Night terrors

Definition

Childhood night terrors are a parasomnia, or partial-sleep disorder, common in young children. They occur in the deepest stage of sleep and are characterized by an abrupt arousal, usually within the first hour of sleep. The child may sit bolt upright in acute terror, screaming inconsolably. Night terrors are a confusional arousal resulting from immature sleep patterns with an intense activation of the flight or fight emotion.

Description

Night terrors are not a dream or typical nightmare. They occur in non-REM, slow-wave sleep. The panicked screaming, kicking, thrashing, and flailing is alarming in its intensity. Sleepwalking, another parasomnia disorder, may also occur in as many as one third of children with night terrors. While experiencing the night terror the child is extremely disoriented and may stare straight ahead, eyes wide open, with the dark centers (pupils) enlarged. There is profuse sweating, the heartbeat is rapid, the breathing fast, and the blood pressure is elevated. As the child is not fully awake, she is unable to see or recognize her parent or caretaker and cannot be easily awakened. The night terror may last from one to 15 minutes or more and is usually followed by a return to deep sleep. Afterwards the child may have no memory of the experience.

Night terrors appear to run in families, though there is no scientific evidence of genetic factors. They are a developmental process and not typically a result of mental or physical illness.

Demographics

Childhood night terrors occur more frequently in boys. Children between the ages of three and five years of age are most likely to experience such nocturnal episodes. Such confusional arousals rarely persist beyond childhood, and they are significantly less frequent or cease entirely after age 12.

Causes and symptoms

Childhood night terrors appear to be a normal physiological process of the immature and developing nervous system. These confusional arousals can be triggered by stressful circumstances such as when a child is overly tired, when there is a loud noise or other unusual disruption, a change in the child's regular sleep-wake schedule, or even a full bladder. Night terrors occurring in adolescence and adult life may be more severe and are often linked with trauma and post-traumatic stress disorders.

When to call the doctor

Consult a pediatrician for night terrors if any of the following occur:

• Episodes occur more than once a week.
• Episodes persist after a schedule of preventive awakenings.
• Episodes last more than 45 minutes.
• The child exhibits drooling, jerking, and stiffening of the body.
• The child is physically endangered during an episode.
• Episodes occur later during the sleep cycle, more than two hours after going to sleep.
• The child has fears that persist throughout the day.

Diagnosis

Diagnosis is based on observation of the following characteristic symptoms:

• recurring episodes of abrupt and partial awakening from deep sleep with panicked screaming and disorientation
• increased heart rate, rapid breathing, and profuse sweating during an episode
• child is unresponsive to efforts to arouse or console during an episode
• child has little or no memory of the event after a full awakening

Treatment

Parents should not attempt to awaken a child experiencing a night terror. Efforts to console may be futile, though holding the child firmly and speaking with soothing words may facilitate the return to deep sleep. The primary effort should be to protect the child from possible harm to herself and others and ease them back to sleep.

In some severe cases, a pediatrician may prescribe a benzodiazepine tranquilizer, such as diazepam, known to suppress the stage four level of deep sleep. Though tranquilizers may be used for short-term control of night terrors, the result is uncertain and not generally advised.

Alternative treatment

Hypnosis, biofeedback, and various relaxation techniques have been used with some success to reduce or eliminate occurrence of childhood night terrors. Calming music or bedtime stories can help lull a child into deep sleep. Maintaining a quiet home without sudden disruptive noise will minimize some of the external stimuli that may trigger night terrors.

Nutritional concerns

Unusually heavy or spicy meals should be avoided before bedtime as indigestion might act as a trigger for night terror arousals.

Prognosis

Childhood night terrors are usually outgrown by the age of seven and rarely persist beyond adolescence.

Prevention

Some pediatricians suggest that parents maintain a sleep diary and observe the child throughout several night terror episodes, noting the amount of time following sleep when the night terror begins. After the sleep-wake pattern is determined, a series of 15–20 minutes prior to the usual occurrence of the night terror and keep the child awake and out of bed for a full five minutes. This may help to break the disruptive sleep pattern that has resulted in the night terrors.

Children often experience night terrors during the toilet-training years. The night terror might be triggered by a full bladder. Assisting the child to the toilet prior to bedtime and even during the course of a night-terror might be beneficial in reducing reoccurrence.

Parental concerns

Childhood night terrors are alarming to witness. Parents may find it particularly difficult when efforts to console the child fail and the child does not recognize them even though his or her eyes may be wide open. The screaming, flailing, and kicking that accompany a night terror may frighten parents who fear the child is having a seizure. It is not a seizure unless the behavior includes eyes rolling back in the head, stiffening of the body, and drooling. Most childhood night terrors will last about 10 minutes.

KEY TERMS

Benzodiazepine —One of a class of drugs that have a hypnotic and sedative action, used mainly as tranquilizers to control symptoms of anxiety. Diazepam (Valium), alprazolam (Xanax), and chlordiazepoxide (Librium) are all benzodiazepines.

Confusional arousal —A partial arousal state occurring during the fourth stage of deepest sleep. Childhood night terrors are a form of confusional arousal.

Parasomnia —A type of sleep disorder characterized by abnormal changes in behavior or body functions during sleep, specific stages of sleep, or the transition from sleeping to waking.

Rapid eye movement (REM) sleep —A phase of sleep during which the person's eyes move rapidly beneath the lids. It accounts for 20–25% of sleep time. Dreaming occurs during REM sleep.

Resources

BOOKS

Schroeder, Carolyn S., and Betty N. Gordon. Assessment & Treatment of Childhood Problems, 2nd ed. New York: Guilford Press, 2002.

ORGANIZATIONS

National Sleep Foundation. 1522 K Street, NW, Suite 500, Washington, DC 20005. Web site: <www.livingwithillness.com/id174.htm>.

WEB SITES

Driver, Helen. "Parasomnias." Canadian Sleep Society. Available online at <www.css.to/sleep/disorders/parasomnia.htm> (accessed October 12, 2004).

Harvie, Jeni. "Disorders: A Wake-up Call for Parents." Sydney Morning Herald, January 29, 2004. Available online at <www.smh.com.au/articles/2004/01/29/10750881124899.html> (accessed October 7, 2004).

"Nightmares and Night Terrors." Cincinnati Children's Hospital Medical Center. Available online at <www.cincinnatichildrens.org/health/info/growth/diagnose/nightmares.htm> (accessed October 12, 2004).

"Nightmares and Night Terrors in Children." American Academy of Family Physicians. Available online at <http://familydoctor.org/566.xml> (accessed October 12, 2004).

Night Terror Resource Center. Available online at <www.nightterrors.org> (accessed October 12, 2004).

"Sleep Behavior Problems (Parasomnias)." Kids Health for Parents. Available online at <www.kidshealth.org/parent/general/sleep/parasomnia.html> (accessed October 12, 2004).

"Sleep Problems in Children." Sleep Matters, March 31, 2004. Available online at <www.sleepfoundation.org/features/children_sleep_problems.cfm#nightmares> (accessed October 12, 2004).

Clare Hanrahan

Night Terrors

Definition

Night terrors are a sleep disorder characterized by anxiety episodes with extreme panic, often accompanied by screaming, flailing, fast breathing, and sweating and that usually occur within a few hours after going to sleep.

Description

Night terrors occur most commonly in children between the ages of four and 12 but can also occur at all ages. Affected individuals usually suffer these episodes within a few hours after going to sleep. They appear to bolt up suddenly, and wake up screaming, sweating and panicked. The episode may last anywhere from five to 20 minutes. During this time, the individual is actually asleep, although the eyes may open. Quite often, nothing can be done to comfort the affected person. Very often, the person has no memory of the episode upon waking the next day.

Night terrors are differentiated from nightmares in that they have been shown to occur during Stage 4 of sleep, or in REM sleep, while nightmares can occur anytime throughout the sleep cycle.

Causes and symptoms

Suffering from night terrors seems to run in families. Extreme tension or stress can increase the incidence of the episodes. In adults, the use of alcohol also contributes to an increased incidence of night terrors. Episodes sometimes occur after an accident involving head injury. Other factors thought to contribute to episodic night terrors, but not actually cause them, include:

• medications
• excessive tiredness at bedtime
• eating a heavy meal prior to bedtime
• drug abuse

Diagnosis

Night terrors are primarily diagnosed by observing the person suffering from an episode. The following symptoms are characteristic of a person suffering from a night terror:

• panic
• sweating
• gasping, moaning, crying or screaming during sleep
• little or no recollection of the episode upon awakening

Treatment

In most cases, the individual will still be asleep as the night terror episode happens and will prove difficult to awaken. The goal should be to help the affected person go back into a calm state of sleep. The lights should be turned on, and soothing comments should be directed at the person, avoiding brusque gestures such as shaking the person or shouting to startle them out of the episode. Any form of stress should be avoided.

Individuals affected by night terrors should be evaluated by a physician if they are really severe and occur frequently. A physician can recommend the best treatment for the particular circumstances of the night terrors. In some severe cases, the physician may prescribe a benzodiazepine tranquilizer, such as Diazepam, known to suppress Stage 4 of sleep. The physician may also refer the affected person for further evaluation by a sleep disorder specialist. It should be noted that episodic night terrors in children are normal and do not suggest the presence of psychological problems. In adults, night terrors are more likely to be related to a significant stress-related or emotional problem.

Prognosis

In children, night terror episodes in children usually end by the age of 12.

Prevention

If a child seems to have a regular pattern of night terror episodes, he should be gently awakened about 15 minutes before the episode usually happens. The child should be kept awake and out of the bed for a short period of time and then allowed to return to bed.

Since sleep deprivation is a strong trigger for night terror episodes, children should not be allowed to become overtired. Having children take a nap during the day may be useful.

Adults affected by night terror episodes should avoid stress, the consumption of alcohol and stimulants before going to sleep.

Resources

PERIODICALS

American Academy of Family Physicians. "Nightmares and Night Terrors in Children." October 2000.

Laberge, Luc, et al. "Development of Parasomnias from Childhood to Early Adolescence." Pediatrics July 2000: 67-74.

ORGANIZATIONS

American Sleep Disorders Association, 6301 Bandel Road Suite 101, Rochester, MN 55901. (507) 287-6008. 〈http://www.asda.org〉.

National Foundation for Sleep and Related Disorders in Children. 4200 W. Peterson Suite 109, Chicago, IL 60646. (708) 971-1086.

KEY TERMS

Benzodiazepines— A class of drugs that suppresses Stage 4 of sleep.

REM sleep— Rapid Eye Movement phase of sleep, a mentally active period during which dreaming occurs.

Sleep disorder— Any disorder that keep a person from falling asleep or staying asleep.

NIGHT TERRORS

Night terrors are pathological phenomena that begin around three or four years of age. The child suddenly wakes up at the beginning of the night; he or she is terrified, screams in bed, and seems to be in the grip of hallucinations. When the worried parents arrive, the child does not recognize them and they are unable to calm the child. This state persists for a few minutes, at most, and brings with it neurovegetative manifestations (sweating, tachycardia, and polypnea). Once he or she has calmed down, the child goes back to sleep. The next day the child has no memory of the episode. Night terrors can be recurrent, but in general they disappear around the age of five or six.

There is no reference to night terrors in the works of Sigmund Freud. The phenomenon is difficult to apprehend from a psychoanalytic point of view; because of the amnesia that follows them, night terrors are not accessible, as dreams are, to any secondary revision. This sleep disorder probably reflects a failure in the dreaming function—a weakness in figuration and the binding of affects with mental representations.

We can refer to the work of Didier Houzel, who used electrophysiological observations as the starting point for a physiological explanation for night terrors. They occur during the phases of slow wave sleep (phase IV), outside of the phases of paradoxical sleep in which dreams occur. Phase IV sleep includes physiological aspects that herald the paradoxical sleep phase. Slow wave sleep is a reparatory phase of dream activity; night terrors suggest a blocking of the dream, which cannot begin during this slow sleep phase and, therefore, cannot proceed with the work of psychically binding instinctual energy.

As for the etiology of night terrors, which coincide with the arrival of oedipal conflict, different factors have been identified: libidinal conflicts proper to this period of emotional life, traumatic events, and, finally, disturbances in the child's affective relationships with people close to him or her. The persistence of night terrors beyond the oedipal period is a sign that the child is incapable of elaborating better psychic defenses. They can mark a return to preoedipal positions.

Philippe Metello

See also: Combined parent figure; Paranoid position; Phobias in children; Somnambulism.

Bibliography

Houzel, Didier. (1980). Rêve et psychopathologie de l'enfant. Neuropsychiatrie de l'Enfance et de l'Adolescence, 28, 155-164.

Sperling, Melitta. (1958). Pavor nocturnus. Journal of the American Psychoanalytic Association, 1, 79-94.

Night terrors

Also referred to as pavor nocturnus, a childhood sleep disorder featuring behavior that appears to be intense fear.

Night terrors, known medically as pavor nocturnus, are episodes that apparently occur during the non-dreaming stages of sleep in some children. Episodes of night terrors are most common in the preschool and early school years. Night terrors usually occur within an hour or two after the child has fallen asleep, and generally do not recur with any frequency or regularity. Many children experience only one episode of night terrors, and few experience more than three or four such episodes over the whole course of childhood . A parent or caregiver witnessing an episode of night terrors, which usually lasts from ten to thirty minutes, will find the behavior unsettling. The child sits up abruptly in bed, appears to be extremely upset, cries out or screams, breathes heavily, and perspires. He or she might also thrash about, kicking, and his or her eyes may bulge out, seemingly in fear of something. The child does not wake during the episode, although his or her eyes will be open, and he or she will be unresponsive to any offers of comfort. The child falls back to sleep, and will have no memory of the occurrence. Night terrors have not been shown to have any link to personality or emotional disorders, although they may be related to a specific feeling of fear that the child has experienced, such as being startled by someone leaping at him or her from behind a chair, or the sight of someone fainting or having an accident.

Further Reading

Beaudet, Denise. Encountering the Monster: Pathways in Children's Dreams. New York: CrossroadContinuum, 1990.

Lansky, Vicki. Getting Your Child to Sleep—and Back to Sleep: Tips for Parents of Infants, Toddlers, and Preschoolers. Deephaven, MN: Book Peddlers, 1991.

Thorpy, Michael. The Encyclopedia of Sleep and Sleep Disorders. New York: Facts of File, 1990.

Further Information

Association of Sleep Disorders Centers (ASDC). 602 Second Street, SW, Rochester, MN 55902 (Professional organization of specialists in sleep disorders; publishes the journal Sleep. )