- Nightmares are frightening dreams that occur during REM sleep usually resulting in waking up out of sleep. A child will remember these and usually seek comfort to be able to go back to sleep.
- Nightmares typically occur during REM sleep. There is a higher percentage of REM sleep within someone’s sleep architecture in the second half of the night so that is why more nightmares occur in the second half of the night.
- The content of dreams may vary depending on the age and development of the child starting usually after age 2. Prior to age 12, there is an estimated equal prevalence of nightmares between boys and girls. After age 12, girls are noted to have more frequent nightmares.
Sophia's Story
Sophia is a 5 yo girl with bad dreams that cause her to go to her parents several nights a week and are now causing more frequent bedtime issues / bedtime fears. Her parents are worried that their child who use to be a good sleeper is now waking up at least once a week during the night and coming to their room because of “bad dreams”. They are not sure what time she comes to their room. She does not seem tired in the day. They are not sure of any new stressors although kindergarten started about a month ago. No concern for any abuse or trauma. She had some sleep issues when 1 year old sister was born.
Expert Insights
BEARS Screening
Sophia and her parents were at her 5 year old well child check up. As part of that visit, the BEARS questionnaire was completed and this is the information obtained.
Bedtime Problems
In general, Sophia goes to sleep without difficulty although on some nights she seems to delay getting to bed. She has more questions about her school schedule the next day as well as worrying about having another nightmare. Parents try to limit her exposure to television prior to bedtime. Sophia has her own room.
Expert Insights
- Because nightmares are often related to nighttime fears or anxiety, there is need to consider that component when discussing treatment.
- If there are bedtime issues, this can contribute to not getting enough sleep. Sleep deprivation can increase the likelihood of more intense and vivid dreams.
- Contributing factors to nightmares include stress, anxiety, trauma, which all can play a role in additional bedtime problems.
Excessive Daytime Sleepiness
- Because of kindergarten, Sophia seems more tired after school than she did in the summer, but parents feel this is likely related to just getting used to a new school.
- Going to sleep has become more difficult. Sophia has more questions about what the school day may entail as well as worrying about having another nightmare.
Expert Insights
- Excessive sleepiness is usually not present. However, more REM sleep is often present the night after being sleep deprived which can lead to more dreaming or nightmares. This reinforces the importance of obtaining adequate and regular amounts of sleep.
- However, an underlying disorder causing excessive daytime sleepiness is unusual.
Awakenings
- Sophia has been coming into her parents’ room at night several times a week.
- The parents think she comes into the room sometime after midnight.
- They usually need to go back to her room with her and either rub her back or sing her a song.
- She appears to go back to sleep within 15-30 minutes although the parents feel this is longer than her usual awakenings to use the bathroom.
Expert Insights
- Awakenings - usually present and child remembers them. Depending on their age, they are more or less able to describe the content. Also, as teenagers, they may no longer come to parents/ caregivers in the night and describe content later.
- Nightmares include content that involves fear or anxiety but other emotions such as sadness, anger, or embarrassment can also be noted.
- It is important to determine in the history if the event at night is truly a nightmare or “something else”. Aspects in history taking to distinguish between night terrors and nightmares can include: timing of the event (with nightmares being present more in the second half of the night); recall of the awakening (children often don’t remember or only partially remember a night terror yet have a vivid memory of a nightmare); how well they go back to sleep (often with night terrors, children can go right back to sleep and with nightmares it is often more difficult).
Regularity & Duration
- Family has a regular bedtime routine. It has gotten more rushed due to school starting but overall they feel like they still get her to bed by 7:30 pm and she usually awakens on her own around 6-6:30 am.
- Recommended total hours of sleep for a 5 year old is usually 10-11 hours of sleep.
- She was not routinely napping during the summer. Since kindergarten started, they have noticed she may take a nap on the weekends for about an hour
Expert Insights
- As mentioned earlier, ability to go to sleep may be disrupted due to fear or anxiety of nightmares. Additionally, not getting enough sleep can be a contributing factor to increased intensity of dreams. Overall, it is important to get a good bedtime history to understand the bedtime routine, concern for insomnia, or anxiety.
Sleep-Disordered Breathing / Snoring
- Sophia is not described to snore. She has had at least one cold since the beginning of kindergarten and sounds more “stuffy” in the doctor’s office today. Parents deny loud breathing at night, snoring heard outside her room, or any witnessed apneas.
Expert Insights
Snoring - usually not an issue but should always screen for it. For some patients, they may be awakening more from REM sleep due to sleep apnea and thus remembering their dreams.
Sophia's Evaluation & Diagnosis
What evaluation & diagnostic protocol should the medical provider use to diagnose Sophia's nighttime behaviors?
Check all that apply:
The evaluation protocol strategies we recommend for Sophia's case are:
- Determine child’s sleep history
- Complete a Sleep Diary
The definition of Nightmare disorder from ICSD (International Classification of Sleep Disorders), third edition, 2014:
Criteria A through C must be met:
A. Repeated occurrences of extended, extremely dysphoric, and well remembered dreams that usually involve threats to survival, security, or physical integrity
B. On awakening from the dysphoric dreams, the person rapidly becomes oriented and alert
C. The dream experience, or the sleep disturbance produced by awakening from it, causes clinically significant distress or impairment in social, occupational or other important areas of functioning as indicated by the report of at least one of the following:
- Mood disturbance
- Sleep resistance
- Cognitive impairments
- Negative impact on caregiver or family functioning
- Behavioral problems
- Daytime sleepiness
- Fatigue or low energy
- Impaired occupational or educational function
- Impaired interpersonal / social function
Elements of Sophia's Sleep History
| Sleep History | Case Specific Questions | Sophia's Evaluation Results |
|---|---|---|
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What the child does at night
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Review timing of events at night |
How often does this happen at night? |
Has occurred after midnight - parents estimate between 2-4am. Not always at a typical time. |
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How long as this been going on for? What was the age when this started? Are the events becoming more or less frequent? |
Usually only happens once a night |
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Screen for other sleep issues? |
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Safety Concerns |
None at this time, however, if there is a concern of abuse or trauma related to the occurrence of bad dreams / nightmares then further evaluation is needed. |
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Review of Medications |
Certain medications impact sleep architecture by altering the amount of REM sleep. This may contribute to increased frequency of bad dreams. |
No medications are being taken by patient. |
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Family History |
Any family history of anxiety, depression, or history of vivid dreams? |
Family psychiatric history was negative for anxiety or depression. |
Other
| Information to obtain includes: | Case Evaluation Results |
|---|---|
|
Nightmares Diary |
Parents kept track of Sophia's nightmares which occur on a nightly basis. |
Options that are Not Recommended
Perform a Physical Exam
A full physical exam is helpful particularly focusing on ENT evaluation if there is a concern of OSA, abdominal exam if concern of constipation, neurologic exam for any underlying neurological concerns.
Order Labs/Other Diagnostic Tests
Ordering labs or extra tests is not recommended in this case.
Sleep Study
This is usually not indicated in the evaluation of nightmares.
Referral to a Specialist
Consider a referral to a psychiatry or psychology if there is a concern of relevant anxiety, or regression in behaviors. Additionally, may need to consider evaluation for abuse or trauma. In some places this would include a specialized child abuse team. Nightmares related to a traumatic event usually begin to occur within 3 months.
Red Flags
- Prior Nighmares
- Stress or traumatic events
- Anxiety - either symptoms of generalized anxiety issues or specific phobias
- Not enough sleep - rebound or increased REM lseep can occur after a period of sleep deprivations
- Trouble sleeping / insomnia
- Certain medications or stopping certain medications
When evaluating a child for possible parasomnias,
consider how other health care providers may also need to be involved.
Evaluation & Diagnosis
If a child wakes up screaming, what features indicate that this is a nightmare rather than a night terror?
Check all that apply:
Sophia's signs and symptoms are consistent with Nightmares.
- Sophia wakes up in the last half of the night
- Difficulty going to sleep at bedtime because of other nighttime fears
- Seeks out caregiver for reassurance after waking up
If Sophia was having night terrors she would not remember that she woke up the next morning. She would scream and could wander around while screaming and/or uninate.
It is important to differentiate between nightmares and night terrors to provide appropriate reassurance to family and patient. The distinguishing features of nightmares often include the timing of the awakening in the last half of the night and the need to seek out comfort for the dream either during the night or on awakening in the morning.
Sophia does remember waking up at night and parents feel like she wakes up after midnight. No bedwetting has been noted.
Sophia's Treatment & Referrals
Now it’s time to recommend treatment options for Sophia's nightmares.
Check all that apply:
The following treatment strategies are recommended for Sophia's nightmares:
- Introduce a security object
- Use of imagination to change the content of dreams
- Reduce the likelihood of nightmares by trying to decrease exposure to issues that cause fear for child - ie TV shows, games, books, stories, etc.
- Get enough sleep.
- Review other sources of stress in day to day life.
- Educate parents - try to offer support to child without giving too much attention to child (especially in the middle of the night).
- Security objects and night lights help.
- Use child’s imagination to empower them to treat the dream - ie. dream catchers, drawing happy endings to the dream, drawing the dream and “throwing it away”, magic wands, flipping pillow over to “change the channel”.
For frequent nightmares consider:
- Imagery rehearsal which is actually practicing the alternative endings during the day with visual cues
- Relaxation techniques or mindfulness activities
- Desensitization if there is specific content that is repeated - for example, a child with a fear of dogs
When to consult a sleep specialist or refer to another discipline:
Sophia's Results:
Good news!
Sophia has been sleeping better. Parents offered reassurance for Sophia’s bad dreams. They allowed her to have a small nightlight in her room. Also, they put a dream catcher in her room as well as adding a “magic wand” that Sophia could use to get rid of scary images that might occur at night.
- They also voiced understanding of other techniques they could use if the frequency of nightmares increased.
- They are also checking with her teacher at school to see how school is going.
- Finally, they are working on making sure Sophia gets to bed on time. They noticed that by the end of the week, she does seem more tired so they think that an earlier bedtime has been helpful in reducing the fatigue and also decreasing the frequency of nightmares.