Nightmares are a type of sleep disruption, or parasomnia, characterized by frightening psychological
content. Nightmares provoke a feeling of imminent physical danger with a sensation of being trapped or suffocated. These frightening dreams occur during rapid eye movement sleep (REM), or dream-time sleep, and trigger a partial or full awakening. Nightmares are a universal human experience occurring throughout the lifespan. They are especially common in early childhood and involve activation of the limbic brain, particularly the area that mediates negative emotion.
Description
Nightmares are greatly influenced by the particular stressors and anxieties present in the child's waking life. Typical childhood nightmares include dreams of abandonment; of being lost; of falling; or being chased, bitten, or eaten by a monster or hostile animal. Dream researchers have observed a developmental progression in the content and frequency of children's nightmares. A two-year-old dreamer may recall a fearful dream, but be unable to give form to the source of the threat. By the age of five, the frightened young dreamer may identify the attacker as a monster or wild animal. Older children who have developed more of an understanding of real-life dangers report dreams of pursuit by mean or bad people.
Children gradually develop the ability to understand the difference between dreams and reality. Very young children have great difficulty believing that the dream is not real. By three to four years of age, however, most children can distinguish between the nightmare content and their waking reality.
When a child is awakened by a nightmare she will soon become fully alert and able to remember the scary dream in elaborate detail, expressing emotions appropriate to the dream content. The frightened child will resist returning to bed and often seek the comfort and reassurance of a parent or caretaker. Nightmares are different than the non-dream sleep disturbance known as a night terror, which causes only a partial arousal from deep sleep and occurs during the first period of sleep known as slow-wave sleep (SWS). A child experiencing a night terror will be difficult to awaken or comfort, will not recognize her parent or caretaker, and will usually have no memory of the terrifying emotions that caused the sleep disturbance.
Demographics
Although infants spend most of their sleep time in the REM stage where dreams are known to occur, there is no reliable way to determine if dreaming actually takes place prior to the development of language and the reflective ability to think in images. Sleep researchers and developmental psychologists generally agree that nightmares first occur in children from 18 months to two years of age. By age three, more than half of all children will report having experienced a nightmare. The incidence of these frightening dreams increases considerably in elementary school children.
In a study of the dreams of four- to 12-year-old children published in the Journal of Clinical Child Psychology in 2000, researchers found that 67.7 percent of four to six year olds, 95.7 percent of seven to nine year olds, and 76.3 percent of ten to 12-year olds reported having had a nightmare experience. Nightmares are common throughout childhood, changing somewhat in content and frequency as children move through different developmental phases and acquire more skills to cope with the changing realities and stresses in their lives.
Causes and symptoms
Childhood nightmares are a normal maintenance function of the developing brain. They are a means of integrating recent and past learning and of establishing psychological equilibrium. Children who have not yet developed sufficient coping mechanisms to deal with many normal childhood fears and problems may feel overwhelmed and insecure. These distressing emotions provide the basis for nightmares. Common stressful events include moving to a different neighborhood or school, encountering a schoolyard bully, watching a horror movie or a violent television or video program, the birth of a sibling, ongoing conflict with siblings, parental marital problems, or any of numerous other stressful situations that may add to a child's sense of vulnerability or powerlessness.
Nightmares may increase and intensify following particularly traumatic events such as the death of a parent, a sibling, or other loved one; parental divorce or separation; an injury, illness, or other medical crises; or witnessing or being subjected to physical or verbal violence or sexual abuse. Children who have been traumatized may suffer ongoing post-traumatic stress and express it through recurring nightmares.
Certain medications used to treat asthma, allergies, and seizures can be a causal factor in the onset of sleep disturbances and nightmares. Abrupt withdrawal from drugs or medications, including barbiturates and benzodiazepines, can also induce these sleep disturbances. Illness with high fever may bring about delirium with frightening episodes of nighttime awakening. The following behaviors are usually present in a normal nightmare episode:
Child awakens during the last third of her sleep period.
Child is frightened and becomes fully alert.
Child can describe the frightening dream in detail.
Child seeks and responds to comfort and reassurance from a parent or caretaker.
Child fears a recurrence of the frightful dream and may resist a return to bed.
When to call the doctor
If a child's nightmares increase in frequency and intensity, it is important to consult a physician or pediatrician to determine if the sleep disruption is due to any injury, illness, or infection, or if it might be caused by the use of or change in medications. Disturbed sleeping patterns in children are also present in some cases of juvenile rheumatoid arthritis, autism, and fibromyalgia.
Nightmares usually diminish in frequency and intensity over time. Recurring nightmares may indicate an ongoing problem that the child is having difficulty resolving. A child who is losing sleep and whose fears persist during day-time hours may benefit from the help of a pediatric psychotherapist in developing coping strategies for the stress and anxiety expressed through the dreams.
Diagnosis
Parental observation of the child's sleeping patterns and careful record-keeping of symptoms of any sleep disruption through use of a sleep journal will usually reveal any parasomnia patterns that may require professional assessment.
Treatment
Parents or caretakers should take into account the age and developmental maturity of their child when responding to the fears and anxieties that a nightmare brings to the surface. The child's ability to understand that the nightmare is not real and that it is an event happening only within their own mind increases with age. The nightmare reflects real fears and stressful circumstances present in the child's waking life. A parent's willingness to listen to and sympathize with a child's fears provides a necessary validation of the child's experience and helps to calm the child's anxiety. Very young children who lack the verbal skills to describe the frightening dream may require more reassurances that they are safe and more time in the comforting presence of a parent or caretaker before they are ready to return to bed.
Anne Sayre Wiseman, writing in her book Nightmare Help: A Guide for Parents and Teachers, suggests that parents approach the nightmare as a dream story with a problem to be solved. Parents who act as dream guides can help their children to find their own solution to the dream problem. The parents' goal, Wiseman counsels, is to "encourage autonomy so the child learns to empower themselves at whatever level they can handle."
Alan Siegel and Kelly Bulkeley, writing in their book, Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares, suggest four beneficial remedies to help a child cope with disturbing nightmares. "The Four R's" of nightmare relief are:
Reassurance: Provide physical and emotional reassurance and a listening ear so the frightened child will feel safe enough to share the dream images.
Rescripting: Discuss the dream images with the child and work together with the frightened dreamer to imagine changes in the outcome. Encourage the child to express the images through artwork, fantasy, drama, and writing.
Rehearsal: Encourage the child to imagine how the various alternative dream endings might change and assist the child in working through the different outcomes to find those that restore a sense of control and safety.
Resolution: Work with the child to help her discover and acknowledge the life problems and stressful circumstances that may be reflected in the nightmare.
Nightmares are a common childhood parasomnia and medication is rarely indicated. Other parasomnias, such as night terrors and night walking, may call for medication if other interventions and treatments fail to relieve seriously disruptive symptoms.
Alternative treatment
Teaching the child simple relaxation skills through guided imagery will provide a valuable self-help resource that may minimize bed-time anxiety. Older children can be encouraged to connect with an "inner guide" as a source of strength when they are awakened by frightening dreams. Inner guides may take the form of a loving voice within that the child can listen for during times of fear or a beloved animal that they may call upon as a companionable inner helper when dealing with problems presented in scary dreams.
Put the child to sleep with a favorite stuffed toy or special blanket.
Keep a nightlight on in the child's room.
Keep the door to the child's room open.
Nutritional concerns
Nightmares are a sleep disturbance that is part of a normal adaptive mechanism of the developing child. They are usually not caused by a child's diet. However fatty foods or spicy meals that may bring about digestive distress at bedtime may trigger sleep disturbances and awaken a child out of an otherwise peaceful slumber.
Prognosis
Childhood nightmares are a normal process of coping with new challenges and integrating new life experiences into the child's understanding of the world. With guidance from a sensitive parent, a child's nightmares can provide an opportunity for parents and children to gain a deeper understanding of, and find solutions to childhood anxieties and insecurities.
Prevention
Nightmares are part of the normal developmental process that literally provide a "wake-up" call to both parent and child to pay attention to strong feelings and problems that may require some resolution. Nightmares diminish as children feel more confidence and control in their lives. If nightmares persist and intensify they may indicate a situation in the child's life that needs to be changed rather than worked through with dream problem-solving.
Establishing a regular bedtime schedule and routine, including a calming-down period prior to sleep, will help reduce the number of sleep disruptions. Eliminating the stimulation of television or video games at bedtime, particularly violent television shows, movies, and games may reduce the nightmares brought about by these unnecessary and sometimes disturbing stimulations.
Parental concerns
Sleep disruptions throughout childhood also cause disruptions for the entire family, particularly parents who must attend to the frightened child and soothe the child back to sleep. Childhood sleep disruptions that persist over time may interfere with the normal sleep-wake cycle of the caregivers. Loss of sleep has a cumulative impact on the well being of both children and adults. Parents may become anxious in sympathy with the child and lie awake in worry long after the frightened dreamer has returned to sleep. There are many good books available to help a parent understand the normal sleep-wake cycles of children and the common parasomnias that all children experience. This knowledge can bring much needed peace of mind and help the parent determine when professional assessment and assistance is appropriate.
KEY TERMS
Limbic system—A group of structures in the brain that includes the hypothalamus, amygdala, olfactory bulbs, and hippocampus. The limbic system plays an important part in regulation of human moods and emotions. Many psychiatric disorders are related to malfunctioning of the limbic system.
Parasomnia—A type of sleep disorder characterized by abnormal changes in behavior or body functions during sleep, specific stages of sleep, or the transition from sleeping to waking.
Rapid eye movement (REM) sleep—A phase of sleep during which the person's eyes move rapidly beneath the lids. It accounts for 20–25% of sleep time. Dreaming occurs during REM sleep.
Slow-wave sleep (SWS)—Stage of deepest sleep characterized by absence of eye movements, decreased body temperature, and involuntary body movements. Night terrors and sleepwalking occur during this stage of sleep.
BOOKS
Hobson, J. Allan. Dreaming: An Introduction to the Science of Sleep. Oxford: Oxford University Press, 2002.
Moorcroft, William H. Understanding Sleep and Dreaming. New York: Kluwer Academic/Plenum Publishers, 2003.
Schroeder, Carolyn S., and Betty N. Gordon. Assessment and Treatment of Childhood Problems, 2nd ed. New York: Guildford Press, 2002.
PERIODICALS
Muris, P., et al. "Fears, Worries, and Scary Dreams in 4 to 12 Year Old Children: Their Content, Developmental
Pattern, and Origins." Journal of Clinical Child Psychology 29, no. 1 (2000): 43–52. Available online at <www.leaonline.com/doi/abs/10.1207/S15374424jccp2901_5> (accessed August 2, 2004).
ORGANIZATIONS
National Sleep Foundation. 1522 K Street, NW, Suite 500, Washington, DC 20005. Web site: <www.livingwithillness.com/id174.htm>
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WEB SITES
Driver, Helen. "Parasomnias." Canadian Sleep Society. Available online at <www.css.to/sleep/disorders/parasomnia.htm> (accessed October 6, 2004).
Harvie, Jeni. "Disorders: A Wake-up Call for Parents." Sydney Morning Herald, January 29, 2004. Available online at <www.smh.com.au/articles/2004/01/29/10750881124899.html> (accessed October 7, 2004).
National Sleep Foundation. "Sleep Matters." Sleep Problems in Children, Winter 2004. Available online at <www.sleepfoundation.org/features/children_sleep_problems.cfm> (accessed October 6, 2004).
"Nightmares and Night Terrors." Cincinnati Children's Hospital Medical Center. Available online at <www.cincinnatichildrens.org/health/info/growth/diagnose/nightmares.htm> (accessed October 6, 2004).
"Nightmares and Night Terrors in Children." American Academy of Family Physicians. Available online at <www.aafp.org/afp/20000401/2044ph.html> (accessed October 7, 2004).
Siegel, Alan. Nightmare Remedies: Helping Your Child Tame the Demons of the Night. Available online at <www.dreamwisdom.info/library/nightmare_remedies_children_print.htm> (accessed October 6, 2004).
"Sleep Behavior Problems (Parasomnias)." Kids Health for Parents. Available online at <www.kidshealth.org/parent/general/sleep/parasomnia.html> (accessed October 6, 2004).
