Last reviewed: 28 Sep 2021
Last updated: 07 Oct 2021



History and exam

Key diagnostic factors

  • disturbed cognition during event (confusional arousals, sleep terrors, sleepwalking)
  • vigorous activity or violent behavior (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behavior disorder [RBD])
  • episodes of inability to move (isolated recurrent sleep paralysis)
  • autonomic hyperactivity during event (sleep terrors)
  • amnesia
  • normal physical exam between episodes

Other diagnostic factors

  • abnormal demeanor and facial expression (confusional arousals, sleepwalking, sleep terrors)
  • evidence of injuries

Risk factors

  • family history of non-rapid eye movement (NREM) parasomnias (confusional arousals, sleepwalking, sleep terrors)
  • presence of HLA gene DQB1*05 and *04 alleles (sleepwalking)
  • psychiatric medications or alcohol
  • history of psychiatric disorder
  • fever
  • acute sleep deprivation or irregular sleep-wake schedule disorder
  • emotional stress and traumatic life events
  • forced awakenings
  • untreated comorbid sleep disorders
  • premenstrual state (in adolescent girls)

Diagnostic investigations

1st investigations to order

  • clinical exam
  • polysomnography (rapid eye movement sleep behavior disorder)

Investigations to consider

  • polysomnography (confusional arousals)
  • polysomnography (sleepwalking)
  • polysomnography (sleep terrors)
  • polysomnography (nightmare disorder)
  • polysomnography (all other parasomnias)
  • polysomnography with expanded electroencephalogram (EEG) video recording
  • urine drug screen

Treatment algorithm



Shalini Paruthi, MD

Co-Medical Director, Sleep Medicine and Research Center

St. Luke's Hospital

Adjunct Associate Professor

Department of Pediatrics

Saint Louis University School of Medicine

St Louis



SP receives royalties from UpToDate for writing two topics: diagnosis and management of pediatric obstructive sleep apnea. SP is a board member of the Restless Legs Syndrome Foundation.


Dr Shalini Paruthi would like to gratefully acknowledge Dr Raman Malhotra and Dr Alon Y. Avidan, previous contributors to this topic.


AYA has been paid honorarium speaking fees by the American Academy of Sleep Medicine, the American Academy of Neurology, the American College of Chest Physicians, Sepracor Inc, Cephalon Inc, and Pfizer Pharmaceuticals.

Peer reviewers

Paul Gringras, MB, ChB, MSc, MRCPCH

Consultant in Paediatric Neurodisability

Evelina Children's Hospital

St Thomas' Hospital




PG is lead applicant on the ongoing MENDS trial, which is concerned with the use of melatonin in children with neurodevelopmental disorders and impaired sleep.

Paul Montgomery, MSc, DipSW, DPhil

Reader in Psycho-Social Intervention

Centre for Evidence Based Intervention

Barnett House

University of Oxford




PM has received funding greater than 6 figures USD from the Swedish Board of Health and Welfare, Martek Biosciences, Danish Social Research Institute, UK Department of Health, UK Health Technology Assessment Programme. PM declares that he has no competing interests.

Lynn A. D'Andrea, MD

Associate Professor of Pediatrics


Division of Pulmonary and Sleep Medicine

Department of Pediatrics

Medical College of Wisconsin

Medical Director

Pulmonary Clinic

Children's Hospital of Wisconsin




LAD declares that she has no competing interests.

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