One of the questions that is frequently asked is about dreams and nightmares. Many parents in attempting to achieve independent sleep for their children face the problem of ‘nightmares.’ These are sometimes clearly described by the children. They may include spiders under the bed, monsters in the cupboard, robbers at the door, or my favourite: ‘teddy will get me during the night’. The oldest patient that I have seen who was disturbed by dreams was 10 years old. Her parents were getting up about three times per night to protect her from robbers at the door. (I will return to this patient in a little while.) Sometimes the dreams are not clearly described and the diagnosis of nightmares is made by the parents based upon their opinions of the child’s ’style of distress’ during the night.

Before addressing the question of nightmares it is worthwhile talking about dreams.

Do young children dream?

Dreaming occurs in a stage of sleep known as rapid eye movement sleep or REM sleep. Children certainly have REM sleep. In fact, the younger the child the more REM sleep which occurs and the earlier in a block of sleep that it begins. In the first six months of life the infant moves straight into REM sleep compared to adults who enter non REM sleep first. REM sleep is a time of much brain activity and, for the young child much body movement. For those who have slept with an infant you will probably have noticed the very ‘vigorous’ way in which they sleep. One mother described it to me as sleeping with a little tornado. REM sleep in adults is our time of dreaming. As this sleep phase is identifiable in babies and children it would appear reasonable to assume that children also ‘dream’ in this phase of their sleep if they are able to.

The next question is what do they dream about? For the very young baby it is of no value to discuss the content of their ‘dreams’ as we have no way of checking with the baby. Once able to talk, the older child may report the content of their dreams. The youngest child whom I have encountered who could talk about dreaming was 18 months old. He was a boy who had developed communication skills very early in life and would report quite clearly on his thoughts. He reported that his dreams contained the stuff of dreams which we would probably predict. He dreamt of toys and play animals, of family members, of Mickey Mouse and Donald Duck. The evidence here was that a child as early as 18 months is having dreams which clearly connect with his life experience. Nightmares are a variety of dreams where the content of the thought process includes fear, anxiety or terror. As we all know, such dreams can interfere with our sleep, and cause us to wake in fear.

Are nightmares relevant to childhood sleep. Are they a possible explanation for nightime waking in tears? The answer here will be divided into two ages. The very young child and the older infant with verbal skills.

Nightmares In The Very Young Child. (Birth to 12 months)

It is difficult to conceive that the child at this age has nightmares. The infant brain is at an early stage of development and is beginning the process of learning how to interpret the environment meaningfully. At the same time the child’s brain is developing rapidly to be capable of ‘thinking’ in a way which is meaningful. I do not wish to become engrossed in a discussion here where no matter what is argued it is nearly impossible to prove the existence of nightmares. My own belief is that nightmares do not occur at this age. This is based upon a belief that the infant brain is not yet able to process information in such a complex way. Whatever the situation, I can predict one thing from experience. It is useful to ‘assume’ that if the child is crying it is not due to nightmares. Excluding this as a diagnosis removes one more problem which the parents could possibly worry about.

Nightmares in the Older Child (18 months plus)

As mentioned above I have spoken to a child who could report on his dreams as early as 18 months of age. Thus the child is now able to coordinate recognisable thought processes while in REM sleep. If nightmares are possible, I then divide them into two groups:

(a) Real and Relevant

An infant’s thoughts will reflect his or her life experience. If that experience includes fear, anxiety, or anger, then that may be reflected in nightmares. Such unhappy daytime experience will almost always be known to the family. If home life contains anger, fighting or instability, then this may be a cause of insecurity resulting in disturbed sleep. These problems need to be addressed as family problems and not as sleep disorders. My advice about sleep will not be useful or appropriate in this setting.

Children of an older age, say school age, may begin to have nightmares reflecting problems with their peers. This again needs to be diagnosed and treated on its merits.

(b) Real but not Relevant

This is an interesting group. This is what occurs most frequently. It is an area where the game of life can be played between parent and child. Irrelevant nightmares can be a powerful tool for a young, talkative child to use in controlling parental behaviour. It is also an area in which parents must recognise what is happening because there are dangers in allowing a child to have nightmares.

This seems a strange concept, doesn’t it. To explain, let me tell you a story. I have seen a girl of ten years, whom I will call Angela. Her parents brought her to see me because of a sleep disorder. She was up, or more to the point, they were up, three times a night on average. After ten years it was all wearing a little thin. This was not a happy family. Angela herself was bright, cheerful, talkative and obviously thriving. (Mum and Dad were still talking. Just.). Anyway it quickly became apparent that Angela was waking her family at night because of ‘the robbers’. There were robbers at the door or the window every night. In fact they had been calling, regularly, every night for about eight years. Angela would wake and cry, Mum or Dad would come to here aid, turn on the light, prove the absence of any thief, and return to their beds. Most nights one of her parents would finally sleep with Angela, or in her room, or on a mattress made ready for the purpose outside their daughter’s room.

The problem was obviously not robbers, but the belief in robbers. This belief structure had existed for eight years. Why? How do these thoughts arise?

It all begins in that time, let’s say about age two years, when verbal skills are beginning to develop. For some reason, the child is up during the night and quite logically seeking contact with Mum or Dad. The parents usually do a check that all is well and attempt to return their child to bed. The child is now old enough and bright enough to offer some alternatives.

• ‘I want a drink.’
• ‘I need a to go to the toilet.’
• ‘I’m hungry.’

These are neutral requests which are easily ignored or complied with. If you want to be getting up to provide your children with a drink of milk for a few months, just start. Your children will be quite happy to continue to push the button for room service until the night staff eventually quit.

Other requests can be more subtle and demanding.

• ‘I’m scared.’
• ‘There’s a monster in the cupboard.’
• ‘There’s a spider under the bed.’

The problem here is that you feel a logical and appropriate desire to reassure your child that they are safe. This rewards the behaviour pattern of reporting the ‘monster’. Next night you feel less inclined to be reassuring and you try to dismiss the claim with ‘There’s no monster’. The child is then obliged to amplify their level of fear to obtain the reward of your company. They appear even more anxious than the night before. The ‘fear’ becomes worse. Now for most parents we eventually get tired of the game, stop attending, or give minimal reassurance. The fear is then not being rewarded, has less relevance, and then stops. Unfortunately, for a few families, the child’s state of fear becomes dramatic enough to continue giving reassurance. This continues to reward the holding of a state of fear. Being scared becomes an unconscious but useful strategy for the child. Now one of the complicating factors here is that because the state of fear is useful, it becomes more complex. As the weeks and months go by, the state of anxiety develops more depth and realism. It can, occasionally become permanent or semi-permanent. While none of this is conscious or planned, these ‘imagined’ problems can become a regular night time event. Unfortunately once the state of fear becomes so ‘real’ at night, it can begin to affect the days.

Let’s return to Angela’s story.

For years Angela had found that she could successfully obtain parental attention at night by reporting with great anguish that the robbers were at the windows. While she was bright and happy in her family circle, she became timid of certain public areas in the day. She was hesitant to walk unaccompanied because ’someone from the robbers’ might get her. The fear had become so real that it interfered with her daytime activities.

The moral of the story is that nightime fears which are obviously without foundation need to be dismissed as rapidly as possible. To reward unfounded nightime fears, leads to those fears being prolonged.

How should we handle nightmares or night fears which are inappropriate?

Firstly, check on the reality. Is there really a spider on the floor? (Don’t spend too much time on checking the monster in the cupboard). Once you are satisfied that the fear is not caused by a real problem, but has been generated in an attempt to control your behaviour, then ignore it. Try to avoid a situation of becoming angry if at all possible. Simply recognise that your child loves you, has awoken at night, and is attempting to either generate contact with you or prolong it. Recognise it for what it is, and politely decline to participate in the life story of the monster in the cupboard. Once you fail to respond, the monster has no value, and goes away.

A little hint. I sometimes ask the child in the consulting room to draw me a picture of the monster, or prompt me in drawing one. Once we have agreed that this picture is correct, I keep it. The parents can then tell the child, ‘Don’t be scared. Dr Symon kept the monster’. This sometimes works quite rapidly.

To conclude Angela’s story. Because of her intelligence and age, I was able to explain the history of the robbers to her and her parents. She could see the logic of it but was left with an involuntary fear state which woke her. The solution was achieved using the following elements.

Mum and Dad were not to respond. (Remove the reward.)

When Angela was woken by fear, she was allowed to take control of her room. She locked the door, making her feel safer. She was allowed to put on a light and read, which she loved. She had a torch to shine at the window to prove to herself that no robbers were present.

Angela was able to sleep a full night two weeks after starting. She didn’t miss the robbers. Her parents enjoyed the increased sleep, and family life has improved dramatically.

Angela was kind enough to agree to write a little about her experience. She typed the summary herself, in her own words.

ANGELA’S COMMENTS ON SLEEP

Dr Symon made me feel like I wasn’t a baby when I had my sleeping problem. And he made me realise that it was just in my head. It was just my brain playing tricks on me; my mind playing games. And when I heard noises, I just pushed it out of my mind, remembering what Dr Symon had said: ‘It’s just my imagination. It’s just my brain playing up.’

One night I heard lots of noises and then in the morning nothing was gone and my mum was sleeping in the lounge room where the noises had come from. So it had to be my imagination – my brain playing with me.

It’s helped me because it has made everyone in my family a lot more cheerful. Now I am happy that I can sleep through the night and not worry every time I go to bed. Now I know I can go back to sleep if I wake up in the middle of the night. Now sometimes I wake up three-or four times a night and can still go back to sleep. Before I was always worried at bedtime because I would wake up in the middle of the night, hear noises, get VERY scared and not be able to get back to sleep on my own. NOW I CAN!

Before I could not sleep over at friend’s houses, but now I feel a lot safer and I can do it. I went on camp and didn’t get scared once! (It was a two night camp.) At the beginning of the year my mum and dad thought I’d never be able to go on camp and didn’t want to pay the money for camp. But I DID IT!!

Angela’s parents informed me that these two example of sleeping over and attending a camp were the first successful nights away in her life.

In conclusion on nightmares

For the young child, say pre-twelve months, it is most useful to assume that nightmares do not occur. For the child from 18 months up, nightmares should be divided into two groups.

Firstly, nightmares can reflect daytime unhappiness or insecurity. If family problems exist, these will need attention in the first instance. Sleep performance will not improve while there is a genuine reason for being insecure and awake overnight.

Secondly, nightmares or fear states which are simply a tool for controlling parental behaviour. These need to be deleted as rapidly as possible. Inappropriate dreams are deleted by not responding to them.

Night Terrors

‘Night terrors’ is an unfortunate title, as it suggests a problem which may not be present. Despite this, the use of the term is so common that it needs to be discussed. ‘Night terrors’ fall into two groups.

Firstly there are inappropriate fears which occur in the child who is old enough to talk and describe specific fears. These need to be reassured, down played and ignored as rapidly as possible. This is discussed above.

Secondly there are inappropriate awakenings. Waking up from sleep is a complex event which sometimes occurs incorrectly. The child is awake but confused, incoherent, makes no meaningful eye contact, often pushes the parent away, and is basically inconsolable. The best solution is to wrap or lay the child down. Reassure the child, to the best of your ability, even though it appears to be ineffective, and leave the child alone. Let him or her get to sleep again as rapidly as possible. Another possible solution is full awakening. I do not recommend this, as you are then left with the problem of a return to sleep anyway. The final note about night terrors is that they become less frequent as the child’s sleep improves.

Both of these sleep disturbances can be worrying for the parent. Both are better controlled by a minor reaction from parents rather than a major reaction.