar D (eds): The Classification of Child and pressed feelings of anxiety, sadness, or unresolved Adolescent Mental Diagnoses in Primary Care (DSM-PC): Child and Adolescent Version: Elk Grove Village, IL, American Academy of Pe- stresses related to home, school, or friendships, fur- diatrics, 1996, pp 199–206 ther exploration is appropriate. Sleepwalking, in 2. Rosen G, Mahowald MW, Ferber R: Sleepwalking, confusional arousals, many of these situations, may play a minor role but and sleep terrors in the child, in Ferber R, Kryger M (eds): Principles serves as a dramatic symptom that brings the patient and Practice of Sleep Medicine in the Child. Philadelphia, PA, WB Saunders, 1995, pp 99–106 to medical attention. Rather than overfocus on the 3. Pesikoff RD, Davis PC: Treatment of pavor nocturnal and somnambu- sleepwalking, the clinical encounter should be used lism in children. Am J Psychiatry 128:134, 1971 to explore the severity of the precipitating condition 4. Kohen DP, Mahowald MW, Rosen RR: Sleep terror disorder in children: on a functional dimension and to determine whether The role of self-hypnosis in management. Am J Clin Hypn 34:233–244, further evaluation or treatment is necessary. 1992 5. Olness K, Kohen DP: Hypnosis and Hypnotherapy with Children, 3rd Dr. Ferber observed that, in most cases of sleep- ed. New York, NY, Guilford Press, 1996, pp 161–162 walking, education of the child or adolescent and the 6. Sugarman LI: Hypnosis: Teaching children self-regulation. Pediatr Rev parents, coupled with reassurance and specific sug- 17:5–11, 1996 gestions for the patient’s safety, is sufficient. In rare 7. Tobin JD Jr: Treatment of somnambulism with anticipatory awakening. J Pediatr 122:426–427, 1993 cases that are resistant to these conservative mea- 8. Frank NC, Spirito A, Stark L, Owens-Stively J: The use of scheduled sures, medications that affect partial arousals may be awakenings to eliminate childhood sleepwalking. J Pediatr Psychol useful. In addition to clonazepam as recommended 22:345–353, 1997

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