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Nightmares in Children


Standing outside a house that has seen too many years you wonder how you got here. Soil baked dry by a hundred summer suns tickles over your toes as you look down. No shoes! Why don’t you have any shoes on? The brown dirt crumbles between your toes as you take a single step forward, away from the decaying house.

A noise. The chitter-chatter of a feral Mogwai fed after midnight? It’s a sound you have heard before but cannot quite place. You turn and look behind you. There is nothing. The sound has stopped.

You take another step forward, earth becoming softer, wetter – feet sinking a little. That sound starts up again, except this time it doesn’t appear to be coming from behind you but from the field of never-mowed grass in front. As leaves bend and melt in the wind you can almost imagine them being moved by some small creature, darting away from you, making a path towards…

What the hell is that? The sky, once a dusty half-light is moving. Chunks of sod shifting, swirling, moving as if guided by some unseen agency, rising higher until…

The tentacles of some Elder God reach out towards you from the mess. They undulate unnaturally on a fast moving current of air. As they approach you feel the temperature drop. Hairs start to rise on the back of your neck. You exhale, a smokers exhale of white wisps.

They are getting closer just a few feet a way. If you reach out, you could almost touch them. Or they could touch you…

A fingers breadth now and you are rooted, stuck to the spot, paralysed, waiting for their not so gentle caress…

And – AWAKE.

Most of us have had a nightmare at some time in our lives, whether it is about a clown in the drain or a Demogorgon chasing us down a school corridor. It is pretty easy to rationalise them away as an adult, but it is not so easy for a child. Nightmares and the fear of nightmares (kakoneirophobia) can have a real impact on quality of life. I’m going to unpack this in this year’s Halloween-themed post.*

So we are all on the same page; a nightmare is a dream associated with strong negative emotions that wake one from sleep and are vividly recalled. It is one of a group of parasomnias, such as night terrors and sleepwalking. They usually occur in the REM stage of sleep and so, more often than not, occur between 4 and 6 am.

Where do nightmare come from?

The prevailing theory is that nightmares result from a mish-mash of factors – personality, coupled with anxiety traits and acute stressors.

Take the case of 13-year-old Will. According to his mother, Joyce, he has always had a nervous personality, with his episodes of anxiety increasing in frequency around the time of her divorce from her husband, Lonnie. A recent mystery illness has led to an increase in the intensity of his nightmares.

Given that sleep disturbance in children leads to sleep disturbance in the parents treating the child often improves the parents’ sleep and thus reduces their anxiety. This co-dependent relationship also works in reverse. Treating the psychopathology of the parents can reduce nocturnal problems.

Whilst these cognitive-behavioural events are the most common cause of nightmares, potential medical problems such as allergies, reflux, or infantile movement disorders must be at the back of one’s mind.

Various models have been used to describe the formation and function of nightmares.

The psychoanalytic model. Why do we dream? In his seminal Interpretation of Dreams(1900), Freud didn’t say much about them. His concept that nightmares are the brain transforming these hidden urges of the libido into self-flagellation and anxiety doesn’t fit in with his general dream theory. In this case, dreams do not represent wish fulfilment. That other great psychoanalyst from history, Jung, argued that nightmares are the leaking out of unresolved psychic stress/conflict.

The evolutionary model. Revonsuo proposed that nightmares are just a virtual reality threat simulation. By actively rehearsing dangerous encounters whilst asleep, the dreamer is better at threat avoidance in the waking world. Children have more nightmares than adults as they are more vulnerable to threats.

Neurobiological models. If dreams are a stimulant – with emotional arousal as the end point – there comes the moment when, perhaps, after several dysphoric dreams, the brain seeks to decouple arousal and response. One neurobiological theory would suggest that nightmares act as a form of decoupling, a circuit breaker, if you will.

If you want to delve further into this complex and somewhat baffling topic then read

Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

How common are nightmares?

According to Coolidge et al., as many as 6.4% of children suffer from terrible nightmares at least once a week (7.7% in boys versus 5.1% in girls). This might be underestimated as researchers often ask the parents (rather than the children) about nightmare symptomatology. And whilst they may seem more common in younger children, this may be because they are more likely to tell their parents. Older children are more likely to try and forget about their bad dreams.

Can we prevent them?

Whilst it is impossible to wrap children up in cotton wool, some common sense approaches may reduce the number of nightmares and their impact. In the main, they revolve around good sleep hygiene – avoidance of stimulating games or programmes in the run-up to bedtime and having a relaxing routine.

What if they happen every night?

The DSM-IV lists Nightmare Disorder as number 307.47 in a long list of potential psychopathologies. Techniques include desensitisation, imagery rehearsal, relaxation techniques and eye movement desensitisation.

Desensitisation. Just as the popular press feels we are becoming inured to the violence of everyday life because of the violence we see on screen, desensitisation therapy requires the dreamer to actively recall their bad dreams. The therapist then guides them on a journey of gradual exposure, first to the outer edges of the fear, then deeper, to the heart of it, pausing at each stage of the trip to allow frayed nerves and bounding hearts to settle.

Imagery Rehearsal/Rescripting. This psychotherapeutic approach involves a degree of supervised practice as the sufferer reviews a moderately scary nightmare and tries to change it into something more pleasant. This, coupled with daily practice over 12 weeks, has had positive outcomes in the adult population. Investigators have replaced verbal descriptors with drawings as an alternate form of imagery rehearsal therapy and found that though it might decrease the frequency, it did not reduce the intensity of feeling.

Eye movement desensitisation. This form of therapy, coined by Shapiro in the late ’80s, is based on a curious premise. Shapiro noticed that if she became stressed or anxious, her eyes would move more rapidly. She found that her stress lessened by deliberately slowing her eye movements down. Whilst far-fetched, there have been several case reports of its successful use in sufferers of PTSD as well as victims of recurrent nightmares.

*Some people like April Fools themed posts (Damian Roland and Radiopaedia, I’m looking at you). I prefer Halloween.


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Simard V, Nielsen T. Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy: Theory, Research, Practice, Training. 2009 Dec;46(4):492.

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Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

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