It has been estimated that as many as 60% of children suffer from sleep problems at some time during their childhood (Fricke-Oerkermann et al., 2007). Of the various sleep disorders, one of the most disturbing for parents is sleepwalking estimated to occur in 40% of children (Fricke-Oerkermann et. al., 2007). Sleepwalking is what is called a partial arousal parasomnia which is defined as a series of complex behaviors that occur during slow wave sleep (Stage III or Stage IV) and which result unusual behaviors while asleep (International Classification of Sleep Disorders Revised [ICSD-R], 1997, p.145).
Childhood Sleepwalking
Sleepwalking most often occurs in the first third of the night. This is when children move from deep sleep or slow wave sleep to a lighter stage of sleep. At this time they may wake briefly, go onto the next sleep cycle or become caught between sleep and wakefulness in a state of partial arousal. This is typically what defines the childhood sleep disorders called parasomnias. These disorders involve activation of the autonomic system, motor system or cognitive processes that result in abnormal movements, behaviors, emotions, perceptions, and dreams or nightmares (Mahowald, & Schenck, 2005). These include sleep talking, night terrors, sleep paralysis and sleepwalking among others (Cleveland Clinic).
In children, sleepwalking is evidenced by behaviors characteristic of both sleeping (eyes closed, incoherent speech) and waking (getting out of bed, unlocking doors, walking down stairs). Sleepwalking episodes range from calm walking in safe areas to agitation and frantic efforts to escape a seemingly threatening situation, which may include leaving the home or other dangerous behaviors. The following morning the child typically has no memory of the event. The peak incidence is between 4 and 8 years of age (ICSD-R, 1997).
The most common treatment for sleepwalking is advising parents to provide a safe environment for their child, but otherwise not to intervene during a sleepwalking episode (Adair & Bauchner, 1993). Even in more extreme cases, such as when the child leaves the house or is in danger of becoming injured, the focus is more on preventing harm than eliminating the sleepwalking behavior. In cases where the child is at extreme risk of harm or when sleepwalking occurs more than once per night, medication may be used though in general it is not effective and because of the chronic course of sleepwalking in children, many physicians are reluctant to prescribe them in children due to possible side effects (Kuhn & Weidinger, 2000).
Due to its potential long-term course, the high level of parental concern, potential harm to the sleepwalking child, and reluctance of physicians to prescribe medications for young children, safe, effective, noninvasive interventions are needed. Behavioral interventions may satisfy that need. Behavioral interventions that target changes in the sleep pattern have been hypothesized to impact the transition from slow wave sleep (Kuhn & Elliot, 2003).
A Behavioral Intervention for Sleepwalking: Scheduled Awakenings
An alternative behavioral intervention for sleepwalking is the use of what has been termed scheduled awakenings. This technique has been used successfully to treat night terrors, which are also thought to involve difficulty transitioning from slow wave sleep (Kuhn & Elliot, 2003). Scheduled awakening involves waking children approximately one-half hour before they are most likely to experience a sleep walking episode, as a means of disrupting sleep staging
Description of Children
In this study, three children with troubling sleep walking behavior were treated with scheduled awakenings. In each case, the child exhibited behaviors that were considered dangerous and it was therefore concluded these were cases for which it would be difficult to provide a safe environment until the child grew out of the disorder.
The children were two boys and one girl: John, Jason, and Milly. All children had a history of sleepwalking at least 3 times a week over a minimum of 12 weeks. All three children met all criteria for the diagnosis of sleepwalking, for the ICSD severity rating of "severe" and the duration rating of "chronic."
John, was a 6-Year-Old Caucasian male. His mother had reported that John had sleepwalking episodes nightly over the preceding 6 months. These episodes would occur approximately 90 minutes after falling asleep and would typically involve John walking around the house. However, during several episodes, his mother reported that she found him trying to climb out a second-story window. Thus, John's mother was concerned about the potential danger John posed to himself. His mother attempted to interrupt the sleepwalking by waking John during these episodes but was never successful.
Jason was a 12-Year-Old Portuguese male. His father reported that Jason had a 3-year history of sleepwalking every night, sometimes several times nightly. Typically, Jason would be found walking around the house but had twice been found opening the door to the basement stairs as if he was about to go down them. As these steps were very unstable, his father feared for his son’s safety. These episodes usually occurred within 2 hours of Jason falling asleep.
Milly was a 7-Year-0ld Caucasian Female. Milly's mother reported that her daughter had been sleepwalking nightly for approximately 3 months. Milly would typically "scurry" down the hallway and through the rooms of the house. However, her mother became frightened when awakened by a neighbor at 2:00am one morning. He reported that he had seen Milly walking down the middle of the street and without waking her put her in his car and brought her home. Given that Milly had managed to unlock and open the door and wander away from the house, her mother was concerned that Milly could harm herself during sleepwalking episodes.
None of the three children had any memory of their sleepwalking episodes.
Using a Sleep Record for Parents to Monitor Their Child’s Sleepwalking Behavior
Parents recorded their child's sleep behavior using a Sleep Record, to document each incident of sleepwalking, time of onset, latency from time the child fell asleep. The time of onset and latency to the episode were used to determine the optimal time of the night for implementing the scheduled awakening procedure.
Intervention for Sleepwalking: Scheduled Awakenings
Parents were taught to use scheduled awakenings approximately 15 to 30 minutes before the usual time of each child’s regular sleepwalking onset. This was typically within the first two hours after the child fell asleep. Parents were instructed to wake their child by shaking them lightly and calling their name. Once the child responded, parents were instructed to allow their child to fall back asleep. Parents implemented scheduled awakenings for 1 month. During this time, they continued to keep the Sleep Record nightly (Durand, (2010).
Outcomes of the Use of Scheduled Awakenings to Treat Sleepwalking
Before the intervention all three children were consistently having sleepwalking episodes and For John, sleepwalking occurred every night during the month prior to the intervention, for Jason sleepwalking occurred on all but two of the nights during the month and for Millie sleepwalking occurred on 25 nights out of 28 nights in the month. All three children responded immediately to the intervention of scheduled awakenings. Starting on the very first night when the intervention was implemented, each child's sleepwalking reduced to zero incidence and remained there for the month of treatment.
Follow-up and Maintenance of Treatment Gains
After the month of parents using Scheduled Awakenings to treat sleepwalking in their children they were instructed to stop the intervention and children were followed monthly for six months. Each parent reported that their children had evidenced no episodes of sleep walking at each monthly follow-up call, despite the fact that parents were no longer waking them.
The reason for the maintenance of treatment gains following the end of treatment is not clear from the present study. However, anecdotal reports from all three participating parents indicate that the children began to arouse on their own soon after treatment began. Thus, one hypothesis is that the children become conditioned to self-arouse prior to transition from slow wave sleep, thereby eliminating the need to be woken by parents, leading to treatment maintenance. This plausible hypothesis provides a direction for future research.
Parent Satisfaction with Treatment Effects
These results are encouraging, especially the maintenance of treatment gains, because there are so few effective interventions documented for the treatment of sleepwalking. In addition, it is likely this is an intervention parents would be willing to use due to what was reported after the end of treatment. This involves the primary concern reported anecdotally by parents which was that they would need to get up in the middle of the night to awaken their child indefinitely. The fact that children seemed to learn to arouse on their own without parental assistance, allowing parents to sleep through the night lead to ratings of high satisfaction with the intervention by parents.
Conclusions
The present study is significant as it demonstrates that the behavioral intervention of scheduled awakenings is comparable to or potentially better than other treatments, such as medication, without potentially harmful side effects. No increase in daytime sleepiness or difficulty with morning awakening was reported, suggesting that the intervention did not adversely affect other aspects of the children's sleep. The degree and speed of change in the target behavior, combined with the relative ease of administration of the treatment, makes scheduled awakenings an appealing treatment option worthy of further investigation with a larger number of sleepwalking subjects.
Sources
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- Cleveland Clinic, Diseases and Conditions: Parasomnias. Retrieved May 16, 2011.
- Durand, V. M., (2010, June). When Children Don't Sleep Well: Interventions for Pediatric Sleep Disorders: Therapist Guide. Avax Home eBooks. Retrieved May 22, 2011
- Fricke-Oerkermann, L., Plück,J., Schredl, M., Heinz, K, Mitschke, A., Wiater, A., &Lehmkuhl, G. (2007, October). Prevalence and Course of Sleep Problems in Childhood. Sleep, (30), 1371-1377.
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- Kuhn BR, Weidinger D., (2000). Interventions for infant and toddler sleep disturbance: A review. Child & Family Behavior Therapy 22, 33-50.
- Kuhn, B. R., & Elliott, A. J. (2003). Treatment efficacy in behavioral pediatric sleep medicine. Journal of Psychosomatic Research, 54, 587–597.
- Mahowald, M., & Schenck, C., (2005). Insights from studying human sleep disorders. Nature. 437(7063), 1279-85
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