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:

Nightmares are an important means of addressing difficult events and emotions to weave them into the fabric of our minds in a constructive way. Traumatic events are known to cause a predictable pattern of nightmares: first come 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.¹

Nightmares are generally thought to be most common at the ages of 3 to 5 years –the peak ages when children express fears — they are said to begin around that time, or shortly before. Conventional wisdom tells us that nightmares begin not too long before then.

The available evidence leads me to a vastly different conclusion: that just like other dreams, nightmares are most common in infancy. 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, tooth extraction, and motor vehicle accidents. ^2,3,4Why wouldn’t they follow the ultimate extraction, 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. These nightmares may even be an important reason that crying diminishes after 6 weeks.

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.

She learns to pull herself to standing. Soon she is cruising ’round and ’round the crib, instead of going down for a nap. Then she begins to bounce up and down. Before long, she catapults over the top — generally landing with a loud thud. A long silence follows, then a heart-stopping wail.

It’s high time for a big-girl bed.

Your first task in this transition is to make your child’s room as safe as their crib used to be. This means fresh, aggressive childproofing.

• Check furniture such as bookshelves for stability. If need be, fasten furniture to the wall.
• Put locks on dresser drawers — toddlers love to pull out drawers and use them as stair steps to the top of a piece of furniture.
• Replace standard electrical outlet covers with childproof covers. I prefer these to the plastic-cap-type that are inserted into the outlet. The plastic caps are easily removed by an adult and then lost, leaving the plug uncovered. Worse yet, the plugs can be removed by children who will put them in their mouths while exploring the outlet.
• Make sure mini-blind, drapery, and curtain cords are well out of reach
• Remove any toys or other small objects that could be a choking hazard.
• Put any potentially hazardous materials, such as disposable diapers, in the closet and install a childproof latch on the closet door.

Next, make her room a place where she feels safe — especially at night.

• Night lights are important, but at this age many kids want even more light than that. A 15- or 25-watt bulb in a lamp can keep the monsters that “live under her bed” at bay. Put the lamp on a timer so that it goes on at bedtime and off when it is time to wake up. This serves two very useful purposes. First if your child does wake up during the night, she won’t be as frightened as she would be in the dark. Also, you can begin telling her that when she wakes up, if her lamp is still on, it’s still night-night time.
• Kids love stories at this age, so it’s a wonderful time to introduce a cassette tape, CD, or even a MP3 player that your child can learn to turn on and off all by herself. There are lots of great story tapes available now for children. Investing in a few of these is smart. It’s an even better investment to make your own. There are no sounds in the world that are as comforting as mom’s and dad’s voices.
• You might want to install a sturdy, metal child gate that swings open. Do not use a wooden, accordion style gate — both for your convenience and her safety. Let your child see you assembling the gate. When it’s in place, make a game of opening the gate and walking through it, then closing it and opening it again. Next close the door with you both inside. Explain to her that the gate is there to help her stay safely in her own room. When she’s comfortable with this, leave the room and stand just outside. Remind her that while she is in her room, she will be safe. Walk out of her sight and come back so that she gets used to being alone, inside her room, with the gate in place. You have just re-created the safety of her crib — only larger.
• Just before bedtime, tell her again that the lamp will be on as long as it’s nighttime. Remind her that while it is on she needs to stay in her room. When you put her to bed, help her turn on her tape player and, after your normal good night hugs and kisses, leave closing the gate behind you.

Your child will undoubtedly test you to see if you will enforce the “night-night time in your room” rule. She will probably stand at the gate and call for you to come and let her out– if you are lucky.

She also might cry mercilessly and try to make you feel guilty for confining him to his room. When this does happen, check on her to make sure she has not been awakened by a bad dream or she is not sick. Feel free to go into her room and help her get comfortable again so that she can go back to sleep. Let her know that she can read a book, listen to a tape, or play with her toys (since you can’t stop it, don’t make a fuss over it).

But she can’t leave her room till morning!

Leave and be prepared for an unhappy child. She will probably try to manipulate you into opening the gate and letting her come into your room. Children will often respond to new rules by testing them. Don’t give in.

Unless you have decided that you want to have a family bed, teaching your child to sleep through the night in her own room is a real gift to the whole family.