166 Chapter 20
These are presentations, not diagnoses. Making a diagnosis requires a
detailed clinical history and may also require special investigations, for
example, polysomnography, involving simultaneous recordings of brain
activity (EEG), muscle movements and eye movements during sleep.
Specific types of sleep disturbance
The sleep problems that are most relevant to child mental health practi-
tioners are discussed below.
Difficulty getting to sleep or staying asleep
This is the commonest sleep problem from infancy to old age, but is
particularly common among preschool children. The problem can usually
be tackled successfully by improving sleep hygiene (see Box 20.2) and
phasing out rewards for not being asleep. When children need parental
attention to get back to sleep after waking in the middle of the night,
this is often because they haven’t learned the skill of getting to sleep by
themselves. The easiest way to teach them this skill is by practising at bed
time. If parents progressively fade themselves out at bedtime (for example,
leaving the bedroom before the child is asleep), children learn how to get
to sleep by themselves, and can usually then do so in the middle of the
night too. Sometimes, children are kept awake by fears and worries that
need to be tackled in their own right (see Chapter 9).
Circadian sleep–wake cycle disorder
If you move from London to New York or vice versa, your body
clock and sleep–wake cycle adjust. Imagine what would happen if your
sleep–wake cycle didn’t adjust. The Londoner in New York would always
go to sleep before everyone else, and then wake ridiculously early (ad-
vanced sleep phase syndrome). Conversely, the New Yorker in London
would get up very late each day and not go to sleep until the early hours
of the morning (delayed sleep phase syndrome). This sort of problem
with being ‘stuck in the wrong time zone’ is exactly what happens to
some children and more adolescents. Advanced sleep phase syndrome is
relatively unusual, and is usually due to parents putting children to bed
too soon, with the result that they habitually wake too early and disturb
the rest of the family.
Delayed sleep phase syndrome is far commoner, particularly among
teenagers. They stay up late (TV, homework, parties) and then sleep in late
whenever they can. It is hard to wake them for school, and the principal
complaint is often of deteriorating school performance (and behaviour)
because of daytime sleepiness. Once the sleep phase has shifted, having an
early night no longer helps but just condemns the teenager to lying awake
for hours before finally falling asleep in the early hours ‘as normal’.
Reprogramming the sleep phase is possible with patience, effort and
motivation (and some adolescents are not motivated to change). When