- Does the child complain of being too sleepy or weary during the day?
- Is there any evidence of daytime sleepiness, such as excessive or inappropriate napping? Or, paradoxically, are there symptoms of inattention, poor concentration, and hyperactivity?
- Are school functioning, cognitive performance, or peer relationships compromised?
Concomitant with a thorough sleep-wake history, a structured 24-hour log of sleep-wake patterns filled in by parents or, in the case of adolescents, by the adolescents themselves over a 1- to 2-week baseline period helps to substantiate information obtained from the history. In addition to nightly bedtimes, sleep-onset times, middle-of-the-night awakening times, and morning rising times, the diary should provide information about bedtime routines, sleeping arrangements, parent and sibling sleep patterns, and associated daytime stresses. To save time and to focus the clinician’s initial evaluation, the log may be completed in advance of the first visit. Sleep-wake logs maintained during and after treatment are useful in follow-up visits to evaluate the efficacy of treatment.
To further substantiate history and sleep logs, more objective, technical methods of assessment are available. Referrals to accredited sleep disorders centers, directed by certified specialists in sleep disorders medicine and staffed by certified clinical polysomnographic technicians, can provide detailed information about REM and NREM sleep-state and waking-state organization. Polysomnographic recording is recommended when clinicians have reason to suspect an intrinsic cause for a sleep disorder or when severe daytime sleepiness occurs with no reasonable explanation. Polysomnography usually requires the child to sleep all night in a sleep laboratory, although ambulatory polysomnography in the home is becoming more popular for young infants and children.
For dyssomnias that are related more to extrinsic causes, and for which polysomnography is not indicated, alternative methods of objectively recording sleep in the home are available. These methods include time-lapse video recording (Anders and Sostek 1976), pressure-sensitive mattress recording of motility and respiration (Thoman and Glazier 1987), and limb actigraph recording (Sadeh et al. 1991). Each of these methods has advantages and limitations, but each generally provides clinicians with valid and reliable information, derived from algorithms that approximate polysomnographic sleep-wake state scoring regarding sleep quality, sleep efficiency, and age-appropriate level of sleep-wake state maturation. With the increasing popularity of camcorders and home video systems, many parents are able to document their child’s sleep disruptions on their own. Such methods are particularly well suited for parasomnias, which usually do not occur nightly and, therefore, are likely to be missed on a scheduled laboratory or home recording session. The parent’s videotape, in direct response to the sleep disruption, is useful in capturing episodic events such as night terror attacks, sleepwalking, nightmares, and seizures during sleep.
Revision date: July 3, 2011
Last revised: by Jorge P. Ribeiro, MD