Related concepts:

Confusional arousal; Partial arousal state; Sleep terrors

Introduction to night terrors:

Your little angel wakes up screaming in the middle of the night, calling for his mommy – but his mommy is right there, unrecognized. You try to comfort him, but he shrieks even louder, eyes bulging. He might be having a night terror.

What are night terrors?

Within fifteen minutes of your child’s falling asleep, he will probably enter his 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, become stuck and are 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 closely related phenomena are all part of the same spectrum of behavior.
When most people (including the popular press and popular parenting literature) speak of night terrors, they are generally referring to what are called confusional arousals by most pediatric sleep experts.
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 fight or flight sensation. Once it is finally over, the child usually settles back to quiet sleep without difficulty.
These are very different from nightmares.
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.

Who gets night terrors?

The tendency toward sleepwalking, confusional arousals, and true sleep terrors often runs in families. They tend to be more common in boys, and are much less common after age 7.
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).

What are the symptoms of night terrors?

Typically, 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 his parents’ names, he will not recognize them. He will appear to look right through them, unable to see them. Parental attempts to comfort the child by holding or cuddling often prolong the situation.

Are night terrors contagious?

No.

How long do night terrors last?

Most often, 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.

How are night terrors diagnosed?

The diagnosis is based on the history. When a question remains, a physical exam or tests may be run to rule out other possibilities.

How are night terrors treated?

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 his subjective experience is one of being held or restrained; he would likely arch his 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.
Night terrors can also be treated with medications, hypnotherapy, or with other types of relaxation training if they become a significant problem.
A Novel Approach – The Greene Technique
When my youngest child was going though night terrors, I observed that he was also “working on” achieving nighttime dryness. In fact, night terrors are most common at the same ages that children are becoming aware of the bladder feeling full during sleep. It dawned on me that perhaps some of these kids just need to go to the bathroom, but are not yet able to wake up fully when their bladders are full. I’ve now treated many kids by having the parents take them to toilet while they’re still asleep. For many of these children, even though they do not recognize their parents, they will often recognize the toilet and urinate. For these children, the episodes stop abruptly and they return to sleep. The calm is dramatic.

How can night terrors be prevented?

Prevention usually involves trying to avoid letting the child get over-tired, and trying to keep the wake/sleep schedule as regular as possible. Taking the child to the bathroom before the parents go to bed can also prevent some night terrors.

Related A-to-Z Information:

Enuresis (Bedwetting), Epilepsy, Nightmares, Sleep Apnea

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.

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.

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 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.

If readers try this and let me know what happens, we will find out. If you give it a try, let us know the results, either way. I’ll correlate the different experiences and broadcast the results. Together we can learn more about the wonder and mystery of sleep in children.

Dr. Greene’s Answer:

The truth about dreams, nightmares, and night terrors will surprise you.

Dreams have been described since the beginning of human history, but it was only in 1953 that Aserinsky and Kleitman discovered the brain wave pattern we call REM (rapid-eye-movement) sleep. During sleep, we go through four progressively deeper stages of sleep (stages 1 to 4) in which the brain is quiet but the body may move or shift.

In a separate stage, called REM sleep, the brain is highly active, but the body seems paralyzed (except for the eyes, which dart back and forth). This REM sleep is what we know as dreaming. As adults, we spend about 20% of our sleep time in REM sleep.

A preschool-aged child patters down the hall in the middle of the night to appear at her parent’s bedroom door. Tears streak her face. “Mom, I’ve had a bad dream!” she reports. “Robbers were chasing me!”

At age 3 or 4, most children begin remarking about their dreams. In their desire to imitate adult behavior, children at that age assert (with confidence) many things that aren’t quite factual. Are they really having dreams? Or might they be using their fertile imaginations to describe what they’ve heard others talk about, perhaps as yet another way to try to maneuver into the parents’ big bed?

“I can’t sleep. Can I get in?”

Alternatively, might children begin dreaming even earlier, and only start talking about it as preschoolers?

To solve this mystery, Roffwarg and associates undertook a classic study in 1966 (the associates included Dement, whose popular new book The Promise of Sleep is getting rave reviews). The research team began by studying sleep waves in newborns. The investigators believed that infants do not have REM sleep because they do not dream, but the researchers intended to discover what newborn sleep waves looked like. The team would continue to measure sleep waves throughout infancy and toddlerhood to learn when and how dreaming begins.

The startling discovery was, not only do newborns dream — even on the first day of life — they actually dream more than the college students in the original studies (Science, 1966; 152:604).

This study has been repeated several times, confirming and expanding our knowledge. We dream more in the first 2 weeks of life than at any other time. The visual part of the brain is more active during newborn REM sleep than during adult sleep. They seem to have more vivid visual dreams.

Infants 3 to 5 months old dream much more than infants 6 to 12 months old do. 18-month-olds dream almost twice as much as 3-year-olds do. By age 3, the amount of time spent dreaming per night is in the same range as that of young adults. As the wheel of time turns throughout life, each year we dream a little less (Science, 1966; 152:604).

If children dream from the moment that they are born, might they dream before that time? We now know that they begin to sleep at as early as 4 weeks of gestation (Electroencephalography and Clinical Neurophysiology, 1975; 38:175). REM sleep waves have been found at as early as 28 weeks of gestation, and REM sleep waves accompanied by the eye movements of dreams by 30 weeks of gestation (Principles and Practice of Sleep Medicine in the Child, WB Saunders, 1995). It seems dreaming begins 2 or 3 months before babies are even born!

Dreams appear to be a kind of parallel processing by which we integrate our experience, making new connections in our brains. In the uterus, babies probably dream about the muted light they see and the sounds they hear (heartbeats, voices, and music). After birth, perhaps they dream about the explosion of new sights, sounds, tastes, smells, and textures as they delight in getting to know their parents.

We may dream more during the day than we do at night! As mentioned earlier, when we sleep, we dream only about 20%of the time. During non-REM sleep, the brain rests. Growing evidence suggests that we have real dreams all day long, but these are not noticed because of the “loudness” of our senses and our conscious thinking (Principles and Practice of Sleep Medicine, WB Saunders, 1994). In a similar way, we have an unobstructed view of stars in the sky all day long, but we can’t see them because they are overwhelmed by the light of the sun.

At night, the stars and the dreams come out.

Nightmares are unpleasant dreams that awaken a dreamer from sleep.

Traumatic events are known to cause a predictable pattern of nightmares: first dreams that relive the event, then dreams that relive the primary emotion of the event using different scenarios (different pictures), then dreams that incorporate aspects of the event into other parts of life. Nightmares are an important means of addressing difficult events and emotions to weave them into the fabric of our minds in a constructive way. Because the forces that produce nightmares are simpler than the complex drives that may initiate our other dreams, nightmares might be a good entrance into understanding the significance of dreams in general (Psychiatry, 1998; 61:223-238).

Nightmares are thought to be most common between the ages of 3 to 5 years –the peak age for fears — they are said to begin around that time, or shortly before. Though I don’t know of any others who concur, the available evidence leads me to a vastly different conclusion: that just like other dreams, nightmares are most common long before the preschool period.

Stressful events, such as injections, circumcision (which should never be done without anesthesia), being left alone or dropped, or even feeling hungry, need to be learned about and integrated. It seems to me that anything worth crying about is worth dreaming about.

We know from older children that nightmares commonly follow surgery (Anesthesia and Analgesia, 1999; 88:1042-1047), tooth extraction (British Dental Journal, 1999 13; 186:245-247), and motor vehicle accidents (European Child and Adolescent Psychiatry, 1998; 7:61-68). Why wouldn’t they follow childbirth?

We don’t want to believe that our little ones experience anything unpleasant. So strong is this desire that it led to the long-held (now finally and forcefully disproved) belief that newborns don’t feel pain when circumcised. How absurd!

Knowing how much young babies dream and cry (and wake up crying), it seems equally absurd to me to believe that all of their dreams are happy ones. Birth is a wonderful and terrible experience. There is much to be happy about and much to learn about in the weeks that follow. Babies’ dreams must incorporate and address those things that bring them pleasure and those that make them cry. In all likelihood, the peak age of crying, the first 6 weeks, is also the peak age of nightmares.

These nightmares are not unsuccessful dreams. Far from it! They help babies learn and grow; nightmares may even be an important reason that crying diminishes after 6 weeks.

Confusional arousals (popularly called night terrors) are an entirely different phenomenon, which I have described elsewhere. These happen when children get stuck between two stages of non-REM sleep. They might talk, scream, or open their eyes, but they aren’t awake and they aren’t dreaming.

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 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? If readers try this and let me know what happens, we will find out. If you give it a try, let me know the results, either way. I’ll correlate the different experiences and broadcast the results. Together we can learn more about the wonder and mystery of sleep in children.

Aren’t they angelic when they are asleep?

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.

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.

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.

Dr. Greene’s Answer:

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.

Try to avoid letting your child get over-tired, and try to keep the wake/sleep schedule as regular as possible. When an event does occur, do not try to wake him — 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 his subjective experience is one of being held or restrained; he would likely arch his 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 and the 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.

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.