You’ve heard about sleepwalking, night terrors, possibly even sleep eating. These are all what experts call “parasomnias“, a code word for “unwanted behaviors you do in your sleep.” What do all these parasomnias have in common? They are all kinds of confusional arousals. Because I am a lumper and not a splitter, I tend to look at these sleep behaviors as variations of the same thing, rather than as separate disorders. It’s not that the rest of the world are splitters. It’s only that for centuries humans have observed their family members doing weird things in their sleep. They did not realize that all these weird things were somehow connected. The version of these behaviors in babies and toddlers is not as dramatic as sleepwalking or screaming in a night terror. So in the little ones, we simply call them “confusional arousals”
Confusional Arousals: What’s the Connection?
What all confusional arousals have in common is that they are caused by a transition from deep sleep to shallow sleep. Sometimes deep sleep is called “non-REM (NREM) sleep” to indicate that we are not talking about “rapid eye movement” sleep. In children, NREM sleep tends to be deeper than in adults. It is much more difficult to awaken a child in NREM sleep. Did you ever move a sleeping child from the car to her bed and wonder why she didn’t wake up? Deep NREM sleep. That’s why.
We all cycle between the various stages of sleep, up and down, as in a wave. Children, and some adults, cycle out of NREM sleep only partially, and sort of get “stuck” between sleep and wakefulness. They aren’t really awake, but they aren’t completely awake either. It’s an altered state of consciousness. Dr. Ferber calls these events “sudden partial awakenings“.
It is during these sudden partial awakenings that parasomnias like sleepwalking happen. They occur mostly in the first half of the night, during the first or second sleep cycle. A major difference between these parasomnias and other sleep disturbances like nightmares is that sudden partial awakenings happen in the first half of the night and nightmares tend to occur in the early morning.
Most adult sleepers wake up enough to behave more or less normally, though confused. Ferber tells the story of the mother who must wake up in the middle of the night to give an ill child her medicine. She gets out of bed, shuffles to the kitchen, and then forgets why she is there. This is a classic confusional arousal.
Most of the other parasomnias are variations of confusional arousals. They only differ by degree, or as Ferber would say, by their intensity. He considers night terrors to be more intense confusional arousals than, say, teeth grinding. Somewhere in between we find sleepwalking. Ferber and I agree that these sleep behaviors all fit somewhere on a spectrum. This is because they all result from the same oddity of sleep cycles. And, more important, the treatment of all of them is basically the same (see below).
What About Babies?
Is there a group of children who have the type of sudden partial awakenings we would call simply “confusional arousals”? Yes. That would be the toddlers.
In toddlers, the only sign you may see is a child who sits up suddenly in bed. Maybe she will mumble incoherently (as opposed to other toddlers, who of course are completely clear when they speak!) Sometimes they will moan and thrash. These episodes tend to be short, a few minutes in length at the most. But occasionally, the period of confusion will last up to 30 minutes. You cannot communicate with a child in this state, and it’s not a good idea to try and wake her. The effort will probably fail, and if you do succeed, you’ll only frighten the child.
What Causes Confusional Arousals?
No one really knows why children do this. There does not seem to be any evolutionary explanation for why children and some adults have such deep NREM sleep, and then experience sudden partial awakenings. We do, however, know some things that make confusional arousals more common.
Sleep Deprivation – All kinds of disruptions in a child’s day can make confusional arousals more likely, but sleep deprivation is a major cause. The theory is that an exhausted child will sleep more deeply than normal. Then when she has a sudden partial awakening, she won’t quite wake all the way up, leading to moaning or thrashing.
Emotional Stress – Unfortunately, even toddlers and small children experience stress as well. For reasons that we do not fully understand, stress during the day can lead to parasomnias at night. Some kinds of stress are not avoidable. But it’s always best to try and keep a child’s day as peaceful and stress-free as possible. Children are often made stressed-out by parental stress. So it’s important to be aware of your own stress level and ask yourself if you are showing it to your child.
Medications – The ingredients of many cold medicines can cause sudden partial awakenings. Antihistamines are fairly common suspects. This is not the main reason why cold remedies are not recommended for small children, but it’s a pretty good reason to avoid them.
Is There Any Treatment?
The good news is that confusional arousals is that they are not harmful to the child, so there is no pressing reason to treat them. Even better news is that the child is likely to grow out of them.The exception are the children who have what Ferber calls “intense” sudden partial awakenings. Some children might thrash around to the point that they could harm themselves on furniture. For these children it makes sense to do some strategic child-proofing in her room.
For the rest, it’s important to remember that these behaviors can be triggered by some sleep behaviors that can be fine-tuned by parents. As usual the basic rules of healthy sleep apply.
- Make the child’s day as regular and predictable as possible: Children thrive on regularity and consistency.
- Keep a consistent bedtime: If at all possible, make sure she does not become sleep-deprived.
- Stress-reduction: The routine from the beginning of dinner until the moment of sleep should be calm and relaxing. Avoid too much excitement. Even funny books can rev a child’s motor too much! If you find that the child is reading your own stress, you might consider looking into stress-reduction techniques for yourself.
- Avoid giving medications that can disrupt your child’s sleep, such as antihistamines.
Have you tried all these things and your child is still having confusional arousals? Contact me. I can help.