Restless Nights

  My three year old wakes me up frequently at night.  He talks, fights with siblings, and cries while sleeping.  He does this loudly so I am usually awakened.  This has been happening nearly every night for the past couple months.  There has been no obvious change in the house except for the elimination of his afternoon nap.  Could eliminating his nap, being overtired, cause the increase in his sleep talking/crying?  Some nights he says his leg (not legs) hurt and asks me to rub it.  
  What suggestions do you have for me to make my night and his more restful?  I am a chronic headache sufferer with FMS so sleep is important to me!  
  He goes to bed around 8:00 and wakes up at 7:30.  His talking usually starts after midnight.
  Any suggestions you provide are appreciated.  Thanks for your time.
  Sincerely,
  Julia
Dear Julia:
First, sleep problems in children are challenges for many parents. You
are not alone. Few 3-5 year-old children don't have some form of interrupted
or restless sleep. Second, the understanding of sleep, its disorders,
and their management is improving steadily. Help is increasingly available.
Normal sleep is divided into two primary stages, nonrapid eye movement
(NREM, deep) and rapid eye movement (REM, light). You most likely know
REM sleep as dreaming/nightmare sleep. Sleep alternates between these
two different stages throughout the night, usually beginning with NREM
sleep.
Sleep disturbances are divided in dysomnias (insufficient, excessive,
or inefficient sleep involving disorders of sleep-wake organization)and
parasomnias (disruptions of sleep continuity). In contrast to children with
dysomnias, children with parasomnias are not conscious of their behaviors.
For the latter group, it is the parents rather than the children who
complain.
Sleep awakening is a common problem. Since REM sleep is a regular part
of sleep, normal children will be on the verge of awakening several times
each night. Any disturbance, whether internal (pain, other illness,
nightmares) or external (noise from siblings sleeping in the same room)
may be sufficient to rouse the child.
With excessive sleep awakening, our goal is first to reduce the frequency
of full awakenings if possible, but ultimately to have the awakening well
child self-settle, that is put himself or herself back to sleep without
help from the parent or with only minimal help from the parent. We can
encourage this behavior in several ways.
Children should always be put to bed awake, usually after a reassuring
bedtime ritual, in their own beds. This ensures that they do not wake up
in unfamiliar surroundings.
If a nightmare occasions arousal, the child should be reassured simply,
without extensive discussion. You can distinguish a nightmare (a dysomnia)
from a night terror (a parasomnia) by the fact that a child is truly awake
after a nightmare, recognizes his parent, and can recall details.
Furthermore, nightmares tend to occur during the second half of the night,
while night terrors tend to occur soon after falling asleep.
When illness or a nightmare is not the explanation of awakening, the
bedtime ritual can be exploited to help the child settle without your
help. You may offer two stories instead of one the following night if
the child can put himself/herself back to sleep without your help and
without disturbing the household. For example, talking to oneself quietly
as a means of reassurance might be okay, but engaging siblings in
discussion would not. Our daughter used to sing softly at night. We
thought this was fine.
Success can also be rewarded by a wider range of choice for breakfast
the next morning. Star charts can be utilized as well, wherein
a certain number of stars for good behavior are translated into a trip
to the park or other spend time together activity. Rewarding good
behavior is generally more effective than punishing unwelcome behavior.
Children can awaken for other reasons. Occasionally a child may have airway
obstruction and resultant sleep apnea as the cause. Such children tend to
snore, hold their breath during sleep, and are unusually drowsy during the
day.
Your son seems to be going to bed at an appropriate time. However, he
may still need his afternoon nap. Children often do until about age
four. I am uncertain why this was eliminated. Perhaps at least a quiet
time could be reinstituted for him in the afternoon and you could see
what effect, if any, this has on his night time sleep pattern. Having a
separate bedroom at night, if he does not have one, could help by facilitating the
attenuation of sound, once you are assured of his otherwise good health.
Such a sleeping arrangement may not be possible in your circumstances.
Parasomnias include night terrors, sleep walking, and sleep talking.
You state your son talks, fights with siblings, and cries during sleep.
If he appears to be asleep during all of this, he could be having nightmares
or he could be sleep talking. However, usually sleep talkers (somniloquists)
do not talk coherently and such parasomnias are more common among school age
children than among preschoolers. These points may help differentiate the
two states.
Sleep disorders are more common during stressful life circumstances. This
is especially true of nightmares. Has anything changed in your son's life,
which from his special developmental perspective, might be especially
stressful and which might be addressed during the day (e.g., disruption of
family routine, new preschool or other day care arrangement, toilet
training)?
Pain in the legs is common in well young children (activity or growing
pains). Pain in one leg is less common and this deserves review by your
pediatrician. As mentioned above, pain of any source can exacerbate
sleep difficulties.
I hope this review and these suggestions prove useful to you. This information
is provided for educational purposes only. Your child's pediatrician has the
ultimate responsibility for working with you to sort this matter out.
If you would like further assistance from the Henry Ford Health System,
please call [phone].
HFHS. MD-HSW  
Keywords: Dysomnia, parasomnia