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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.
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Clinical Child and Family Psychology Review (2021) 24:391–413
A 25‑Year Review ofNighttime Fears inChildren: Past, Present,
KrystalM.Lewis1 · RenathaElRahi‑Ferreira2· GabrielleF.Freitag3· MaryComan4· ThomasH.Ollendick5
Accepted: 25 May 2021 / Published online: 14 June 2021
© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2021
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) guide-
lines, 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.
Keywords Nighttime fears· Children· Dark phobia· Treatment· Assessment
Nighttime fears in young children are common, as many
researchers have documented a developmental progression
of normal fears from early childhood into adolescence (Fer-
arri, 1986; Gullone, 2000; Muris etal., 2001). These fears
generally dissolve across development; however, for a signif-
icant number of children, nighttime fears persist and become
pathological (Bauer, 1976; Warren & Sroufe, 2004). Not
only may these fears persist into adolescence, but they can
also have adverse effects on child development, leading to
later anxiety and other diverse forms of child psychopathol-
ogy (Bittner etal., 2007). Indeed, fear of the dark or sleeping
alone constitutes one of the 10 most common fears in chil-
dren between seven and 10years of age (Canals etal., 2019;
Muris etal., 2001). Common fears can extend beyond fear
of being in the dark alone to fear of scary creatures or to bad
things happening at night, and such core fears can change
across development (Muris etal., 2001). Research with non-
clinical samples suggests that 73.3% of children and adoles-
cents report nighttime fears with rates varying depending on
developmental period (Muris etal., 2001). Within clinical
populations, up to 20–30% of children have severe, debili-
tating nighttime fears and sleep difficulties (Bauer, 1976;
Gordon, 2004; Gordon etal., 2007a; Ollendick & Muris,
2015; Sadeh, 2005). Furthermore, up to 15% of referrals for
the treatment of childhood phobias are related to the dark
* Krystal M. Lewis
1 National Institute ofMental Health, 9000 Rockville Pike, 10
Center Drive, Bldg.10 RM B1D43S, Bethesda, MD20814,
2 Institute ofPsychiatry, Hospital da Clinicas - Faculty
ofMedicine, University ofSao Paulo, 785 Ovídio Pires de
Campos, SãoPaulo, SP05403903, Brazil
3 Department ofPsychology, Center forChildren andFamilies,
Florida International University, 11200 SW 8th Street,
Miami, FL33199, USA
4 Rochester, MN, USA
5 Department ofPsychology, Child Study Center, Virginia
Polytechnic Institute andState University, Blacksburg,
VA24060, USA
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... The total number of participants was 6,120. Four studies included a variety of anxiety diagnoses (i.e., OAD, SAD, SOP, AG, GAD, AD, SP, school phobia, OCD and PTSD) and only one focused exclusively on nighttime fears (Lewis et al., 2021). The ages of the participants ranged from 3 to 17 years. ...
... All five studies aimed to examine the effectiveness of psychological interventions for the treatment of anxiety disorders. Four reviews included CBT interventions (Gibby et al., 2017;Oldham-Cooper & Loades, 2017;Santacruz et al., 2002) or CBT-based techniques (Lewis et al., 2021), and one included brief, intensive, or concentrated (BIC) treatments (Öst & Ollendick, 2017). The study of Oldham-Cooper & Loades (2017) included CBT along with other therapeutic approaches (e.g., acceptance and commitment therapy, family-based interventions, or educational support). ...
... The psychological interventions reported ranged from 1 (one-session interventions) to 29 sessions, and the duration could last between 1 day and 20 weeks. Three reviews did not report the mean number of sessions and the duration of the treatments (Gibby et al., 2017;Lewis et al., 2021;Oldham-Cooper & Loades, 2017). Three studies reported the professionals providing the interventions: clinical psychologists with high level of expertise (Santacruz et al., 2002); clinical psychologists, counselors, and students (Öst & Ollendick, 2017); and all the aforementioned along with social workers and family therapists (Oldham-Cooper & Loades, 2017). ...
Anxiety disorders are highly prevalent in children and adolescents. The associated functional limitations and the negative psychological consequences have led to increased research into effective psychological interventions. What is missing, however, is a comprehensive review of the literature addressing the effectiveness of these treatments for specific disorders. A systematic review of systematic reviews and meta-analyses evaluating the effectiveness of psychological treatments for specific anxiety disorders in children and adolescents was performed. The study followed PRISMA guidelines. Four bibliographic databases were searched: MEDLINE (PubMed), PsycINFO, Web of Science (Core Collection), and The Cochrane Library. Two authors independently screened the articles by title, abstract, and full-text, according to established inclusion and exclusion criteria. Two independent authors evaluated the methodological quality of the included reviews using AMSTAR-2. Five records were included in this systematic review. Four studies included children and adolescents with specific phobias, generalized anxiety disorder, and separation anxiety disorder and one focused solely on nocturnal fears. Cognitive behavioral therapy-based interventions have been shown to be effective for the treatment of these diagnoses in both short and long term. The methodological quality of the included studies was classified as critically low. Cognitive behavioral interventions are effective in treating specific phobias, generalized anxiety disorder, and separation anxiety disorder and nighttime fears in children and adolescents. The improvement of the methodological quality and the need for further studies focusing on the effectiveness of treatments for specific disorders are discussed.
... In their recent 25-year review of studies into the treatment of children's nighttime fears, Lewis and colleagues [35] conclude that "A goal of clinical scientists should be to expand the accessibility of evidence-based treatment in order to reach as many children and families as possible" (p. 409). ...
Study Objectives Recurrent nightmares in childhood may have a range of detrimental effects for both the child and parents. This randomized controlled trial evaluated the efficacy of a novel parent-based intervention for childhood nightmares, using a new device called the “Dream Changer.” Methods A total of 56 children aged 3–10 years (M = 7.1 ± 2.1 years; 51.8% boys), and one of their parents were randomized to either the intervention or waitlist control group. The intervention group received a “Dream Changer”—a light-emitting remote-control-like device that the child was encouraged to take to bed and use upon experiencing a nightmare. Parents completed online surveys at baseline, 1-week, and 2-weeks following the intervention. Parents in the intervention group additionally completed a 3-month follow-up survey. Outcome variables included children’s nightmare frequency, sleep-wake patterns, and sleep anxiety, as well as parents’ daytime sleepiness. Results Significant group-by-time interaction effects were found for nightmare frequency (p = 0.001) and sleep anxiety (p = 0.006). Parents of children who received the “Dream Changer” reported fewer nightmares (Mdifference = 1.7, p < 0.001, d = 1.06) and decreased anxiety (Mdifference = 0.9, p = 0.001, d =0.41) at post-intervention, whereas such benefits were not found in the waitlist control group. Three-month follow-up assessments demonstrated that gains were maintained over-time. Interaction effects were not significant for children’s sleep metrics or for parents’ daytime sleepiness. Conclusions The present study provides preliminary evidence for the efficacy of a brief, highly accessible intervention for reducing children’s nightmares and nighttime anxiety. Future research may wish to test these effects using larger samples and longer follow-up assessments. Clinical Trial Registration The trial has been registered at the Australian New Zealand Clinical Trials Registry (; Identifier:ACTRN12620000633987).
Objective: Evidence of poor sleep health among children in foster care continues to mount, but information about whether and how sleep problems are addressed is unavailable. The goal of this study was to begin to fill these significant knowledge gaps. Methods: Four hundred eighty-five foster caregivers from across the United States completed a survey focused on the sleep health of one child, 4 to 11 years (M = 6.4; SD = 2.2) currently in their care. Caregivers provided quantitative and qualitative responses to questions regarding training, information, and services received in relation to their child's sleep. Caregivers also reported on the factors and strategies they perceived as most important for helping children in their care sleep well. Results: Only 13% of caregivers reported receiving any information/education about sleep from agencies or case workers, whereas 55% had sought help from a health provider related to their child's sleep. Nearly half of all caregivers (46%) reported giving their child melatonin. Caregivers reported that a bedtime routine/consistency, reassurance of safety/love, and a calming environment were most important for helping their child sleep well. A recurrent theme in qualitative responses was a need to mitigate child fear/anxiety at night. Conclusion: Children in foster care face a range of risk factors that increase the likelihood of poor/insufficient sleep, but these findings suggest this critical aspect of health requires greater clinical and research attention. As these data were collected during the initial months of the COVID-19 pandemic, replication studies are necessary.
Coping strategies can play an important role in dealing with nighttime fears and related anxiety problems in school-aged children, but well-established self-reporting tools are lacking, and research in this area is limited. The aim of this study was to develop a new self-report instrument assessing coping strategies in school-aged children when facing nighttime fears, the Nighttime Coping Response Scale (NCRS), and to examine its psychometric properties. Participants were 786 children (48.7% boys) aged 8–12 years, who completed the NCRS and other measures related to anxiety and behavioral problems. The construction of the NCRS was based on relevant prior literature and experts’ criteria. Exploratory and confirmatory analyses supported a three-factor structure, comprising 15 items measuring coping strategies related to self-control, social support seeking, and avoidance. The NCRS was shown to have good internal consistency, test-retest reliability, and convergent and divergent validity. This research found preliminary support for the use of the NCRS, suggesting the potential suitability of this brief tool to be used by clinicians and researchers to identify and address the use of children’s maladaptive coping strategies when dealing with nighttime fears. The NCRS could also be important to enable the development of further research in this field.
Full-text available
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.
Full-text available
Sleep difficulties are a common pediatric complaint, and the majority of these sleep difficulties are behavioral in nature (e.g., difficulties initiating or maintaining sleep). Although research supports behavioral interventions to improve sleep in young children with behavioral sleep difficulties, anxiety and child distress are common in this age range and these factors can impact treatment outcomes directly (e.g., increased distress and resistance at bedtime) and indirectly (e.g., poor parental compliance with behavioral strategies). Anxiety is an important aspect of treatment in adolescents and adults with behavioral sleep difficulties, but this factor is rarely considered in the literature for younger children. Thus, this manuscript reviews the literature on anxiety as it relates to behavioral sleep difficulties in young children (i.e., the preschool and surrounding age range), provides an overview of empirically supported behavioral intervention and research incorporating anxiety into behavioral sleep treatments, and provides recommendations and future directions for continuing to advance the literature and treatment in this area.
Background Sleep problems and cumulative risk factors (e.g., caregiver depression, socioeconomic disadvantage) have independently been linked to adverse child development, but few studies have examined the interplay of these factors. We examined whether cumulative risk exposure moderated the link between sleep problems, including insomnia and poor sleep health, and child psychological outcomes. Methods 205 caregiver-child dyads (child Mage = 3.3 years; 53.7% girls; 62.9% Black, 22.4% non-Latinx White, and 4.4% Latinx; 85.4% maternal caregiver reporter) completed child sleep, family sociodemographic, and child psychological functioning (internalizing, externalizing, and executive functioning) questionnaires. Indexes of cumulative risk exposure, insomnia symptoms, and poor sleep health were created. Results Ninety percent of children had ≥1 cumulative risks, 62.9% had ≥1 insomnia symptom, and 84.5% had ≥1 poor sleep health behavior. Increased insomnia symptoms were significantly associated with increased child internalizing, externalizing, and global executive functioning impairments controlling for child age, race/ethnicity, and sex. Poor sleep health behaviors were associated with internalizing concerns. Cumulative risk exposure was not associated with outcomes but moderated the association between insomnia symptoms and all psychological outcomes, such that children with higher cumulative risk exposure and insomnia symptoms had the greatest impairments. Children with the poorest sleep health behaviors and highest cumulative risks had the greatest internalizing concerns. Conclusions Insomnia symptoms in particular are associated with poor child outcomes, which are exacerbated when accompanied by greater cumulative risk exposure. Clinicians should assess sleep when treating early psychological concerns, especially within the context of increased cumulative risks.
Anxiety disorders are one of the most prevalent disorders in youth and can have substantial negative impacts when left untreated. Parent-child interaction therapy (PCIT) is an evidence-based approach for treating externalizing problems within youth. However, PCIT may have a unique advantage for treating anxiety symptoms and disorders because of its accessibility for younger children that may be too young to benefit from traditional cognitive behavioral therapy. The parent training aspect of PCIT could also give added support to parents by teaching them more effective ways to cope with their child’s anxiety symptoms. The current meta-analysis aimed to determine the efficacy of PCIT and adaptations to PCIT in reducing anxious symptomology in youth. PsycINFO and PubMed were searched for relevant articles and yielded 15 articles that met inclusion criteria. Statistical analyses showed that PCIT overall was significantly more effective at reducing anxious symptomology than control groups. In addition, participants who had comorbid diagnoses in addition to anxiety had comparable reductions in anxiety as participants who did not have comorbid diagnoses. Participants with subclinical anxiety levels also demonstrated significant reductions in anxiety symptoms overall, suggesting that PCIT may be a promising early intervention for halting the progression toward disorder-threshold anxiety. Overall, this meta-analysis provides preliminary evidence that PCIT is an effective intervention for in ameliorating anxiety symptoms in youth.
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.
Objective: Sleep-related problems, defined as sleep patterns atypical for the child's developmental stage, are common in children with elevated anxiety symptoms and linked to significant mental and physical health consequences. Despite the consequences of sleep-related problems, it remains unclear how these problems are initiated and maintained in children with elevated anxiety symptoms. The current study examines the relationship between sleep-related problems and parental accommodation (e.g., co-sleeping) to determine whether higher levels of accommodation are associated with more frequent sleep-related problems in a sample of children with elevated anxiety symptoms. Methods: Participants were 122 children aged 8 to 17 years old (M = 11.97, SD = 2.68; 57% female) and their parents who presented to a university-based anxiety specialty clinic for assessment and treatment. Children completed the Multidimensional Anxiety Scale for Children, and their parents completed the Children's Sleep Habits Questionnaire and Family Accommodation Checklist and Interference Scale. Multiple regression analyses were performed to examine variance in sleep-related problems explained by parental accommodation. Results: Parental accommodation accounted for a significant amount of variance in sleep-related problems over and above child anxiety and age for both mother report (19%) and father report (15%). When individual accommodation items were examined, parental sleep accommodations (e.g., slept in my child's bed) and nonsleep accommodations (e.g., came home early) were significant predictors for mother-reported sleep-related problems, but only sleep accommodations (e.g., let my child sleep with the lights on) were significant for father-reported sleep-related problems. Conclusion: Parents of children with elevated anxiety symptoms and sleep-related problems engage in accommodation related to their child's sleep (e.g., co-sleeping). Future research elucidating the potential bidirectional and causal links between parental accommodation and sleep-related problems is a necessary step in adapting sleep treatments for this population.
Background Young children with Type 1 diabetes (T1D) are at risk for extreme blood glucose variability, a risk factor for suboptimal glycated hemoglobin A1c (HbA1c) and long-term health complications. We know that a reciprocal relationship exists between sleep and glycemic outcomes in older youth with T1D; however, little research has examined objective sleep in young children (<7 years) with T1D. Purpose This study examines bidirectional associations between sleep behaviors and glycemic variability in young children with T1D. Methods Thirty-nine young children with T1D (Mage 4.33 ± 1.46 years; MHbA1c 8.10 ± 1.06%) provided accelerometry data to objectively measure sleep onset latency, number of nighttime awakenings, and total sleep time. We also assessed HbA1c, average blood glucose, and glycemic variability (i.e., standard deviation of blood glucose from device downloads). We evaluated bidirectional relationships using multilevel modeling in SAS, with weekday/weekend as a Level 2 moderator. Results Children averaged 8.5 ± 1.44 hr of sleep per night, but only 12.8% met current sleep recommendations. Children experienced more nighttime awakenings, higher blood glucose, and more glycemic variability on weekends. Sleep onset latency and nighttime awakenings predicted greater glycemic variability on weekends, and weekend glycemic variability predicted increased nighttime awakenings. Conclusions Most young children with T1D did not meet sleep recommendations. Young children experienced more nighttime awakenings, higher blood glucose, and increased glycemic variability on weekends only, when routines may be less predictable. Findings suggest that one way families of young children with T1D may be able to decrease glycemic variability is to keep consistent routines on weekdays and weekends.
Efficacious treatments for childhood anxiety disorders include Cognitive Behavioral Therapy (CBT) and medications, yet there is urgent need for additional efficacious treatment modalities. Parent-based treatment provides such an alternative. Recent literature has supported that SPACE (Supportive Parenting for Anxious Childhood Emotions), an entirely parent-based treatment, is as efficacious as CBT in reducing child anxiety. SPACE focuses on systematically reducing family accommodation, or changes to parental behavior aimed at alleviating or avoiding a child’s distress related to their anxiety disorder, while maintaining a supportive stance toward the child. To date, SPACE is the only intervention that places the reduction of parental accommodation at the center of its theoretical foundation and treatment objectives. This article provides theoretical and empirical background for SPACE and illustrates its implementation through a case description.
Objective: Maternal depression is associated with infant and child sleep patterns, and with infant temperament. Here, we examine whether infant temperament mediated an association between maternal antenatal depression and toddler sleep. Method: Within the prebirth longitudinal cohort Growing Up in New Zealand, symptoms of antenatal and postnatal depression were measured in 5,568 women using the Edinburgh Postnatal Depression Scale (EPDS). Infant temperament was measured at age 9 months using the Very Short Form of Infant Behavior Questionnaire-Revised (IBQ-R VSF). Sleep duration and nighttime awakenings were reported by parents when children were 2 years old. Results: Independent associations of maternal depression with child sleep patterns at age 2 years, adjusted for maternal demographics, physical health, family relationships, and child health and feeding, were determined using multivariate logistic regression analysis. The odds of having ≥2 nighttime awakenings were increased for children whose mothers had antenatal (1.36, 1.07-1.73) but not postnatal (1.22, 0.88-1.68) or both antenatal and postnatal depression (0.89, 0.56-1.36). There was no association of maternal depression with shorter sleep duration. Two of five dimensions of infant temperament (fear and negative affect) were associated with both antenatal depression scores and increased nighttime awakenings. Mediation analyses controlling for postnatal depression and other predictors of child sleep supported an indirect pathway of antenatal depression to child sleep through infant temperamental negative affectivity. Conclusion: Antenatal depression is independently associated with more frequent nighttime awakenings in early childhood. Findings support an indirect pathway through infant negative affect characteristics.
Background The Online Assessment of Preschool Anxiety (OAPA) is a newly developed measure that assesses anxiety disorders in preschool children aged 3–6 years. This study aimed to explore the OAPA's initial psychometric properties with a particular focus on examining its construct validity, both convergent and discriminant. Method The OAPA was completed online by a community sample of 319 Australian parents of temperamentally inhibited preschool children (M: 5.3 years). Preliminary diagnoses were automatically generated before assessment reports were reviewed by a psychologist. Construct validity was examined by assessing the degree of agreement between the OAPA and existing valid questionnaire measures that were simultaneously administered online. Results Nearly half of participants met criteria for a child anxiety disorder according to the OAPA, most commonly social phobia. Findings supported convergent validity with the Revised Preschool Anxiety Scale (an anxiety symptom measure), the Children's Anxiety Life Interference Scale – Preschool Version (a measure of life interference from anxiety), the Emotional Symptoms scale of the Strengths and Difficulties Questionnaire‐Parent Version (a measure of broader internalizing symptoms), as well as an over‐involved/protective parenting scale. Findings also supported initial discriminant validity with the Conduct Problems scale of the Strengths and Difficulties Questionnaire‐Parent Version. Conclusions Results of this study provide evidence for the OAPA's preliminary construct validity. With further research into the OAPA's reliability (test–retest and interrater) and confirming construct validity, the OAPA may be a useful instrument for use in research settings and clinical practice.