Understanding Sleep Terrors in Children

Authors: Ana Fins, PhD and Nicole Carmona, PhD, DBSM

Society of Behavioral Sleep Medicine; Outreach and Public Education Committee

This blog post was adapted from an interview between Sarah Honaker, PhD, DBSM and Alaina Tiani, PhD, DBSM. Click here to watch the full interview.

Sleep terrors can be quite common in children and frightening for caregivers to witness. This article describes what sleep terrors are, how they differ from other types of disruptive sleep behaviours, and how to treat them.

What are sleep terrors? 

Sleep terrors are part of a family of sleep disorders called “parasomnias,” which refer to unusual behaviors that occur during sleep. Sleep terrors are characterized by episodes of what seem like abrupt awakenings from sleep, during which a child screams in distress. These intense fear reactions are often accompanied by increases in breathing rate, heart rate, and sweating, and may also include thrashing, sitting up in bed or running out of the bed. During these episodes, caregivers report that children do not respond to attempts to comfort or console them, and they may not remember the episode when they awaken in the morning.

Sleep terrors probably have a genetic link, as they tend to run in families. Often, a child who experiences sleep terrors has a family member who either had sleep terrors as a child or was a sleepwalker. While sleep terrors are less frequent among older children and generally decline or resolve after puberty, children who experience sleep terrors are more likely to become sleepwalkers as adolescents or adults.

Sleep terrors or nightmares – what’s the difference?

While nightmares are pretty common among children, only 10-20% of children experience sleep terrors. Sleep terrors most commonly occur between the ages of three and eight, peaking during preschool age, whereas nightmares can occur at any age. Nightmares occur during sleep but may result in a complete awakening, which is when the child (or adult) experiences fear or distress. In contrast, during sleep terrors, the child remains asleep the entire time, even while they are yelling, crying, sitting up or thrashing. Another difference between sleep terrors and nightmares is the ability to recall the dream content. Children who experience sleep terrors usually have no memory of the event. Nightmares, however, are fully remembered upon awakening.

Nightmares and sleep terrors also occur during different stages of sleep: sleep terrors occur during deep sleep (also called slow wave sleep), whereas nightmares occur during rapid eye movement sleep, which is a lighter stage of sleep when dreaming takes place. Knowing that these different sleep experiences occur during different stages of sleep helps determine what type of episode a child may be experiencing – sleep terrors tend to occur in the first third of the night when we see the highest proportion of deep sleep, so approximately during the first three hours of sleep. Nightmares can occur at any time of night, although they are more common in the early morning hours when we spend more time in REM sleep.

Impact of sleep terrors 

There are no known consequences for children who experience sleep terrors. This is because they are asleep during the entire event and have no recall. As long as the child goes through the episode and remains asleep, the child will not experience the daytime consequences we might see in a child who has a prolonged nighttime awakening or misses out on sleep.

However, for the family, sleep terrors can be very stressful and scary, especially if the caregivers don’t understand sleep terrors or why they happen. Oftentimes, caregivers worry that the episodes are harmful to the child. Even after gaining an understanding of the process and the benign nature of sleep terrors, caregivers will still experience sleep disruption due to being awakened by the child who is yelling and crying.

Caregivers may be particularly frightened by their child’s lack of responsiveness to their efforts to console them during the sleep terror. Typically, caregivers observe that their child will not seem aware of the caregiver during an episode—a good clue that the child is experiencing a sleep terror. While children may have limited memory of the dream (or the episode entirely), it is also possible that children who were awakened by a caregiver remember in the morning that the parent looked scared or distressed, which can be distressing to the child. Thus, sleep specialists recommend that caregivers only monitor children for safety and be in the room, if it makes them feel better, but to avoid interfering and allow the episode to pass naturally. Trying to awaken the child from a sleep terror does not necessarily shorten the episode and will awaken the child, which can lead to sleep loss. Despite the distressing nature of sleep terrors for the caregiver, it is best for the caregiver to allow the episode to run its course where the child will continue sleeping through it rather than attempt to awaken the child.

It is important for caregivers to remember that sleep terrors are more like sleep walking than like nightmares and that the child often does not remember the event at all. Sleep terrors are not necessarily a sign that there is something psychologically or emotionally wrong with the child or that the child has experienced a trauma.

Managing sleep terrors 

There are some strategies to prevent these episodes from occurring. We know that there can be internal and external triggers that increase the chance of a sleep terror by disrupting deep sleep, resulting in the incomplete awakenings that characterize sleep terror episodes. Examples of internal triggers include being sick (such as with a virus), having a full bladder, or another sleep disorder such as sleep apnea. Caregivers can ensure that the child empties the bladder before going to bed. Alternatively, they can wake the child up an hour or two after falling asleep and walk them to the bathroom to encourage them to void the bladder. If the child snores, they may have sleep apnea, and this condition may be adversely impacting the child’s sleep quality and increasing the likelihood that sleep terrors occur. If this is the case, the child should be evaluated by a sleep medicine provider for appropriate testing and treatment. External triggers such as sleeping in a different environment than normal, or an environment with lots of noise can disrupt sleep and therefore increase the likelihood of a sleep terror. Minimizing internal and external sleep disruptors can help reduce the frequency of sleep terrors.

Caregivers should also ensure that children who experience sleep terrors are getting enough sleep. When we routinely do not get enough sleep, our brains compensate by producing more deep sleep, which is the stage of sleep where sleep terrors occur. Sometimes ensuring children go to bed consistently 20 to 30 minutes earlier every night may be helpful in reducing sleep terrors.

Treatment for sleep terrors

Usually sleep physicians are great providers to connect with if caregivers have concerns about their children’s sleep symptoms. These specialists can look for underlying causes such as sleep apnea. Medications are usually not indicated or advisable in treating sleep terrors and are only used in very severe cases. While children often grow out of their sleep terrors, behavioral treatments (including use of the strategies above) can often help families in managing sleep terrors in childhood.

Conclusion 

In sum, while sleep terrors may be distressing to witness, children are not significantly affected by sleep terrors and there are preventative measures that can be taken to manage them. If you have concerns about your child’s sleep terrors, reach out to your doctor for a referral to a sleep medicine provider.