History and exam
Key diagnostic factors
common
presence of risk factors
Factors associated with parasomnias in children include FHx of NREM parasomnias, the presence of HLA gene DQB1*05 and *04 alleles (risk of sleepwalking), underlying comorbid psychiatric disorder (risk of nightmares), comorbid psychiatric medications or alcohol, fever, acute sleep deprivation or irregular sleep-wake schedule disorder, emotional stress and traumatic life events, forced awakenings, and untreated comorbid sleep disorders.
disturbed cognition during event (confusional arousals, sleep terrors, sleepwalking)
Occurs during and immediately following the episode, specifically in non-rapid eye movement (NREM) sleep. Features include disorientation and confusion, mental slowing, and speech disturbances.
vigorous activity or violent behaviour (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behaviour disorder [RBD])
May be witnessed, or there may be evidence of these features in terms of disturbances around the house and injuries noted after the event.
episodes of inability to move (isolated recurrent sleep paralysis)
Described in isolated recurrent sleep paralysis.
autonomic hyperactivity during event (sleep terrors)
Tachycardia, tachypnoea, pupillary dilation, and diaphoresis are noted in sleep terrors.
May occur in nightmares but less commonly.
amnesia
Children typically do not recall events with sleep terrors, sleepwalking, or confusional arousals.
They may be able to recall and describe some events following a nightmare.[48]
normal physical examination between episodes
Ambulatory examination in the office setting is normal.
Other diagnostic factors
common
abnormal demeanour and facial expression (confusional arousals, sleepwalking, sleep terrors)
Occurs during and immediately following an event.
Patient has a dazed, confused look and is disorientated.
uncommon
evidence of injuries
Such injuries include wounds and bruises to the face and body.
Presence suggests sleepwalking or another parasomnia with vigorous or violent activity, such as sleep terror or rapid eye movement sleep behaviour disorder (RBD). RBD is uncommon in children.
Risk factors
strong
family history of non-rapid eye movement (NREM) parasomnias (confusional arousals, sleepwalking, sleep terrors)
Family history is particularly strongly associated with sleepwalking (very common), confusional arousals, and sleep terrors.[36][37] A family history of sleepwalking or sleep terrors may occur in up to 80% of individuals who sleepwalk. The risk for sleepwalking is further increased (to as much as 60% of offspring) when both parents have a history of the disorder.[12]
presence of HLA gene DQB1*05 and *04 alleles (sleepwalking)
These alleles have been reported to be associated with a risk of sleepwalking.[38]
medications or alcohol
A risk factor for both non-rapid eye movement (NREM) and rapid eye movement (REM) parasomnias.
In particular, sedative antidepressants and non-benzodiazepine hypnotics are associated with an increased risk of sleepwalking; regular zolpidem and antidepressants are associated with sleep-related eating disorder; and serotonin selective reuptake inhibitors are associated with an increased risk of REM sleep without atonia.[39]
Certain pharmaceutical agents that suppress REM sleep (e.g., antidepressants, anxiolytics, and clonidine) can result in REM sleep rebound, dramatic and vivid dreaming, and nightmares.
Alcohol may predispose to parasomnias.[40]
acute sleep deprivation or irregular sleep-wake schedule disorder
May trigger an arousal disorder.[44] However, there is a stronger association with this factor and parasomnias in adults compared with children.
Should be viewed as a triggering event in susceptible individuals rather than as a causal factor.
emotional stress and traumatic life events
May trigger an arousal disorder.[44] However, there is a stronger association with this factor and parasomnias in adults compared with children.
Should be viewed as a triggering event in susceptible individuals rather than as a causal factor.
forced awakenings
Parasomnias are commonly reported to occur after forced awakening from sleep.
untreated comorbid sleep disorders
Disappearance of sleep terrors and sleepwalking after treatment for sleep-disordered breathing, restless legs syndrome, or periodic limb movement syndrome in pre-pubertal children suggests that these comorbid sleep disorders may trigger sleep terrors and sleepwalking.[27]
A variety of primary sleep disorders, such as nocturnal epilepsy, or sleep-disordered breathing may provoke disorders of arousal.[28][37]
Although rapid eye movement sleep behaviour disorder (RBD) is very rare in children, its appearance may indicate a new onset of narcolepsy, especially in patients in whom HLA-DQB1 *0602 is positive and cerebrospinal fluid hypocretin level (Hcrt-1) is extremely low.[21][45]
weak
history of psychiatric disorder
fever
May trigger an arousal disorder.[43]
Should be viewed as a triggering event in susceptible individuals rather than as a causal factor.
premenstrual state (in adolescent girls)
There have been reports of sleepwalking and sleep terrors temporally related to menses in adolescent girls.[46]
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