Question 1

What is the next step if story telling doesn't help with a child that delays going to bed, is scared and has difficulty sleeping? What would CBT involve in this scenario? Thank you

Krystal Lewis · Accepted Answer

Cognitive Behavioral Therapy, also known as CBT, is a type of intervention that helps people address unhelpful cognitions, behavioral avoidance, and accompanying physiological distress. A mental health professional, such as a licensed therapist or clinical psychologist, will typically perform an assessment to understand the nature of the child’s problem and determine the best approach to addressing it. The therapist would then help educate both parent and child about fear and anxiety, encourage modeling, help with exposures, and discuss reinforcement strategies. The relationship with the therapist is important, as they can help to provide a supportive and safe environment for the child. The therapist may teach the child ways to relax their body if they are experiencing physiological responses, such as a racing heart or changes in breathing, and help them identify more helpful ways of thinking. Exposure is an important part of CBT, so the therapist may work on slowly exposing the child to the dark, being away from the parent, and sleeping in their own bed. The therapist can also help the parent and child structure exposures, or practices, at home.

Question 2

How does bibliotherapy work?

Krystal Lewis · Accepted Answer

Bibliotherapy is the use of books as a form of therapy in the treatment of mental disorders. The theory behind bibliotherapy is that reading about one's problem areas can produce change that is specific and predictable. The theoretical underpinnings of bibliotherapy for anxiety are that the books incorporate common anxiety-reduction principles, including coping strategies, exposure to anxiety provoking situations, reinforcement, and modelling of desired behaviors through the use of storytelling. Bibliotherapy can promote problem-solving and increase self-awareness. Research with children and adolescents has identified bibliotherapy as an effective first line intervention for mild nighttime and separation fears (see research papers below). Jorm, A. F., Christensen, H., Griffiths, K. M., Parslow, R. A., Rodgers, B., & Blewitt, K. A. (2004). Effectiveness of complementary and self‐help treatments for anxiety disorders. Medical Journal of Australia, 181, S29-S46 Lewis, K. M., Amatya, K., Coffman, M. F., & Ollendick, T. H. (2015). Treating nighttime fears in young children with bibliotherapy: Evaluating anxiety symptoms and monitoring behavior change. Journal of Anxiety Disorders, 30, 103-112. Rafihi-Ferreira, E., Lewis, K. M., McFayden, T., & Ollendick, T. H. (2019). Predictors of nighttime fears and sleep problems in young children. Journal of Child and Family Studies, 28(4), 941-949. Rapee, R., Wignall, A., Spence, S., Lyneham, H., & Cobham, V. (2008). Helping your anxious child: A step-by-step guide for parents. New Harbinger Publications.

Question 3

Is a nightlight a good option for children when they are scared of the dark and being alone in their own room? Could the light possibly disrupt the quality of their sleep and is it reinforcing the anxiety?

Krystal Lewis · Accepted Answer

Many children use nightlights to help with the transition to sleep. When using a nightlight in the room at night, a low-light dim light is recommended. Additionally, it is important to place the light far enough away from the child’s bed so that the light is not directly in the child’s face. Alternatively, keeping the hallway light on with the child’s bedroom door cracked open can also be helpful. Bright lights may disrupt the child’s sleep and keeping the bedroom light or other bright lights on during the night may reinforce the child’s fear of the dark, if that is at the core of the nighttime fears. It is recommended to start with the amount of light necessary to help the child go to sleep and then slowly reduce the amount of light with reinforced practice. It can be helpful for the child to practice being in the dark for short periods of time throughout the day, in their bedroom but also other parts of the house if they are part of the child’s nighttime fears. If the fear is not getting better or is interfering in daily functioning and family life, the next step is typically to consult a health care provider for more help.

Question 4

My child is scared of the dark - does that mean they are at risk of an anxiety disorder?

Krystal Lewis · Accepted Answer

Fear of the dark and other fears are part of normal development. There are many risk factors for anxiety and having any one risk factor does not mean that a child will automatically develop an anxiety disorder. That said, there are biological and environmental risk factors that may increase the risk that children will develop anxiety disorders later. For example, biological risk factors include having a genetic predisposition, specific medical conditions, biological sex, and temperament. On the environmental side, parenting perceptions and behaviors, negative social experiences, loss of a loved one, and neighborhood factors are all external influences that may increase the risk for children. Having an anxiety disorder in childhood does increase the risk of anxiety in adulthood. Left untreated, anxiety can lead to an array of difficulties that impact social and family functioning, including depression and substance use. The good news is that anxiety is highly treatable, and the key is early identification and intervention. We have solid treatments for child anxiety, so the best thing concerned parents can do is talk to the child’s health care provider or schedule an appointment with a qualified mental health professional. Evidence-based information about anxiety and mental health in children is also available online. See, for example: https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health https://www.cdc.gov/childrensmentalhealth/depression.html https://adaa.org/find-help/by-demographics/children/children-teens

Question 5

How do parents differentiate between normal developmental fears of the dark and fears and sleep problems that they should seek professional help with?

Krystal Lewis · Accepted Answer

Fear of the dark is a normal part of childhood development. Many children have a fear of the dark and tend to overcome this fear as they get older with support from their parents. It is completely normal for young children to be fearful of things like monsters under the bed or in the closet, dark rooms or being alone in dark rooms, and scary movies/shows, all of which may make it difficult to sleep at night. Moreover, some children are scared to be far away from their parents and have trouble sleeping alone in their rooms. Over time, these fears may dissipate, as children’s cognition and emotion regulation abilities develop as well as their sense of self-efficacy. For some kids, fears can get more extreme as they get older and that can be a sign of an anxiety disorder. If a child’s fear seems extreme and keeps them from doing things that are developmentally appropriate (brushing teeth, sleeping alone, going outside, etc.) or causes physically distressing symptoms (stomachaches, racing heart, headaches, dizziness, etc.), parents may want to speak with their child’s health care provider. A health care provider can help determine the best course of action and provide relevant referrals.

Question 6

What common mistakes do parents make that may contribute to their children’s nighttime fears?

Krystal Lewis · Accepted Answer

There are many factors that contribute to childhood fear, but there are certain things that parents can do to help their child become more independent at night. Many parents may engage in accommodation to ease their child’s fears, such as sleeping on the floor of the child’s bedroom, allowing the child to sleep in their bed, or engaging in excessive nighttime rituals with the child. Although parents may believe that this type of accommodation is helpful, we know that it often has the opposite effect, maintaining rather than minimizing the child’s anxiety. It can be hard for parents to see their child feeling scared or anxious, but it is important to know that avoiding nighttime fears does not help the fear dissipate in the long term. When parents engage in behaviors that suggest the child can’t handle scary situations, it impacts the child’s sense of efficacy and ability to do hard things. Allowing the child to view developmentally inappropriate shows can also contribute to their fear and experience of scary thoughts. These are just a few things that parents may do that actual increase or maintain their child’s nighttime fears.

Question 7

What sort of books are suitable for children with nighttime fears and how should they be used?

Krystal Lewis · Accepted Answer

There are many self-help books that can be used to help children with nighttime fears. As an example, Mary Coffman and her team created Uncle Lightfoot, Flip That Switch: Overcoming Fear of the Dark. This book has been translated into several languages and has been used in several research studies (Lewis et al., 2015; Milkulas et al., 1985). Benny Goes to Bed by Himself: Kids and Parents beating Nighttime Fears Together by Jonathan Kushnir is another book based on cognitive behavioral therapy that could be useful. The topic or focus of the book may depend on whether the crux of the fear is the dark, being alone, worries, or scary dreams. There are self-help books that parents can buy and use on their own. However, if the fear continues to be impairing and interfering, it is recommended that families work with a licensed provider to receive guidance on implementing techniques and to teach children coping skills. Lewis, K. M., Amatya, K., Coffman, M. F., & Ollendick, T. H. (2015). Treating nighttime fears in young children with bibliotherapy: Evaluating anxiety symptoms and monitoring behavior change. Journal of Anxiety Disorders, 30, 103-112. Mikulas, W. L., Coffman, M. G., Dayton, D., Frayne, C., & Maier, P. L. (1986). Behavioral bibliotherapy and games for treating fear of the dark. Child & Family Behavior Therapy, 7(3), 1-8.

Question 8

I am curious as how to best treat night terrors in a 14 year old?

Krystal Lewis · Accepted Answer

As children age, night terrors typically become less common; however, there is a subset of adolescents and adults who continue to experience night terrors. Night terrors can also develop following stressful or traumatic events. It may be helpful to create a sleep log and track events and activities that occur prior to bedtime, during the night, and upon waking to potentially identify any patterns. It is most important to consider sleep hygiene and focus on ways to enhance the sleep experience. Sleep deprivation is a known trigger for night terrors, so focusing on improving sleep quality can be immensely helpful. Adolescents and adults who continue to experience night terrors could benefit most from an evaluation by a health care professional to determine whether there is an underlying cause and identify sleep patterns. Therapy and certain medications can be effective ways to manage night terrors when they are part of a treatment plan developed by a qualified professional.

Question 9

What are good strategies for helping kids who ruminate over scary images from the media?

Krystal Lewis · Accepted Answer

Kids will be exposed to all types of imagery from media including television, social media, and movies. Depending on their age and developmental stage, some kids will be significantly affected by scary images that they view. It is most important to make sure that whatever the child is viewing is age appropriate. Although some kids like scary movies and science fiction, sometimes that content is not appropriate for a young child to watch. Following suggested guidelines and limiting media exposure as necessary can be helpful, especially if the child tends to scare easily. We know that avoidance isn’t the answer – trying to completely avoid exposure will be difficult and may be counterproductive in the long run. If the child is ruminating on a scary image from something they saw, talking with them about what they are imagining can help. Perhaps drawing out the images and discussing the content can help lessen the “scariness” of the thought. Normalize their worries and let them know that it is okay to be scared of something. For some kids who ruminate and get thoughts stuck in their head, it can be helpful to: 1. Limit the amount of time spent focused on the thoughts. 2. Teach them strategies to relax if they are getting very upset when having the thoughts. 3. Find ways to distract them from the thoughts. 4. Teach them to name the scary thought and say “there is that scary thought again” to create distance between themselves and the image.

Question 10

Does co-sleeping help, or can it make things worse?

Krystal Lewis · Accepted Answer

Co-sleeping is one strategy parents may use for dealing with nighttime fears. Children’s request for co-sleeping can be reactive and in response to anxiety. If there are other indicators of nighttime fears, such as behavioral disruptions at night, difficulty going into rooms alone, difficulties with transition to bedtime, expressed worries about safety and bad things happening at night, these are all signs that there is underlying fear and anxiety that is making it difficult for the child to sleep alone. In this case, co-sleeping can help the child sleep at night. However, co-sleeping can also lead to dependency, in which the child needs to be with a parent or sibling at night in order to sleep. It is recommended that the parent sit in the child’s room for a period of time to help the child fall asleep but not sleep in the bed with the child. Reward systems are often helpful for getting the child to stay in their own room, but if the child is significantly fearful then it may be necessary to help the child learn strategies to manage their fear/anxiety and practice being alone and being in the dark. Fear of the dark and nighttime anxiety can be treated by a qualified professional when attempts by the parent and child are not successful.

Night-Time Fears in Young Children