Anxiety, dreams and nightmares and the effect on sleep
by Consuela Hendriks
All parents eventually deal with it. Anxiety, dreams, and nightmares that affect their child’s sleep. To some extent, that’s perfectly normal. In this blog I’ll explain what fear, dreams and nightmares are and what the effect on sleep can be.
Dreams and nightmares
Nightmares are so-called parasomnias that can occur in the REM (Rapid Eye Movement) sleep phase. A parasomnia is a ‘sleep disorder’ in which abnormal movements, behaviors, emotions, perceptions, or dreams can often be seen. During REM sleep, you dream. If a dream is frightening (or evokes other negative emotions) it can wake you up, and it is called a nightmare. Nightmares are common and belong to normal development. They are most common between the ages of 5 and 10 (Schredl et al., 2009). Chronic or frequent nightmares occur in about 2-5% of children, depending on which study you are looking at (Mindell & Owens, 2015; Schredl et al., 2000; Steinsbekk et al., 2013). Nightmares are more common in the second half of the night, as the amount of REM sleep is proportionally higher.
Risk factors/ factors that can provoke or increase nightmares are:
- Sleep deprivation
- Fear (more on fear later on)
Do babies dream or have nightmares?
It’s long been thought that babies don’t dream. I really doubt that. Since dreams are characteristic of REM sleep, it is very likely that babies can also dream, and therefore also have nightmares. They have much more REM sleep than adults or older children. However, we cannot investigate this, after all, babies cannot tell that they have had a dream or nightmare. The research into the occurrence of nightmares is therefore also mainly done from the age that a child can talk (and adulthood). In addition, many parents do not seek help for nightmares (because they are normal to some extent) and therefore there are few data. But given the amount of REM sleep (50% in newborns compared to 25% in adults), certain movements or sounds and the fact that babies sometimes suddenly wake up crying during active sleep, I believe babies can also have dreams, and nightmares. Perhaps not in the same form and complexity as in adults or older children, since babies do not yet have such a number of memories and experiences that can ‘participate’ in their dreams, but they do experience a lot in a day. All the new experiences and information are absorbed and processed. In my opinion, dreaming has a function in this respect, just as it does with adults. A baby’s dream may not be about being chased or a holiday but perhaps a delicious bottle of milk that ends when empty or a loud sound that triggers anxiety.
Anxious children and sleep architecture
Fear changes the architecture of sleep. In other words, sleep is arranged differently when you are anxious. If you are anxious, sleep onset is often delayed (it takes longer to fall asleep), sleep is less continuous (Papadimitriou & Linkowski, 2005) and there is less deep NREM sleep and more light NREM sleep, less REM sleep and more frequent waking during the first part of the night (Fuller et al., 1997; Rosa et al., 1983). The total duration of sleep is also less.
Falling asleep takes longer because an anxious child worries more and ‘ruminates’ (repeated and prolonged thinking about feelings and problems), making it harder to fall asleep. More wakefulness and lighter sleep are likely due to the increased level of anxiety and stress, which makes children more ‘alert’ and keeps them in lighter stages of sleep. If you are anxious, your hypothalamic-pituitary-adrenal axis (HPA axis) is stimulated and it produces cortisol (the stress hormone). For a short time, this is not a problem and is useful and important for survival and alertness. However, chronic anxiety causes chronic stress and that isn’t good for overall health and is counterproductive to sleep.
In short, anxious children sleep less and less efficiently. Anxious children often have more scary dreams or nightmares. And often you see a vicious circle emerge:
anxiety leads to rumination → sleep onset is delayed (trouble falling asleep) → changes sleep architecture → more fatigue and sleep deprivation → more anxiety → night sweats, nightmares, night wakes, hypervigilance → more trouble falling asleep etc.
And this illustrates how “sleep hygiene” can be negatively affected and sleep inefficiency arises which can lead to insomnia.
Normal anxiety and pathological anxiety
Of course, it is important to distinguish normal fear and anxiety from pathological anxiety.
It is quite normal for children to go through periods of increased separation anxiety. It is also quite normal for older children to go through phases where they want the parent to stay close to them while they fall asleep or being anxious in the middle of the night. Nightmares and night awakenings are also normal in child development. Often these are phases surrounding a significant developmental leap or an important life event, and often this is transient.
With pathological anxiety, it is about more persistent anxiety, for example, generalized anxiety or specific phobias. You often notice this not only around sleeping but also throughout the day. Expressions may include (not an exclusive list):
- Fear of dark
- Bedtime resistance
- Lots of night waking (more than developmentally normal)
- Pre-bedtime anxiety
- Wants to have parents close.
- Wanting to sleep in parental bed.
Differential diagnosis is important. After all, all these expressions/symptoms can also fall within the ‘normal’ or could be symptoms of other underlying causes such as missing boundaries, other underlying behavioral or developmental problems or inconsistency in parenthood, to name a few.
Risk factors for anxiety
Although almost all children are anxious from time to time, anxiety expressions are more often visible if one or more of the following risk factors occur:
- Witnessing trauma on TV. Research shows that indirect exposure to something traumatic on TV can already trigger post-traumatic stress in vulnerable children.
- Being bullied. Being bullied makes a child more anxious, and being anxious increases the risk of being bullied.
- Extreme embarrassment. These children are more withdrawn, worry more and experience more social anxiety.
- Developmental disorders such as Autism Spectrum Disorder, Asperger’s Syndrome, sensory processing problems, giftedness. These are known to have a higher risk of comorbid anxiety disorder.
- Prenatal exposure to anxiety. Maternal depression or anxiety in pregnancy increases the risk of behavioral and emotional problems, more crying and more separation anxiety.
- Family history of anxiety, depression. There is a genetic component.
- Attachment problems (insecure attachment). Insecurely attached children tend to internalize more. And internalizing in its turn increases the risk of anxiety.
- An overprotective or controlling parenting style. The child does not get enough exploration opportunities and/or has to deal with excessive alertness/anxiety of the parent.
- Little emotional coaching from the parents. Children develop less emotional regulation skills if they are not coached by parents.
What can you do about such sleep problems?
When you are dealing with anxiety, you can influence sleep by treating anxiety, with strategies that influence self-esteem, independence, self-confidence and therefore sleep. In sleep consultation, it’s important to look at this. Every child and every (family) situation is unique, but some examples to work with are:
- Strategies that increase self-confidence in children (age-appropriate tasks, rough and tumble play, working on a growth mindset)
- Parenting style (setting loving age-appropriate boundaries, attachment and connection building, working on consistency in parenting)
- Anxiety reduction techniques (meditation, mindfulness, relaxation techniques, play therapy techniques, skin-to-skin contact, and practical applications around bedtime)
- Emotion coaching (emotion recognition, emotion naming, co-regulation)
- Sleep hygiene (creating a healthy sleeping space, installing a soothing bedtime ritual, use of social stories, reading books)
- Treat parental anxiety (this has a positive effect on the parent’s sleep, mental health of the parent, increases the tolerance to normal sleep behavior of the child and increases the parent-child attachment).
All these things contribute to achieving a calm and more relaxed state in both parent and child, which positively influences sleep.
Read this blog in Dutch here.
Fuller, K. H., Waters, W. F., Binks, P. G., & Anderson, T. (1997). Generalized anxiety and sleep architecture: a polysomnographic investigation. Sleep, 20(5), 370-376.
Mindell, J. A., & Owens, J. A. (2015). A clinical guide to pediatric sleep: diagnosis and management of sleep problems. Lippincott Williams & Wilkins.
Papadimitriou, G. N., & Linkowski, P. (2005). Sleep disturbance in anxiety disorders. International review of psychiatry, 17(4), 229-236.
Rosa, R. R., Bonnet, M. H., & Kramer, M. (1983). The relationship of sleep and anxiety in anxious subjects. Biological Psychology, 16(1-2), 119-126.
Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009). Longitudinal study of nightmares in children: stability and effect of emotional symptoms. Child psychiatry and human development, 40(3), 439-449.
Steinsbekk, S., Berg-Nielsen, T. S., & Wichstrøm, L. (2013). Sleep disorders in preschoolers: prevalence and comorbidity with psychiatric symptoms. Journal of Developmental & Behavioral Pediatrics, 34(9), 633-641.