Solve Your Child's Sleep Problems

Part IV

Interruptions During Sleep

Chapter 14

Nightmares

What Nightmares Are
and Why They Occur

Nightmares are dreams—very scary dreams that wake you and leave you frightened and full of dread. A nightmare begins as an ordinary dream, but then, toward the end, it turns frightening. A child might dream he is happily walking his dog in the park on a sunny day. Then it suddenly gets dark, he finds he is lost in the woods, and a monster jumps at him—and he wakes frightened. When we speak of nightmares, we’re concerned with dreams that are frightening enough to wake your child. Most dreams, even scary ones, are forgotten unless we wake at the end at least briefly.

Like all dreams, nightmares occur in REM sleep. Although newborn babies presumably have rudimentary dreams—since they spend a great deal of time in REM sleep, during which they show eye movements and little smiles—we do not know whether they experience what we generally consider to be true dreaming with complex images, sounds, feelings, and thoughts. But dreams, including nightmares, unquestionably do occur during the second year of life, a fact that becomes progressively clearer as a child develops speech and hence the ability to describe his dreams.

The content of a one-year-old’s nightmare is likely to be simple. Typically he will re-create and reexperience a recent frightening event. Even though a one-year-old cannot describe his dream well, he may have enough verbal ability to indicate that it concerned a recent blood test, car accident, or bee sting. A child of this age does not understand the difference between a dream and reality, so, on waking, he will not understand that the dream is over. He may still be afraid, as if the threat from the dream were still present. If he dreamed of a bee, for instance, his continued behavior (pointing) and words (“Buzz-buzz here”) may further demonstrate his conviction that the bee is still in the room.

By the time a child is two, his dreams have become more symbolic, with monsters or wild animals typically representing his impulses and fears. By this time he has begun to understand the concept of a dream, but he cannot yet fully appreciate the difference between dreaming and reality. He may describe dreaming of a monster yet still insist that “the monster hasn’t gone yet.”

As the child grows, his dreams become more complex. At the same time, he becomes more and more capable of distinguishing dreams from the real world. By about age five, he is likely to wake from a dream with an immediate and full understanding that he has been dreaming. It will be harder for him to reach this point after waking from a nightmare. A child’s ability to accept a dream as “just a dream” continues to develop, so that by age seven he may be able to handle an occasional nightmare without waking anyone for support. Still, even in an older child, the feeling of fright on waking from a nightmare is very real. As one child said: “Mom, I know what happened in the dream wasn’t real, but the dream was real!” The rational knowledge that nightmares come out of one’s own imagination may have limited power compared to the emotional impact of the experience. Thus Hannah, an eleven-year-old girl, got up during the night to check that her younger brother was all right after dreaming that he had died—even though she knew full well that it was only a dream.

Although nightmares occur during sleep, for the most part they are caused by, and reflect, emotional conflicts that arise from a child’s waking life. These conflicts are just the usual struggles children face throughout their normal development. Partly for this reason, all children have nightmares at one time or another. Some nightmares have other causes, such as illness or medication, and some seem to happen for no particular reason at all (at least none that can be easily identified).

The specific content or “story” of your child’s nightmares depends on several factors: his stage of physical and emotional development, the particular emotional conflicts he faces at his current developmental stage, and any particularly scary or threatening daytime events he’s been exposed to recently. The anxieties that produce nightmares may also lead to fears at bedtime and during periods of wakefulness at night, possibly interfering with your child’s ability to fall asleep or get back to sleep (these problems are discussed in Chapter 7.

Young toddlers commonly fear separation from their parents. Your child may have nightmares when he first goes to day care, when you go out of town or must be hospitalized, or after he has briefly gotten lost in a store. As he gets a little older, he becomes more concerned about losing your love than about temporary physical separation; for example, he may fear that he is losing you to a new brother or sister. Or, in his third year, during toilet training, he may struggle with his own impulse to soil while at the same time wanting to please you and fearing your disapproval. His dreams at these times may well reflect these anxieties.

Children between the ages of three and six must resolve many aggressive and sexual impulses. Your child will discover that he enjoys touching his genitals, and he may be jealous of your attention to a new baby and want to hit him or her. But he may also be frightened by his desire to do such things, especially if he believes you won’t help him control his aggressive urges or thinks he will be punished for giving in to the sexual ones. If he isn’t taught that such urges are normal, shown what kinds of behavior are acceptable, and helped to control temptations toward truly inappropriate or harmful behavior, then the scary feelings associated with these impulses may take shape as “monsters” that frighten him at bedtime and during dreams. A three- to six-year-old may also be disturbed if he witnesses violent behavior or overhears loud arguments at home. He may sense that you cannot control your own behavior and worry that you won’t be able to help him stay in control himself.

A child may also feel conflicts deriving from the desire to replace one parent as the other parent’s partner. Such anxieties can be stimulated further if the child is allowed to act out these feelings. Daniel, a five-year-old boy I saw, came into his parents’ bed every night and ordered his father to leave. If his father did not go immediately, Daniel would begin to hit him. At that point his father would always move to another room—it was easier to give in than to struggle, and he could at least get some sleep that way. But for Daniel, having this power over his father was frightening. He was not sleeping well at all during this time, and he had frequent nightmares in which he was threatened by monsters.

Children around this age are often also struggling to understand the concept of death, and they may be afraid of falling asleep and never waking again. Alexander, age six, never had any difficulty sleeping until he went to his uncle’s wake. He was told not to worry, because his uncle “would look just like he was sleeping”—in fact, he learned, his uncle had died in his sleep. Alexander’s nightmares after this experience were related to his concerns about death and his confusion between sleep and death.

Anything that a child finds frightening or cause for worry can trigger bad dreams. Lauren, a five-year-old girl, came to see me with her family after three weeks of nighttime wakings that began after she saw a scary movie—one she probably should not have been allowed to see. Since then she had been waking and screaming for her parents at about three in the morning several times a week. They would find her awake, alert, and shaking, clearly very frightened. Her dreams were not identical from night to night, but their content resembled that of the movie she had seen. Her parents would stay with her only briefly and refused to allow her into their bed because they did not want her to develop what they considered to be bad habits. But being unable to get help at night only scared Lauren more, and her nights got even worse. Soon she did not want to go to bed at all, and she fought with her parents to keep them from leaving her alone at night.

In children between seven and eleven years old, nightmares ordinarily occur only occasionally—generally less than once a month. The conflicts of the preceding years should have been largely resolved by then (or at least repressed until adolescence), and new stresses are likely to be taken more in stride. If you have a child who, at this age, still has frequent nightmares—perhaps several each month—he may be struggling with conflicts that were not successfully resolved at an earlier age, or he may be facing significant new or ongoing stresses.

During puberty and throughout adolescence, new conflicts and anxieties emerge. As your child becomes an adult physically, sexually, emotionally, and cognitively, he has to face new stresses every day. Nightmares seem to become somewhat more common at this time, although it is often difficult to say for certain, because adolescents are less likely than younger children to talk to family members during the day about their dreams, and they are certainly less likely to wake their parents at night after having a bad dream.

How to Help Your Child
If he is Having Nightmares

If your child has nightmares only now and then, maybe one every few months, a straightforward approach is usually sufficient. If your child is less than two years old, remember that he does not yet understand that dreams are not reality—you won’t have much success by trying to show him that “it was just a dream.” He simply needs to be held and comforted just as he would after a frightening event in the daytime. For a two-year-old, soothing, reassuring words will also help. At this age he may also be comforted if you listen sympathetically while he describes his dream or fears to you.

If your child is three or four, it may be useful to remind him that he was dreaming, though you must still treat his fear with empathy and reassurance. Even if he did not find it important to sleep with a night-light on or his door open when he was younger, he may now. When he wakes from a dream, the night-light lets him see around his room and remember that he is at home and not in the dream scene. With the door open, he will feel less shut off from the rest of the house and closer to other family members. It will be easier for him to orient himself and accept that the dream is over and he is safe. After waking from a particularly frightening dream, he may even want an even brighter light turned on.

The main point to remember when your child wakes from a nightmare is that he is truly frightened and needs your full reassurance and support. If he is afraid to go back to sleep, you may have to stay with him for a considerable time. (The length of time it will take for him to calm down may vary. Younger children typically need more time than older children, and, of course, the more intensely frightened they are, the longer it will take.) Occasionally lying down with him or even taking him into your bed won’t hurt, and, in fact, it’s the most reasonable approach when your child is very upset. Be supportive in a calm and convincing way, showing that you are in control and able to keep him safe. This is not the time to be extremely firm: it is unwise to shut your child’s door when he is already too afraid to be alone.

On the other hand, you should not feel obliged to grant all your child’s requests in an effort to allay his fears. For instance (as discussed in Chapter 7), don’t feel compelled to turn on lights all over the house, look under the bed, rifle through the closet, rearrange the furniture, and lock the windows. Remember, rather than reassuring him, such actions ultimately only support beliefs that monsters may be real and somewhere in the house. Instead, respond to his true needs by letting him know calmly and clearly that you will take care of him and protect him. Often even a thirteen-year-old who feels too “grown-up” to be hugged in the daytime will appreciate such reassurance when he wakes frightened after a nightmare, and while an older adolescent may not need the physical comfort, he may on occasion still want someone close by to talk to.

If your child is having frequent nightmares—several a month, say—you need to work with him during the day to solve the problem. Try to determine what is worrying him and see if you can help relieve his anxiety. For example, if your one-year-old has difficulty leaving your side, activities that practice separation, such as peek-a-boo—which makes a game of your disappearance and reappearance—might help your child feel comfortable when he is apart from you. If your two-year-old is having nightmares during toilet training, even when it has been going well, try relaxing the training efforts for a while and encourage messy play such as finger painting. For three- to six-year-olds, children’s books about sleep and dreams may help; you can also begin to talk directly to your child at this age about his fears and concerns. Screen the books, movies, and television shows that your child sees. It goes without saying that you will want to avoid very scary ones, but because so much sex and violence regularly appear on prime-time television and in commercials, you will also need to monitor the rest of his viewing. Even if your four- or five-year-old enjoys these shows and does not seem frightened by them, they could still stimulate enough anxiety to cause nightmares.

By all means allow your child to express his feelings, whatever his age, but teach him appropriate limits. Avoid moral condemnation. Don’t make him feel guilty about having angry or sexual feelings; instead, help him learn acceptable ways to express them, such as by talking angrily but not hitting. He may be reassured to learn that you used to have fights with your sister or brother or that everyone finds that it feels good to touch his or her genitals. With an older child, foster open communication and frankness, and encourage him to discuss his concerns, even if they have to do with difficult issues such as divorce, sex, or drugs.

Daniel was the five-year-old who kicked his father out of bed every night and struggled with frequent nightmares. When I discussed the situation with his parents, they agreed that they should be the ones making the decisions about who slept where, not Daniel. But they also came to understand that by giving in to his nightly demands they had unwittingly been depriving him of a sense of security. They began insisting that Daniel stay in his own bed at night, and despite his initial protests and struggles, Daniel was ultimately much more comfortable with this demonstration that his parents were in control. Before long, his nightmares disappeared altogether.

Alexander, whose nightmares began after he attended his uncle’s wake, clearly needed to work through the fears that he had developed in its aftermath. With coaching, his parents began encouraging him to discuss his feelings openly about his uncle’s death and funeral, and after they corrected some of his misconceptions and read him a children’s book about death, his bad dreams went away.

Lauren’s fears and frequent nightmares had started after she saw a scary movie, and they didn’t seem to reflect any deeper anxieties. Because she was so frightened when alone at night, I suggested that one of Lauren’s parents temporarily sleep in her room all night until her fears and nightmares stopped. In the meantime, during the day, they would discuss the movie with her to help her deal with the fear. Lauren was relieved by this show of support. Within two weeks she was going to bed happily, and the nighttime wakings and scary dreams had stopped. She then agreed to try sleeping alone again, but with the promise that if she had another bad dream one of her parents would return and stay the rest of the night. She had one more nightmare the next week, and her mother came willingly. After that, the problem was gone.

Occasionally, nightmares are a symptom of severe emotional difficulties. Regardless of your child’s age, if he has frequent nightmares—perhaps weekly or more—over a period of more than one or two months, and you can’t identify the cause of the stress he is feeling and help him resolve it, then you should consider seeking professional help. This is especially true if your child also is troubled by fears during the daytime that seem excessive for his age, such as marked difficulties being away from you, unreasonable fears of being in his bedroom alone, reluctance to go to school, or major phobias. As a parent, you should expect to take some part in at least some of the counseling sessions. If your child’s anxiety reflects things he has seen or heard and perhaps does not understand, you may merely need help learning to recognize and deal with the causes of his distress. But if the issues are more deep-seated, they will be less responsive to emotional support alone. In that case, longer-term therapy will likely be needed.

Nightmares and Confusional Events

Before you try to address your child’s nightmares, you should first be sure that nightmares are in fact the problem. If he cries out in the middle of the night and seems frightened, or jumps out of bed appearing very upset, then you might assume he had a bad dream. But you should also be aware that he might have had a confusional event, specifically a sleep terror, confusional arousal, or episode of agitated sleepwalking (as discussed in Chapter 13). It is important to determine which kind of event it is, because the appropriate responses are quite different. The two phenomena are easy to mistake for one another, and to further confuse matters, the terms “nightmare” and “sleep terror” have sometimes incorrectly been used interchangeably. Nightmares are frightening dreams that occur in REM sleep and are followed by full waking. Sleep terrors, on the other hand, like other confusional events, occur during a partial arousal from the deepest phase of nondreaming sleep. Although in principle it sounds easy to distinguish the two, in practice the distinction is not always so obvious, especially in a young child.

The differences between nightmares and sleep terrors (and other intense confusional events) are discussed here and summarized in Figure 16. Chapter 13 deals with confusional events in detail. Nightmares usually occur toward the end of the night, when REM sleep is most intense; in contrast, confusional events happen during the first few hours after a child has fallen asleep, when non-REM sleep is deepest. After a nightmare, a child who is old enough can describe a dream, but after a confusional event there is no dream to report. When your child wakes from a nightmare, he will cry (if he is young) or he may call for you (if he is older). He recognizes you immediately and wants you to hold him and comfort him. He remembers the dream then, and he will still remember it in the morning. A child in the midst of a confusional event, on the other hand, is not fully awake. He may cry out, regardless of his age, but the cry may sound more like a scream, or he may talk, moan, and cry all at the same time in a confused and possibly unintelligible way. During the episode he will not recognize you or allow you to comfort him. If you try to hold him, he may push you away and become more agitated. If he does wake briefly at the end of the confusional event, he will not remember the preceding yelling and thrashing, and he will have no memory of a dream. In the morning, he may vaguely remember being awake and perhaps talking to you during the night—that is, the period after the confusional event—but no more.

A child who has been frightened by a nightmare will remain frightened even when fully awake. Often he will be reluctant to go back to sleep alone in his bed afterward. He may even be afraid to go to bed for several nights following an especially scary dream. On fully waking after a confusional event, however, the child will relax; all signs of fear and agitation disappear, and he will return to sleep rapidly. Since he is unaware of the episodes, he will not be reluctant to go to bed on following nights.

It is much more common for parents to misinterpret confusional events as nightmares than the other way around. If a child is too young to describe his dreams, his parents may simply assume he has had a bad dream whenever he wakes crying and upset. They may make the same assumption when an older child “wakes” thrashing or screaming, even if he does not describe a dream after he quiets down. If a child calls out, “Help me!” his parents may understandably jump to the conclusion that he is fully awake and reacting to a nightmare that he just had.

Parents struggling to wake their child from a sleep terror may be misled by his initial confusion and lack of receptiveness. If he pushes them away, they may conclude that he is still dreaming, “fighting off monsters.” If they succeed in waking him as the event ends, their own anxious questions may make him fearful, as he would be after an actual nightmare; telling him about his bizarre behavior may do the same, since until it’s described to him, he’ll be unaware that anything unusual had even happened. Now, instead of returning to sleep rapidly as he otherwise would, he may be unable to or unwilling to try. Even if he isn’t frightened, once he is fully awake he may enjoy the attention, and if his parents keep asking him what he was dreaming about, he may make up a story to satisfy them.

FIGURE 16. NIGHTMARES VERSUS SLEEP TERRORS

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Remember, as we saw in the previous chapter, a sleep terror is more physical than mental. During a sleep terror a child experiences all the physical changes usually associated with fear—his heart is beating rapidly, he is sweating, and his blood pressure rises—and he looks and acts frightened, but when he wakes fully there is nothing frightening to remember. After a nightmare, however, a child is truly frightened and remembers the dream, but physical changes, such as of heart rate and blood pressure, are relatively mild.

When an intense sleep terror begins suddenly and (as may happen in the adolescent) lasts only a minute or two, a child may wake spontaneously to find himself still sweating and his heart still pounding and racing. To explain these feelings to himself—ones typically associated with fear—he may attribute them to a vague threat and say, perhaps, “It was going to get me.” By contrast, if a child has had a nightmare he will be able to give a full dream report, with a story line, characters, and settings. After a sleep terror, although he may feel some of the physical effects associated with fear, they will usually fade rapidly and he will be able to return to sleep quickly if his parents remain calm.

However, even though a child waking from a nightmare will usually be normally responsive—reaching up to be lifted out of the crib as soon as you come into his room, clinging to you when you pick him up, or, if he is old enough, even getting out of bed and running into your room for reassurance—occasionally he may behave at first almost as if he were having a sleep terror. He may appear confused and seem unresponsive to your efforts to comfort him for several minutes. He may point around the room and refer to animals or monsters, but be too upset to describe a coherent dream. This situation happens most often with a very young child who does not fully understand what a dream is, that the monsters are not real, and that the dream is over and he is safe at home. Still, he will not thrash around as wildly, or be as unresponsive, as a child actually having a sleep terror.

Finally, although both sleep terrors and nightmares may occur frequently or occasionally, events that occur very frequently—several times a week, nightly, or even several times a night—are not likely to be true nightmares, particularly when such frequent events continue for more than one or two weeks; these events are much more likely to be of a confusional nature.

Nightmares or “ ‘No’-mares”?:
“I had a bad dream”

As we saw in Chapter 7, children sometimes report having nightmares when in fact they have not. They call for their parents or come to their room at night, even every single night, saying “I had a bad dream.” These children have simply learned that whenever they say those magic words, they get a big response. If they say “I want to sleep in your bed,” they will be sent back to their rooms, but if they say “I had a bad dream,” they are told, “Come on in.”

Of course, you should comfort your child when he really has had a scary dream. So how do you know if the complaint is genuine? Generally, it’s not very difficult to tell. Since a child waking from a nightmare is truly scared, he will look and act scared. If your child—like the child described in the section on “How Severe Is Your Child’s Anxiety?” in Chapter 7—gathers up his blanket and teddy bear every night, walks calmly to your room, and taps you on the shoulder before saying he had a bad dream, then you can be sure that he didn’t. If he can’t describe what happened in the dream, that is another sign that it didn’t happen. If it had, he would have run to you, or clutched you tightly when you answered his call, and he would have a dream story to report. If you are in doubt, err on the side of leniency for a night or two, but remember that scary dreams almost never happen nightly. Whether your child is truly having nightmares should become clear very soon.

However, for some children the words “I had a bad dream” really mean “I’m scared.” In such cases, it makes little difference whether these children actually had a dream or not. If your child is truly frightened, then you must deal with his fears (as discussed in Chapter 7), whether they arose from wakeful thoughts or from dreams.