Dyssomnias

Extrinsic Dyssomnias

Night waking and/or reluctance to go to bed are the most common sleep complaints of parents about their infants and young children. These disruptions in sleep might better be classified as extrinsic "proto" or "potential" dyssomnias. Night-waking problems begin to cause concern in the last 3 months of the child's first year of life and become more prominent in the second year (Anders et al. 2000). Before the child is 9 months old, night waking is tolerated as "normal" (Ferber 1999; Goodlin-Jones et al. 2000). Moore and Ucko (1957) defined night waking as a "disorder" when a child awakens and cries one or more times between midnight and 5 a.m. on at least 4 of 7 nights, for at least 4 consecutive weeks. By age 1 year, 50% of infants who had previously slept through the night were reported as experiencing night waking. Moore and Ucko reported a further transient increase in problem night awakenings during the second year of life. In other studies, nearly 20% of toddlers were described as experiencing night waking (Bernal 1973; Jenkins et al. 1980). The prevalence decreases to 1%-5% in school-age children (Gass and Straugh 1984; Richman et al. 1982).

In this regard, it is important to acknowledge that there are significant family, community, and cultural determinants in the definitions of infant sleep problems. Some families and some cultures tolerate sleep disruptions better for longer periods (Lee 1992). Similarly, some families and cultures are more flexible in devising workable solutions. For example, having an infant sleep alone seems to be highly valued in our culture. Yet, infants' sleeping alone is a custom that is relatively new in the span of human evolution and is characteristic of only a small segment of our global society (Caudill and Plath 1966; Lozoff et al. 1984; McKenna et al. 1990; Thevenin 1987). The use of a sleep aid has cultural, community, and family implications as well. For some parents, use of sleep aids is viewed as unhealthy and is discouraged. Community and family values must be considered in evaluating problems and prescribing treatments.

Little is known about the outcomes of "proto" dyssomnias in regard to their progression to genuine dyssomnias with daytime impairment. Zuckerman and colleagues (1987) followed up 8-month-old infants with sleep problems and found that 41% of them still had problems when they were 3 years old. Only 26% of the children with sleep problems at age 3 years had not manifested them when they were 8 months old. Kataria and colleagues (1987) found that in their sample, 84% of 3-year-olds still had their sleep problems 3 years later. Richman and colleagues (1982) found that almost half of 3-year-old children who experienced night waking had had their problem from birth, and 40% of the children who had sleep problems at 8 years had had problems at least from the time they were 3 years old. Although some studies attribute the origins of these problems to intrinsic factors related to temperament (Carey 1974; Schaefer 1990; Weissbluth et al. 1984), others have emphasized the importance of extrinsic factors such as nutritional and allergenic factors, stress, and states of physical discomfort (Beal 1969; Kahn et al. 1989; Wright et al. 1983). Parental conflict, maternal personality, and maternal depression have also been identified as contributing factors (Field 1994; Guedeney and Kreisler 1987; Zuckerman et al. 1987). When the disturbance is severe, ICSD-CDM diagnostic labels such as "inadequate sleep hygiene," "environmental sleep disorder," "insufficient sleep syndrome," "limit setting sleep disorder," "sleep-onset association disorder," and "food allergy insomnia" may be appropriate (see ).