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Abstract

Objectives This study had two major aims: (1) to explore the relationship between sleep related difficulties and behavioral and emotional problems in young children, and (2) to identify predictors of child fear and problematic sleep behaviors. Methods Sixty-eight children (34 boys), ages 4–6 years (M = 4.9, SD = 0.9) who experienced nighttime fears and who co-slept with their parents were evaluated using parental reports of internalizing and externalizing behavioral problems, sleep difficulties and related anxiety, as well as child and parental reports of fear. Results Child-reported fear was significantly predicted by internalizing problems when controlling for other variables whereas parent-reported fear was primarily related to child endorsed fears on a preschool fear questionnaire when controlling for the other variables. In contrast, sleep-related problems were primarily related to externalizing behavior problems whereas the number of nights slept alone was primarily related to separation anxiety on a preschool anxiety questionnaire. Conclusions Findings from the present study point to the multiplicity of factors that account for nighttime fears and sleep difficulties in young children. Child fear and separation anxiety were related to co-sleeping. Moreover, internalizing symptoms in young children predicted child fear whereas, externalizing symptoms predicted sleep problems. Based on the reciprocal relationship between emotional/behavior problems and sleep, frequent co-sleeping and nighttime fears might serve as a risk and/or maintaining factor of disrupted sleep practices. When treating nighttime fears in young children, co-sleeping should be targeted for intervention as well.
Predictors of Nighttime Fears and Sleep Problems in Young Children
Renatha El Rafihi-Ferreira, Krystal M. Lewis, Tyler McFayden & Thomas H.
Ollendick
Journal of Child and Family Studies
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Abstract
Objective: '%%( ) * % +,-%,)-
%, ../%- 0-- ,%-(-1 /-2
--.(,/%./.-,/%,0%"Methods:
+(1/- & (%2 1%  (% 34"2  4" ) +,-/
-1.% - )/%, )  ,-%) 0 %-1,-
,%.--5-1- +-5-10,%2%,../%-
-+(2%)%/-,-,%.."Results: ,
.)%%1-./-(,/(--5-1,%)-/--1.
0% )%,-,.)%,(/-% .%
1
-,%/.6%--)-/--1.0%"-/-%2
%,  ,%  )  ,(      +-5-1  0  ,%
)%-.-1%%,-)%,(%,--+(
-,%/-+(6%--" Conclusions: --1%.,%-%(
,-      ,/(  .  ./%    //-  .  -1  .%  -  %,
../%-(-1/-".-%,--+() /
%,-1"302 --5-1%(,%-(-1 /- ,/  / .
)%2 +-5-1 %(,% ,/ %, ,%" 7%- /,/
-%,  )-  -$0  ,%  -  %,2  .6-  /%,-1
--1.%1%0%%8-$---1./.%,%,
,//%"9- -1 -1 .% - (-1 /-2 /%,-1 % 
1.-0--%)"
Keywords:-1.%:%,,%:/-+(:0,%
1.%/--/--%(--%("
;)02.%<.(-1/-2-1.%-%%/
,%/*%11-%%/)/--%0%,
,%2-+(2-%..-1./--.%=-2>-12
=-23%?!-/82#"'1(-/--.%.%0(2
-1-1.%,-%%.%"1"2)(,-%0-12
,%-%.("1"2..8-,,218-1-21-(
/%"1"2..1%%--%%2%/(%2-(..
8--1-"--2%.%-.)(02
-1%/2//2--%,,%2%)%)%-
2
-+(1/(,%%-%/-/-(
=-"2#2#:>%-?2:3%23/8/23(?
@-%2:3%23/8/2!-/82>-12?712"
!.-2/-)-1.%0../(.-1%,-
---1%,)/2--2(%-/%,-1)/10%%2
=--2%-21--2?3-2:>%-?2"-
%((%-/1%)&#/-)-1%.A-2
-<./%,%,-1.%/,-(A<.%(
%,%-/-/-"-%%(2/%,%%%)../(
%,-1)(.2..%,-1---82---1
,-,%-"'6%%./-/%,.-/0-
.6-(//-%,-%-+(,%%"2:@2
-23%2?B.-2"
B1%-%,1-%%.-1.%-*
1-%/%(%%2(,.%0%%"78-1.%-1
%,-%-/.-,-/-.12.-%-/2%/-.
1-%%.%,--+(%B/-@%(//B%%/-2
&2)%,--/..%,-1-..8%
/-./-%(,%.%,/./,B/-@%(//B%%/-2
&"302-01A<./-)-+(%%,%-)
%,,%%/%../(.-1%,--1.%:
.20-/%11%%-1%,%(--(,0
%,6(%%--0/---+(,%B.-2
=-%1?>-1(2#:-?B.-2:>%-?2"
-2..//(./1-00,(--1-.%0
3
-1.%%--%-%0%%0,%&(%
-?B.-2:=-"2#:>-2C--2B,2?2#:
>%-?2:!-/82;1-2?;-5-12:2A:
)?=-2"2%/%0,00-/.%,
,0--/---+(%(,%%%.-0--%.
-1.%-?B.-2:>-2"2#:>%-?2
"
'%%/-%-1-1.%2%,2--+(,%0
-)/--"+,2%((9-"A
/-%1--+(%-%0(-.%)-D%(.
%,-%,1-1"C%//-/(>%--
%%11%%/-)-1.%%8.0,-1,%,
6(2)/(./,%,%(/1/)-1"302
%((>%-2=.--%/-)--%
-1.%,%-))0(..%-0
,%"---1.%2/%,-1)%%%/)-+(-
,%,6(-%((@""/0(%.--1%
%,,,-/./-/-1-%/-%.-6("
=0-1)-1-%--1.%-,%//--
%%-8%)--1.%2%,,%2/%,-12.2-+(2-
0,%2./-%()%0 -%,%
)-%--5-1-+-5-1,%-%,0%-
-1.%"!.%(,%%)%--5-1%(,%),/
/,-,-,."!%/-(,%%)%+-5-1
0%),/%,,%--.-1%%,-"
4
Method
Participants
(,/,-%-//-&(%21%(%34"2
 4"2)0%,-1--)/%,)%"'
/-2,0(%2)//%,.-5
/-//-/-750../0-%%.,(
-,1.-1.%-%(-1/-C.2
0%2B%2?!-/82"'/-8,/%-1
0%-%--)%,,%2%)%-'%",//%/%.
/--,-%,%--'"!-(/-)
-1/,--$,%(//%(,%2%,(,-%2)
+/"!)%./-)-/"
Insert TABLE 1 here
Procedure
(,/%)/-/-,,0.C%/E/%
.-0%%)%0/%),."')
//-//.-%@%/1.F-0%G
@:-B%/-/B-+( %%@1.-%
@%6;%,%H-/%/3/-F-0%
G@I,6;3F@--H-/G3/%@-1JK
-2(.%-1)-%/%%%--
%,0%-./-%/-/%,0%"@-%)%1-,.,/,-
-.-.-1.%))%%./L%
-%%%%-%)%-%/"'/10%/,
5
-%-%-%%%-%)/%,,+(-%"'%/
,0+,--%-/,-.-%---6)
,-%,.%,-))%%%-/"E0--/%%)
,-/%%,-)%%%-/2%/--
%%%.)-(6%-%"'%,1)%%-/10%-)8
.-0)-)//.%0-(%,-,%-
-0)"
Measures
--0)'.)-1-.-)%-121-2/-
,%(//%(./-1)120./-2%%2
//,--%/%%.,-%"
,J1B(,)%/,(,-%2%8-1(/%,
--)--1MB-2(/%)-(-1.%M
-D%-0)-)%8,06-0-.-
1-1%0(..-1/%%%%--,-J8%/
4--&4/2)/-/-/-1%/)-./%"
%-1.-1%28-/-1%/)-./%
%0%.0-5-%%.-1
.%-(-1/-"1"2J)%2B(2..-2?!-/82A:-
?!-/82:)?=-2-0-%%%--(
/-0--%%%,%%%%-1//,0(-(;%-?
7/82"
,;%-0-(.@%/-;@ 0,()2
>-2=-%1-B-%#2;@)%-%-75-
6
@1%)-%0-/.(-0(7%?-%2
"%--.,%//--%%%%%,%-/.%,
,%(%8-1,-%/L%%,%-%)8"'
;@%#6%--),-J8%/%-/.02
.6-0" .../0%,-%%/%-
%/)-(5"-,%-%,2(.;@
%--/."-"A.../0%,-%%/2)/
//,10--.%---0,,-1//%/%.
%"
@%/B-+(/@B 0,(,-/2C,23/ ---1
2@B%%/,(,-%./-1
%+(%%%%%/-L%-+("'.%%%/-A,-
%/2-1-1.%-.-2-%%-,-6%-
1-1/+,-/%"'%//-%%%.1--+(%/
/%,-%%.%-.0%,/./%%/%1-5-+(2
%/-+(2%%%0/,%0%2.%.,(%/-*%-
%,--+("-,%-%(2-(%/-%/.
%,--+(%%/A%)%"'6%--)%-%
.E-1%-75-@1%2-/8-%E-1%2-.-(
0%1--75-@1%-/-%-%%1-)%/)-
-%%"@%(//0-%.@B0%)-6%--
,%%%%%1(-0(%7-?3%2:,-/"2
"/-%(2(%%)%%./(4".
%-4".%,--+(%%/"
7
0(/.-.-%@%/%@7%-0(
/.-C0%!-/82&2@%%%%%.%-,
%//-"@-%%,-%--/-L%.%2-
%/-1-1.-/:1%/1--%(.
."'@20,(9-2!-/8--%2%%)-
1--/-%%-/(-1/-01--%/--0()E-1%
%,8-1/10%:)0275-0%-.%/%--
0"'6%--)%-%.E-1%-75-@1%2
-/8-%E-1%2-.-(0%1--75-@1%-
/-%-%%1-)%/)--%%"/-%(2
%,%%%%1--/-%%-/(4"A"
70/8%NA(%7J'%%--%-0,(
B/-/-C%/-%-5%%.0
,%-/-%-,-,%"'7J%)(%-
,%%%%%)%%,%(//,,%B/-/?C%/22
1,%.(-0(.75-0%-
-/-(0";)02%)%%27J)%
-%.E-1%-75-@1%2-/8-%E-1%2-
.-(0%1--75-@1%-/-%-%%1-)%/
)--%%"'7J"AA/--%%-)/,-%-/
%-%not true2somewhat or sometimes true 2very true or often true
/-()-,%)-%"'7J(%-%/%
'@%2--5-1@%2E+-5-1@%2-%+-)
-%/%E-(C/02 ,%%$B-+%29)-2/2,
@%2B--2-B11%%-"''%/%.B-+(@%2,
8
@%2--5-1@%-E+-5-1@%)%-%%("
'/%61-A/-%-/-/-12)%
%/%)---0-1"%%(2B-+(@%
4"A2,@%4"2+-5-1,%4"---5-1
,%4"&)%-).-,%%%%6--
/-%%-/%"
Data Analysis
-(%%)%/-/%-173@%%/%.)"'
,(,--0%)%/-0%1.,2
@-,2-%,,%7J,@%2.1%
,B-"%,)%,1%%--(%%)/-/)%
,(,--0%.-%"B--1-,--0%2
-/-11,/./%2)-/-%,)%)-(-
0/%,4"A""212%+2E27J--5-127J
E+-5-12@B,-B-+(2@2-;@,-B../"
Results
3-%2%-0-%2-@%-/-%.0%
,%--'"
Insert TABLE 2 here
,-1.)%%1-./-(-1%%,-r
4"&2pO"2--5-1%(,%r 4"pO"A2+-5-1%(,%r
4"2pO"A2-1-.%,-@4"2,O"A"9-
,/%)--,1%%-2-(7J--5-1)%
.-%1-./-,/.,.74"2p4"2
//--1."A<.0-/B*%C4"A"
9
@-,-1.)%%1-./-(@r4"2
pO"A"9---%,)%1%%-2@74"-;@
,-B../74"1%%1-./-,/%pO"2//--1
.0<.0-/B*%C4"&"
7J,@%)%%1-./-(7J--5-1r4"
A2pO"27JE+-5-1r4"&2pO"2;@,-B../r4"2
pO"2-.1%,B-r4"A2pO"A"9---
%,)%1%%-27JE+-5-1)%-(%1-./-,/.7J
,,%74"#A2pO"2//--1.0&<.0-/
B*%C4"&"
.1%,B-)%%1-./-(7J%,
,%2%--0r4"A2pO"A2@B,-B-+(r4"#2p
O"A2-,r4"&#2pO""9---%,)%
1%%-2@B,-B-+()%-(%1-./-,/..
1%,B-74"2pO"A2//--1.,,+(<.
0-/B*%C4""
Discussion
'%%()*%+,-%,)-%,
../%-0--,%-(-1/-:-
-.(,/%./.-%,0%"!.--1%-/
,--(--5-1%%7J--5-12@2-;@
,-B../,//,-,-,.2%/-.-1
.%(,%%"!.--1%%-/+-5-1%%7J
E+-5-12and--5-1%%@B,-B-+(,/%,
,%--.-1%%,-2%,(%,,-1%/-
10
(,%%"'%%%,0%,,.--%,,%
./-%%/)both--5-1-+-5-1../%"
@0%%/%%%11%-%,)-%,
../%-0--,%-/-=1(2E-29%
?%2:;2P/82-2@%-%?>-/582#:/2
P8-?E,%-2A:-23-%-2!(2B-?7-/2
";2)%)--5-1%(,%,//.-
+-5-1%(,%-/.,/%,../%"'%.--1%
,-,/(../%-1.%-%,
../%-(-1/-"
-//-/)(,%%2%%-%--5-1
%(,%-/-,/-1."302-1.,/
/../%)%,-1--)-"'.--1-1.
%%1-./-,/./%,-1%%-11(%"
2),%1-./-(1.6-/(..%-%-1/-"
2/-%((@"/-.%%%/-)-
/%,-1--+(2-%-110%.-+(,%--
/-)%,),-%"
%,-1%-%)--.-(%1%%(,-%
-1-1.%-/->%-?2";)02%
%1((0-10%--1/-%6-/%%%%0
%)-/%,-1%%%/)-/%-1)8-12,%,
)/-/%.)%.%,2-1-1---)2
)2?3%%2&:3-22>(?;)2:2'858(2
11
?/2"=0-,-/.%,-,(%/--.
(-1/-2/%,-1/-/-/--1)-%--
0../%,,/-%6-/.%,//"'
/--.,%%-/.%-%,,%%8(,%
%1-./-0,-/-1)/(,/(../%
%"
'1.6-/(./%,-1,-%75-%,0
-1%,)8%'%810-0/8./%,-1
%/-%,,-"%%//-.,./%2-/-1
%,//%/%-//81-%2-/%%(,
-%-%,,-%-/--,-%-0,,,,-
/(%-%0-0--%"3%,/./(2.-%--1.
-%,)-%,-02.%/%-/
,/.,--10%--1-%-.(-0---
/-L%%,../%-+-5-1---5-1%(,%"
-2+,-1./%%%/)/L%%,../(%//.
../0-0--,---1=1(?2"
!.--1%%1-),0%%/,%5%%%/-
)-%,,%-+-5-1,%-/-=1("2:
;"2#:C.20%2@%2B%%,QG?32:
-2:-1"2"E+-5-1%(,%).-
%1-./-,/.%,../%.-%-%,-1-2+,-/-1
-1%2%%-/-1-12%,-1%%28-1)%,2-)8-1
,.--%,"B%%/-%)-%,-0,%8(
12
/-2%/-%../-%,-,%+/-
-0../%"J/8.%,/-/,%-1--
-/%(2.)///%/%.--5-1-+-5-1
,%"!--20,%/-/,%%,,-%2%
/%%,%%/-%%/)0(.,%(/,1%
=1(?2"-%/%%/-(+,-/%1-./-
.%)%+/0,%2%-%,-%
.+,%,../%.+-5-1,%"/-
+,,%-0%.%-1%28-1/828-1
%2/"2)/16%,,--,,/%-(-1
%(--,,/1%-(-+%-..0-%
/-"
-%-1,/%,,%--1.%/-0-
)-1./-2,-/.0,-1,0-0--0--
%%%,-"C/-%%0..0-/.%,,0-
-/---+((5-1-0--%.-1.%2-/-1.
-)/%-%2%/%'170',('7'2-?
B.-221-070',(-/-1@--00@(7'
@@:>-"2#:>%-?22-,(J)%"2
A:C."2"
%/%%+,-0--./%)/(,(-
,---%,)-%,-0,%-/-"
E(-=1(2E(2!L--2-@-,--0--
./%.6-(%%/)%,,%--
13
--5-1-0+-5-1,%"+,2%/
%11%%/8.--%-1.,--1/-%%/)
--5-1-+-5-1,%=1("2:0%-"2
A"3020%--/1%,-%(-1
/10%-,%-,-/-%,%%/)%,
../%---5-1-+-5-1,%-/-"
=0--.-/.,-0%-/0-%,2.
%%%-0%1,-,%(/,1(-*%-2-
-%,%)/%,-1--1.%"2/,-
/--%,%(-.-/%,%2%%/(3/2
7%8(2--&-.-.-%)-%/%%-/-%
)8(-%/-/(%1-./-%,../%";(%2
C%-)%11-.-,/%%/%,-1-(
/)/-/%(.%.-12-1.-1%-
,-D%2-.-1%,-,-D%)%%(%,%
-%%-1/-%,%-%/(*/%"'.2
.%%%+,6(2,-%-%.%,-0-
-1-.-/(-(/2%/-%(-(+,/-%,
%.,%/%"
J-%.,%-%(%/8-)1"'%%(
0%,,%%(1,--/,-%-%"
%%%%%*/0%%.%,%/%/1,(2---0%0
.%-1%,,-%%-1)/80/)--)%"%
---/(%%,16-./---(%%.
14
/0(2),0-1%-%.%,-%-/(:%,../-/(:
&)8.%,-%:-%,"'%1(2-1)%.
%.,-%-%2)%.-,0-11%,/./-.%,
//%/%-%,,-"B-,--.%(%
)+/,-.;@%/2-%-%)-0-
75"-%-1/8.0%/%-7500%-
-%-,%//-2%-/%%(..%%0%
%/%.75-,,-"2%-).)
/--%-,//%---/-%%-/(%%.%
%%)1-(6-75-%,"
-/-/%-2%%(./%-,--1(.-1.%-
/%,-1"'-8%)--1.%2-+(%%-%,,%
%.+,-1%,%./---..-/%"B%
,2/-)-1.%001-.---5-1
%(,%"J.-2-+(-./-00%../%-/
0,--,/,%(/,1("7%-/,/-%,
)--$0,%-%,2/%,-1--1.%
1%0%%8-$---1./%.%,%,"-%//%%2/
%,-1-1)-1.%%/-%%1%.-0--"
%%%%+,../%.(-0----1.
-%,,-%-(-1/-)/---1-.(%1-./-,/%
./.--10"
Compliance with Ethical Standards
Conflict of Interest
15
'%/(0-/-./.-%"
Ethical Approval
B,/%,.-%%-00-1-,/,-%)-//-/
)/%-%.-%--$--%//-
);%-8/--%--%/,/
%-%"B%(,/%),,0(F-0%(.G@2G
@C7"
Informed Consent
-./-%-)%-.-0,/,-%-/-%("
Author Contributions
CC%1--+/%(2%%%)-(%%2-)
,,">3J%%%)-(%%-/-)-1.
%(--1..--%/,"'3-(52).%%
-/-)-1--1..--%/,"';!,
%1-%(2%%%)-(%%2-/-)-1-
-1..--%/,"
References
B/-/2'"3"?C%/2J"B""Manual for the ASEBA Preschool Forms
& Profiles"7-1-2'F-0%(.-2C%/-.-2
R2?%"
B.-2"B"2=-%12=""?>-1(2""#",,%-1
/--%/-%)-+(%%"Journal of the American Academy
16
of Child and Adolescent Psychiatry22&" 
"#$"/"&&""
B/-@%(//B%%/-"&"Diagnostic and statistical manual of
mental disorders"A""9%-1-2 B/-@%(//B%%/-"
7%27";"3"?-%23"J""QG,JH-1@1% %
E%/%,B0QG;S%T--Q%"Journal of
Epilepsy and Clinical Neurophysiology2&2&"
7-2"?3%2@""@%(//0-.)-),--1
%/%.%-1-+(%(,%-(-1 //-"Journal of
Anxiety Disorders, 2A" "$*"*-+%"#""
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1-5-+(%B%%-(%%./-1%--+(-
%,"Journal of Anxiety Disorders22A" 
"$*"*-+%"&"""
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0%%%(%,-1-/-),%/-
,%-,-%%%"70,3/-22AA" 
"$AA
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-%.1"Journal of the American Academy of Child and Adolescent
Psychiatry,2AAA"
17
-2B"="2?!-/82'";""'-,1%.%0-1
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Psychiatry, 20(2##"
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Clinical Psychology Review2#&" "$*"/,""#"
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.%./--%/-%6-/(2/--2%0(22+,/-%2
%/%2-/,-10%"Behaviour Research and Therapy2A
#" "$*""#"&"&
=1(2B"3"2E(2'""2!D--2'"="2?@-2C""E1%.
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and Adolescent Medicine,2&&&&A" "$/,"""&&"
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%0""&"#"
18
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B%-@%/%"Infant and Child Development22AA&" 
"$/"A#
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Journal: Official Publication of The World Association for Infant Mental
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19
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-,%//-"European Journal of Pediatrics, 1712##A" 
"#$%&"
J)%2>"3"2B(2>"2..-23""?!-/82'";"A"'-1
-1.%-(-1/-),(0-1-+(%(,%
---10/-1"Journal of Anxiety Disorders2&&" 
"$*"*-+%"""
3/2@"27%8(2"2?-2@"&"-.-%,%%-/-
,,%--.-%)-%/%%-0%%-%/0-
/-%"Sleep and Hypnosis252#"
3-2"B"22B"2>(2"2?;)2'";""@-0%-
%,/%--.-%-%/%%//,%-" Sleep
Medicine,2&&I" "$*"%,""""
3%2@"23/8/2;"23(27"?@-%2E"";)%%/-
/.%MBehaviour Research and Therapy2&&2#" 
"$A##
3%2@"23/8/2;"2!-/82'";"2>-12""?712""
-D%-1.%,-I/-1%..6-/(2/--21-%2
/,-10%-%0(. Behaviour Research and Therapy2&2&"
"$A##AA
!-/82'";"&"C(-0(.C0%0(/
.-C"Behaviour Research and Therapy2212AI"
20
!-/82'";"2;1,-2J"@"2?;-5-12C"3""1-070
',()1.-2Journal of Behavior Therapy and
Experimental Psychiatry, 22(2),&"
@2"2-23"B"23%2"3"2?B.-2"B"",-1-1
/B1B-+%--B-+%-B%%/-%),
(-'-1"Journal of Abnormal Child Psychology, [Epub ahead of
print]. "#$%#&#
C.2C"20%2E""3"2B%2"C"2?!-/82'""7.
-.-1.%-/%,-1,%B-5/-/"
-.B-+( %%2A2A" "$*"*-+%""""
C.2C"20%2E""3"2@%23"J""2B%%,QG2"7"?32
"7""-/,-/-Q%-%%0Q
,%/1"C0%@%/1'@S/2182A#" 
,$$+""1$"A&$$,%/1"0-,A#
B"A"1-00-./%,%%"
Clinical Psychology Review, 252" "$*"/,"A""
2B"2'858(2J"2?/2B""@--1--.-%,"Sleep
Medicine Review, 2&I" "$*"%0""A"&"
/2B"2P8-2"?E,%-2C"A"@%%--1)8-1-%-1
../%/%%.%((,/%%.0,%M
ournal of reproductive and Infant Psychology2&2##"
"$&A&&&&
21
-12";"2=2"""2?-129"'""B%%/-)-/
%,,%-,-./%2,--%%%-0
,%"Journal of Sleep Research2152&#&" !"$*"&A"
""+"
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;(%-123"A"J--0,%%%/)%,
,%-%-1-%("The Jounal of the American Medical
Association Pediatrics, 1692A#AA" "$*,/%"A"#"
-2B""E--0,%-%,..--%
(%"European Child & Adolescent Psychiatry2102" 
"#$%###&"
,-/2";"2C,2C"23/ -2"?-123""'%/.
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"The final publication is available at link.springer.com”.
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... As crianças que apresentam medos noturnos ficam extremamente ansiosas durante a noite, solicitam companhia para adormecer e, quando sozinhas, podem apresentar dificuldades para relaxar e, consequentemente, para dormir (Gordon et al., 2007). Dado o estresse causado pelo medo no período em que é esperado a criança dormir, não é infrequente que crianças com medo noturno também apresentem problemas de sono, tais como dificuldades de adormecer e despertares noturnos, especialmente quando estão sozinhas (Rafihi-Ferreira et al., 2019). Cerca de 20% das crianças apresentam medo noturno e problemas de sono em comorbidade (Gordon et al., 2007). ...
... Um estudo recente, realizado por Rafihi-Ferreira et al. (2019), teve como objetivo identificar os preditores dos medos noturnos e de problemas comportamentais relacionados com o sono em 68 crianças em idade pré-escolar que apresentavam medos noturnos e que compartilhavam a cama com seus pais. Os resultados demonstraram que os problemas internalizantes prediziam o medo infantil e que os problemas de sono foram associados a problemas de comportamento do tipo externalizante. ...
... Embora a associação entre medo, sono e comportamento já tenha sido reportada em estudo prévio (Rafihi-Ferreira et al., 2019), pouco se sabe em termos descritivos sobre os conteúdos dos medos infantis e quais são os hábitos relacionados ao sono das crianças com muitos medos e, ainda, se há diferenças destes aspectos em função do sexo e da idade da criança. O presente estudo se insere nesse contexto. ...
Article
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Os medos noturnos em crianças podem afetar o seu sono e os seus comportamentos diurnos. Este estudo objetivou verificar em crianças em idade pré-escolar com intensos medos noturnos: 1) o conteúdo dos medos; 2) o efeito do sexo e da idade na frequência e conteúdo dos medos; e 3) os hábitos e padrões de sono e os problemas de comportamento. O estudo envolveu uma amostra de 71 pais de crianças com idade entre os 4 e os 6 anos (51% meninas) com intensos medos noturnos, que responderam a questionários sobre conteúdos de medo, hábitos e padrões de sono e problemas de comportamento dos filhos. Os medos de “fantasma”, “escuro” e “sonhos assustados” foram os mais comuns, enquanto que “escuro” e “dormir longe dos pais” foram os mais intensos. Poucas diferenças foram encontradas quanto ao sexo, todavia, a idade foi uma variável significativa para 27.2% dos medos avaliados – os mais velhos apresentaram mais medo. Padrões e rotina de sono inadequados foram identificados: horários tardios de ir para a cama, demora para adormecer, e frequentes despertares noturnos e problemas de comportamento internalizantes. Estes resultados sugerem a necessidade de tratamentos voltados para os medos noturnos frequentes, semelhantes para meninos e meninas e que sejam fornecidas orientações sobre higiene do sono para pais de crianças em idade pré-escolar como prevenção de hábitos e padrões inadequados.
... These are, in turn, associated with considerable risk of homotypic and heterotypic comorbidity (e.g., depression), significant impairment, and a high symptom persistence (Canals, Voltas, Hernández-Martínez, Cosi, & Arija, 2019;Romero et al., 2010). Moreover, children's nighttime fears have been related to sleep problems (e.g., difficulties in sleeping alone, resistance to going to bed, sleeping less), internalizing and externalizing symptoms, and it is argued that frequent nighttime fears may be a maintenance or risk factor of sleep-disruptive practices (El Rafihi-Ferreira, Lewis, McFayden, & Ollendick, 2019). ...
... Overall, our findings suggest that a higher presence of children's nighttime fears as measured by the NFS are related to higher internalizing symptoms (e.g., anxiety) and sleep-related problems. Also, the low but positive significant correlations with externalizing problems, along with the other stronger positive correlations found, can be in line with authors suggesting links among nighttime fears, sleep problems, internalizing and externalizing symptoms (El Rafihi-Ferreira et al., 2019). ...
Article
Nighttime fears are highly prevalent in children and are linked to children’s distress and internalizing problems, especially childhood anxiety. Although its assessment may be critical, there is a lack of available standardized self-reports. This study aimed to describe the development and psychometric evaluation of the Nighttime Fears Scale (NFS), a new standardized self-report for assessing nighttime fears in school-aged children. The construction of the scale was based on prior relevant research and involvement of researchers and clinicians, experts in childhood anxiety, and fears. A total of 794 Spanish-speaking children (51.1% girls) aged 8-12 years completed the NFS along with measures of anxiety, sleep problems, internalizing and externalizing problems, and positive behaviors. Exploratory and confirmatory factor analyses supported a four-factor structure of the NFS, consisting of 21 items measuring a range of potentially fear-provoking stimuli at nighttime. Strong internal consistency (alphas ranging from .87 to .94), adequate test-retest reliability, and evidence of convergent, divergent and incremental validity was found. This study provides initial support for the use of the NFS by clinicians and researchers, suggesting that it is a promising tool for a rapid and easily-administered assessment to identify the presence and intensity levels of a set of common children’s nighttime fears.
... Sleep disturbance may be an important factor to explore when examining the relation between trauma and behavior problems because sleep difficulties and behavior problems frequently are comorbid in young children (Coto et al. 2018;Rafihi-Ferreira et al. 2019). In a large sample of 2-to 3-yearold children, the number of nighttime awakenings was positively correlated with parent-rated aggressive behavior (Reid et al. 2009). ...
... In addition, these results concur with the well-established relationship between sleep and behavior problems (e.g., Becker 2014;Coto et al. 2018;Lavigne et al. 1999;Rafihi-Ferreira et al. 2019;Reid et al. 2009), but add the important finding that, in a trauma population referred for treatment, sleep problems can impact behavior even when more "obvious" trauma symptoms are relatively low. Therefore, sleep may be a key clinical target in children with relatively low traumatic stress symptoms, because sleep problems may be a central factor impacting the child's behavior even if other traumatic stress symptoms are less apparent. ...
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Empirical evidence suggests young children who have experienced trauma are at risk of developing sleep problems and behavior difficulties, but it is unclear of the specific relation between these behavioral health concerns. The primary purpose of the study is to determine whether sleep problems moderate the relation between traumatic stress and behavior problems in a sample of young children referred for treatment. A secondary purpose is to explore if sleep problems also moderate the relation between specific domains of traumatic stress (i.e., intrusion, avoidance, arousal) and behavior problems. Data from 170 preschoolers ages 3 through 5 referred for treatment were gathered at intake and utilized in this study. Results indicate sleep problems moderate the effect of overall traumatic stress on behavior problems. This statistical finding also was found with intrusive symptoms, and the moderation analyses approached significance with avoidance and arousal. Our findings highlight the importance for clinicians to assess for sleep problems when young children who have experienced trauma are referred to them for treatment, particularly if a low level of overall traumatic stress is present.
... Previous research indicates that anxiety near bedtime is linked with disturbed sleep (e.g., Palmer, Clementi, Meers, & Alfano, 2018;Rafihi-Ferreira, Lewis, McFayden, & Ollendick, 2019;Sadeh, 1996). Conway et al. (2017) argued that difficulty with regulating fear and arousal contributes to longer sleep onset latencies, as heightened cognitive and physiological arousal (Alfano et al., 2010) and heightened fear and anxiety at bedtime (Hansen et al., 2011) interfere with sleep initiation (Palmer et al., 2018). ...
Article
Bedtime routines have “strong” support for addressing bedtime behavior problems and sleep; however, little research has examined factors associated with bedtime routines and sleep quality. Parents of 155 children ages 3 to 5 were surveyed about their children’s bedtime routines, bedtime anxiety, compliance, and sleep quality. Regression models supported a simple indirect effect of bedtime routine consistency on sleep quality through bedtime anxiety, but not through compliance at bedtime. In a serial model, consistent bedtime routines were related to sleep quality through first bedtime anxiety and then compliance near bedtime. Clinically, results suggest that if parents can alleviate child anxiety around bedtime through routines, compliance around bedtime, and a good night sleep may follow.
... The locations of imaginary images engendering nighttime fear of young children are clearly contextual with respect to bedroom geometry and being alone in the dark (see El Rafihi-Ferreira et al., 2019). The emergence of scary imaginary images in the dark and their directional components in young children could reflect neural-circuit exercising as contextual rehearsals for later use in a world that exists today only in developing countries with dangerous felid predators that attack at night (see Corbett, 1948;Packer et al., 2011Packer et al., , 2019. ...
Article
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Young children frequently report imaginary scary things in their bedrooms at night. This study examined the remembrances of 140 preschool children and 404 adults selecting either above, side, or below locations for a scary thing relative to their beds. The theoretical framework for this investigation posited that sexual-size dimorphism in Australopithecus afarensis , the presumed human ancestor in the Middle Pliocene, constrained sleeping site choice to mitigate predation. Smaller-bodied females nesting in trees would have anticipated predatory attacks from below, while male nesting on the ground would have anticipated attacks from their side. Such anticipation of nighttime attacks from below is present in many arboreal primates and might still persist as a cognitive relict in humans. In remembrances of nighttime fear, girls and women were predicted to select the below location and males the side location. Following interviews of children and adult questionnaires, multinomial log-linear analyses indicated statistically significant interactions ( p < 0.001) of sex by location for the combined sample and each age class driven, in part, by larger frequencies of males selecting the side location and females selecting the below location. Data partitioning further revealed that males selected the side location at larger frequencies ( p < 0.001) than the below location, whereas female selection of side and below locations did not differ significantly. While indicative of evolutionary persistence in cognitive appraisal of threat locations, the female hypothesis did not consider natural selection acting on assessment of nighttime terrestrial threats following the advent of early Homo in the Late Pliocene.
... An estimated 2% of children have darkness phobia [5], which mainly manifests itself by protests against going to bed and not wanting to sleep with the lights turned off [6]. Research findings suggest that nighttime fears or fear of the dark in childhood are associated with sleep problems [7,8], co-sleeping with caregivers [9], externalizing and internalizing problems [7,[10][11][12], anxiety disorders [3], and fears, other than nighttime fears [11,12]. ...
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The aims of the present study were to evaluate the efficacy of a brief intervention, and to determine for whom the treatment works. 73 children between 3 and 8 years of age with significant nighttime fears were enrolled in an intervention group (n = 36) or in a waitlist group (n = 37). The intervention involved a 5-week parent delivered therapy. Assessments took place at baseline, post-treatment, and 20 weeks following baseline. In the intervention group, compared with the waitlist group, nighttime-related fears and phobic symptoms decreased more, whereas adaptive nighttime behavior increased to a greater extent. The more time children spent with exposure and relaxation games during the intervention, the more their separation anxiety and maladaptive nighttime behavior were reduced. Girls’ fear of darkness was reduced to a greater extent. The present study provides support for the use of parent-delivered therapy in the treatment of childhood nighttime fears.
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Nighttime fears in children are common, interfere with daily functioning, and result in considerable disruption in the family. The aim of the present review was to examine empirical literature from the past 25 years that investigated the assessment of nighttime fears in young children and the efficacy and effectiveness of psychosocial treatments for children's nighttime fears. The last review of this literature was in 1997 and examined studies conducted in and prior to 1995 (King et al. in Clin Psychol Rev 17:431–443, 1997). Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review of the literature aimed at providing a synthesis of the Randomized Control Trials (RCTs) and controlled single-case multiple baseline design studies (MBLs) on the treatment of nighttime fears in children. A search of the literature identified 12 articles, with nine studies utilizing a between-group randomized controlled trial design and three studies utilizing a multiple baseline design. Results demonstrated significant improvements in children’s nighttime fears and reductions in disruptive nighttime behaviors using behavioral interventions and cognitive-behavioral strategies. This review provides a commentary on the effectiveness and limitations of the assessment and treatment approaches for nighttime fears in children and suggests directions for future research.
Article
Poor sleep quality is closely related to aggression, but despite the promise of new therapeutic possibilities, a systematic synthesis of observational research on the association between sleep quality and aggression is lacking. This systematic review and meta-analysis examined the association between sleep quality and aggression, using the academic databases PubMed and PsycINFO. Subjective and objective measures of sleep quality were included, as well as multiple measures of aggression, assessing aggressive and externalizing behavior, anger, hostility and irritability. Ninety-two observational articles, containing 96 studies, encompassing a total of 58.154 children, adolescents and adults were sourced out of 7161 references identified. Methodological quality was moderate or strong in 76% of studies. Data for meta-analysis was available from 74 studies. Poorer sleep quality was associated with higher aggression in 80.8% of studies. Pooled results showed a correlation of 0.28 (95%CI 0.25-0.31; I²=90.1%) and odds ratio of 3.61 (95%CI 1.13-11.51; I²=88.3%). Effect estimates and heterogeneity varied according to population type and measurement instruments, but not according to article quality or age group. Our findings confirm that poor sleep quality is consistently associated with higher aggression. As most evidence is cross-sectional, more prospective and high-quality experimental evidence is required to elucidate cause-effect and optimize prevention and treatment of aggression.
Article
Sleep-related problems are highly prevalent among childhood and adolescent anxiety disorders. The objective of this review was to summarize the relevant clinical research literature as it pertains to the nature of the association between sleep-related problems and youth anxiety, developmental factors relevant to this association, and intervention efforts to target comorbid sleep challenges and anxiety. Limitations of the literature and future directions are discussed.
Article
Behavioral sleep problems in early childhood are common, affecting about 25% of children, and include symptoms such as problems going to sleep and staying asleep. This review employed the developmental psychopathology framework and 4P model (Predisposing, Precipitating, Perpetuating, Protective) to organize the diverse risk/protective factors (distal variables experienced indirectly by the child) and processes (proximal variables experienced directly by the child) for child sleep problems among preschool (1-5 years) and school-age (6-10 years) children. Variables were categorized into biological, psychological, and environmental factors/processes at the individual, family/parent, and community levels. The quality of evidence was assessed using GRADE. A literature search identified 98 articles meeting inclusion criteria. Older child age, difficult temperament, previous sleep problems, externalizing psychopathology, internalizing psychopathology, and electronics use (e.g., bedtime TV viewing) were identified as child risk variables predicting sleep problems. Parental presence at bedtime (risk), negative parenting style (e.g., lax or permissive parenting; risk), consistent bedtime routines (protective), and lower composite socioeconomic status (risk) were identified as family/parent variables predicting child sleep problems. No well-established predictors were found at the community level. Future research should employ advanced research designs more frequently and investigate: 1) risk pathways across development; and 2) nightly fluctuations in sleep problems.
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Little is known about the co-sleeping behaviors of school-aged children, particularly among anxious youth who commonly present for the treatment of sleep problems. The current study examined the occurrence of co-sleeping in both healthy and clinically anxious children and its associated sleep patterns. A total of 113 children (ages 6–12), 75 with primary generalized anxiety disorder and 38 healthy controls, participated along with their primary caregiver. Families completed structured diagnostic assessments, and parents reported on their child’s co-sleeping behaviors and anxiety severity. Children provided reports of anxiety severity and completed one week of wrist-based actigraphy to assess objective sleep patterns. A significantly greater proportion of anxious youth compared to healthy children co-slept, and greater anxiety severity was related to more frequent co-sleeping. Co-sleeping in anxious youth was associated with a delay in sleep timing and with greater sleep variability (i.e., more variable nightly sleep duration). All analyses controlled for child age, race/ethnicity, family income, and parental marital status. Co-sleeping is highly common in anxious school-aged children, with more than 1 in 3 found to co-sleep at least sometimes (2–4 times a week). Co-sleeping was even more common for youth with greater anxiety severity. Increased dependence on others to initiate and maintain sleep may contribute to poorer sleep in this population via shifted schedules and more variable sleep patterns.
Article
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Nighttime fear, including fear of monsters and the dark, is common. For most children and adolescents, nighttime fears are transient. However, approximately 10% experience severe nighttime fear that negatively impacts sleep, adjustment, and family life. Research conducted in the 1980s indicates that cognitive-behavioural therapy can reduce nighttime fear in as few as three sessions. The aims of the present study were to replicate and extend earlier research by evaluating a cognitive-behavioural treatment package for children’s severe nighttime fear, and addressing methodological issues in previous studies. A manualised, multi-component treatment package was developed, based on current evidence-based practice for the treatment of children’s anxiety. Interventions included graded exposure, muscle relaxation, cognitive restructuring, and social and material reinforcement. Treatment was individually tailored and delivered via weekly modules. A multiple baseline across-subjects design was utilised. Four ‘families’—1 parent and 1 child—participated; children’s ages ranged from 6 to 10 years. Families attended five weekly intervention sessions and a one-month follow-up. Multiple outcome measures were administered pre- and post-treatment. All children displayed changes consistent with reduced nighttime fear following treatment, including fewer phobic symptoms, reduced general fear, and improved nighttime and general behaviour. These changes were maintained at follow-up. Parents reported a high degree of satisfaction with the program and would recommend it to other families. The results support the effectiveness of manualised, parent-assisted treatment for nighttime fear in as few as three sessions. In cases of severe nighttime fear, therapist support is recommended. Treatment implications for children with complex presentations are discussed.
Article
Abstract Objective To compare the efficacy of a developmentally appropriate cognitive–behavioral therapy protocol for preschoolers with severe nighttime fears and sleep-related problems, with an active control treatment. Methods Ninety children aged four to six years (63% boys) with severe nighttime fears and their parents were randomized to either cognitive–behavioral therapy including parent involved play (CBT-PIP) or to a structurally equivalent non-directive treatment (TEPT; triadic expressive play therapy). Treatment conditions were also equivalent in parent- and child-rated credibility and expectancy, and in therapist-rated compliance. Children and parents were assessed at baseline, during the first intervention week and four weeks after treatment. Measures included actigraphy, daily sleep logs, structured diagnostic interviews and parent questionnaires. Results Significant reductions were observed in nighttime fears and objectively and subjectively measured sleep disruptions in both intervention groups following treatment. Parent reports indicated more advantageous outcomes for CBT-PIP compared to TEPT, with greater reductions in sleep problems and co-sleeping as well as higher customer satisfaction in the former group. Conclusions While CBT-PIP showed no significant advantage compared to the active control in reducing fears or in improving objectively measured sleep, it was significantly more beneficial in reducing the adverse behavioral features of nighttime fears.
Article
Behavioural and emotional problems in Finnish three-year-olds was studied using the Child Behavior Checklist for ages 2-3 as a standardised rating scale at well-baby clinics in two cities in Finland. Altogether 374 questionnaires were analysed which is 71% of the target population. When compared with studies from other countries the mean scores and prevalences of preschool children's problem behaviours were rather similar. Boys were reported to be more destructive than girls. Parental education level, living in one-parent family and parental unemployment were associated with a higher level of problem behaviours. No significant differences were found in emotional or behavioural problems related to the child's day care. Co-sleeping with parents was associated with sleep problems.
Article
Anxiety disorders constitute the most common mental health disturbance experienced by youth. Sleep-related problems (SRPs) are highly prevalent among anxious youth and encompass a variety of problems including nighttime fears, insomnia, and refusal to sleep alone. Given that chronic sleep disturbance is associated with a range of behavioral and physical problems in youth and predicts future psychopathology, it is important to elucidate the nature of SRPs in anxious youth. The present study investigated the relationship between sleep problems and anxiety sensitivity in a sample of 101 anxious youth, ages 6-17. Heightened anxiety sensitivity significantly predicted prolonged sleep onset latency across the sample, even after accounting for severity of anxiety, depression, and age. Results support previous research indicating that SRPs are common among anxious youth and suggest that anxiety sensitivity may play a particularly important role in sleep onset latency. Copyright © 2015. Published by Elsevier Ltd.
Article
Childhood sleep problems have been linked to a range of adverse health outcomes, but there is limited knowledge as to the temporal association between sleep problems and subsequent emotional and behavioral problems in young children. To examine whether sleep problems in toddlers aged 18 months are related to both concurrent and subsequent emotional and behavioral problems in preschool children aged 5 years. A large population-based longitudinal study was conducted in September 2014 using data from the Norwegian Mother and Child Cohort Study conducted at the Norwegian Institute of Public Health from June 1, 1999, to December 31, 2008. A total of 32 662 children or pregnancies were included. Sleep was assessed by mother-reported child sleep duration and nocturnal awakenings. Emotional and behavioral problems were measured with items from the Child Behavior Checklist and operationalized according to recommended clinical cutoffs, corresponding to T scores of greater than 65 (93rd percentile). Risk ratios (RRs) were calculated using negative binomial regression, controlling for emotional and behavioral problems at 18 months and other relevant covariates. Short sleep duration (≤10 hours) in 556 children (1.7%) and frequent nocturnal awakenings (≥3 times) in 1033 children (3.2%) at 18 months significantly predicted both concurrent and later incidence of emotional and behavioral problems at 5 years. The longitudinal RRs were generally larger for internalizing problems, with adjusted RRs of 1.59 (95% CI, 1.23-2.08) for both short sleep duration and 1.57 (95% CI, 1.28-1.93) for nocturnal awakenings; RRs for externalizing problems were 1.77 (95% CI, 1.37-2.30) and 1.25 (95% CI, 1.00-1.58), respectively. Additional adjustment for emotional and behavioral problems at 18 months slightly reduced the strength of these associations, and all RRs remained significant in the fully adjusted models. Early sleep problems predict later development of emotional and behavioral problems. Intervention studies are needed to examine whether sleep programs targeting early childhood may avert the onset of later adverse outcomes.
Article
To examine if children who suffer from significant Nighttime Fears (NF) experience higher degree of general fears and behavioral problems and to explore whether effortful control mediates NF association with internalizing problems. One-hundred and nine preschool children (64 boys) between the ages 4 and 6years suffering from significant NF and 30 healthy children (16 boys) were evaluated using parental reports of behavioral problems [Child Behavior Checklist (CBCL)], parental and child report of fears [Fear Survey Revised for Parents (FSS-PC), Koala Fear Questionnaire (KFQ)], and a measure of effortful control derived from the Child Behavior Questionnaire (CBQ). Children with severe NF also suffer from an increased level of a wide variety of fears other than NF, and exhibit more behavioral problems than controls both on parental and children's measures of general fears, and main CBCL scale scores (Internalizing, Externalizing, Total score). Additionally, children with NF had lower abilities of effortful control (as manifested in CBQ attention and inhibitory control scales). Attention control mediated NF association to internalizing problems scale. NF may serve as a marker for anxiety vulnerability, and this vulnerability might be mediated by abnormal attentional control. Our finding also highlights the need for a more comprehensive assessment of behavioral problems, fears and anxiety phenomena among children referred with NF.