General Principles

Sleep disorders should be considered whenever a child is being evaluated for a behavioral problem. Insufficient quality or quantity of sleep may be associated with learning difficulties and attention problems (8,18-23). When a child does not sleep well it can disrupt the entire household and lead to significant stress for the family (24-26). Unrecognized and under-treated sleep disturbances may carry over into adulthood (27).

In pediatrics, a medical history usually starts with the history of the pregnancy and delivery. However, an adequate history of a child's sleep disorder should begin with a history of the sleep patterns of the parents/caretakers before they were ever parents. For example, if an infant sleeps continuously for seven hours at night and the mother was in the habit of sleeping 6.5 hours before the pregnancy she might be pleased with the way the child is sleeping. However, if the mother usually slept for eight or nine hours she might complain that the child is not sleeping enough at night. If a parent had a history of occasional insomnia before the infant was born, the parent might be overly sensitized to interruptions of sleep by the infant, whereas another parent might find the disruption more tolerable. A parent who has a history of snoring or mild OSA might be less able to tolerate what would otherwise be considered normal or expected interruptions of sleep by a child.

The child and family's cultural background must be taken into account when evaluating a complaint of poor sleep. Also the influence of other family members or caretakers, such as grandparents, in shaping the family's views should be considered. The parents need to agree about their expectations of the child's sleep, especially if the parents come from different cultural backgrounds. The individual parent (mother or father) may view the infant's sleep pattern from quite different perspectives.

In any evaluation, it is crucial to keep in mind the interaction between the physiological need for sleep and the psychology of sleep. All of us sleep best when we go to sleep feeling safe and comfortable. We learn to feel this way by forming associations with our sleeping environment and these associations are formed starting from infancy. Infant and children, like adults, may develop maladaptive associations that result in sleep difficulties. When evaluating school-age children for a sleep problem it is important to ask the child directly if he or she is scared of the dark or of being alone. The parents may minimize these concerns and the children may be too embarrassed to volunteer the information.

It is not uncommon in a clinical situation to have two or more sleep disorders interacting in the same patient. A child may have an awakening due to difficulty breathing from sleep apnea, but then be unable to return to sleep because he or she has not learned to settle back down without the parents' intervention.

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