Night terrors

A night terror is frightening to watch and not frightening to have. The child will have no memory of it at all.

What is actually happening

Sleep is not a single state. Deep non-REM sleep — the heavy, hard-to-rouse stage that dominates the first part of the night — is quite different from the REM sleep in which dreaming mostly happens, and the mechanism is set out under how sleep works.

A night terror is a partial arousal out of deep non-REM sleep. Part of the brain comes up towards waking while the rest stays in deep sleep, and the result is a child who is physically active, emotionally overwhelmed and simultaneously asleep. The systems that would let them recognise a parent, understand speech or lay down a memory are not running.

That explains every feature of it at once: why the eyes are open but nobody is home, why consoling does not land, why the child cannot say what is wrong, and why there is nothing to discuss in the morning.

Who gets them

Night terrors are commonest between the ages of about two and six, can start as early as 18 months, and almost all children grow out of them as the nervous system matures — usually well before puberty. They are not a sign of distress, a difficult temperament or anything having gone wrong at home.

The family link is strong. Where a parent or a sibling had night terrors or sleepwalking, a child is very likely to have them too, and that inheritance is by some distance the biggest single predictor.

Telling a night terror from a nightmare

These are different events in different stages of sleep, and the distinction decides what to do.

• Timing. A night terror comes in the first few hours after falling asleep, when deep sleep is concentrated. A nightmare comes later in the night or towards morning, when REM sleep predominates.
• Awake or not. After a nightmare the child is properly awake, knows who is there, and wants comfort. During a night terror the child is asleep and does not register anyone.
• Memory. A nightmare is remembered, often in detail and often the next day. A night terror is not remembered at all.
• Movement. Nightmares rarely involve much movement. Night terrors frequently involve thrashing, getting out of bed and walking.
• Afterwards. A child who has had a nightmare may be reluctant to go back to sleep. A child who has had a night terror typically settles straight back down and sleeps soundly.

Nightmares, and bedtime fears generally, are covered under bedtime and night fears in children.

What to do during an episode

• Do not wake the child. This is the main thing. Being hauled out of deep sleep mid-episode produces confusion and genuine fear, lengthens the episode and can leave a frightened child who then will not settle. There is nothing to wake them from.
• Keep them safe. Move anything hard, hot or breakable out of the way, block the stairs, and stay between the child and anything they could hurt themselves on. This is the only active job.
• Stay quiet and stay close. Opinions differ on whether gentle soothing helps or is simply inaudible to the child; either way it does no harm, and holding or restraining usually makes the thrashing worse.
• Wait. Episodes last anywhere from a minute to twenty, and they end on their own.
• Do not go over it the next day. Describing the episode to a child who has no memory of it only tells them that something alarming happens to them at night, which is the raw material for a bedtime fear they did not previously have.

Preventing them

More sleep. Being short of sleep is the commonest trigger, because the body compensates by taking deeper non-REM sleep, which is where the episodes come from. The counter-intuitive consequence is that an earlier bedtime, a later morning or a restored afternoon nap will often reduce night terrors more effectively than anything else — and that pushing bedtime later makes them more likely.

Other triggers worth removing:

• An irregular bedtime, or a disrupted routine such as a holiday or a time change
• Illness, and particularly a fever
• A full bladder — a drink immediately before bed, or a nappy or toilet trip skipped
• Stress and change: a new school, a new sibling, exam pressure in older children
• Noise or disturbance in the room during the first hours of sleep
• An untreated sleep problem such as obstructive sleep apnoea or restless legs, which fragment sleep and provoke arousals. Persistent snoring with pauses or gasping is worth investigating for exactly this reason.

Scheduled awakening

Where episodes happen most nights and at roughly the same time, this is the method that works, and it is the only active treatment needed in most cases.

1. Keep a note of the time of each episode for a week or two, to establish the pattern.
2. Rouse the child gently about 15 to 30 minutes before the usual time — enough to stir and shift position, not enough to wake them properly.
3. Let them settle again straight away.
4. Continue nightly until there have been about seven clear nights.
5. Then do it every other night for another week.
6. Then stop.

If the episodes come back, the sequence can simply be repeated. The mechanism is that a brief disturbance interrupts the deep sleep cycle just before the point at which the partial arousal would have happened.

The same family: sleepwalking and the rest

Night terrors belong to a group of events called non-REM parasomnias, all of which arise from the same partial arousal out of deep sleep, all of which happen in the first part of the night, and none of which are remembered. They run in the same families and frequently in the same child at different ages.

• Sleepwalking — getting up and walking, sometimes doing quite complex things, with a blank expression and no recall. Common in childhood and usually outgrown by puberty.
• Confusional arousals — the mildest form: sitting up, mumbling, looking bewildered, perhaps crying, then lying down again.
• Sleep talking — extremely common, harmless, and not worth attending to.
• Sleep eating — occasionally seen in older children and adults, and worth mentioning to a doctor.

Sleepwalking safety

There is no treatment to apply; the handling is about the house.

• A stair gate at the top of the stairs
• External doors locked, and the keys kept out of reach rather than in the lock
• Windows secured, particularly upstairs
• Nothing hot, sharp or breakable on the route between bedroom and bathroom
• A top bunk avoided for a child who sleepwalks
• Extra care wherever the child is sleeping somewhere unfamiliar — a hotel, a caravan, a relative's house — because the layout they navigate from memory is the wrong one

A sleepwalker should be guided gently back to bed rather than woken. Waking a sleepwalker is not dangerous, contrary to a persistent piece of folklore, but it is pointless, and a child woken mid-episode is frightened and disorientated for no gain.

Medicines, and what older advice gets wrong

Older material on this subject often ends by suggesting that where the simple measures fail, a doctor may prescribe something to stop the night terrors.

That is not how childhood night terrors are managed in the UK. There is no routine medication for them. The approach is the one above — more sleep, a regular bedtime, removing triggers, keeping the child safe, and scheduled awakening where there is a pattern — and the condition resolves with age in the great majority of children. Where a specialist does consider medication, it is in unusual and severe cases, under their supervision, and it is not something to expect from a GP appointment.

Melatonin is not a treatment for night terrors. It is a prescription-only medicine in the UK, started by specialist teams for a defined group of children with particular conditions, and it has no role here.

When to see a doctor

• Episodes most nights, several times a night, or going on for many months without easing
• Injury to the child or to anyone else during an episode
• Episodes that look identical each time — the same movements in the same order — or that involve stiffening, jerking of the limbs or odd postures, since nocturnal seizures can resemble night terrors and are treated quite differently
• Episodes continuing well beyond puberty, or starting for the first time in adolescence or adulthood
• Loud snoring, pauses in breathing or gasping, which point at an underlying cause worth treating
• Daytime sleepiness, difficulty concentrating, or a change in behaviour at school
• Night terrors in an adult, which are less common than in children and more often associated with another condition, sleep deprivation, alcohol or a medicine

A note of the times and a short video of an episode, taken on a phone, is more useful to a doctor than any description, and is the single most helpful thing to bring to the appointment.