- 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?
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Sophia's Treatment & Referrals
Now it’s time to recommend treatment options for Sophia's nightmares.
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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.