latest research on night terrors

Sleep Terrors: An Updated Review

Affiliations.

• 1 Department of Pediatrics, The University of Calgary and The Alberta Children’s Hospital, Calgary, Alberta, Canada
• 2 Department of Family Medicine, The University of Alberta, Edmonton, Alberta, Canada
• 3 Department of Family Medicine, The University of Calgary, Calgary, Alberta, Canada
• 4 Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
• 5 Department of Paediatrics and Adolescent Medicine, Hong Kong Children’s Hospital, Hong Kong
• PMID: 31612833
• PMCID: PMC8193803
• DOI: 10.2174/1573396315666191014152136

Background: Sleep terrors are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

Objective: To familiarize physicians with the clinical manifestations, diagnosis, and management of children with sleep terrors.

Methods: A PubMed search was completed in Clinical Queries using the key terms "sleep terrors" OR "night terrors". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

Results: It is estimated that sleep terrors occur in 1 to 6.5% of children 1 to 12 years of age. Sleep terrors typically occur in children between 4 and 12 years of age, with a peak between 5 and 7 years of age. The exact etiology is not known. Developmental, environmental, organic, psychological, and genetic factors have been identified as a potential cause of sleep terrors. Sleep terrors tend to occur within the first three hours of the major sleep episode, during arousal from stage three or four non-rapid eye movement (NREM) sleep. In a typical attack, the child awakens abruptly from sleep, sits upright in bed or jumps out of bed, screams in terror and intense fear, is panicky, and has a frightened expression. The child is confused and incoherent: verbalization is generally present but disorganized. Autonomic hyperactivity is manifested by tachycardia, tachypnea, diaphoresis, flushed face, dilated pupils, agitation, tremulousness, and increased muscle tone. The child is difficult to arouse and console and may express feelings of anxiety or doom. In the majority of cases, the patient does not awaken fully and settles back to quiet and deep sleep. There is retrograde amnesia for the attack the following morning. Attempts to interrupt a sleep terror episode should be avoided. As sleep deprivation can predispose to sleep terrors, it is important that the child has good sleep hygiene and an appropriate sleeping environment. Medical intervention is usually not necessary, but clonazepam may be considered on a short-term basis at bedtime if sleep terrors are frequent and severe or are associated with functional impairment, such as fatigue, daytime sleepiness, and distress. Anticipatory awakening, performed approximately half an hour before the child is most likely to experience a sleep terror episode, is often effective for the treatment of frequently occurring sleep terrors.

Conclusion: Most children outgrow the disorder by late adolescence. In the majority of cases, there is no specific treatment other than reassurance and parental education. Underlying conditions, however, should be treated if possible and precipitating factors should be avoided.

Keywords: Impaired arousal; night terrors; nightmares; non-rapid eye movement sleep; parasomnias; pavor nocturnus.

Copyright© Bentham Science Publishers; For any queries, please email at [email protected].

Publication types

• Child, Preschool
• Diagnosis, Differential
• Night Terrors / diagnosis*
• Night Terrors / epidemiology
• Night Terrors / etiology
• Night Terrors / therapy*
• Sleep / physiology

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Nightmares and Night Terrors

What are night terrors.

Night terrors are a sleep disorder in which a person quickly awakens from sleep in a terrified state. The cause is unknown but night terrors are often triggered by fever, lack of sleep or periods of emotional tension, stress or conflict. Night terrors are like nightmares, except that nightmares usually occur during rapid eye movement (REM) sleep and are most common in the early morning. Night terrors usually happen in the first half of the night. Also, night terrors are most common in preadolescent boys, though they are fairly common in children three to five years old.

The following are common characteristics of a night terror:

Sudden awakening from sleep

Persistent fear or terror that occurs at night

Rapid heart rate

No recall of bad dreams or nightmares

Unable to fully wake up

Difficult to comfort

How to help a child during a night terror

Try to help your child return to normal sleep. Do not try to awaken your child. Make soothing comments. Hold your child if it seems to help him or her feel better. Shaking or shouting at your child may cause the child to become more upset.

Protect your child against injury. During a night terror, a child can fall down a stairway, run into a wall, or break a window. Try to gently direct your child back to bed.

Prepare babysitters for these episodes. Explain to people who care for your child what a night terror is and what to do if one happens.

Try to prevent night terrors. A night terror can be triggered if your child becomes overly-tired. Be sure your child goes to bed at a regular time, and early enough to give him or her enough sleep. Younger children may need to return to a daily nap.

In many cases, a child who has a night terror only needs comfort and reassurance. Psychotherapy or counseling may be appropriate in some cases. Benzodiazepine medications used at bedtime will often reduce night terrors; however, medication is not usually recommended to treat this disorder.

When to call your child's healthcare provider

While night terrors are not harmful, they can resemble other conditions or lead to problems for the child. Consult your child's healthcare provider if you notice any of the following:

The child has drooling, jerking, or stiffening

Terrors are interrupting sleep on a regular basis

Terrors last longer than 30 minutes

Your child does something dangerous during an episode

Other symptoms occur with the night terrors

Your child has daytime fears

You feel family stress may be a factor

You have other questions or concerns about your child's night terrors

In many cases, no examination or testing is needed. If the night terror is severe or prolonged, the child may need a psychological evaluation.

What are nightmares?

Nightmares are scary dreams that awaken children and make them afraid to go back to sleep. Nightmares may happen for no known reason, but sometimes occur when your child has seen or heard things that upset him or her. These can be things that actually happen or are make-believe. Nightmares often relate to developmental stages of a child: toddlers may dream about separation from their parents; preschoolers may dream about monsters or the dark; school-aged children may dream about death or real dangers.

How to help a child with nightmares

Comfort, reassure, and cuddle your child.

Help your child talk about the bad dreams during the day.

Protect your child from seeing or hearing frightening movies and television shows.

Leave the bedroom door open (never close the door on a fearful child).

Provide a "security blanket" or toy for comfort.

Let your child go back to sleep in his or her own bed.

Do not spend a lot of time searching for "the monster."

During the bedtime routine, before your child goes to sleep, talk about happy or fun things.

Read some stories to your child about getting over nighttime fears.

Consult your child's healthcare provider if you notice any of the following:

The nightmares become worse or happen more often

The fear interferes with daytime activities

You have other concerns or questions about your child's nightmares 

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Sleep terrors.

Also called "night terrors", these episodes are characterized by extreme terror and a temporary inability to attain full consciousness. The person may abruptly exhibit behaviors of fear, panic, confusion, or an apparent desire to escape. There is no response to soothing from others. They may experience gasping, moaning or screaming. However, the person is not fully awake, and once the episode passes, often returns to normal sleep without ever fully waking up. In most cases, there is no recollection of the episode in the morning.

Like  sleepwalking , night terror episodes usually occur during NREM delta (slow wave) sleep. They are most likely to occur during the first part of the night. The timing of the events helps differentiate the episodes from nightmares, which occur during the last third of the sleep period.

While sleep terrors are more common in children, they can occur at any age. Research has shown that a predisposition to night terrors may be hereditary. Emotional stress during the day, fatigue or an irregular routine are thought to trigger episodes. Ensuring a child has the proper amount of sleep, as well as addressing any daytime stresses, will help reduce terrors.

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Sleepwalking, Sleep Terrors, Sexsomnia, and Human Brain Evolution

Studies of sleep disorders may reveal previously hidden secrets about the brain..

Posted May 15, 2022 | Reviewed by Gary Drevitch

• Very little is known about the origin or neurobiology of sleeping disorders.
• Recent research has revealed that sleepwalking, night terrors, and sexsomnia may be due to similar underlying patterns of brain activity.
• People with sleep disorders have an unusual front-to-back gradient of awake-like and sleep-like patterns of brain activity.

It can be hard to get a good night’s sleep if you suffer from a sleep disorder . It can also be hard to get a good night’s sleep if you are sleeping next to someone with a sleep disorder. Currently, little is known about the origin or neurobiology of sleeping disorders. Recent research has revealed that sleepwalking, night terrors, and sexsomnia may be due to an underlying pattern of brain activity shared by dolphins and aquatic seabirds.

Sleepwalking is more than just getting out of bed and walking around. Sleepwalkers often perform many different normal, routine behaviors. Rarely, sleepwalkers may climb out a window or even attempt to drive a car. During the daytime, sleepwalkers are at a greater than average risk of regular headaches or migraines . Older people who sleepwalk report more daytime depression . Young people, especially males age 20 to 29 who use marijuana, are also more likely to sleepwalk. The mechanisms underlying these features of sleepwalking are unknown.

Sleep terrors are characterized by the onset of abrupt terror associated with a frightening scream, usually shortly after going to bed. The person physically experiences the terror and displays signs of intense arousal including dilated pupils, fast heart rate and breathing, as well as profuse sweating. While sleepwalkers are often quiet, people with sleep terrors will open their eyes, raise up their heads, and start screaming; they may even jump out of bed to alert others.

Sexsomnia is the display of sexual behaviors while asleep. Patients may masturbate or make loud sexual vocalizations while asleep. Some people, mostly women, report having spontaneous sleep orgasms that are not accompanied by erotic dreams. Bedpartners report being sexually molested to the point of forced sexual intercourse. The perpetrator usually has total amnesia upon awakening (although this claim has been challenged in recent literature). Interestingly, sexsomnia is not associated with unusually high sex drive during wakefulness.

The relatedness of these disorders is demonstrated by the fact that about 10 percent of people with classical sleepwalking or sleep terrors display sexsomnia during sleep. Sleepwalking and sleep terrors equally affect adult men and women. In contrast, sexsomnia is reported more often in men.

Sleepwalking, night terrors, and sexsomnia are considered to occur during non-rapid eye movement sleep, a phase of sleep typically not associated with dreaming . Dreams that occur during non-rapid eye movement sleep tend to lack a narrative. During the past few years, a series of studies involving electroencephalography and functional brain imaging have shown that the brain regions responsible for the control of movement and emotions (known as the limbic system) show surprisingly large levels of activation as compared to other brain regions. This is surprising because control subjects show quite low levels of activation in these two brain regions. (To learn more about the limbic system and how the brain controls sleep, see my book .)

Scientists speculate that the front-to-back gradient of localized brain activity seen in people with sleep disorders might be normal during early brain development and then convert into an adult pattern with maturation. The coexistence of awake-like and sleep-like activity patterns may be normal for the developing brain and may recapitulate a pattern of brain activity shared with other vertebrates.

A similar coexistence of awake-like and sleep-like patterns of brain activity occurs in sea-going birds and aquatic mammals, such as dolphins. This well-known pattern of brain activity allows these animals to continue swimming, flying, or monitoring for predators. The only difference is that in the bird and dolphin brains the activity gradient is lateralized to one hemisphere at a time while in humans the disordered sleeping brain has an anterior-to-posterior gradient of activity during non-rapid eye movement sleep. It is possible that the peculiar features of these human sleep disorders are revealing hidden secrets about how the human brain evolved.

Idir Y et al (2022) Sleepwalking, sleep terrors, sexsomnia and other disorders of arousal: the old and the new. J of Sleep Research, DOI: 10.1111/jsr.13596J

Wenk GL (2017) The Brain: What Everyone Needs to Know. Oxford Univ Press.

Gary L. Wenk, Ph.D. , is a professor of psychology, neuroscience, molecular virology, immunology and medical genetics at the Ohio State University.

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Article Contents

Introduction, historical versus modern environments: the mismatch hypothesis, attachment theory, extensions, testable predictions and limitations, acknowledgements.

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An evolutionary perspective on night terrors

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Sean D Boyden, Martha Pott, Philip T Starks, An evolutionary perspective on night terrors, Evolution, Medicine, and Public Health , Volume 2018, Issue 1, 2018, Pages 100–105, https://doi.org/10.1093/emph/eoy010

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Night terrors, also known as sleep terrors, are an early childhood parasomnia characterized by screams or cries, behavioral manifestations of extreme fear, difficulty waking and inconsolability upon awakening. The mechanism causing night terrors is unknown, and a consistently successful treatment has yet to be documented. Here, we argue that cultural practices have moved us away from an ultimate solution: cosleeping. Cosleeping is the norm for closely related primates and for humans in non-Western cultures. In recent years, however, cosleeping has been discouraged by the Western medical community. From an evolutionary perspective, cosleeping provides health and safety benefits for developing children. We discuss night terrors, and immediate and long-term health features, with respect to cosleeping, room-sharing and solitary sleeping. We suggest that cosleeping with children (≥1-year-old) may prevent night terrors and that, under certain circumstances, cosleeping with infants (≤11-months-old) is preferable to room-sharing, and both are preferable to solitary sleeping.

Night terrors are an early childhood parasomnia associated with disturbance from non-REM, slow-wave sleep [ 1 ]. According to the American Academy of Sleep Medicine’s (AASM) International Classification of Sleep Disorders , night terrors (also known as sleep terrors) are defined as ‘a cry or piercing scream, accompanied by autonomic nervous system and behavioral manifestations of intense fear. … Sometimes there is prolonged inconsolability associated with a [night] terror’ [ 2 ]. Notably, night terrors are distinguishable from less severe nightmares by difficulty in waking the child [ 3 ]. These events are stressful and disturbing for the child experiencing them, the parents of the child and other family members [ 4 ].

The prevalence of night terrors in children is difficult to assess. Research has yielded discrepant results regarding the likelihood of experiencing night terrors with measurements ranging from 1.7% to almost 56% of individuals and ages ranging from 18 months to adolescence [ 4–6 ]. (Night terrors also occur in adults, but rarely so.) Prevalence has most frequently been assessed in school-age children, although research has demonstrated that night terrors are most common in children between 1 and 5 years of age [ 1 , 4 , 5 ]. The difficulties in determining prevalence are probably due to the varying definitions of night terrors used in research studies. This underscores a broader finding by Hublin and colleagues that the general public does not have one clear definition of night terrors, and thus often confuses them with simple nightmares [ 7 ]. Because of this, we use the AASM’s definition of night terrors provided above [ 2 ].

Attempts to treat night terrors have yet to establish an effective remedy for the condition. Currently, the recommended treatment for night terrors is to leave the child alone; parents are encouraged to let the terror proceed uninterrupted, as the child is unlikely to respond to attempts to be woken and is often inconsolable upon awakening [ 4 ]. Some sedative medications have proven effective in case studies [ 8 , 9 ]; however, such medications may lead to tolerance or dependence in children, and the notion of treating children with sedatives is troubling to many. Scheduled awakenings, performed around the time when the child transitions from non-REM to REM sleep, have also been used as treatment for night terrors [ 10 ].

One practice that has not been investigated in the context of night terrors is cosleeping. One of us (PTS) has a personal anecdote on this topic. By the summer of 2014, PTS’ 3-year-old child had been experiencing four to seven night terrors weekly for several months. Finding this behavior disturbing, PTS standardized the child’s schedule, modified his diet, and monitored for suitability the images and stories to which he was exposed. When these failed to have any discernable effect, PTS subjected the child to scheduled awakenings, which similarly had little impact. Finally, and possibly due to exhaustion, PTS began cosleeping with the child; the child’s night terrors rapidly ceased and have not reoccurred.

Cosleeping is not a novel behavior. Cosleeping is observed in all closely related primates and in many current human societies. It is traditionally defined as caregivers sharing a bed with offspring, and this is the definition we use here. In addition to the potential benefit to children (≥1-year-old) suggested by the anecdote above, cosleeping has demonstrated physiological effects on infants (≤11-months-old) [ 11 , 12 ]. Moreover, the impact on a mothers’ sleep duration or stage of sleep is negligible [ 13 ]. In spite of this, cosleeping with infants has been advised against by the American Academy of Pediatrics [ 14 ].

Here, we present an argument that night terrors are the result of an environmental mismatch between evolved behavior and the modern cultural practice of solitary sleeping. Using an environmental mismatch approach, attachment theory and research on the physiological, behavioral and psychosocial impacts of cosleeping, we argue that cosleeping is beneficial for children and may prevent or greatly reduce night terrors. We further suggest that under certain circumstances cosleeping with infants is preferable to room-sharing, and both are preferable to solitary sleeping.

In recent years, the environmental mismatch hypothesis—the idea that specific traits evolved to maximize their fitness in an environment very different from the one in which they are expressed today—has become a growing model for the study of the evolutionary basis of disease [ 15 ]. Many disorders have been studied through an environmental mismatch lens. One popular example is obesity, a particularly concerning condition due to its links with diabetes and cardiovascular disease. Several environmental mismatch hypotheses have been proposed for the rising prevalence of obesity; for example, genes linked with increased fat storage would have been evolutionarily favorable for Paleolithic hunter-gatherers, for whom food was not always readily available. However, as humans progressed into developed, sedentary societies with consistent access to food, this adaptation has become a pathology: average body weight and obesity have increased throughout the world [ 16 ].

The mismatch approach has also been applied to the study of human sleep behavior and sleep disorders. Significant changes to human sleep patterns have occurred throughout evolutionary time, including a decrease in the amount of time humans sleep relative to other primates [ 17 ]. Such changes have been explored as potential factors in sleep disorders ranging from insomnia to sleep apnea [ 18 ]. Additional research has shown an increase in sleep disorders in recent years; this increase has been partially attributed to the increase in light pollution and constant mental stimulation of developed societies [ 15 , 19 , 20 ].

The likely relative behavioral and physiological effects of solitary sleeping, cosleeping and room-sharing between a caregiver and an infant (≤11-months-old) a

(Proper bedding and surrounds are assumed for all conditions.) Solitary sleeping is considered the standard (–). ↑ indicates a beneficial effect, ↓ indicates a detrimental effect and – indicates no change in situation for the infant relative to the standard. Multiple designations are provided when the outcome is in question. From a cost-benefit approach, solitary sleeping fairs very poorly and cosleeping is preferable whenever the risk of smothering (purple) is lower than the added benefits over room-sharing (orange).

The practice of cosleeping is also supported by attachment theory, which addresses the prolonged period of helplessness in human infants and the infant’s need to elicit the mother’s (or other caregiver’s) protection and care [ 28 ]. These behaviors are rooted in evolution, providing a survival advantage by increasing caregiver-infant proximity. They include infant rooting and signaling (e.g. crying) and caregiver responsivity (meeting the infant’s need) and sensitivity (meeting the need in a timely fashion). The attachment system is activated in the presence of stress, either internally or externally derived. Evidence of the system can be seen in the first few weeks of life, when the infant begins signaling and the caregiver responds. It peaks at about 1 year of age, the time when the child typically develops independent locomotion and can get away from the mother, and continues at high intensity throughout the years of dependency in early childhood [ 29 ]. It is of interest that the age range during which attachment behaviors are strongest is the age range when night terrors first present [ 4 , 5 ]. Indeed, one Swiss study found that cosleeping, while uncommon in children below 1 year of age (<10%), increased during ages when night terrors are most common [ 30 ].

Primates and cosleeping: an ancient and modern practice

Cosleeping is observed in all closely related primates, as well as a significant portion of human populations. Barry and colleagues collected data on sleeping arrangements for 90 cultures, and found that mother and infant slept in the same bed in 41 of them (46%); mother slept in the same room with the infant but in an unspecified bed in 30 (33%), and in the same room in separate beds in 19 (21%). In none of 90 cultures did the mother and infant sleep in a separate room [ 31 ]. Despite this, cosleeping has been discouraged by the American Academy of Pediatrics due to a stated link with sleep-related infant deaths [ 25 ]. Research on the rates of cosleeping in the US has shown that, although cosleeping increased from 6.5% to 13.0% from 1993 to 2010, no significant increase was observed in white families from 2001 to 2010; these findings suggest that recommendations against cosleeping are not uniformly followed across cultural groups [ 32 ].

Cosleeping has, however, persisted in small-scale, high-fertility/high-mortality cultures that characterized human societies for much of our evolutionary history. A study on the Aka hunter-gatherers and Ngandu farmers of central Africa by Hewlett and Roulett found that an overwhelming majority of offspring coslept with their parents from infancy through adolescence, although rates decreased as children aged [ 33 ]. Reasons for cosleeping include limitations in space, protection from predators and shared heat sources (e.g. body heat), similar adaptive benefits that likely promoted cosleeping in early human evolution [ 33 ].

Attitudes about cosleeping are beginning to change on a broad scale in Western nations. In particular, the UK, which formerly held views similar to those in the US that discourage cosleeping, has begun to embrace parents’ choice to cosleep [ 34 ]. Overall, the UK has become more open to parents’ decisions on infant cosleeping; the same cannot be said for the US [ 14 , 35 ]. Data suggest that this may be unfortunate.

The adaptive benefits of cosleeping in humans can easily be seen through the physiological effects on parent and infants [ 27 ]. We summarize some of these and other findings on the study of different sleeping practices on parent and infant behavior and physiology in Table 1 . Although the American Academy of Pediatrics has reported risks of cosleeping over solitary sleeping or room-sharing, including overheating and smothering [ 25 ], they may have overemphasized these risks or ignored factors contributing to them [ 36 ]. In addition, the reported risks may be balanced by the benefits provided by cosleeping, including improvements in thermoregulation and respiratory regulation, increased breastfeeding and easier arousal of both infants and parents (see Table 1 ).

The relative psychosocial effects of solitary sleeping and cosleeping between a caregiver and child (ages ranging from 2 to 13 years of age across studies) a

Solitary sleeping is considered the standard (–). ↑ indicates a beneficial effect and – indicates no change in situation for the child relative to the standard. We have excluded room sharing due to the lack of data and to difficulties predicting outcomes. Cosleeping appears to be preferable to solitary sleeping.

For many families, solitary sleeping has replaced cosleeping, and is often accomplished through the practice of sleep training. Sleep training involves parents leaving an infant or child alone in a separate room at night, and limiting responsiveness to its cries to the point of extinction, thus encouraging it to self-settle [ 43 ]. These practices are arguably disturbing for the infant or child, who is responding to the separation from its caregiver, and the cries are stressful for parents [ 44 ]. Although very popular and widely recommended [ 45 ], sleep training is counterintuitive to attachment theory and other evolutionary tenets of a responsive parent-offspring relationship.

Although formally a proponent of solitary sleeping [ 14 ], the American Academy of Pediatrics has recently revised its recommendations for safe infant sleep to include room-sharing, but not bed-sharing, of the parents and infant [ 25 ]. These recommendations posit that room-sharing with an infant increases the ability of the parent to quickly respond to the infant, while minimizing the risk of suffocation or overheating. These revisions are a move in the right direction; however, cosleeping in a safe environment appears to have increased benefits on infant ( Table 1 ), and thus could offer more benefits than simply sharing the same room. The difference in short-term ( Table 1 ) and long-term ( Table 2 ) benefits between cosleeping, room-sharing, and solitary sleeping merits increased attention from sleep researchers.

We propose that cosleeping with children may reduce or possibly prevent night terrors. Accordingly, we are referring to the post-infancy stage with respect to this parasomnia. We include the infancy data, however, because there appear to be benefits for cosleeping with infants and because cosleeping with infants is likely to lead to cosleeping with children. It is important to note that not all children develop night terrors, and many are able to sleep in rooms separate from their parents nightly. The argument presented in this commentary is not, however, to suggest that night terrors will always result from separation of a parent and child at night; rather, we propose night terrors to be an extreme outcome of this separation, one that likely works together with other physiological and/or psychosocial factors.

Several testable predictions, both observational and interventional, arise from the argument made here. One observational prediction is that children who cosleep will have a lower prevalence of night terrors compared with children who sleep solitarily. A comparison between the prevalence of night terrors in children who cosleep and children who sleep in the same room with parents should be undertaken to determine the degree of physical proximity with the parent necessary to influence positive change, should it occur. Previous research suggests that cosleeping and room-sharing have beneficial effects for infants (see Table 1 ), but it is unclear if either approach is superior with respect to parasomnias in young children.

One interventional prediction of our hypothesis is that children with night terrors would experience a decrease in incidence once they began cosleeping with their parents. There are currently no findings on the correlation between these phenomena beyond our anecdotal report (see above), but an interventional, prospective study could easily test this prediction. However, possible complications could arise as a result of the lack of understanding surrounding night terrors in the lay public and scientific community alike [ 7 ]. Any study undertaken to assess cosleeping as an intervention for night terrors would have to take care in defining night terror symptoms (intensity, duration, etc.) as well as defining cosleeping (bed-sharing vs room-sharing). We are currently beginning work on such a study.

Alternative hypotheses

We have presented a mechanistic hypothesis with an evolutionary basis: the lack of cosleeping could reasonably trigger night terrors. This does not necessarily mean that cosleeping currently provides a fitness advantage.

One could hypothesize that solitary sleeping fosters a child’s independence from its parents. Fitness benefits may accrue from this if children who learn separation from their parents earlier display better adjustment or self-reliance in adulthood. We do not favor this hypothesis because, to our knowledge, there is no evidence that solitary sleeping leads to better adjustment. In fact, attachment theory suggests the opposite; caregiver sensitivity and responsivity lead to secure attachment in children. Secure attachment is associated with child compliance (increases safety), increased and better social relationships (survival and reproductive advantage) [ 28 , 29 ]. Long-term psychosocial benefits due to cosleeping, which are indicative of secure attachment, can be found in Table 2 .

One could hypothesize a direct fitness cost to cosleeping: cosleeping may present significant risk to the child in the form of accidental smothering while the parent is sleeping. This is the core argument the medical field uses against cosleeping [ 25 ]. We do not favor this hypothesis for caregiver-child cosleeping: we could not locate any studies of accidental smothering deaths in children beyond infancy.

Cosleeping may present a direct fitness cost for infants. It is unclear, however, how great this risk is or how costly the absence of cosleeping is to infants. Smothering rates are very low (0.1 per 1000 live births, as described in a New Zealand population study [ 46 ]), and many cases of smothering involve drug and/or alcohol abuse, or some other extenuating circumstance, that prevents the parent from waking up to their offspring’s cries or movements [ 47 , 48 , 49 ]. It may be that, for responsible, sober parents, the benefits to an infant for cosleeping with a caregiver on an appropriately designed bed outweighs the risk of smothering ( Table 1 ). This warrants future exploration.

In short, we are unaware of any fitness benefit to the child (or parent) for solitary sleeping. Since our most closely related primates all cosleep with their young, and since individuals from many non-Western cultures cosleep with their young, solitary sleeping is clearly a culturally derived trait. At best, solitary sleeping may be selectively neutral, but data on SIDS rates and the American Academy of Pediatrics’ recent recommendations against it [ 25 ], suggest that solitary sleeping is maladaptive.

To our knowledge, this paper is the first to propose that night terrors are an extreme response to a novel environment by children who sleep apart from their parents. We have addressed the many benefits of cosleeping to the infant ( Table 1 ), and this paper extends the argument into the early childhood years ( Table 2 ), showing that physiological and psychosocial benefits for infants (i.e. survival, protection) give way to physiological and psychosocial benefits for young children (i.e. survival, protection and relational dependence). This bio-behavioral scaffolding is precisely what contributes to the child feeling protected and thus safe in a sleeping environment that includes the caregiver. Cosleeping, however, is currently discouraged in Western cultures. Further research is needed to understand if the discouragement is warranted. It may be that a return to cosleeping practices in Western cultures will lead to better child health overall, including a reduction in the prevalence of night terrors.

We thank Caroline Blackie, Rachael Bonoan, Sara Lewis and Avalon Owens for helpful comments on a draft of this manuscript.

The authors declare no research funding for this project, however PTS received a Tufts University FRAC award to cover the open access fees.

Conflict of interest : None declared.

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Night Terrors in Children and Adults

Screaming and physical episodes happen while still asleep

Night Terrors in Children

• Sleep Routine
• Mental Health
• When a Child Has a Night Terror

Night terrors, also called sleep terrors, are a type of sleep disorder. During a sleep terror, you might scream or cry while asleep, or it may seem like you’re acting out a bad dream. These episodes can affect children or adults, but they’re more common during early childhood.

Generally, sleep terrors are not considered to be harmful to your physical or psychological health, but sometimes they can be a sign of underlying anxiety. If you think that you or your child has sleep terrors, you should rest assured that they can be well managed with lifestyle changes and medical care.

In this article, learn about the causes of sleep terrors and how to deal with them in adults and children.

Sleep terrors are not common, but they are not rare either. They are more common among young children under age 5 than any other age group. One research article published in 2022 estimated the frequency of sleep terrors during early childhood to be between 16.7% and 20.5%.  

There is a genetic predisposition to night terrors, but not everyone with this sleep disorder has a family member who also has had them.  

Causes of sleep terrors during childhood include:

• Fatigue, sleep deprivation
• Sleep disruption
• Waking up during sleep
• Behavioral problems

Night terrors typically occur during transitions between the phases that cycle throughout sleep . Children are more prone to waking up between sleep phases than adults are. Sleep normally becomes more regulated as the brain matures, and night terrors are rare during adulthood. 

Sleep Phases ofr Night Terrors

Night terrors occur during non-rapid eye movement (non-REM) sleep, during stage 3 (slow-wave) sleep. Dreams are normally part of rapid eye-movement (REM) sleep . During the REM dream phase of sleep, people are unable to move, cry, scream, or speak. Unlike nightmares, night terrors happen when a person is not dreaming, which is why physical movements, screaming, and crying can occur during sleep terror episodes.

Some Adults Experience Night Terrors Too

While the most common age for night terrors is early childhood, these episodes can continue or begin during adolescence or adulthood.

Having night terrors at any age does not indicate a psychiatric condition, and there is no reason to be embarrassed or concerned if you or your child is having them. However, if you experience night terrors at any age, it is important to get a medical evaluation. These episodes can sometimes be related to underlying health conditions.

Risk factors for adult-onset night terrors include:

• Sleep deprivation
• Sleep disorders, such as obstructive sleep apnea
• Medication side effects, especially antihistamines and antidepressants

If you have been experiencing sleep terrors, it would be beneficial to learn whether you have an underlying medical condition so that you can get appropriate treatment. Treatment will help the underlying condition and lower the risk of recurrent sleep terrors.

An anxiety disorder can cause anxiety symptoms, but that’s not always the case. Many people can experience periods of anxiety due to stress without having an anxiety disorder. 

People Unaware of Night Terror Episodes

One of the key characteristics of sleep terrors is that people are not aware that they are having them and are unable to recall the episodes.

Symptoms: Night Terrors, Nightmares, or Nightmare Disorder?

Night terrors occur during sleep, and people who are experiencing these episodes are unaware that the episodes are occurring. When a person has night terrors, they may cry, scream, or punch while they appear to be sleeping.

Symptoms and characteristics of night terrors include:

• Making sounds or movements that indicate distress during sleep
• Rapid breathing
• Rapid heart rate
• Dilated pupils
• Muscle tension
• Not responding to the speech of other people in the room during the episode
• Not being able to remember or describe what happened

After having a night terror, sometimes people can recall having experienced some anxiety during the night or might describe a sense of doom. 

Other Parasomnias 

Night terrors are a type of parasomnia . A parasomnia is an unpleasant sleep experience, such as a nightmare . However, night terrors are not the same as nightmares or other parasomnias.

How other parasomnias compare to night terrors include:

• Nightmares are bad dreams, and people usually remember some of the content of a nightmare. Unlike sleep terrors, people do not act out during a nightmare, and others who are in the room usually don’t notice any changes in movement or behavior. 
• Sleepwalking is a type of coordinated physical movement that occurs during sleep. Sleepwalking does not occur during the dream stage of sleep, and people experiencing them will not recall sleepwalking. They are more common among children than adults.
• Sleep paralysis is a terrifying experience during which you are unable to physically move any part of your own body even though you feel you are awake. Most people remember sleep paralysis episodes, and others who might be present in the room typically do not see any altered behavior.
• Sleep talking is when people talk when they are asleep. This can happen during any stage of sleep, and it isn't usually unpleasant.

Sleep Routines to Stop Night Terrors

If you have been experiencing sleep terrors, there are some ways to prevent them from occurring. You should start by seeing a healthcare provider, who will evaluate your overall health and consider underlying psychological issues (especially anxiety) and health conditions that could be putting you at risk.

Some recommendations for preventing recurrent sleep terrors include lifestyle adjustments. 

Measures you can take to avoid sleep terrors include:

• Avoiding alcohol, caffeine, and other stimulants (such as medications with stimulant action), especially before bedtime
• Avoiding disturbing content, such as frightening books, media, or discussions, especially before bed
• Getting enough sleep if you have not been sleeping well
• Regulating your sleep schedule to sleep and wake up at approximately the same time every day

Additionally, consider going over the following with your healthcare provider:

• A review of your medication list to detect whether you have been taking any medications that could be causing sleep terrors as a side effect
• Whether you may have anxiety that could be overwhelming for you, and how to get help and support with distressful issues
• Whether a sleep evaluation is needed to identify an underlying sleep disorder that needs an assessment and treatment

For a child with ongoing night terrors that occur at a regular time each night, a healthcare provider may recommend scheduled awakenings. In this process, the usual time of the night terror is noted over the course of two weeks.

The parent gently wakes the child 15 to 30 minutes before that time each night and allows them to return to sleep. This is done for two to four weeks.

Mental Health and Night Terrors 

Sometimes people who experience sleep terrors become concerned about whether these events could be an indication of an underlying mental health problem. Older research on this subject has not shown a strong association between sleep terrors and psychiatric conditions.

In general, people who have psychiatric diagnoses, such as post-traumatic stress disorder (PTSD), anxiety disorders, borderline personality disorder, or schizophrenia, may be at a slightly higher risk of experiencing sleep terrors or other parasomnias. However, having sleep terrors is not an indication of an underlying or undiagnosed psychiatric condition.

For Parents: When You See Your Child Having Night Terrors 

If you’ve experienced night terrors in your children, you might be concerned that your child could be having a seizure or a panic attack. It can be difficult for parents to know the difference between night terrors and psychiatric illnesses or neurological conditions.

It could be helpful for you to video or audio record the episodes so that you can share the recordings with your child’s pediatrician when you take them in for an evaluation.

During a Night Terror

If your child is having a night terror, it’s best not to wake them up, not to move them, and not to interact with them. When they wake up, be sure to allow them to talk about any distress they’re experiencing, and offer gentle reassurance.

Many children become stressed about a variety of things in life, ranging from exaggerated anxiety about issues that they don’t have control over to serious concerns about issues like parental fighting or bullying at school.

If you feel that you are not able to address your child’s anxiety, it could be helpful to seek professional help from someone who is experienced in counseling children and families with young children.

Night terrors, also called sleep terrors, are more common among young children than any other age group, but they can occur at any age. Sometimes sleep disruption, sleep deprivation, or daytime anxiety can contribute to the risk of having night terrors, and they can also occur as a medication side effect.

Night terrors are episodes that involve acting out a sense of terror during sleep, which can be alarming to other people but does not cause distress to the person who is experiencing the episode. Some people may feel a sense of doom or anxiety before or after a night terror. The key feature of night terrors is that people do not remember having them.

If you or your child has been experiencing night terrors, it will be helpful to see a healthcare provider who can try to identify the underlying cause and provide some guidance to help with management.

Leung AKC, Leung AAM, Wong AHC, Hon KL. Sleep terrors: An updated review . Curr Pediatr Rev. 2020;16(3):176-182. doi:10.2174/1573396315666191014152136

Laganière C, Gaudreau H, Pokhvisneva I, Kenny S, Bouvette-Turcot AA, Meaney M, Pennestri MH. Sleep terrors in early childhood and associated emotional-behavioral problems . J Clin Sleep Med . 2022;18(9):2253-2260. doi:10.5664/jcsm.10080

Petit D, Pennestri MH, Paquet J, et al.  Childhood sleepwalking and sleep terrors: a longitudinal study of prevalence and familial aggregation .  JAMA Pediatr.  2015;169(7):653-8. doi:10.1001/jamapediatrics.2015.127

Futenma K, Inoue Y, Saso A, Takaesu Y, Yamashiro Y, Matsuura M. Three cases of parasomnias similar to sleep terrors occurring during sleep-wake transitions from REM sleep . J Clin Sleep Med . 2022;18(2):669-675. doi:10.5664/jcsm.9666

Silber MH. Parasomnias occurring in non-rapid eye movement sleep . Continuum (Minneap Minn). 2020;26(4):946-962. doi:10.1212/CON.0000000000000877

Ting CY, Thomas B. Behavioural sleep problems in children . Singapore Med J . 2023. doi:10.4103/singaporemedj.SMJ-2021-102

Gau SF, Soong WT. Psychiatric comorbidity of adolescents with sleep terrors or sleepwalking: a case-control study . Aust N Z J Psychiatry. 1999;33(5):734-9. doi:10.1080/j.1440-1614.1999.00610.x This is the best study that could be found, although older.

By Heidi Moawad, MD Dr. Moawad is a neurologist and expert in brain health. She regularly writes and edits health content for medical books and publications.

• Patient Care & Health Information
• Diseases & Conditions
• Sleep terrors (night terrors)

Sleep terrors are times of screaming or crying, intense fear, and sometimes waving arms and legs when not fully awake. Also known as night terrors, sleep terrors may lead to sleepwalking. Like sleepwalking, sleep terrors are a type of parasomnia. Parasomnias are disturbing or strange behaviors or experiences during sleep. A sleep terror usually lasts from seconds to a few minutes, but it may last longer.

Sleep terrors may happen in children between the ages of 1 and 12 years. They happen much less often in adults. Although sleep terrors can be frightening to those around the person with sleep terrors, they aren't usually a cause for concern. Most children outgrow sleep terrors by their teenage years.

Sleep terrors may need treatment if they cause problems with getting enough sleep or cause a safety risk.

Sleep terrors differ from nightmares. A nightmare is a bad dream. The person who has a nightmare wakes up from the dream and may remember details. A person who has a sleep terror remains asleep. Children usually don't remember anything about their sleep terrors in the morning. Adults may recall part of a dream they had during the sleep terrors.

Sleep terrors generally happen in the first part of sleep time, and rarely during naps. A sleep terror may lead to sleepwalking.

During a sleep terror, a person may:

• Start by screaming, shouting or crying.
• Sit up in bed and look scared.
• Stare wide-eyed.
• Sweat, breathe heavily, and have a racing pulse, flushed face and enlarged pupils.
• Kick and thrash.
• Be hard to wake up and be confused if awakened.
• Not be comforted or soothed.
• Have no or little memory of the event the next morning.
• Possibly, get out of bed and run around the house or have aggressive behavior if blocked or held back.

When to see a doctor

Occasional sleep terrors aren't usually a cause for concern. If your child has sleep terrors, you can simply mention them at a routine well-child exam. But if you have concerns for you or your child, talk to your doctor or other healthcare professional sooner, especially if sleep terrors:

• Happen more often.
• Regularly disrupt the sleep of the person with sleep terrors or other family members.
• Lead to safety concerns or injury.
• Result in daytime symptoms of extreme sleepiness or problems with daily activities.
• Continue beyond the teen years or start as an adult.

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Sleep terrors are a type of parasomnia. A parasomnia is a disturbing or strange behavior or experience during sleep. People who have sleep terrors don't completely wake up from sleep during the episodes. Their appearance may suggest they are awake, but they remain partially asleep.

Several issues can contribute to sleep terrors, such as:

• Serious lack of sleep and extreme tiredness.
• Sleep schedule changes, travel or sleep interruptions.

Sleep terrors sometimes can be triggered by conditions that interfere with sleep, such as:

• Sleep-disordered breathing — a group of disorders that include breathing patterns that are not typical during sleep. The most common type of sleep-disordered breathing is obstructive sleep apnea.
• Restless legs syndrome.
• Some medicines.
• Mood disorders, such as depression and anxiety.
• Alcohol use.

Risk factors

Sleep terrors are more common if family members have a history of sleep terrors or sleepwalking.

Complications

Some complications that may result from sleep terrors include:

• Being too sleepy during the day, which can lead to problems at school or work or with everyday tasks.
• Disturbed sleep.
• Embarrassment about the sleep terrors or problems with relationships.
• Injury to the person having a sleep terror or, rarely, to someone nearby.
• Sateia M. Sleep terrors. In: International Classification of Sleep Disorders. 3rd ed. American Academy of Sleep Medicine; 2014. https://learn.aasm.org/Listing/a1341000002XmRvAAK. Accessed March 1, 2023.
• Kryger M, et al., eds. Disorders of arousal. In: Principles and Practice of Sleep Medicine. 7th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 1, 2023.
• Parasomnias. Merck Manual Professional Version. https://www.merckmanuals.com/professional/neurologic-disorders/sleep-and-wakefulness-disorders/parasomnias. March 3, 2023.
• Sleep-wake disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR. 5th ed. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed. March 2, 2023.
• Leung AKC, et al. Sleep terrors: An updated review. Current Pediatric Reviews. 2020; doi:10.2174/1573396315666191014152136.
• Bruni O, et al. The parasomnias. Child and Adolescent Psychiatric Clinics of North America. 2021; doi:10.1016/j.chc.2020.08.007.
• Olson EJ (expert opinion). Mayo Clinic. March 10, 2023.

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• J Clin Sleep Med
• v.18(9); 2022 Sep 1

Sleep terrors in early childhood and associated emotional–behavioral problems

Christine laganière.

1 Department of Educational and Counselling Psychology, McGill University, Montreal, Quebec, Canada

2 Douglas Mental Health University Institute, Centre intégré universitaire de santé et de services sociaux de l’Ouest-de-l’Ile-de-Montréal, Montreal, Quebec, Canada

3 Hôpital en Santé Mentale Rivière-des-Prairies, Centre intégré universitaire de santé et de services sociaux du Nord-de-l’Ile-de-Montréal, Montreal, Quebec, Canada

Hélène Gaudreau

Irina pokhvisneva, samantha kenny, andrée-anne bouvette-turcot, michael meaney.

4 Department of Psychiatry, McGill University, Montreal, Quebec, Canada

Marie-Hélène Pennestri

Study objectives:.

While sleep terrors are associated with emotional–behavioral problems in school-aged children and adults, little is known about these associations in early childhood, when sleep terrors prevalence is at its highest. Moreover, studies using a longitudinal design and controlling for confounding variables are scarce. This study’s objective was to determine whether the frequency of sleep terrors in toddlers predicts emotional–behavioral problems during the preschool years.

Participants (n = 324) were enrolled in the prospective Maternal Adversity Vulnerability and Neurodevelopment cohort study. The frequency of sleep terrors in children was assessed at 12, 18, 24, and 36 months using maternal reports. Children's emotional–behavioral problems were measured at 48 and 60 months using the Child Behavior Checklist. Relevant confounders linked to the child, mother, and environment were also taken into consideration.

The frequency of sleep terrors was relatively stable across early childhood (16.7–20.5%). A generalized estimating equation revealed that the frequency of sleep terrors in early childhood was associated with increased emotional–behavioral problems at 4 and 5 years of age, more specifically with internalizing problems ( P < .001), after controlling for child’s sex, time point, family socioeconomic status, maternal depressive symptoms, and nighttime sleep duration. The frequency of sleep terrors was further associated with the emotionally reactive, anxious/depressed, and somatic complaints scales ( P < .01).

Conclusions:

This longitudinal study provides further support for a high prevalence of sleep terrors in early childhood. Our findings show meaningful associations between higher frequency of sleep terrors and emotional–behavioral problems as early as toddlerhood, especially internalizing problems.

Laganière C, Gaudreau H, Pokhvisneva I, et al. Sleep terrors in early childhood and associated emotional–behavioral problems. J Clin Sleep Med . 2022;18(9):2253–2260.

BRIEF SUMMARY

Current Knowledge/Study Rationale: While the prevalence of sleep terrors peaks in toddlerhood, most studies investigating the association between sleep terrors and emotional–behavioral problems focus on school-aged children, adolescents, and adults. Moreover, longitudinal studies are lacking.

Study Impact: This longitudinal study shows that sleep terrors in toddlerhood are highly prevalent and are associated with emotional–behavioral problems at 4 and 5 years old. Therefore, in some children, sleep terrors can represent an early warning sign of internalizing problems.

INTRODUCTION

Sleep terrors (also called night terrors) are described as sudden and partial arousals from sleep, often accompanied by a cry or piercing scream. 1 These events are characterized by arousal of the autonomic nervous system (increased heart rate, sweating, and rapid breathing) and behavioral manifestations of intense fear, such as sitting upright in the bed suddenly, looking scared, and screaming. This parasomnia (or disorder of arousal) is typically present in early childhood and is often associated with prolonged inconsolability during the night. Along with sleepwalking and confusional arousals, sleep terrors are believed to result from incomplete arousal from slow-wave sleep. 2 , 3

While the prevalence of sleep terrors in adults seems low (1–2% in the general population), this sleep disorder is quite common in children, especially young ones. 4 – 7 In a community sample of children between 2.5 and 6 years old, the prevalence of sleep terrors was as high as 39.8%. 8 The prevalence is known to gradually decrease with age, with rates of about 35% at 18 months old and about 20% at 30 months old. 9 , 10 The occurrence of sleep terrors appears to decline further in school-aged children, as shown by a prevalence of 6.5% in a sample of 2,584 children with a mean age of 10.8 years old. 11 These studies highlight the greater prevalence of sleep terrors in toddlers as opposed to older children.

In adulthood, a significant association was described between sleep terrors and more affective difficulties, such as anxiety symptoms. 12 In school-aged children, sleep terrors have also been linked with higher separation anxiety, internalizing problems (anxious/depressed, withdrawn symptoms), and psychotic symptoms. 8 , 13 – 15 Very few studies have documented the presence of externalizing symptoms in patients experiencing sleep terrors. A cross-sectional study revealed significant associations between sleep terrors and several types of externalizing problems (aggressive behavior, attention problems, delinquent behavior, and social problems) in school-aged children. 15 A recent study also showed greater internalizing and externalizing symptoms in a clinical sample of 41 children and adolescents (aged between 6 and 17 years old) with a diagnosis of disorder of arousal (including sleep terrors) compared to healthy controls. 16

While these studies suggest a positive link between sleep terrors and emotional–behavioral symptoms in school-aged children, adolescents, and adults, studies assessing toddlers are scarce. Furthermore, apart from Petit et al 8 and Fisher et al, 13 studies evaluating these associations were cross-sectional or retrospective and very few of them included covariables that could influence emotional–behavioral measures, such as nocturnal sleep duration and maternal well-being. Considering that sleep terrors are particularly prevalent in children younger than 5 years old, 10 it is unfortunate that the majority of studies describing emotional–behavioral functioning in individuals with this sleep disorder have focused on older children and adults. Besides, toddlerhood is a crucial period for the development of emotional regulation in children. Poor emotion regulation is linked to internalizing and externalizing problems in preschoolers and predicts psychopathology later in life. 17 – 19 It is thus crucial to investigate whether associations between sleep terrors and mental health problems emerge during early childhood. Moreover, longitudinal assessments (as opposed to retrospective or cross-sectional studies) of sleep terrors and internalizing and externalizing symptoms in children are clearly lacking.

As such, the objective of this study is to longitudinally assess the associations between sleep terrors in early childhood and emotional–behavioral problems in preschoolers. To take into consideration the several time points and the frequency of sleep terrors at each time point, the average frequency of sleep terrors during early childhood will be calculated. Considering previous findings in older children and adults, sleep terrors in early childhood are expected to be associated with increased subsequent internalizing and externalizing problems in preschoolers. To further identify which type of emotional–behavioral problems are associated with sleep terrors, specific subscales will also be considered in a second step: emotionally reactive, anxious/depressed, somatic complaints, withdrawn, attention problems, and aggressive behavior. Finally, important confounding variables related to the child, the mother, and the environment will be included.

Participants

This study is part of the Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN) project. 20 The MAVAN study was approved by the ethics committee of the Douglas Mental Health University Institute (Montreal, Quebec) and by the ethics committee of St. Joseph’s Healthcare/McMaster University (Hamilton, Ontario). Mothers-to-be were recruited during pregnancy in obstetric clinics in Montreal and Hamilton. To be included in the cohort, mothers had to be at least 18 years old and not have any severe health conditions or chronic illness. Exclusion criteria were an APGAR score under 7, prematurity (≤ 37 weeks of gestation), or severe health conditions. Written consent was obtained from all participants (N = 629). A total of 324 mother–child dyads were included in the present study (54.5% male children). Participants were excluded either because they dropped out of the study or failed to complete some critical study measures. Included and excluded participants had similar demographic characteristics (child’s sex and socioeconomic status [SES]), birth weight, and maternal age at birth. Additionally, maternal depressive symptoms at 48 and 60 months postpartum did not differ between included and excluded participants ( P > .05). Internalizing problems were higher in excluded participants at 48 months ( P = .024) and 60 months ( P = .016). Externalizing problems were higher in excluded participants, but only at 60 months ( P = .049). Trained research assistants collected data during home and laboratory visits from pregnancy until the child was 5 years old.

Sleep terrors

At 12, 18, 24, and 36 months, mothers completed the Questions About Sleep Habits questionnaire, a questionnaire adapted from the Quebec Longitudinal Study of Child Development. 8 Sleep terrors were assessed using the question “Does your child have night terrors (wakes up crying or screaming, she/he is confused, looks terrified, and is in a sweat)?” Response options were “No” (1), “Sometimes” (2), “Often” (3), or “Every night” (4).

First, descriptive statistics were used to document the frequency of sleep terrors at each time point and percentages of children presenting a borderline-clinical degree of emotional–behavioral problems among those who experienced sleep terrors and those who did not. The frequency of sleep terrors was dichotomized into the presence and absence of sleep terrors in that first descriptive section. Children who presented sleep terrors at least sometimes were considered to experience sleep terrors (presence), as in Petit et al. 8

For the main analyses, the average frequency of sleep terrors in early childhood (12, 18, 24, and 36 months) was used as a continuous variable. The average frequency of sleep terrors in early childhood was calculated across the four time points. This led to a score between 1 and 4, with a higher score representing a higher average frequency of sleep terrors in early childhood. Analyses of variance did not reveal a significant difference between participants with 1, 2, 3, or 4 time-point measurements of sleep terror in early childhood in terms of birth weight, maternal age, frequency of sleep terrors, internalizing problems, or externalizing problems ( P > .05).

Children's emotional and behavioral problems

The Child Behavior Checklist (CBCL) was completed by the mother when her child was 48 and 60 months old. 21 , 22 Statements regarding the child's behaviors are listed. The mother selected the frequency of these behaviors on a 5-point Likert-type scale. The total score, the internalizing problems score, and the externalizing problems score were used at both time points. Children with a T-score of 60 and above are considered in the borderline-clinical range 21 and this threshold was used in the descriptive statistics. While the CBCL alone is not a diagnostic tool, a score in the borderline-clinical range is of concern and should warrant further diagnostic assessment. 21 Moreover, to further specify which internalizing and externalizing problems were associated with sleep terrors, the syndrome scales (emotionally reactive, anxious/depressed, somatic complaints, withdrawn, attention problems, and aggressive behavior) were also calculated at both time points.

Maternal depression

The mother completed the Center for Epidemiologic Studies Depression scale when her child was 48 and 60 months old. 23 This scale assesses depressive symptoms, with a higher score indicating more depressive symptoms. The total score of the Center for Epidemiologic Studies Depression scale was used as a control variable to control for mood biases and the reported association between maternal mood and child’s emotional–behavioral problems. 24 , 25

Sleep duration

Nighttime sleep duration at 48 and 60 months was assessed using the Children Sleep Habits Questionnaire. 26 , 27 It was used as a control variable supported by the extensive literature on the association between sleep duration and emotional–behavioral problems. 28 , 29

Sociodemographics

Family SES was assessed at 12 months postpartum. Mothers reported their education level and family income; both variables were dichotomized into high and low groups. Statistics Canada’s low-income cutoff was used. 30 Maternal education was considered high if the mother attended college or university. Dyads who had low maternal education and low income were categorized into the low SES group. Dyads who had high maternal education and high income were categorized in the high SES group. Dyads who were high for one variable and low for the other formed the middle SES group. Since this sample mainly comprised high-SES mothers, the low-SES dyads (n = 7) were merged with the middle-SES group. SES was used as a control variable given its well-known association with our main outcome (children’s emotional–behavioral problems). 31

Statistical analyses

Generalized estimating equation (GEE) method for repeated measures assessed the associations between the average frequency of sleep terrors in early childhood (12, 18, 24, and 36 months) and emotional–behavioral problems in toddlerhood (48 and 60 months). Covariates included child’s sex, SES, concurrent nocturnal sleep duration (48 and 60 months), and concurrent maternal depressive symptoms (48 and 60 months). A linear GEE model was used to estimate population effects in analyzing longitudinal data. The total CBCL score, the internalizing problems score, the externalizing problems score, and the syndrome scales of the CBCL were used as outcome variables.

Statistical analyses were performed using IBM Statistical Package for the Social Sciences Version 24 for Windows (IBM, Armonk, NY). Statistical significance was defined as P < .05. The Holm-Bonferroni method was used to correct for multiple comparisons.

Frequency of sleep terrors

Frequencies of the presence of sleep terrors (at least sometimes) between 12 and 36 months in the MAVAN cohort appear in Figure 1 . Sleep terrors were least frequent in children at 18 months (16.7%) and most frequent at 12 months (20.5%). Figure 2 shows the percentages of children with a borderline-clinical degree of emotional–behavioral problems among those with and without sleep terrors.

The figure shows the percentage of children at each time point who presented sleep terrors at least sometimes according to maternal report. The reported frequency of sleep terrors was relatively stable across time (16.7–20.5%). Across all time points, 34.26% (n = 111) children of the sample (N = 324) presented sleep terrors at least once during early childhood (12–36 months).

The figure shows the percentages of children presenting a borderline or clinical degree of emotional–behavioral problems (T score of 60 and above) for the three scales of the Child Behavior Checklist (total score, internalizing problems, and externalizing problems) measured at 48 and 60 months as a function of the presence or absence of sleep terrors in early childhood (12–36 months). Among the 309 participants at 48 months, 102 of them presented sleep terrors during early childhood (12–36 months). Among the 263 participants at 60 months, 91 of them presented sleep terrors during early childhood (12–36 months). The percentage of children with a borderline-clinical degree of internalizing problems at 60 months was significantly higher among children with sleep terrors (23.1%) than among children without sleep terrors (11.0%) (χ 2 = 6.679, P = .010). CBCL = Child Behavior Checklist.

Emotional–behavioral problems

Results of the first GEE model showed that higher average frequency of sleep terrors in early childhood was associated with more emotional–behavioral problems in preschoolers (CBCL total score at 48 and 60 months) (B = 9.489, P < .001; Table 1 ) while controlling for maternal depressive symptoms, time, child’s sex, and total nocturnal sleep duration. The second GEE model also showed a positive association between the average frequency of sleep terrors in early childhood and internalizing problems in preschoolers, controlling for the same covariates (B = 3.505, P < .001; Table 2 ). Results for the total CBCL score and internalizing problems remained significant even after applying the Holm-Bonferroni correction. Therefore, a higher average frequency of sleep terrors in early childhood was associated with more emotional–behavioral problems (total CBCL score) and more internalizing problems in preschoolers when controlling for confounders (maternal depressive symptoms, time, child’s sex, SES, and total nocturnal sleep duration in preschool) and applying the Holm-Bonferroni correction. The third GEE model initially showed an association between the average frequency of sleep terrors in early childhood and externalizing problems in preschoolers, but this relationship became nonsignificant after the Holm-Bonferroni correction was applied (B = 2.295, P = .026; Table 3 ).

Associations between frequency of sleep terrors in early childhood and emotional–behavioral problems in preschool (total CBCL score).

Frequency of sleep terrors is measured at 12, 18, 24, and 36 months. Socioeconomic status is measured at 12 months. Maternal depressive symptoms and nighttime sleep duration are measured at 48 and 60 months. CBCL = Child Behavior Checklist, CES-D = Center for Epidemiologic Studies Depression scale, CI = confidence interval.

Associations between frequency of sleep terrors in early childhood and internalizing problems in preschool.

Frequency of sleep terrors is measured at 12, 18, 24, and 36 months. Socioeconomic status is measured at 12 months. Maternal depressive symptoms and nighttime sleep duration are measured at 48 and 60 months. CES-D = Center for Epidemiologic Studies Depression scale, CI = confidence interval.

Associations between frequency of sleep terrors in early childhood and externalizing problems in preschool.

Posthoc binary logistic GEE showed that the frequency of sleep terrors in early childhood was not significantly associated with a borderline-clinical degree for the total CBCL score ( P = .065). However, there was a significant association between a higher average frequency of sleep terrors in early childhood and a borderline-clinical degree of internalizing problems in preschoolers ( P = .014; Table S1 and Table S2 in the supplemental material). In other words, a higher average frequency of sleep terrors in early childhood significantly increased the odds of presenting a borderline-clinical degree of internalizing problems in preschool.

Table 4 shows the beta coefficients obtained from GEE, analyzing the associations between frequency of sleep terrors in early childhood (12–36 months) and all the syndrome scales (48–60 months). Again, control variables were child’s sex, time, SES, maternal depressive symptoms (48 and 60 months), and nighttime sleep duration (48 and 60 months). After applying the Holm-Bonferroni correction, associations remained significant for the emotionally reactive scale (B = 0.837, P = .008), anxious/depressed scale (B = 1.219, P < .001), and the somatic complaints scale (B = 0.931, P = .002). The associations between frequency of sleep terrors and the withdrawn and aggressive behavior scales showed marginal associations but were no longer statistically significant after applying the Holm-Bonferroni correction (B = 0.505, P = .041; B = 2.027, P = .022; Table 4 ). There was no significant association between frequency of sleep terrors and attention problems (B = 0.253, P = .267; Table 4 ).

Associations between frequency of sleep terrors in early childhood and emotional–behavioral problems in preschool (syndrome scales).

Controlled for child’s sex, time, socioeconomic status (measured at 12 months), maternal depressive symptoms (measured at 48 and 60 months), and nighttime sleep duration (measured at 48 and 60 months). Underscored P values represent significant associations after Holm-Bonferonni correction. CI = confidence interval.

The frequency of sleep terrors in the MAVAN cohort was relatively stable in early childhood, with between 16.7 and 20.5% of children presenting with this parasomnia between the ages of 12 and 36 months. A greater frequency of sleep terrors in early childhood was associated with more emotional–behavioral problems in preschoolers, particularly internalizing problems.

To our knowledge, only 2 epidemiological studies investigated sleep terrors in toddlers. 9 , 10 They documented a prevalence of around 35% at 18 months and 20% at 30 months, which is slightly higher than what was observed in the present sample. 9 , 10 In most studies, including the present one, the presence of sleep terrors was assessed using parental reports. As noted by other authors, this method of data collection could result in either overestimating or underestimating the presence of this parasomnia. For instance, it is often challenging for parents to differentiate sleep terrors from nightmares. 10 Exclusion criteria for the current sample may also contribute to this discrepancy. Indeed, the current sample excluded children born prematurely or with severe health conditions, whereas epidemiological studies did not necessarily exclude these participants.

Present results showed an association between a higher frequency of sleep terrors in early childhood and internalizing problems at 4–5 years old. Moreover, a higher frequency of sleep terrors in early childhood significantly increased the likelihood of presenting a clinically significant degree of internalizing problems in preschool. These results are consistent with previous studies documenting links between the presence of sleep terrors with anxiety symptoms separation anxiety, and other psychological and psychiatric symptoms in children aged 2.5–15 years old. 8 , 9 , 11 , 13 , 15 A recent study also showed an association between disorder of arousal and internalizing symptoms using the same questionnaire (CBCL) in a smaller clinical sample of 41 participants aged 6–17 years old. 16 However, very few studies considered those relationships in early childhood, during the peak prevalence period of sleep terrors. 8 , 9 Present results are also consistent with longitudinal studies showing that sleep disturbances often precede symptoms of anxiety and depression in children. 32 – 35

As mentioned, very few studies have investigated the association between externalizing problems and sleep terrors. In the present study, while the frequency of sleep terrors was marginally associated with externalizing problems (more specifically aggressive behavior), these associations were nonsignificant after adjusting the threshold for multiple comparisons. Previous studies have found associations between aggressivity, delinquent behavior, and sleep terrors in children. 15 , 36 Other studies report associations between parasomnias and externalizing behaviors but are not specific to sleep terrors. 13 , 16 , 37 – 41 While we cannot draw conclusions about the nonexistence of such an association, results from this study showed a much clearer association between frequency of sleep terrors in early childhood and internalizing than externalizing problems in toddlerhood.

A strength of the present study was the use of a longitudinal design, allowing for the prediction of more emotional–behavioral symptoms at 4 and 5 years old based on the presence of sleep terrors earlier in development, while controlling for concurrent maternal depression, nocturnal sleep duration, child’s sex, and SES. It is notable that the association between sleep terrors and internalizing problems was maintained even when controlling for sleep duration. Indeed, shorter sleep duration is a well-known factor influencing mental health difficulties. 28 , 29 , 42 Results of the present study show that even if sleep terrors potentially impacted sleep duration, shorter sleep duration did not completely explain the association between sleep terrors and the development of internalizing problems. Similarly, while SES and maternal mood were both significantly associated with CBCL scores in our models, the relationship between the frequency of sleep terrors in early childhood and later emotional–behavioral problems remained statistically significant when controlling for these confounding factors. Therefore, the link found between sleep terrors and emotional–behavioral problems was independent from the effects of confounders.

Most children who experience sleep terrors in early childhood will often naturally stop experiencing them around age 5. 8 – 11 , 14 Therefore, in several children, this manifestation appears to be part of a normal developmental process. Still, for other children, sleep terrors may be an early warning sign for future internalizing problems, particularly depressive and anxiety symptoms. While it is not clear yet how to identify this specific subgroup, the results of this study suggest that some internalizing symptoms may be detected as early as age 4 years and that higher frequency of sleep terrors in early childhood might be a marker of this subgroup. This is consistent with results from Castelnovo et al, 16 who reported a positive correlation between emotional–behavioral problems in children and the severity of disorder of arousal episodes, measured with the Paris Arousal Disorders Severity Scale, 43 a measure that includes the complexity of episodes, their frequency, and negative consequence. Therefore, a high frequency of sleep terrors in early childhood might represent a prodromal manifestation of emotional difficulties.

Different mechanisms could be contributing to this relationship. Sleep terrors might interfere with sleep continuity, which would in turn negatively impact the development of emotion regulation in these children. Further longitudinal research in this age group would be needed to clarify this hypothesis and to identify other potential markers. For instance, the contribution of genetics should also be explored, considering the documented familial aggregation. 10 Following this hypothesis, it is possible that some children are more genetically at risk of developing both sleep disorders and emotional–behavioral difficulties.

Despite the association between sleep terrors and internalizing problems, sleep terrors alone should not warrant a cause for major concern among parents and clinicians, and the present study results should not be used as an argument for the prescription of medication to treat sleep terrors in children. As discussed earlier, sleep terrors are likely to stop without treatment for most children as they age. Instead, parents and clinicians should be mindful of symptoms of internalizing problems (ie, indicators of depression or anxiety) in children who present sleep terrors to ensure they receive appropriate support for their internalizing difficulties.

Limitations

Certain limitations should be kept in mind when interpreting the results of the present study. First, measures were obtained through maternal reports and, while maternal depressive symptoms were used as a control variable to minimize negative mood bias, reporting and common-method biases may still be influencing results. Although maternal depression was controlled to minimize this bias, using an objective measure of sleep such as polysomnography or actigraphy to record sleep would be ideal to confirm these results. Our sample comprised mostly high-SES participants; thus, results may not be generalizable to the general population. The presence of obstructive sleep apnea was not assessed in the present study, but future studies should include this variable since studies have shown associations with emotional–behavioral problems. 16 Finally, as it is often the case in longitudinal studies, it is likely that most vulnerable families dropped out the study. Therefore, this might contribute to explain some of the nonsignificant associations after applying the Holm-Bonferroni correction. Indeed, participants who were excluded from the study for not completing sufficient study measures had more emotional–behavioral problems in general than families who completed the study.

CONCLUSIONS

Despite these limitations, the present study offers novel insights into childhood sleep terrors. Longitudinal studies on sleep terrors in early childhood are lacking and are most often conducted on clinical populations. Our research with a healthy cohort of children further reinforces that higher frequency of sleep terrors is associated with internalizing symptoms, even in a younger population of preschoolers.

ACKNOWLEDGMENTS

The authors thank all families who participated in the MAVAN project and all current and past research staff for their contribution.

ABBREVIATIONS

Disclosure statement.

All authors have read and approved the final version of the manuscript. Work for this study was performed at McGill University. This study was funded by the Ludmer Foundation (M. Meaney) and the Fonds de recherche en santé du Québec under grant 268331 (C. Laganière) and 265486 (M.H. Pennestri). The authors report no conflicts of interest.

Night Terrors Resource Guide

• by Rose MacDowell
• Updated: September 7, 2023

Table of Contents

Night terrors, also called sleep terrors, are a type of sleep disorder that disrupts sleep and causes intense fear similar to that caused by nightmares. Unlike nightmares, night terror episodes may involve flailing, screaming, feelings of extreme panic, or sleepwalking.

Night terrors are considered a parasomnia, a classification of sleep disorders characterized by unusual behavior, vocalization, or movement during sleep . Night terrors are more common in children, but adults may suffer from them, as well. Though episodes normally last anywhere from a few seconds to a few minutes, they have been known to last thirty minutes or even longer.

Note: The content on Sleepopolis is meant to be informative in nature, but it shouldn’t take the place of medical advice and supervision from a trained professional. If you feel you may be suffering from any sleep disorder or medical condition, please see your healthcare provider immediately.

What Are Night Terrors?

Night terrors are a sleep disorder that typically occurs during the transition between the deepest stage of sleep, known as N3, and REM sleep , the fourth and final stage of sleep when vivid dreaming occurs. ( 1 ) The disorder results from a partial arousal from sleep, when the sufferer is not fully asleep but not conscious. Night terrors are characterized by a state of heightened fear, but do not typically involve dreams or nightmares .

Night terrors affect only a small percentage of children — approximately one to three percent — and an even smaller percentage of adults. ( 2 ) The disorder is more common in boys, and occurs most often around the age of one and a half.

While frightening for both children and parents, night terrors are not generally a cause for concern. Most children outgrow them by their teens or earlier. Night terrors may require treatment if they cause persistent sleep problems or become a safety risk.

Symptoms of Night Terrors

People who experience night terrors may scream, flail, sit up in bed , run around, or exhibit aggressive behavior. Some sufferers may leave the home, break windows, or damage furniture and other objects. ( 3 )

Other symptoms of night terrors include overwhelming fear and the inability to be awakened . Bedwetting occurs in some children. Sufferers may also experience some or all of the following:

• Rapid breathing
• Elevated heart rate
• Dilated pupils

One of the defining features of night terrors is amnesia, or the complete inability to recall the experience the following day . Even children who are awakened during an episode rarely remember it. ( 4 ) Though amnesia prevents direct recall of the occurrence, sufferers may experience the effects of night terrors after waking, including daytime sleepiness due to disrupted sleep.

Amnesia The short or long-term loss of memories, including experiences and facts.

Causes of Night Terrors

In children, night terrors can be a normal part of nervous system development . Sleep stages may not be clearly defined in young children, making night terrors, sleepwalking, and other parasomnias more likely. ( 5 ) Nervous system immaturity can cause the fight-or-flight system to activate at inappropriate times during sleep, triggering night terrors.

The disorder can also be associated with underlying medical conditions, such as seizure disorders and acid reflux. Other related triggers may include :

• Sleep apnea
• Narcolepsy and other forms of hypersomnia
• Light or noise
• An unfamiliar environment
• Restless legs syndrome

Night terrors may also occur as a side effect of certain medications. Other factors that can contribute to the disorder include stress, sleep deprivation, and fever . ( 6 )

Night terrors tend to run in families, and in adults may be associated with a history of anxiety or depressive disorders. They may also be caused by alcohol or recreational drug use in adults.

Diagnosis of Night Terrors

Night terrors are normally diagnosed by a doctor based on the patient’s or parents’ description of events . Doctors may conduct a psychological or physical exam to identify conditions that could be contributing to night terrors. If the diagnosis is unclear, doctors might recommend a sleep study, known as a polysomnography. ( 7 )

A polysomnography typically involves an overnight stay at a sleep lab. Brain waves, heart rate, and blood pressure are measured using sensors attached to the head and body. Limb movements and breathing are measured, as well. Though a sleep study may be helpful in cases where the diagnosis is less clear, the majority of night terrors sufferers can be diagnosed by symptoms alone.

Treatment of Night Terrors

Infrequent sleep terrors do not generally require treatment . Treatment may be needed if night terrors persist or cause significant sleep disruption. Treatment options include improving sleep habits , treating underlying conditions, and in rare cases, the use of medication. ( 8 ) Reducing stress and vigorous daily exercise may also be recommended.

Scheduled awakenings to avoid long periods spent asleep can also help. ( 9 ) These awakenings may be accomplished by parents, or by a machine designed to vibrate and slightly rouse the sleeper when it senses night terrors beginning.

Some studies show that co-sleeping with very young children may help reduce the incidence of night terrors . ( 10 ) Simply sharing a room with parents can reassure a child and make night terrors less likely.

Co-sleeping The practice of a parent and child sleeping in the same bed.

At-home treatment for night terrors includes the following :

• Do not awaken a child during a night terror. Try to help your child return to normal sleep by holding them or speaking in a soothing tone
• To help prevent injury, protect your child from stairways, windows, or leaving the home
• Explain night terrors and how to respond to them with anyone who stays with your child during naps or overnight
• Avoid triggers whenever possible. A child who is overly tired is more likely to suffer from night terrors. A regular sleep schedule, consistent afternoon naps, and treatment of related medical conditions can help prevent or reduce the frequency of the disorder

Night Terrors Vs. Nightmares

Though night terrors and nightmares share features such as intense fear, elevated heart rate, and sleep disruption, they are distinct entities . Nightmares involve frightening dreams , whereas night terrors do not. People who suffer from nightmares typically know where they are when they wake, and are able to remember specific details of their dreams. People suffering from night terrors remain asleep, and don’t normally remember their experiences in the morning.

Night terrors also differ from nightmares in that they occur during the first half of the night when N3 sleep dominates the sleep cycle. Nightmares normally occur during the last half of the night, when REM sleep cycles are longer. ( 11 )

While it is relatively easy to wake a child or adult from a nightmare, it is very difficult to wake a person suffering from night terrors . Sleep specialists generally warn against trying to wake someone from a night terror, and advise keeping the sleeper as safe and comfortable as possible until the episode passes. If you’re still curious about these differences, please check out our full guide on Nightmares vs Night Terrors .

Last Word From Sleepopolis

Night terrors are a fairly unusual occurrence in children, and quite rare in adults. They are considered a parasomnia, a sleep disorder associated with unusual behavior, dreams, or sensations. When night terrors do happen, they typically occur only on occasion and resolve by themselves by early adolescence. 

Frightening as night terrors can be to outside observers, sufferers do not remember the incidents. A regular sleep schedule, naps, and a dark, quiet sleep environment can help prevent disturbed sleep and night terrors. If the disorder occurs frequently or puts a child at risk of injury, treatments such as medication or scheduled awakenings can help reduce or even eliminate occurrences .

• Megan A. Moreno, Sleep Terrors and Sleepwalking:  Common Parasomnias of Childhood,  JAMA Pediatrics Patient Page , July, 2015
• Theodoros   Mazarakis,  A case of adult night terrors, Tzu Chi Medical Journal , Sept. 2014
• Wills L, Garcia J., Parasomnias: epidemiology and management, CNS Drugs , 2002
• Thornton B.A. Mason, II, MD, PhD., Pediatric Parasomnias, Sleep , Feb. 2007
• Irfan M, Schenck CH, Howell MJ., Non-Rapid Eye Movement Sleep and Overlap Parasomnias, Continuum, Aug. 2017
• Ngoc L. Van Horn; Megan Street, Night Terrors, StatPearls , Mar.2, 2019
• Eve G Spratt, MD, MSc; Chief Editor: Caroly Pataki, MD, Sleep Terrors, Medscape , Mar.14,2019
• DJ Nutt, Adult night terrors and paroxetine, The Lancet , July  19, 1997
•  Eve G Spratt, MD, Carolyn Pataki, MD, Sleep Terrors Treatment & Management, Medscape , Mar. 14, 2019
• Boyden SD, Pott M, Starks PT., An evolutionary perspective on night terrors, Evolution, Medicine, and Public Health , Apr. 14, 2018
• Rochelle Zak, MD, Nightmares and nightmare disorder in adults, UpToDate , Mar. 16, 201

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This chapter discusses the relationship between a commonly misdiagnosed parasomnia and various precipitating factors. Expertise in differentiating a benign parasomnia from significant medical disorders in adults and children is important, as is the ability to correctly identify and modify predisposing and precipitating factors. The case presented in this chapter illustrates how making a premature decision based on a small piece of information delayed an important diagnosis and increased the risk of further morbidity. The peak prevalence of sleep terrors is 18 months of age, but they may be seen at any age during childhood. When recurrent sleep terrors recur or develop in adults, evaluation for other primary sleep disorders, including sleep apnea, restless legs, shift work, and sleep deprivation, is warranted, and polysomnography is usually indicated. Identifying and correcting precipitating factors may minimize the recurrence of sleep terrors. Treatment of sleep apnea may greatly reduce the frequency of night terrors and other parasomnias.

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Effects of acupuncture therapy on 83 cases of infants with night terrors, export citation format, share document.

Night terror

A night terror, also known as sleep terror or pavor nocturnus, is a parasomnia sleep disorder characterized by extreme terror and a temporary inability to regain full consciousness.

• Sleep Disorder Research
• Insomnia Research
• Diseases and Conditions
• Sleep Disorders
• Sleep disorder
• Rapid eye movement
• Delayed sleep phase syndrome
• Circadian rhythm sleep disorder
• Sleep deprivation

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