Re: Nightmares and night terrors
Quitting Nightmares in Kids
The Faster Times blog: Pediatrics
by Jack Maypole, MD
April 8, 2010
Nightmares are nightmarish. You can quote me as Dr. Obvious on that one, but it’s true. For younger children, whom they afflict most frequently, nightmares are the stuff of dread, of hating bedtime, and of feeling most alone, and wee and vulnerable in the world. For parents, they can be equally distressing for their sudden appearance, and their ferocious impact. Consoling a freaked out child in the predawn dark is no easy task, and the impacts can linger far past the rise of the sun. What’s more, some children may be more prone to them than others.
Recently, the mother of a healthy preschooler emailed me about her son’s growing problem with terrible dreams. Like so many children, this boy’s troubles appear to have begun with a seminal moment, with an otherwise innoccuous cameo of a dinosaur (nope, not Barney) on a children’s program. Henceforth, an indelible image was made, and thus began a troublesome ricochet for many nights to come. Tears, stories about tricks of the light and monsters in the shadows followed. Wisely, his mother deployed good goin’-to-bed ideas: a stuffed animal posse (”they’re watching me!”), nightlights and hall lights…but all that failed to quell the fear and the dreams continued. So, this good mom asked, what to do?
Here’s what we know. Nightmares occur the world round in children, regardless of culture, gender, or ethnicity. The incidence of nightmares tends to peak in children aged 3-6 years of age—with about half of kids having some kind of problem at some point. What a setup we have here: Toddler to preschool time, when nightmares peak, is known in Child Study circles as the age of Magical Thinking. (Examples? Happy magical thinking: Santa. Not so good magical thinking: Santa’s overworked reindeer coming down the chimney and kicking your butt). What’s more, young brains are ever more sensitive to their environment, without having the adult tools to assess risks and messy stuff of life (eg thunderstorms, car accidents, public speaking, going to the Department of Motor Vehicles, etc). And, as we will discuss, nightmares can arise from a combination of factors including the environment, temperament, genetics, medical conditions, and even medications. Pleasant dreams, little ones!
Approximately 7% of children with frequent nightmares have a significant family history of relatives with them. And, of note, some recent research has identified some children as being vulnerable to ‘bad dreams’ as young as 5-7 months of age. Interesting this may be, but it can be hard to tease out ‘bad dreams’ from the usual wakenings of infants and toddlers. A point to remember in any case: bad dreams may occur for a short time in healthy children. Typically, nightmares fade in a week or two, often while families feverishly work to help the kids cope, and dispel their fears.
Less appreciated by the public and, I think, by many primary care providers, is the high rate of nightmares in children with developmental or neurologic or emotional problems. They haunt children with depression (less suprising, perhaps) and are more common with kids who have ADHD (more surprising). Children on the autistic spectrum, and/or cognitive delays also appear to have higher rates of bad dreams than their peers.
Most healthy children by age 2-4 years and beyond have established sleeping 8-10 uninterrupted hours a night. Nightmares tend to occur in the wee hours of the morning or even towards dawn. For the red-eyed parent recalling the history of these events in the light of a doctor’s office, a few things are key to remember. Kids experiencing nightmares may have a limited amount of sleep talking, appear sweaty and excited, and clearly upset when they awaken from a bad dream.
Nightmares are to be distinguished from other sleep disorders, called night terrors by the sleepologists. Night terrors generally occur in children of a younger age, sometimes as early as 18 months. And, to the parents, these occasions can be even more scary than nightmares. Kids with night terrors may produce a bloodcurdling shriek that brings the family running. On entering the bedroom, parents describe these children as seeming both distressed, but still asleep. They may or may not be kicking or moving some, the won’t respond to voices, and their eyes may be open (or not), and unfocused. The best approach for night terrors is to keep the child safe, and in bed, until it runs its course. Kids with night terrors cannot recall these episodes; kids with nightmares cannot forget theirs.
Parents may be understandably worried about the appearance of either of these behaviors (and hey, rightfully so). These are good times to make an appointment with a primary care provider specifically to talk about sleep issues. It comes up more often than you might think.
I am a former sufferer of nightmares at this age. I appreciate the magnitude of the fear and the scope of the problem. Of course, in my case it was my own fault. I was paradoxically drawn to watch the creepy Chiller Theater on TV…only to be up freaking out or padding into my parents room where I slept on the floor some nights. Oh, I remember being scared, watching the shadows move on the wall. Other times, I was haunted by pictures or images from books (thanks, brothers Grimm!), or some other movie or TV show that’d get my brain running on overtime. Like many such kids, I had a perfectly happy childhood, but I had my share of dreaming of physical danger (mummies), psychological nightmares (bullies), and so on. However, I did not have my nightmares of loss of control until medical school (the old chestnut of being poorly clothed, and late for an exam. BTW: that was a dream, people!)
And, so, back to our little friend, at the top of the article. What can his family do for his persistent nightmares? This little fella’s mom helped me a great deal from the doctor’s perspective. Using parents’ observations helps the physician get a sense of triggers or stessors that can be setting off the nightmares, including their duration, intensity, and connection to events in the child’s daytime and emotional life. Along the way, I’ll want to be mindful of other potential causes and to evaluate or intervene accordingly: Illness? (fever or large tonsils causing disruptive snoring can prompt wacky and terrifying dreams); Medications? (Benadryl, Zyrtec, Prednisone and other meds may cause nightmares in some kids): Trauma? (PTSD, loss of loved ones, anxiety issues or other emotional problems may explain nightmares that are persisting or disrupting the child’s daily life).
For most kids, a few simple good ‘sleep hygiene’ ideas do the job most of the time:
–A nightlight: These are benign, I find, and work for most children who habituate to sleeping with the extra photons. Giving kids control, such as where to put the light and having them turn it on, can be extra helpful.
–Pets. For families who have them, I urge a moving of the sleeping place of the dog, cat, gerbil, or even fish to the child’s bedroom, if possile. The companionship offsets the loneliness for kids.
–Keeping the bed for sleep and changing to lighter fare: Here, families do well to take TVs and computers out of the room (stolen after hours screen time is a leading cause of sleep deprivation in younger kids to teens, and can be a source of overstimulating/scary content). And, families should avoiding the triggers that set off their offspring. For example, choose Up versus Poltergeist this weekend, ok?
–Medications or supplements? Generally, meds or dietary supplements, like Benadryl, are not a first, or even second line approach to most kids with sleep problems. While an herbal tea can actually help (chamomile, anyone?), or even some aromatherapy (mmm, lavendar), I generally recommend families talk through with their physician about their use for a whole bunch of reasons.
–Monster spray: Fill a spray bottle with water, and have your child label it accordingly. By light of day, you can go around his room, misting scarycorners, dispelling Bad Dreams and Monsters from the premises. For some imaginative kids, this does the trick.
–Talking it out. Some kids are more verbal, and benefit from working out their fears in conversation. For these children, moving in the frightening nighttime spaces while the sun is up robs them of their power. Sitting with them or playing in the closet or corners, that can end the tyranny of the dark.
–Mindfulness and relaxation: Kids as young as preschool age do very well with these approaches. Yoga, massage, or even some basic bedtime relaxation techniques can reduce stress and move a child’s focus to a happier place.
And, tonight, maybe give Lemony Snicket a pass if your little one is scrunching deeper into her pillow during a reading. Or, think twice about popping a Harry Potter flick (or Chiller Theater) into the DVD player if your audience includes someone who gets wound up from such stuff. Instead, trundle up to bed with your child, turn on the nightlight and kiss their forehead and wish for a good night. If the cry comes in the night anyway, give them the hugs and kisses they need. Remember, as sure as the sun will rise, you can give your child’s doctor a call if needed.
Jack Maypole, MD is director of Pediatrics at the South End Community Health Center and director of the Comprehensive Care Program at Boston Medical Center. He is assistant professor of pediatrics at Boston University School of Medicine.
"What lies behind us and what lies before us are tiny matters compared to what lies within us." ~ Ralph Waldo Emerson