Night Terrors

The sleep disorder of night terrors typically occurs in children aged 3-12 years, with a peak onset in children aged 3½ years.
 
Sleep is divided into 2 categories: rapid eye movement (REM) and nonrapid eye movement (non-REM). Non-REM sleep is further divided into 4 stages, progressing from stages 1-4. Night terrors occur during the transition from stage 3 non-REM sleep to stage 4 non-REM sleep, beginning approximately 90 minutes after the child falls asleep.
 
Night terrors are distinctly different from the much more common nightmares, which occur during REM sleep. Night terrors are characterized by frequent recurrent episodes of intense crying and fear during sleep, with difficulty arousing the child. Night terrors are frightening episodes that disrupt family life.  
 
An estimated 1-6% of children experience night terrors. Boys and girls are equally affected. Children of all races also seem to be affected equally. The disorder usually resolves during adolescence.

Causes:
Night terrors may be caused by the following: 

                                     
Symptoms:
In addition to frequent recurrent episodes of intense crying and fear during sleep, with difficulty arousing the child, children with night terrors may also experience the following: 

Unlike nightmares, most children do not recall a dream after a night terror episode, and they usually do not remember the episode the next morning. 

The typical night terror episode usually begins approximately 90 minutes after falling asleep. The child sits up in bed and screams, appearing awake but is confused, disoriented, and unresponsive to stimuli. Although the child seems to be awake, the child does not seem to be aware of the parents' presence and usually does not talk. The child may thrash around in bed and does not respond to comforting by the parents. 

Most episodes last 1-2 minutes, but they may last up to 30 minutes before the child relaxes and returns to normal sleep. 

If the child does awake during a night terror, only small pieces of the episode may be recalled. Usually, the child does not remember the episode upon waking in the morning.

When to Seek Medical Care:
Sleep disruption is parents' most frequent concern during the first years of a child's life. Half of all children develop a disrupted sleep pattern serious enough to warrant physician assistance. 

      ■  In children younger than 3½ years, peak frequency of night terrors is at least 1 episode per week.
      ■  Among older children, peak frequency of night terrors is 1-2 episodes per month.  

If your child seems to be experiencing night terrors, an evaluation by the child's pediatrician may be useful. During this evaluation, the pediatrician may also be able to exclude other possible disorders that might cause night terrors. 

Exams and Tests
Usually, a complete history and a physical examination are sufficient to diagnose night terrors.  
If other disorders are suspected, additional tests may be useful to exclude them: 

   ■  An electroencephalogram (EEG), which is a test to measure brain activity, may be performed if a seizure disorder is suspected.
   ■  Polysomnography (a combination of tests used to check for adequate breathing while asleep) may be done if a breathing disorder is suspected.
   ■  CT scans and MRIs are usually not necessary.

Night Terrors Treatment
Parents might take the following precautions at home:
 
  ■  Make the child's room safe to try to prevent the child from being injured during an episode.
  ■  Eliminate all sources of sleep disturbance.
  ■  Maintain a consistent bedtime routine and wake-up time.

Medical Treatment
Unfortunately, no adequate treatment exists for night terrors. Management primarily consists of educating the family about the disorder and reassuring them that the episodes are not harmful.
 
In severe cases in which daily activities (for example, school performance or peer or family relations) are affected, tricyclic antidepressants (such as imipramine) may be used as a temporary treatment.

Follow-up
Frequent follow-up care with the family to provide support and reassurance helps alleviate their anxieties.

Prevention
If your child has several night terrors, you can try to interrupt his/her sleep in order to prevent the night terror.
   ■  Note how many minutes the night terror occurs from your child's bedtime.
   ■  Then, awaken your child 15 minutes before the expected night terror, and keep him/her awake and out of bed for 5 minutes. You may want to take your child to the bathroom to see if he/she will urinate.
   ■  Continue this routine for a week.

Outlook
Night terror episodes are short-lived and usually occur over several weeks. Nearly all children outgrow night terrors by adolescence.

Support Groups and Counseling
Parents should be advised to examine the adequacy of the child's sleep. Parents should be educated about the importance of establishing a consistent bedtime routine and maintaining a consistent wake-up time.
 
Additionally, parents should be instructed to make the child's room a safe environment and to provide barriers that prevent the child from impulsively leaving the room and going into environments that could lead to injury. Potential sources of sleep disturbance should also be eliminated.

Authors and Editors
Author: Kevin P Connelly, DO, Medical Director, Paws for Health Pet Visitation Program, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University and Children's Medical Center.

Editors: Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia; Mary L Windle, Pharm D, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine.com, Inc; Carmel Armon, MD, MHS, MSc, Professor of Neurology, Tufts University School of Medicine, Chief, Division of Neurology, Baystate Medical Center, Springfield, Massachusetts.