Behavioral Issues

Night Terrors and Nightmares




Night Terrors

Night terrors are a common disorder that affects about 3-5% of the population. It occurs more often in boys and for those with positive family history.  Can start as early 18 months and usually resolves in adolescence (peak at ages 5-7)

They occurs during non-REM sleep during stages 3 and 4; usually within the first third of sleeping (often between 15-90 min after falling asleep). Lasts for about 5-10 minutes and the child is usually able to easily fall back asleep.

Some features of Night Terrors includes:

  1. Episodes that occur many nights in a row and then stop for a period of time.
  2. Child appears very agitated and may exhibit facial expressions and vocalizations that convey fear. May also strike out and thrash. Episodes are associated with diaphoresis, tachycardia, tachypnea, and myadriasis.
  3. Child is incredibly difficult to arouse, is unresponsive to the environment (i.e. wont respond to parents yelling or shaking), and doesn't remember the incidence
  4. Triggers include fevers, stress, and sleep deprivation. Also associated with certain drugs: stimulants, neuroleptics, sedatives and antihistamines

The episodes are usually very frightening and disruptive to the parents and family members.  Don'tundersestimate this component and the impact they may have.         

Parents should only intervene to protect child from hurting themselves secondary to thrashing. Also, there is an 18-33% incidence of sleep walking, which carries a risk of the child leaving their homes. If this occurs, some mechanism must be used to awake the parents if the child tries to leave their room (connecting a bell to the child’s door, locking the window and door, etc). 


  1. Don't try to arouse the child during the episode (unless child is at risk for injury). If a timing pattern occurs, parents can awaken the child 30 minutes before the expected event in an effort to break up the pattern.
  2. Protect the child from injury
  3. Reassure the parents that night terrors usually spontaneously disappear, but also recognize the stress this adds to them and their family.  Provide social support and healthy coping as needed. 
  4. Relieve any triggers if possible.
  5. In randomized trial without blinding, L-5-hydroxytryptophan was shown to significantly increase resolution of sleep terrors compared to placebo.


In contrast to Night Terrors, Nightmares are frightening dreams that occur in the second half of sleep during REM

They have a 7-15% incidence rate, affects girls & boys equally, and most often occur between 3-6 years, but can occur at any age

With nightmares, the child awakens from sleep and usually has a vague or sometimes very distinct memory of the dream. They do not thrash due to skeletal muscle inhibition during REM stage.

Other features of Nightmares includes:

  1. Ability to generally be comforted by the parent
  2. Increased incidence during stresses such as familial difficulties and toilet training.
  3. Recurrent nightmares are associated with post-traumatic stress disorder


  1. Reassure the child
  2. Tell parents, not to try to bring up long discussions about the dream. If the child wants to discuss the content, do it during the daytime. Also, don't go looking for monsters with flashlights because this may reinforce the fear.
  3. Recognize and help the family with the emotional and physical stress this places on them, providing support where needed.
  4. Relieve any triggers if possible.

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  1. Blum, Nathan and Carey, William. Sleep Problems Among Infants and Young Children. Pediatrics in Review, March 1996
  2. Bruni O et al. L -5-Hydroxytryptophan treatment of sleep terrors in children. Eur J Pediatr. Jul 2004;163(7):402-7
  3. Davey M. Kids that go bump in the night. Aust Fam Physician. May 2009 38: 290-4
  4. Howard B. and Wong J. Sleep Disorders Pediatrics in Review October 2001
  5. 5. Mason TB, Pack AL. Sleep Terrors in Childhood J Pediatrics