Dr. Timothy Jeider

I would recommend an in-depth evaluation by a developmental pediatrician or a Child/Adolescent Psychiatrist to determine as accurate of a diagnosis as possible. Often times an evaluation can/will lead to a referral to a Speech Therapist of Occupational Therapist, but it really starts with an accurate evaluation and diagnosis.

There can be a number of causes for this. First step is to see a pediatrician to see if there is a physical health issues causing the nocturnal enuresis. From there, an evaluation from a therapist or child psychiatrist may be warranted to see if its related to a mental health concern.

https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf

This is a frequently used rating scale for ADHD symptoms. Please use in conjunction with a licensed provider.

https://www.autismspeaks.org/applied-behavior-analysis-aba-0

"okay" really depends on the child's understanding of the imaginary friend. Then understanding the child's interaction/integration into other aspects of their life. A one time evaluation form a psychiatrist of therapist can help clarify if there should be any concern of if the child is within normal development.

From: https://emedicine.medscape.com/article/1188854-overview#a4

The parasomnias have been thought to represent not pathologic cerebral functioning but, rather, a response to central nervous system (CNS) activation that results in sleep-wake or rapid eye movement (REM)–NREM state confusion, instability, or overlap. However, studies have demonstrated differences between sleep patterns and neuronal sleep control mechanisms in individuals who have parasomnias and corresponding patterns and mechanisms in individuals who do not.

Normal sleep involves cyclic hypnic patterns throughout the night between wakefulness, NREM, and REM states. The CNS remains active during all sleep-wake states, though rapid changes are required in neural networks, rhythms, and neurotransmitters with state changes. The length of each cycle averages 50 minutes for a full-term newborn, increasing to approximately 90 minutes by adolescence.

Slow-wave sleep (SWS) normally occurs in the first 2 hypnic cycles; younger children have an additional SWS period toward the end of the sleep period. Children typically enter their deepest sleep within 15 minutes of sleep onset, and this first SWS period lasts from 45-75 minutes. This explains why it is easy to move children without rousing them soon after sleep onset.

Parasomnias occur as children are caught in a mixed state of transition from one sleep cycle to the next (eg, from NREM sleep to wakefulness). This transition state is characterized by a high arousal threshold, mental confusion, and unclear perception.

School refusal is actually quite common and is typically multifactorial. In general, a good place to start is conferencing with the school to see if there are issues/concerns they have already identified. Another good place to start is with an individual and or family therapist.

When to worry is a case by case discussion, but a general rule to go by is if three is functional impairment somewhere in your child's life. I have had parents bring in 2 years old kids for evaluation. If you take your child for an evaluation, use your parent intuition on wither or not the physician takes a thorough history that evaluates multiple aspects of your child's life. Many times at age 4, medications are not the immediate answer. Also, symptoms that look like ADHD may be in fact related to something that is not actually ADHD. So I can not stress the importance of a detailed evaluation, preferably by a Board Certified Child and Adolescent Psychiatrist.