Sleep Problems in Infants and Toddlers John A. Biever, MD Central Pennsylvania Institute for Mental Health Clinical Associate Professor of Psychiatry PennState Hershey Medical Center
Status of Diagnostic Thought • International Classification of Sleep Disorders • Subcategorizes as dyssomnias, parasomnias and sleep problems secondary to medical/psychiatric disorders • Does not extend diagnostic criteria to infants and toddlers • DSM-IV • Similar subcategorization as ICSD • Again, developmental norms do not extend to infants and toddlers.
DC:0-3 Diagnostic Classification System for Infants/Toddlers Sleep Behavior Disorders • For children >12 months of age • Sleep-onset disorder: at least 4 weeks of needing parental contact in order to get to sleep • Night-waking disorder: at least 4 weeks of wakings that require parental attention • Sleep problems also included as symptoms in several other disorders
A Proposed Alternative Classification System* • Takes into account the relational component of sleep disturbances in infants/toddlers • Considers, therefore, the status of the attachment bond between parent and child • Considers the dual functions of homeostatic and social/affective regulation in the dyadic interaction *Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
“Protodyssomnias” • “Proto-” because they do not require “functional impairment” as does DSM-IV • Night Waking Protodyssomnia • Sleep-Onset Protodyssomnia • Diagnostic criteria vary by age and severity
Underlying Premises • Unreasonable to classify sleep disturbances in infants <12 months of age (instead, look at the relationship/attachment) • Assumes that child is sleeping in own bed • Child is being reared in a diurnal environment (sleep at night, wake during day)
Clinical Interventions • Perturbation: normal—reassurance with information • Disturbance: at risk—parent education and guidance • Disorder: more intensive treatment, individualized to the particular problem
Proposed Multiaxial Diagnostic System* Axis I: Perturbation/disturbance/disorder Night waking protodyssomnia Sleep-onset protodyssomnia Schedule disruption protodyssomnia (e.g. daytime napping) Parasomnias, sleep apnea Axis II: Parent-child interaction styles Balanced/synchronous Overregulating/controlling Underregulating/distant Inconsistent/unpredictable *Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press. 2000.
Multiaxial System, cont’d. Axis III: Infant Factors Temperament Developmental quotient Medical illnesses Axis IV: Context factors Family/marital stress Parenting stress/hassle Family psychopathology Family trauma/violence
Neurobiology of Sleep • Circadian rhythm: the 24 hour sleep-wake cycle • Ultradian rhythm: the 60-90 minute sleep cycle of alternating REM (rapid eye movement) and non-REM phases of sleep • Diurnal: the circadian cycle that gets entrained into light-dark conditions.
Infant Evolution of the Diurnal Cycle • Average newborn daily sleep is 18 hours, ranging from 10 to 22, with typically a period of wakefulness every 3-4 hours. • By 6 months, periods of sleep stretch out to as long as 6 hours, and begin to concentrate during dark hours, while wakefulness concentrated during light hours. • By 1 year, typically 1-2 long nighttime sleep periods, 1-2 short daytime naps.
Later Evolution of Sleep • Second year: one long nighttime sleep period and 1 nap, usually afternoon • Later, nap may be eliminated depending on social circumstances, although naps may be preserved throughout life.
Ultradian Cycle Evolution • 1st 3 months: 50% of sleep is REM (syn. “dream”, “active sleep”, “paradoxical sleep”), other half in n-REM (“slow wave”, “quiet”) sleep • 2-3 y/o child: 35% REM • Adult: 20% REM
Ultradian Cycle Evolution, cont’d. • By 3 months of age, cycles remain at 50-60 minutes but REM duration diminishes. • REM becomes more prominent in later phase of sleep (toward morning) and n-REM in earlier phase. • By adolescence, cycle lengthens to 90 minutes.
Night Waking Problems • By 8 months, most (60-70%) infants soothe selves when they awaken. • During second year, often an increase in nighttime awakenings. • Infants and toddlers have more awakenings than “signaled” (crying, etc.) awakenings. i.e. often they return to sleep without signaling.
Sleep-Onset Problems • Going-to-bed and falling-asleep problems. • By 12 months, 70% infants placed in crib awake at night—gives them opportunity to learn to fall asleep on own • 2nd yr. of life: separation anxiety, and also… • limited family time • maternal depression • marital problems
Parasomnias • Begin in toddlerhood • Boys > girls • Night terrors: stage 4 n-REM sleep (deepest stage), normally outgrown by adolescence • Nightmares: REM sleep, child alert when they cause awakening, unlike in night terrors. Reassurance and decreasing daytime stress are recommended. • Rhythmic movements: 58% down to 22% by 2 years: parental reassurance, unless head banging is injurious.
Sleep Apnea • Central or obstructive: screen for asthma, snoring, mouth breathing • Normally, decreased oxygen saturation causes micro-arousal and restoration of breathing, with person unaware of the arousal. • In children, apnea can cause inability to achieve stage IV sleep, resulting in diminished growth hormone secretion and growth retardation.
Causes of Sleep Problems • Nutritional and/or physical discomfort, including food/milk allergies, colic • Temperament, especially low sensory threshold, low adaptability, high distractibility, negativity of mood. • Parental conflict, maternal psychopathology, family stress, traumatic events
Co-sleeping • In infants, correlates with more sleep time at night, especially when breast-fed. • More frequent, but brief arousals: Protective against SIDS? • In older toddlers, is co-sleeping a cause or effect of sleep problems?
Assessment • Importance: ½ of children with infant-toddlerhood sleep problems will continue to have sleep problems later on. • Ask routine screening questions re the above, including child’s degree of rested-ness and wakefulness during the day. • Suggest keeping a diary if sleep problem is suspected.
Treatment • Behavioral approaches, based on the idea that sleep-onset problems represent learned interactional patterns between child and caregiver • Interpersonal/psychodynamic approaches: looking at the relationship between caregiver and child for problems and for solutions • The transitional object: thumb, special blanket • Brief period of parent sleeping in same room