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

“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

Night Waking Protodyssomnia* Age (months)Perturbation (1 night/wk; 2-4 wk duration) Disturbance (2-4 nights/wk; 2-4+wk duration) Disorder (5-7 nights/wk; >4 wk duration) awakings(AW)/ night and/or >10 min. AW 2 AW/night and/or >10 min AW 2 AW/night and/or >10 min AW AW/night and/or >20 min AW 1-2 AW/night and/or >20 min AW 1-2 AW/night and/or >20 min AW >361 AW/night and/or >30 min AW 1 AW/night and/or >30 min AW 1 AW/night and/or >30 min AW Note: Occurs after infant has been asleep for >10 minutes. AW, awakenings from sleep that are accompanied by signaling (crying or calling). *Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press

Sleep-Onset Protodyssomnia* Age (months)Perturbation (1 night/wk; 2-4 week duration) Disturbance (2-4 nights/wk; 2-4+week duration Disorder (5-7 nights/wk; >4 wk duration >30 min to fall asleep and/or parent remains in room for sleep onset and/or more than 1 reunion >30 min to fall asleep and/or parent remains in room for sleep onset and/or more than 1 reunion >24 >20 min to fall asleep and/or parent remains in room for sleep onset and/or more than 1 reunion Note: Occurs at bedtime or nap time Reunions refer to resistances to going to sleep. Reunions may differ in style: (1) repeated bids (kisses, hugs, glasses of water), or (2) struggles (crying, screaming, physical resistance), or (3) mixed. Reunions should be subclassified as to type. *Thomas Anders, Beth Goodlin-Jones and Avi Sadeh in Handbook of Infant Mental Health. Second edition. Guilford Press

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

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 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 1 st 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 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 2 nd 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