Letter to the Editor

Melatonın Treatment for Childhood Sleep Terror

Ozlem Ozcan, MD, and Yunus Emre Donmez, MD

To The Editor:

Sleep terror is a parasomnia seen during nonrapid eye

movement (NREM) sleep, and characterized by extreme

terror, motor agitation, intense vocalization, and high levels of

autonomic discharge (profuse sweating, mydriasis, tachycardia,

and tachypnea). The episode usually lasts no more than a few

minutes; afterward, the child usually relaxes and returns spon-

taneously to sleep. Sleep terrors are classified as arousal disor-

ders by The International Classification of Sleep Disorders

(ICSD-2) (American Academy of Sleep Medicine 2005; Provini

et al. 2011).

Sleep terror is reported to affect * 3% of children and < 1% of

adults, and is most commonly observed in toddlers and pre-

schoolers (Robinson and Guilleminault 2003). Prevalence of the

disorder decreases as the age increases; however, the colorful and

scary images seen during sleep can adversely affect the function-

ality of the child and the family (DiMario and Emery 1987;

Heussler et al. 2013).

The etiology of sleep terror is not fully understood, and there is,

to date, no clearly defined treatment for it. Different therapeutic

strategies have been proposed for sleep terror such as a behavioral

approach, reinforcing age-appropriate sleep patterns, reassuring

and guiding parents, and pharmacotherapy (Weissbluth 1984). The

most commonly used medications in the pharmacological treat-

ment of sleep terror are benzodiazepines and antidepressants

(Howell 2012).

The purpose of this case report is to discuss the response of a 36-

month-old male patient beginning treatment with melatonin after

being diagnosed with sleep terror.

Case Report

A 36-month-old male patient was brought to the child psychiatry

clinic by his parents with complaints of a sleep disorder exhibited

by the child waking up frequently at night. It was understood from

the interview with his parents that the patient had had sleep prob-

lems since his birth; he slept well for 30 minutes to 1 hour during

the daytime, and his parents rocked him to sleep at *10 pm. His

parents stated that he shouted out agitatedly, screamed, and made

gestures such as struggling *30 minutes after sleeping, had ta-

chypnea, repeated such screams and actions four to five times at

night, and then fell sleep again, and that he had a facial expression

as if crying during moments of shouting, screaming, and struggling.

According to the information obtained from the parents; the patient

was an intended and planned baby, born after a stressful pregnancy,

that he started to walk when he was 18 months old, started to talk

when he was 24 months old, and had no health problem other than

the sleep disorder.

The mother described the patient as a warm-hearted child who

shouted and insisted when he was angry. The patient had been taken

care of by his babysitter during the daytime for the past 1.5 years;

the 32-year-old university graduate mother described herself as a

hot-tempered and intolerant person, and she stated that she received

regular psychiatric support for manic-depressive disorder. The 32-

year-old university graduate father had no psychiatric disorder, but

had similar sleep problems when he was a child; the 8-year-old

brother of the patient had short sleeping periods and had difficulty

falling asleep.

During the psychiatric evaluation, it was observed that the pa-

tient was dressed appropriately for his age and sociocultural level,

and that his verbal and nonverbal communication was normal and

his cognitive functions were consistent with his age. Moreover, it

was observed that he had a shy temperatment, and a mild level of

articulation disorder. During the evaluation made using American

Psychiatric Association, Diagnostic and Statistical Manual of

Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) diagnostic

criteria, pervasive developmental disorder symptoms were not

observed in the patient (American Psychiatric Association 2000).

As a result of the application of Vineland Adaptive Behaviour

Scale, it was determined that the patient’s developmental level in

all areas was similar to his peers’. A pediatric neurology consul-

tation was requested for the patient and his electroencephalogram

(EEG) was assessed as normal, and no neuropathology was de-

tected. As a result of the psychiatric evaluation made using DSM-

IV-TR diagnostic criteria, the patient was diagnosed with sleep

terror and was followed up; his parents were informed about sleep

terror, the follow-up, and the treatment process. Suggestions were

given with relation to the sleep pattern and sleep hygiene of the

child. After a 1 month follow-up process, no difference was ob-

served in the duration and severity of the complaint; therefore, 1 mg

melatonin treatment on a daily basis was started for the patient, and

the patient was followed up for 6 months at regular intervals. The

complaint completely disappeared 2 weeks after starting melatonin,

no side effects were observed as a result of melatonin usage, and the

patient tolerated the melatonin well.

Discussion

The most important role of the melatonin hormone, also known

as N-acetyl-5-methoxytryptamine, is that it regulates the day–

night and sleeping–awakening circles (Ozcelik et al. 2013).

Melatonin has an effect on the suprachiasmatic nucleus, which

is responsible for circadian rhythm, and melatonin release is

Department of Child and Adolescent Psychiatry, _Inonu University Medical Faculty, Malatya, Turkey.

JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGYVolume 24, Number x, 2014ª Mary Ann Liebert, Inc.Pp. 1–2DOI: 10.1089/cap.2014.0061

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regulated by transferring light information to the suprachiasmatic

nucleus pineal gland (Stores 2003). The circadian rhythm of

melatonin usually develops between the 2nd and 3rd months of

life. Neonates and infants depend on their mothers’ melatonin

circadian rhythm through their milk (Touitou 2001). A sleep

disorder, which began in infancy as in our case, may be associated

with problems in the development of the circadian rhythm of

melatonin.

Melatonin, which is very popular for use in insomnia treatment

in children, ensures an effective treatment if taken in appropriate

dosages. It has been indicated in studies that in addition to helping

those with sleeping problems, melatonin is also effective in regu-

lating start time of sleeping, the latency phase, and the sleep quality

of children with autism spectrum disorder, mental retardation, and

attention-deficit/hyperactivity disorder accompanied by sleeping

problems (Pelayo and Yuen 2012).

In our case report, melatonin was used for the treatment of sleep

terror occurring through stimulation at an early age, and there was

an effective and reliable response to the treatment. In the literature,

there is only one case report on this subject. Jan et al. reported that

melatonin was used for the treatment of a 12-year-old male patient

with Asperger syndrome and sleep terror and somnambulism

complaints, and that the patient benefited from the treatment ( Jan

et al. 2004). However, our patient was very young, and our

knowledge about the efficacy of melatonin usage at early ages is

limited.

Studies in children using melatonin reported that melatonin use

was not associated with any side effects even with > 4 years of use

( Jan and O’Donnel 1996). In our case, no side effects were ob-

served as a result of melatonin use. Melatonin may be an option in

the treatment of arousal disorders such as sleep terror. Controlled

and comprehensive studies are required on the use of melatononin

in children with disorders of arousal.

References

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Sleep Disorders: Diagnostic and Coding Manual, 2nd ed.

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American Psychiatric Association: Diagnostic and Statistical Manual

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Jan JE, Freeman RD, Wasdell MB, Bomben MM: A child with severe

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Address correspondence to:

Yunus Emre Donmez, MD

Department of Child and Adolescent Psychiatry

Inonu University School of Medicine

Malatya

Turkey

E-mail: dryemredonmez@yahoo.com

2 OZCAN AND DONMEZ