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.