What are Night Terrors?

What are “night terrors” and why do children get them?
Grace Montenegro – Fremont, California

What are Night Terrors?

Dr. Greene’s Answer:

Within fifteen minutes of your daughter’s falling asleep, she will probably enter her deepest sleep of the night. This period of slow wave sleep, or deep non-REM sleep, will typically last from forty-five to seventy-five minutes. At this time, most children will transition to a lighter sleep stage or will wake briefly before returning to sleep. Some children, however, get stuck — unable to completely emerge from slow wave sleep. Caught between stages, these children experience a period of partial arousal.

Partial arousal states are classified in three categories: 1) sleep walking, 2) confusional arousal, and 3) true sleep terrors. These are closely related phenomena that are all part of the same spectrum of behavior.

When most people (including the popular press and popular parenting literature) speak of sleep terrors, they are generally referring to what are called confusional arousals by most pediatric sleep experts (Principles and Practice of Sleep Medicine in the Child, by Ferber and Kryger). Confusional arousals are quite common, taking place in as many as 15% of toddler and pre-school children. They typically occur in the first third of the night on nights when the child is over-tired, or when the sleep-wake schedule has been irregular for several days.

A confusional arousal begins with the child moaning and moving about. It progresses quickly to the child crying out and thrashing wildly. The eyes may be open or closed, and perspiration is common. The child will look confused, upset, or even “possessed” (a description volunteered by many parents). Even if the child does call out her parents’ names, she will not recognize them. She will appear to look right through them, unable to see them. Parental attempts to comfort the child by holding or cuddling tend to prolong the situation. Typically a confusional arousal will last for about ten minutes, although it may be as short as one minute, and it is not unusual for the episode to last for a seemingly eternal forty minutes.

During these frightening episodes, the child is not dreaming and typically will have no memory of the event afterwards (unlike a nightmare). If any memory persists, it will be a vague feeling of being chased, or of being trapped. The event itself seems to be a storm of neural emissions in which the child experiences an intense flight or fight sensation. A child usually settles back to quiet sleep without difficulty.

These are very different from nightmares. Nightmares are quite common, occurring in about 60% of children in the preschool years (Pediatrics in Review, March 1996). You won’t become aware of your child’s nightmares until after she awakens and tells you about them. They are scary dreams that usually occur during the second half of the night, when dreaming is most concentrated. A child may be fearful following a nightmare, but will recognize you and be reassured by your presence. She may have trouble falling back asleep, though, because of her vivid memory of the scary dream.

True sleep terrors are a more intense form of partial arousal. They are considerably less common than confusional arousals, and are seldom described in popular parenting literature. True sleep terrors are primarily a phenomenon of adolescence. They occur in less than 1% of the population. These bizarre episodes begin with the child suddenly sitting bolt upright with the eyes bulging wide-open, and emitting a blood-curdling scream. The child is drenched in sweat with a look of abject terror on his or her face. The child will leap out of bed, heart pounding, and run blindly from an unseen threat, breaking windows and furniture that block the way. Thus true sleep terrors can be quite dangerous, in that injury during these episodes is not unusual. Thankfully they are much shorter in duration than the more common confusional arousals of the pre-school period.

The tendency toward sleepwalking, confusional arousals, and true sleep terrors often runs in families. The events are often triggered by sleep deprivation or by the sleep schedule’s shifting irregularly over the preceding few days. A coincidentally timed external stimulus, such as moving a blanket or making a loud noise, can also trigger a partial arousal (which again shows that the event is a sudden neural storm rather than a result of a complicated dream).

Interestingly, a recent study published in the journal Pediatrics in January 2003, showed that children who have recurrent partial arousal states may also have other sleep disorders (including sleep disordered breathing and restless leg syndrome) that may benefit from a physician’s care.

Treatment usually involves trying to avoid letting the child get over-tired, and trying to keep the wake/sleep schedule as regular as possible. When an event does occur, do not try to wake the child — not because it is dangerous, but because it will tend to prolong the event. It is generally best not to hold or restrain the child, since her subjective experience is one of being held or restrained; she would likely arch her back and struggle all the more. Instead, try to relax and to verbally comfort the child if possible. Speak slowly, soothingly, and repetitively. Turning on the lights may also be calming. Protect your child from injury by moving furniture and standing between him or her and windows. In most cases the event will be over in a matter of minutes. True night terrors, or bothersome confusional arousals, can also be treated with medications, hypnotherapy, or with other types of relaxation training.

Recently, my youngest son was having a confusional arousal, and his mother observed that these events are most common at the same ages that children are becoming aware of the bladder feeling full during sleep. Perhaps some of these kids just need to go to the bathroom? We stood him in front of the toilet, and he urinated, still not awake. The episode faded abruptly, and he returned to sleep. The calm was dramatic.

Was this a coincidence? Or might this be a revolutionary new help for parents whose kids have these frightening episodes? A number of readers have tried this approach. Most said it worked wonders; a few said it had no effect. If you try it, let me know the results, either way. Together we can learn more about the wonder and mystery of sleep in children. I have sat with my children through confusional arousals, and know how powerfully these episodes tug at a parent’s heart. Just understanding what they are (normal childhood sleep phenomena that children outgrow — not a sign of maladjustment or the result of bad parenting) helps tremendously.

Dr. Alan Greene

Dr. Greene is the founder of DrGreene.com (cited by the AMA as “the pioneer physician Web site”), a practicing pediatrician, father of four, & author of Raising Baby Green & Feeding Baby Green. He appears frequently in the media including such venues as the The New York Times, the TODAY Show, Good Morning America, & the Dr. Oz Show.

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  1. Katrina May

    Dr Greene , I think you’ve hit the nail on the head with regards to night terrors and their causes/origins! My much younger sister would constantly experience night terrors beginning about age 6 until about 10 or 12 yrs old. We would usually attribute it to a bad nightmare, but it was far more sinister than that because as you said she didn’t recognize us and would be flailing her arms around with her eyes open and talking in a highly anxious and rapid state that was frightening to watch – and if I didn’t know better it appeared to have similar characteristics of a seizure, but it was not because it only happened after she had been asleep for about an hour or two.

    She would start calling out names and then when we would come into the room she would not recognize or connect with anyone as if she were still in the dream. But most of the time she was crying a lot and for no apparent reason as she went to bed fine. If we didn’t get to her quickly enough before realizing she was having one of her night terrors (it didn’t happen every night) she always headed to the bathroom and went in the toilet to urinate. We never put two and two together, but she did outgrow it over time, thank goodness! However you have cleared up a big question for me which I will pass on to her one day – and that is what caused her to have these episodes:; being tired I can see was probably a big contributor but having to go to the bathroom with a full bladder to pee while in a deep sleep was definitely the culprit! After she would go to the bathroom and we’d bring her back to bed – usually having to carry her in both directions until she got too big and heavy – she would then sleep the whole night through.

    So I am convinced that you are absolutely right about the full bladder connection and being very overtired – maybe too tired even to subconsciously make the connection between needing to get up to go to the bathroom to relieve ones self. But it still begs the question: why do some kids get night terrors with a full bladder vs others wetting their beds vs the majority who get up and go to the potty without any night terrors? And what goes on in the mind that causes so much fear and terror in otherwise very normal children? My sister was a very well adjusted child – smart, popular, nice and very attractive and athletic too. But she did have these night terrors that seemed to go on for many years and they were upsetting for all of us to see her suffer through.

    There is some documented research suggesting that mood disorders or bipolar personality disorder is associated with night terrors. If you had asked me if she suffered from either as a child I would say definitely not at all. However, as an adult today she really is struggling with a lot of mood and personality issues that we are at a loss for – I am constantly searching for answers and tell tale clues from the earlier years of our life and the night terrors are the only real significant episodes that we can link back to figure out what may have been abnormal behavior.

    As an older sibling I feel obligated to help her figure out what went wrong so she can get the help she needs now. In my opinion, I think night terrors are linked to full bladders, but they are also indicative of some underlying serious psychological disorders, too. I hope you can weigh in some more on this and educate other parents and family members to be alert to the connections and patterns that link night terrors to a full bladder and a warning sign that things are not all that they seem – and that there are probably other issues going on for the child, too. Reminding these kids to always go to the bathroom right before bed is a key component here!

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  2. Hagar Berlin

    My 10 month old just woke up with what fits the confusion arousal description perfectly. It was very different from any of her previous night waking and a bit scary, except that she was clearly asleep the whole time despite her screams. Is confusion arousal possible so young?

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    • HippieMom

      My daughter’s nighttime crying started somewhere around 3 months old. We didn’t know for a long time that it was night terrors. When she was older and talking it became more obvious that she wasn’t really seeing or hearing me. I’d always read that night terrors were triggered by over tiredness, heat, cold or pain. When we figured it out for my daughter, it was garlic, primarily in spaghetti sauce. When we eliminated fresh garlic and onions from her diet the night terrors virtually went away. I loved garlic before that, so there was likely a lot of garlic in my breastmilk too.

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  3. gortday

    I love this article. I have loved it since my oldest daughter (now 6) was potty training and this helped me stop her confusional arousals in their tracks. I still use this trick on my youngest with great success and again just tonight when my eldest was sleepwalking and not making any sense. Guiding her to the potty helped me get her back into bed quickly without any harm.

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