Last Updated on March 13, 2023 by Mike Robinson
Sleepwalking in children, characterized by a sequence of more or less complex behaviors that occur during slow-wave sleep, occurs between phases 3 and 4 of NREM sleep, usually in the first third of the night.
It is classified within sleep disorders and is a problem that falls within the parasomnias, in the disorders of awakening. Parasomnias are characterized by abnormal events or behaviors associated with sleep, its specific phases, or moments of the sleep-wake transition.
Other parasomnias besides sleepwalking are nightmares, night terrors, or other unspecified parasomnias ( sleep paralysis, behavioral disturbance of REM sleep).An episode of sleepwalking begins with bodily movements that can cause the subject to sit on the bed in an abrupt manner or to get up and start wandering.
It may be associated with other sleep disorders. In this way, we frequently find that the same individual also presents somnambulism or somniloquy, which indicates that there could be some kind of relationship.
In addition, in children, many episodes of sleepwalking precede nocturnal terrors, and children with enuresis are more likely to experience sleepwalking throughout adolescence.
With disorders of awakening, we refer to the manifestations of partial awakening that occur throughout the dream. They are primary disorders of the mechanisms of normal awakening.
Classification and diagnosis of sleepwalking
Sleepwalking is the group with parasomnias. They are not serious disorders in childhood, although they can become annoying and draw the attention of the family because they are bulky.
In addition, excessive fatigue, feverish processes, or anxiety can increase them. The diagnosis of parasomnia must occur with a detailed clinical history; in some cases, polysomnography can help differentiate it from some types of epilepsy.
During the episode, the child may respond in monosyllables to the questions, but not always, since he or she will generally not understand the meaning of the words.
In addition, it is difficult to wake him up because he is deeply asleep, and if he is able to do so, he will be insecure and will act strange since he will not recognize the situation.
Sleepwalking is in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), within parasomnias and non-REM sleep arousal disorders. The diagnosis occurs when the person has repeated episodes in which the individual gets out of bed and walks during sleep.
During this episode, he has his gaze fixed and blank and is relatively insensitive to the efforts that other people make to communicate with him, waking up only after much difficulty.
Symptomatology and characteristics of sleepwalking
Sleepwalking would consist of a dissociated state of consciousness since the phenomenon of sleep (a neurophysiological state) goes with that of waking (appearance, behavior). It is, therefore, in the category of an arousal disorder.
As we have said, it occurs in the first half of the night, when phases 3 and 4 of non-REM sleep are more frequent.
Due to the disorder’s characteristics, you would expect it to happen during REM sleep, with rapid encephalographic activity and high cerebral activation.
However, in the records, it appears in non-REM sleep, where the cortex is progressively deactivated. Slow waves appear, in addition to decreased muscle tone, lower cerebral blood flow, and heart rate or glucose metabolism.
The symptoms of the sleepwalker are the body movements that he performs, which can lead him to get out of bed, to wander, to sit on the bed, and so on. In addition, he keeps his eyes open and fixed, being able to inspect the environment and thus avoid the different objects that may be blocking his way.
However, there are different risks, such as falling downstairs or through a window The somnambulist can perform different actions: she can dress, open doors and windows, leave home, feed, do personal hygiene tasks, etc.
Occasionally he can speak, although his articulation is very poor and usually only murmurs. In addition, a false response occurs throughout the episode, whose end can occur in multiple ways. In this way, attracting the attention of the person or waking them up does not usually have a result.
Duration of sleepwalking
The duration of the sleepwalking episode is variable since it can go from about 1 minute to even exceed 30 minutes. And usually, a single episode takes place in one night. The frequency with which it can occur—even several episodes within a week—and that it can even last several years—is unpredictable.
In addition, the person with somnambulism does not have to have any alteration in their behavior during the day since the problem occurs exclusively during sleep. Neither does it have to predispose to other pathologies.
However, the occurrence of frequent sleepwalking episodes worries the family, and there may be an alteration in relationships with other people. Sleepwalking implies that the child automatically repeats behaviors he has learned during waking periods during sleep. The child is deeply asleep when he does it.
The episode usually appears when the child has slept between 2 and 4 hours. Normally, the episode ends when the child returns to bed. In addition, the child forgets the episode the next day.
A typical sequence of events may be that the child gets out of bed, even if his eyes are open, goes to the bathroom, pees on the floor, and returns to bed, for example.
In addition, the most frequent form of sleepwalking is that which appears in childhood, presents a family predisposition, and disappears at puberty.
However, there is another, less common form: when it appears in preadolescence and has never been present before. In this case, they are usually reactive. and it is usual for it to be comorbid with other psychopathological manifestations.
In children with somnambulism, there is amnesia about the episode. or a fragmentary memory?
Causes of Sleepwalking in Children
Sleepwalking could have a hereditary basis since it usually occurs to a greater extent in children whose parents were also somnambulists in their childhood than in the normal population.
In addition, in monozygotic (identical) twins there is greater concordance than in dizygotic (twins), which would also support this statement.
On the other hand, we could indicate that there is a genetic predisposition in children that, in times of stress (for example, school stress or exams), would awaken these episodes.
Sleepwalking in children does not indicate that there are also effective alterations, which do seem to be related in that stressful episodes exacerbate their appearance.
Sleep deprivation can also affect the timing of episodes of sleepwalking.
Different hypotheses about the etiology of sleepwalking have been described. For example, both emotional factors and maturational delays have been included.
Other studies have shown, through the polygraph, that it is a disorder of awakening where the subject, after phases III and IV of the dream, passes abruptly to the first two phases, so that a superficial dream occurs.
According to a study by the University of Washington (United States) that was published in the journal “Neurology,” a failure on chromosome 20 could help to show sleepwalking.
According to other studies, the risk of a child being a sleepwalker is seven times greater if their parents were sleepwalkers too. For example, 25% of the children had parents who had not been sleepwalking, compared to 47% who had a father who had been sleepwalking, or 62% where the two had been sleepwalking.
We could conclude that this alert disorder is due to an interaction between genetic, maturational, organic, and psychological causes and that it usually occurs in stages of a child’s development.
Research and Studies on Sleepwalking
Sleepwalking begins between approximately 4 and 8 years, being more frequent in the male than in the female. In addition, it is common to disappear throughout adolescence, so it is a disorder most often given in childhood.
Around 15% of children have, at some point, an episode of sleepwalking. Normally, it disappears spontaneously at 15 years old, and after this age, only 0.5% of adults conserve these episodes of sleepwalking.
Also, several studies have shown that about 25% of children have one episode per year and 10% at least once a week. When episodes are very frequent or persist with age, it is advisable to perform the differential diagnosis of temporal lobe epilepsy.
It is important to note that the prevalence of sleepwalking increases when sleep ends prematurely. Sleepwalking increases in children under five when someone abruptly wakes them up.
It happens because “sleep deprivation” occurs so that when children start sleeping at night, they quickly enter the 3–4 phase of sleep.
Evaluation and treatment
You should evaluate sleep disorders in children by considering their age since there are pathological behaviors that at certain ages are normal or vice versa. And also ask if there really is a problem or if there are expectations from the parents.
Parents should know about these sleep problems and know that they are harmless and will get better over time. In the evaluation, which should take into account the anamnesis and physical examination (if it is a transient or chronic problem, etc.), you can use sleep diaries and questionnaires, psychophysiological techniques, etc.
In the case of sleepwalking, you should record the time of the episode after the dream started and a family history of parasomnias. A camera could even be helpful to record episodes.
Some sleep disorders, such as sleepwalking, require a differential diagnosis with other neurological diseases, usually epileptic seizures. In most cases, the diagnosis can be made using EEG and polysomnography techniques. The EEG record during sleepwalking shows a combination of alpha, theta, and delta frequencies, without a typical wakefulness pattern.
In sleepwalking episodes, there is no evidence of complete awakening, even though the person’s behavior may be complex. The child shows an absence of response to stimuli and different levels of autonomous activation.
There is no specific treatment, although episodes usually decrease with the child’s age. Normally, since it is a benign sleep disorder, no special treatment is usually necessary.
Safety precautions to consider
Parents should make sure their child doesn’t hurt himself or herself while sleepwalking. Think about how easy it is to get to the windows, don’t put dangerous things in the room, lock dangerous places like windows or doors, don’t have high beds or bunk beds, block the stairs, etc.
The precaution also includes avoiding all the factors that can trigger the episodes: fatigue, anxiety, etc. And you should practice good sleep hygiene.
In addition, if it is an intense problem causing anguish to the parents, the specialist can be asked for an assessment to deal with pharmacotherapy, such as diazepam, in a short period of time.
Another way to treat sleepwalking is to wake the child up about 15 minutes before it happens.
The most appropriate is to attend to environmental control measures to avoid accidents and also to use behavioral procedures that are less intrusive and have fewer side effects than medication.
Alternative Options
Some authors propose that a practice based on scheduled and therapeutically controlled naps can mitigate or reduce the frequency with which episodes of sleepwalking occur due to their effects on deep sleep.
Another available alternative is to put in some kind of alarm that can help the child not get hurt when he gets up during the night.
How should I act before the episode? During these, it is advisable to take the child back to his bed and talk to him in a relaxed manner. In addition, you should speak with short and very simple sentences.
Sleepwalking is not a serious health problem for the child or one that affects their brain development. However, it can affect your nightly rest and may worry the family a lot, so prevention, in this case, is the most appropriate measure.
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