Month: October 2021

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Does Your Child Have Nightmares?

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When should you be concerned, and what should you do?

All of us can clearly recall at least one heart-pounding, fear-inducing nightmare from childhood that startled us out of our sleep. Whether it was a chasing dragon or a precipitous fall from a great height, it felt so real it left us shaken long after awakening. However, as adults we know that there isn’t a monster under our beds waiting to snatch us, even if we just dreamt about one. For children, nightmares can be confusing because they feel so very real. And as young children, the line between fantasy and reality is blurred,

Nightmares are completely normal phenomena, especially for children. They usually begin between age 2-4 and tail off by age 10-12. They are a developmental process and are a normal response to fear. They can be triggered by stressful events like starting school, family illness or conflict. In fact, nightmares can actually help process emotional events.

However, despite their potential to be helpful, nightmares do cause considerable distress and can disrupt sleep. So how can you help your child if they have frequent and distressing dreams?

  1. OFFER COMFORT AND SAFETY

Give them a hug, let them know they’re safe, that they’re not alone. Their nervous system is in a charged state. They need soothing to restore a sense of safety in their bodies.

  1. DON’T DISMISS DREAMS

Don’t try to talk them out of their experience or dismiss their dream using logic. In an attempt to offer comfort, don’t say, “It was just a dream, it’s not real” and expect that to be the end of it. Children experience their dreams as very real, and for certain, the intense feelings nightmares stir up are tangibly experienced.

  1. NORMALIZE TALKING ABOUT DREAMS

Ask your child about their nightmares. If they feel okay telling you about it, listen to the story of their dream. Sharing it with you will help take away some of the charge. It gives them a way to talk about their fears. There may be pressures they are facing that you have no idea about. Growing up is fraught with uncertainty and challenges that may seem inconsequential from an adult perspective.

Some children rarely articulate what’s scary for them, so we don’t get a chance to dispel needless worries or offer help. But their nightmares can do the talking for them in the form of metaphors and expressions of their main concerns.

Keep tabs on your child’s dream life, especially if it seems unusually dark and disturbing. If you make talking about dreams a normal part of the routine, you’ll know how often your child has nightmares and how distressing they are. You’ll be in a good position to know if professional help is warranted. And you will have gathered useful information to convey to a therapist about your child’s sleep.

  1. WHEN TO CONSIDER PROFESSIONAL HELP

Nightmares are considered chronic if they happen every week or more for at least 6 months. Fully 5% of children between the ages of 3-10 experience chronic nightmares, and for many, this is a normal developmental process. However, if chronic nightmares persist past about age 10, they are more likely to continue into adolescence and beyond. Age 9-11 is a critical juncture, a time to consider treatment if your child continues to have frequent, distressing nightmares.

Fortunately, effective treatment is available.

Imagery Rehearsal Therapy, (IRT) has been found to be effective in numerous controlled clinical trials in adult populations (ie with veterans and rape victims). This evidence has also been extended to children in a number of smaller studies that have shown it to reduce nightmare frequency, distress and general anxiety in children. Results were sustained 6-9 months post-treatment.

Imagery Rehearsal Therapy (IRT) is the most highly-recommended approach to nightmare treatment for any age group. Other protocols, like Exposure, Relaxation and Rescripting (ERRT) appear to work as well, but have simply not been studied as much. IRT is a non-invasive, cognitive behavioural approach that simply asks the dreamer to imagine and rehearse a new dream ending. This seeds a new story that often weaves its way into future dreams. One study showed that some children using IRT spontaneously became lucid after treatment and were able to alter their nightmares from right inside the dream.

  1. TRY DREAM THERAPY AT HOME

The original protocol for IRT suggests changing the dream in any way you want. However, for children, I recommend asking them the shift the dream in ways that help them feel better about the dream, ideally ways that bring a sense of hope and mastery.

To try your own version of this approach, first help your child feel safe and calm. Then ask them to recall their nightmare briefly, perhaps just up to the place where they might want something about the dream to change. Then ask them what they imagine could happen next in the dream to make the dream better. For example, ask what form of help, escape route, magic or superpower they might want to use. Let them know it’s their dream, and they can change it it any way they like.

For example, suppose your child dreams there is an evil monster under the bed, lurking and waiting for a limb to dangle over the edge so it can grab an arm or leg and drag them under. You could ask your child to imagine going back into their dream, to the part before it got scary. They could change the dream so what’s now under the bed is a favorite toy, perhaps a cuddly teddy bear that comes to life and takes them off to play in the clouds.

Or they might dream of a fire-breathing dragon chasing them. Often, it can really help to turn and face the dragon or monster, to really see it and perhaps ask what it wants. I did this with my daughter, reminding her of how I often sang Puff the Magic Dragon to her at bedtime. Her dream dragon became like Puff — lonely and in need of a friend. When playing with how to rescript nightmare, encourage children to give their imagination free rein, offer suggestions and keep it positive.

After rescripting, a further step in IRT is to rehearse the new dream ending, something children may need to be reminded to do. You can do a number of things to reinforce the new dream imagery for a child. You might suggest they draw a picture of it, imagine it again during the day, and/or tell you about it again as you tuck them in at bedtime.

What happens when we reimagine our nightmares or help our kids to do so? Sometimes the new dream ending becomes incorporated into future dreams, making them less frightening. Other times, people report a new ability to change their dreams from within. And sometimes the nightmare just stops coming. If the process doesn’t work the first time, try again, and play with different dreams as they come up. Do seek professional help if chronic nightmares persist or the process itself is upsetting (this is extremely rare). With the right support, and in time, your child will have fewer, less distressing nightmares. They may even come to cherish their dreams.

 

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.

 

References

Fernandez, S., DeMarni Cromer, L., Borntrager, C., Swopes, R., Hanson, R. F., & Davis, J. L. (2013). A Case Series: Cognitive-Behavioral Treatment (Exposure, Relaxation, and Rescripting Therapy) of Trauma-Related Nightmares Experienced by Children. Clinical Case Studies, 12(1), 39–59. https://doi.org/10.1177/1534650112462623

Mélanie St-Onge, Pierre Mercier & Joseph De Koninck (2009) Imagery Rehearsal Therapy for Frequent Nightmares in Children, Behavioral Sleep Medicine, 7:2, 81-98, DOI: 10.1080/15402000902762360

Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009). Factors affecting nightmares in children: parents’ vs. children’s ratings. European child & adolescent psychiatry, 18(1), 20–25. https://doi.org/10.1007/s00787-008-0697-5

Schredl, M., Fricke-Oerkermann, L., Mitschke, A. et al. Longitudinal Study of Nightmares in Children: Stability and Effect of Emotional Symptoms. Child Psychiatry Hum Dev 40, 439–449 (2009). https://doi.org/10.1007/s10578-009-0136-y

Simard, V., & Nielsen, T. (2009). Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy: Theory, Research, Practice, Training, 46(4), 492–497. https://doi.org/10.1037/a0017945

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Does Your Child Wake Up Screaming? How to understand and treat night terrors

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I used to dread going to bed when we lived in my lovely heritage apartment in Vancouver. Every night, about two hours after falling asleep, I would be startled awake by the most blood-curdling, agonizing screaming from the woman next door. Her window faced ours, and she sounded as though she was being murdered in her sleep almost every night. I wondered why no one would wake her up or help her. I have since learned that this would not have done much good as she was having night terrors.

So many people I’ve spoken with about this have suffered the same thing with their children. Night terrors are fairly common in very young children, affecting 20-40% of children under age 3, and 3-14% of school age children, but just 2% of adults (APA 2013). In a typical episode, parents will put their child quietly to bed only to hear them thrashing and screaming in terror about three hours later. The kids were hard to fully wake up, disoriented and confused, often with little or no memory of the incident in the morning.

Night terrors are often mistaken for nightmares. At a recent talk I gave about nightmares, most of the questions were actually about night terrors – from desperate parents wanting to know if there was something they could do about them. I treat nightmares, not night terrors, but I did some investigation, and there are a few things to know and to do that can help. First and foremost, know that they are generally benign and kids usually grow out of them.

Who Has Night Terrors?

Before I get into some of the ways you can help your child with their night terrors, it helps to understand what they are, who has them and why. A thorough survey of the literature suggests that although the exact cause is not well understood, genetic, developmental, environmental, psychological and organic factors can all play a part.

Night terrors most common in early childhood. A longitudinal study (Petit et al., 2015) of 1,940 children from Quebec found that 34% of children aged 18 months experience night terrors, 13% at age 5, and 5% at age 13. A recent review (Leung et al., 2020) found the peak may be later, at age 5-7 years. Either way, sleep terrors typically start at a very young age and stop at adolescence. It’s rare that the condition continues into adulthood – although for some it can switch to sleepwalking.

Sleep terrors are more common under a number of conditions that can be controlled, at least to some degree, such as: sleep deprivation, going to bed with a full bladder, emotional stress, anxiety (including separation anxiety), bullying, a noisy sleeping environment and excessive alcohol or caffeine. Other factors associated with this parasomnia include: febrile illness (unexplained fever), ADHD, autism, epilepsy, sleep apnea and PTSD. Some medications, especially those that are sedative, can lead to night terrors because they increase the duration of non-REM, the deep sleep stage in which these episodes occur.

It bears repeating the while night terrors are very distressing and can disrupt sleep for both children and their parents, they are not considered dangerous. They warrant clinical attention only if they are severe enough to disrupt daytime functioning. If you are considering consulting a doctor, keep a sleep diary and track BEARS. Not the big furry animal, but the 5-item assessment tool for children with sleep problems (Owens & Dalzell, 2005):

  • B: bedtime issues
  • E: excessive daytime sleepiness
  • A: night awakenings
  • R: regularity and duration of sleep
  • S: snoring

What Are Night Terrors?

In a typical episode, the child will sit bolt upright or even jump out of bed, heart racing, screaming in terror. They may speak, but what they say will be confused and incoherent because although they appear to be awake, they are in a hybrid sleep-wake state. They will be difficult to wake fully because these episodes occur during very deep (slow-wave) sleep. It’s best not to wake them up during an episode, and typically they won’t recall a thing in the morning.

Night terrors are distinguished from nightmares because they happen in the first half of the night associated with the deeper (stage 3 and 4) of non-REM sleep, while nightmares mainly occur in the second half, and are associated more with REM sleep and dreaming. Nightmares are clearly recalled in vivid detail, and those who have them tend not to thrash around and scream.

Night terrors are much more common in children. When they continue into adulthood, they look a bit different. While two-thirds of children have no recollection after episodes of night terrors or sleepwalking, the same proportion of adults do recall at least one experience and remember their episodes about half the time (Castelnovo, et al., 2021). For adults, night terrors appear to be more of a dissociative experience, and can be accompanied by hallucinations.

What you can do about night terrors

While none of the suggestions below work all the time, there are a number of things you can try to reduce or even eliminate night terrors. Excellent sleep hygiene (such as regular bedtimes; limiting screen time, no food and drink before bed, especially sugar and caffeine; dark, cool quiet bedroom; and wind-down rituals like story time) can all help reduce night terrors. Parents can also do their best to limit stresses on kids who have night terrors – things like bullying and separation anxiety might be addressed. Interestingly, psychological factors are found to be mostly associated with night terrors in teens and adults, but not children.

Wake-up treatment. One treatment that has met with some success is to wake a person up about half an hour before they would typically have an episode. If you do this for two weeks, it can break the cycle and stop it from recurring. In some cases, however, the episodes simply start occurring later in the night.

Co-sleeping. One interesting paper (Boyden, Pott & Starks, 2018) suggests that sleeping with your child stops night terrors, especially with very young children. The authors say that evolution did not design humans to sleep alone when very young and that “night terrors are the result of an environmental mismatch between evolved behaviour and the modern cultural practice of solitary sleeping.” This solution has not been empirically tested, but anecdotally, it appears to work for many.

The bottom line is that while night terrors can seem extreme, they are usually benign and your child will experience them less and less over time. There are a number of things you can try, such as good sleep hygiene, limiting stress, waking them prior to an episode and co-sleeping. To all those exhausted parents reading this, I hope it has been of some help.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davey, M. (2009). Kids that go bump in the night. Australian Family Physician, 30, 290- 294.

Ekambaram, V., & Maski, K. (2017). Non- rapid eye movement arousal parasomnias in children. Pediatric Annals, 46, e327-e331. doi:10.3928/19382359-20170814-01

Golbin, A.Z., Guseva, V.E., & Shepovalnikov, A.N. (2013). Unusual behaviors in sleep as “compensatory” reactions aimed at normalizing the sleep–wake cycle. Human Physiology, 39, 635-641. doi:10.1134/ S0362119713060042

Ivanenko, A., & Johnson, K.P. (2016). Sleep disorders. In M.K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (2nd ed.). Arlington, VA: American Psychiatric Publishing.

Laberge, L., Tremblay, R.E., Vitaro, F., & Montplaisir, J. (2000). Development of parasomnias from childhood to early adoles- cence. Pediatrics, 106, 67-74. doi:10.1542/ peds.106.1.67

Leung, A. K. C., Leung, A. A. M., Wong, A. H. C., & Lun Hon, K. (2020). Sleep terrors: an updated review. Current Pediatric Reviews, 16(3), 176-182.

Murphy, P.J., Frei, M.G., & Papolos, D. (2014). Alterations in skin temperature and sleep in the fear of harm phenotype of pediatric bi- polar disorder. Journal of Clinical Medicine, 3, 959-971. doi:10.3390/jcm3030959

Nguyen, B.H., Pérusse, D., Paquet, J., Petit, D., Boivin, M., Tremblay, R.E., & Montplaisir, J. (2008). Sleep terrors in children: A prospective study of twins. Pediatrics, 122, e1164- e1167. doi:10.1542/peds.2008-1303

Petit, D., Pennestri, M.H., Paquet, J., Desautels, A., Zadra, A., Vitaro, F.,…Montplaisir, J. (2015). Childhood sleepwalking and sleep terrors: A longitudinal study of prevalence and familial aggregation. JAMA Pediatrics, 169, 653-658. doi:10.1001/ jamapediatrics.2015.127

Salazar, F., Baird, G., Chandler, S., Tseng, E., O’Sullivan, T., Howlin, P.,…Simonoff, E. (2015). Co-occurring psychiatric disorders in preschool and elementary school-aged chil- dren with autism spectrum disorder. Journal of Autism and Developmental Disorder, 45, 2283- 2294. doi:10.1007/s10803-015-2361-5

Silvestri, R., Gagliano, A., Aricò, I., Calarese, T., Cedro, C., Bruni, O.,…Bramanti, P. (2009). Sleep disorders in children with attention- deficit/hyperactivity disorder (ADHD) re- corded overnight by video-polysomnography. Sleep Medicine, 10, 1132-1138. doi:10.1016/ j.sleep.2009.04.003

Wolke, D., & Lereya, S.T. (2014). Bullying and parasomnias: A longitudinal cohort study. Pediatrics, 134, e1040-e1048. doi:10.1542/ peds.2014-1295

Are you a parent concerned about the frequency and intensity of your child’s bad dreams? Should you be concerned?
Learn more about Nightmare Relief for Everyone designed by nightmare expert Dr. Leslie Ellis, this self-paced user-friendly and accessible online course covers the very latest in science and research about what nightmares are, and what they’re not. Leslie offers some simple steps you can take to get some relief from nightmares and other nocturnal disturbances – both for yourself and for others, including your children.