Lily is an otherwise happy and healthy 3 ½ year old girl. She’s the only child of Barbara, an attorney and Philip, a career counselor. Lily never had any difficulty falling asleep and staying asleep, until one night last year.
About an hour after putting Lily asleep, Barbara and Philip were startled to hear Lily screaming. Barbara would later describe the screams “as though someone were stabbing my daughter.”
Both parents rushed to Lily’s bedroom, to find Lily thrashing around in her bed, as though possessed. Her eyes were open, but Lily appeared to be “staring right through” Barbara and Phil. Unable to calm Lily down, her parents panicked and bundled her into the car and drove off to the emergency room.
About 20 minutes later, not yet arrived at the hospital, Lily had stopped screaming and was sleeping peacefully in the back seat. Her parents turned around and headed home. Lily had no recollection of these events the next morning at breakfast.
By the time I met the family, they had been to see the pediatrician who found nothing wrong physically with Lily. They were referred to me as this appeared to be a classic case of “night terrors.”
What are night terrors?
As frightening as they are to witness, night terrors are quite benign. They tend to occur in toddlers and young children, with a peak onset at Lily’s age, 3 ½ years. Most children outgrow night terrors by adolescence. About 5% of all children are affected, and in rare cases night terrors persist into adulthood.
In the midst of a night terror, the child’s heart races, she may appear flushed and sweating, and she may shout words like “get away!” or “it’s trying to get me!” This is why night terrors are confused with nightmares, which are different phenomena, as we will see. The episodes last 10-20 minutes, after which the child calms down, yawns and stretches, and falls back to sleep.
Like lucid dreaming, night terrors are best thought of as altered states of consciousness. They occur in the early half of the sleep cycle, as a child is abruptly awakened, if only partially, from stage IV sleep, the deepest stage. At this point the child is no longer completely asleep, but neither is she completely awake: she’s a little bit of both. It’s a mixed-state.
Dick Ferber describes this altered state by asking us to imaging being awakened at 2 AM by your alarm clock because you have to give a child medication. You stumble out of bed, go to the kitchen, and completely forget why you are there. So you stand there, confused. This is because you are not completely awake yet not asleep.
Night terrors are a type of parasomnia, a set of altered states of consciousness that occur from partial awakenings from Stage IV sleep. These include sleep walking, sleep talking, teeth grinding, and (some say) sleep sex.
Night terrors vs. nightmares
Night terrors are very different from nightmares. Nightmares occur during REM sleep, when the child cannot move or thrash about. Nightmares tend to occur in the later stages of the sleep cycle, often shortly before the child wakes up.
Importantly, the child is fully awake immediately and can remember, often vividly, the details of the dream. By contrast, the child has no memory of night terrors whatsoever. Night terrors also tend not to be triggered by scary or traumatic events.
Later in childhood and adolescence, the relationship of a child’s emotional state to the frequency and severity of night terrors becomes more important. But for small children, there appears to be no relationship at all between night terrors and “real life” stressors.
What causes night terrors?
There are two answers: the honest answer and the answer you’ll find on-line. The honest answer is “no one knows.” The best we can do is speculate that some children have a tendency, possibly genetic, to rise only partially out of Stage IV sleep.
Since children sleep more deeply than adults, this provides a partial explanation for why night terrors and other parasomnias are more common in children.
The on-line answer you’ll get is that the child may not be getting enough sleep, or she has obstructive sleep apnea, or that there is some kind of stressor in the house. For older children, adolescents, and adults, all these may be contributing factors.
But for small children who display night terrors most commonly, there appear to be no such causal relationships.
When should I worry about night terrors?
If a child’s night terrors are so intense that she is at risk of harming herself or others, then medical attention is warranted. In very rare instances, a short course of an anti-depressant or an anti-anxiety drug may be prescribed.
This is done not because anyone believes the child has a psychiatric disorder, but only because we have no other tool available to prevent a child from harming herself during a violent night terror.
If a child’s thrashing is more rhythmic, or involves only one limb, and if the thrashing occurs mostly in the early morning, as opposed to early evening, then there is a possibility that what is happening is seizure activity instead of a night terror.
The difference in appearance between a night terror and a seizure tends to be very stark, but if you have any doubts, please consult a physician.
How to manage night terrors
As scary as they are to witness, night terrors have no lasting negative effects on a child. So as much as a parent might want to wake the child, I do not recommend it. You are not likely to succeed in waking her, and if you do, you may only confuse and embarrass her.
Of course you want to make sure that she will not harm herself, so it makes sense to sit as calmly as possible with the child until the night terror is over.
Since the child has no memory of these events, it makes no sense to question the child about them afterwards. The last thing you want to do is convince your toddler that there is something wrong with her or to embarrass her when in fact what is happening is quite normal! It’s best not to mention the episode at all.
Even though we don’t know what causes night terrors and we don’t know how to prevent them, the best advice I can offer is the advice I gave Barbara and Philip:
During a night terror, stay close to the child to make sure she does not hurt herself.
Do not attempt to wake the child. You can only make things worse by doing so.
Avoid the temptation to mention the night terror to the child. You can only embarrass her or make her feel she’s done something wrong.
Remember healthy exercise, healthy diet, and a regular schedule. It can’t hurt, and it might just help.