Sleep terrors: Risk factors and management strategies

Family history. There is a strong genetic predisposition to partial arousal parasomnias, with 80-90% of children who present with them, having a first-degree relative who had/or currently has them.

Increase in deep sleep. As sleep terrors occur during deep sleep, anything that results in a rebound (increase) of deep sleep can increase the likelihood of a sleep terror occurring. Since both sleep disruption (multiple wakings) and sleep deprivation often result in an increase in deep sleep the next night, they increase the likelihood of the occurrence of sleep terrors in vulnerable individuals (those who have a genetic predisposition). In fact, sleep deprivation is often cited as the most common cause of sleep terrors.

Therefore, ensuring that your child is getting adequate day (if age appropriate) and night sleep is important. Establishing a regular sleep schedule (set times for naps and bedtime) can be helpful in preventing sleep deprivation and ensuring adequate sleep. In some cases, it may be necessary to address sleep problems such as frequent night wakings or poor day sleep that are causing sleep deprivation.

Some medications, including those that are used to prevent sleep terrors, suppress deep sleep. However when these medications are weaned there is a rebound in deep sleep increasing the risk of a child having a sleep terror.

Being disturbed during deep sleep. Sleep terrors can be triggered by environmental events, such as noise, that cause a child to partially wake during deep sleep. White noise in a child’s room and/or in the hallway may be helpful in blocking external and household noise.

Decreased arousal threshold: Several things can cause an individual to be more easily awoken during the night (including during periods of deep sleep). Examples include: not feeling well, sleeping with a full bladder, stress, and sleeping in a different environment.

While we unfortunately cannot control whether our child gets sick or not some of these other risk factors can be addressed.
 
Limit fluid intake. Limiting your child’s fluid intake in the few hours before bed (and offering her more earlier in the day) may be helpful.

Address stress & anxiety. Working to address and decrease the stress in your child’s life may be necessary.
     

Sleep terrors: Other management strategies

Parental reassurance. While many parents worry that sleep terrors are indicative of, or may cause, psychological problems, there is no scientific evidence to support this. In fact, following a sleep terror, parents are often more upset than their children, who are unaware of their own behaviour. Parents should be educated regarding the common risk factors for sleep terrors (described above) and encouraged to speak with their child’s physician or another health care professional with training in this area if they have concerns. 

Safety precautions. While displacement from bed is less common during sleep terrors than sleepwalking, concerned parents may want to consider taking some safety precautions including: clearing the floor (in case the child gets out of bed), hanging a bell over the child’s door to be alerted if she leaves the room, installing safety gates at doorway and/or stairwells, and safety locking windows. Using bedrails and protecting your child if she ‘thrashes’ around and could hit herself on a headboard or wall are important (e.g., moving bed away from wall). If your child is sleeping away from home, you may want to inform an adult in charge of your child about the potential for these behaviours.

Do not intervene during a sleep terror. While a natural reaction may be to try and wake your child by picking him up and turning on the light, intervening in the course of a sleep terror has been shown to worsen and/or prolong the terror. Parents are encouraged to sit by their child’s side, if they wish to be present, and to let the terror run its course. Remember that once the episode is over there is a rapid return to a calmer sleep. Also, parents are encouraged to avoid talking to their child about the sleep terror the next day as this can result in fears around going to sleep.

Other treatment options. In more severe cases where sleep terrors are very frequent, cause significant family disruption, and/or involve high risk of injury to the child, other treatment options may include scheduled wakings and medication. 

Scheduled awakenings are best suited for children who experience sleep terrors that occur nightly at highly predictable times. Children are woken on a nightly basis approximately 15-30 minutes before the terror typically occurs to the point that the child is slightly roused (e.g., may mumble, or turn over). This should be continued for 2-4 weeks and restarted if the sleep terrors return. Medication options should be discussed with a physician.      

Nightmares: Risk factors and management strategies

Nightmares are usually a normal developmental phenomenon. However certain factors can be associated with increased risk.

Increase in REM sleep. If we are sleep deprived we lose REM sleep and get a rebound the next sleep period. Getting more REM sleep increases the risk of nightmares. 

So, as with sleep terrors, it is helpful to ensure that your child is sleeping well and addressing any behavioural factors that may be causing her not to be sleeping well. 

Being exposed to a frightening or scary event. Nightmares in young children may start after an exposure to something that, in the child’s view, was “scary”. This may include such things as a trip to the zoo or pet store. Also, children’s movies often have an element of evil (think Snow White, for example). 

Monitoring what your child is exposed to may be helpful.

Greater cognitive development. With greater cognitive development children become aware that the world isn’t a safe place and that bad things can happen. This is a normal part of development and often a sign that your child is developing well.

Discussing your child’s bad dream with her and providing her with appropriate coping skills can be helpful. For some children, this may include drawing a picture of their bad dream and throwing it away or reminding them that “monsters are just pretend”.

Stress. If you suspect that stress or anxiety is resulting in your child’s nightmares, or if your child is having frequent nightmares, addressing these concerns with your child’s physician or a child psychologist may be necessary. Relaxation strategies or visual imagery (such as talking about your child’s dream or imagining with them a calming image before they go to bed) can be helpful.

Nightmares: Other management strategies

Appropriate responding. Parents need to find their own level of comfort in responding to their child’s bad dreams. Often this involves verbal reassurance (“it was only a dream”). It is recommended that parents provide comfort and reassurance to their child following the nightmare but then have her return to sleep independently. If you change your behaviour and for example let your child accompany you back to the parental bed your child may interpret this as a sign that remaining in her own bed was not safe. You may also find that your child will start waking more and wanting to co-sleep with you if she knows it is an option. 

Introduce transitional object. A transitional or security object can be something to help your child soothe to sleep and comfort him during the night. The object chosen should be conducive to sleep and not disturb your child if he rolls on it at night. A ‘blankie’ is a great option.

Use of a night light. If your child is requesting the light be left on, introducing a low-level night light in his room is reasonable. Just be sure that it is not bright because it may interfere with his sleep in the early morning when there is light sleep.

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