Skip to main content
NCBI home page
Journal of Child & Adolescent Trauma logoLink to Journal of Child & Adolescent Trauma
. 2019 Jun 18;13(2):249–256. doi: 10.1007/s40653-019-00268-y

Nightmares in Treatment-Seeking Youth: the Role of Cumulative Trauma Exposure

Marie E Secrist 1,2,✉, Sufna G John 1, Shannon L Harper 1,3, Nicola A Conners Edge 4, Benjamin A Sigel 1, Chad Sievers 1, Teresa Kramer 1
PMCID: PMC7289908  PMID: 32549936

Abstract

Although nightmares are frequently endorsed symptoms in children who have experienced trauma, limited research has been conducted on how nightmares vary with different forms of trauma exposure. Our goal was to assess the relationship between nightmares, trauma exposure, and symptoms of Posttraumatic Stress Disorder (PTSD) in youth. A total of 4440 trauma exposed treatment-seeking youth (ages 7 to 18) were administered the UCLA PTSD Reaction Index. Different trauma types, total traumas experienced, and PTSD symptoms were analyzed with correlations and a logistic regression in relation to nightmare frequency. Overall, 33.1% of participants reported experiencing clinically-significant nightmares. 79.1% of the sample experienced more than one trauma type, with an average of 3.06 trauma types endorsed. A binary logistic regression demonstrated the odds of reporting clinically-significant nightmares increased by 1.3 times for every additional type of trauma experienced. Lastly, nightmares were positively correlated with all PTSD criterion. The current study provides prevalence rates of trauma exposure and nightmares in a large, statewide sample of treatment-seeking youth. Each new trauma type experienced resulted in a greater likelihood of endorsing clinically-significant nightmares. This study provides useful information related to assessing and addressing nightmares in youth who have experienced trauma.

Keywords: Nightmares, Sleep, Parasomnias, Children, Adolescents, Trauma, Youth, UCLA PTSD reaction index

Nightmares have been studied across a wide range of demographics, sleep disorders, and mental health conditions (Agargun et al. 2003; Ossa et al. 2013; Leskin et al. 2002). Nightmares have been described most frequently within the context of trauma exposure and are considered a “hallmark” symptom of Posttraumatic Stress Disorder (PTSD; Ross et al. 1989); however, limited research has been conducted on the association between exposure to distinct types of trauma and the frequency of nightmares. The purpose of this study was to explore the relationship between nightmare frequency and types of trauma, cumulative trauma exposure, and symptoms of PTSD in a statewide sample of children and adolescents in treatment settings.

An Overview of Nightmares

According to the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (DSM-5), “nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and that incite anxiety, fear or other dysphoric emotions” (American Psychiatric Association 2013). Parasomnias include night terrors, nightmares, nocturnal seizures, enuresis, and sleepwalking; all of which represent behaviors, emotions, movements, or dreams that occur beyond typical sleep parameters (American Academy of Sleep Medicine 2005). Lifetime prevalence for nightmares is estimated at 66% within the general population, with approximately 75% of individuals remembering one nightmare from childhood (American Academy of Sleep Medicine 2005; Bjorvatn et al. 2010). Within 3 to 5 year olds, nightmare prevalence rates are between 10% and 50% (Carter et al. 2014).

Nightmares have previously been classified as “re-experiencing” symptoms in the DSM-IV, and are currently classified within “intrusion” (along with physiological/psychological distress related to trauma cues, intrusive memories, and dissociative reactions such as flashbacks) in the DSM-5 symptom criteria for PTSD. In addition to representing a hallmark symptom of PTSD, nightmares also occur with higher co-morbid anxiety symptoms than in the general population (Floress et al. 2016).

Most nightmare research has been conducted with adults, although differences between child and adult samples have been noted. For example, research suggests that adult women report more nightmares than adult men (Agargun et al. 2003; Schredl and Reinhard 2011); however, there are limited reports of gender differences in youth samples (Ossa et al. 2013). Nightmare frequency in children tends to differ based on age (Schredl and Reinhard 2011) and occurs more often in children aged 5 to 10 years than in older age groups (Schredl et al. 2009; Schredl and Reinhard 2011). Conversely, there are no ethnic differences reported on nightmares in either adults (Petrov et al. 2014) or children (Secrist et al. 2018).

Trauma

Dalenberg et al. (2017) discuss the multiple ways in which trauma has been defined and the diverse themes that occur across definitions. Consistent with the most frequently used definition, trauma refers to experiencing an extreme stressor, with an actual or perceived threat, that activates an extreme stress response and surpasses one’s ability to cope (Perry and Azad 1999; Pfefferbaum 1997). These extreme stressors or traumas can occur once or chronically, and may be interpersonal (e.g., physical or sexual abuse) or non-interpersonal (e.g., a natural disaster or serious accident) in nature (Terr 1991). Exposure to highly stressful events is common (Breslau 2002), with a quarter of the general population experiencing at least one extreme stressor before age 16 years. This high prevalence rate exists for both interpersonal and non-interpersonal traumas. For example, 22% of the general population have experienced a natural disaster (Briere and Elliott 2000). Within an adolescent sample, Tierens and colleagues (Tierens et al. 2012) found that 22.4% reported being in a motor vehicle accident during their lifetime. Specifically regarding interpersonal trauma, the U.S. Department of Health and Human Services Child Maltreatment Report ( 2017) found that 7.2 million children were reported as victims of alleged maltreatment across the United States in 2015. An estimated 683,000 children were determined to be victims of abuse or neglect, with 78.1% of the perpetrators reported to be the child’s parent. Within these reports, neglect was the most prevalent type of abuse (75.3%), followed by physical abuse (17.2%) and sexual abuse (8.4%), with 14% of children with substantiated allegations experiencing at least two different types of maltreatment (U.S. Department of Health and Human Services 2017).

Nightmares and Trauma

Kales and colleagues (Kales et al. 1980) were among the first researchers to establish that major life events correlated with the presence of nightmares and that stress increased the frequency of nightmares in adults. Ross et al. (1989) pioneered the research of trauma and sleep and emphasized sleep disturbance and nightmares as a “hallmark symptom” of PTSD. Leskin et al. (2002) reported that 71% of adolescent and adult individuals with PTSD experience posttraumatic nightmares. Similarly, Krakow and colleagues (Krakow et al. 2007) reported that 79% of treatment-seeking adults with a history of trauma endorsed chronic nightmares. These individuals reported less efficient sleep, less total sleep time, and more psychiatric distress than patients who did not report chronic nightmares. In addition to being more frequent, posttraumatic nightmares have been found to be more distressing compared to nightmares with no identified origin (Langston et al. 2010). Nightmares are categorized as a re-experiencing symptom in the DSM-5 and have been compared to other re-experiencing symptoms, such as flashbacks (Duke et al. 2008).

As the severity of the trauma experienced or witnessed increases, the probability of posttraumatic nightmares increases (Nader 1996). In a sample of over 400 Palestinian and Galilean youth, participants with frequent and severe trauma exposure recalled more of their dreams and reported more salient dreams (Punama¨ki 1997). Generally, vivid, frightening, and bizarre dreams are more easily recalled (Schredl et al. 1996). Nightmare frequency and perceived intensity have been compared between traumatized and non-traumatized youth samples by Ossa et al. (2013). In this sample, traumatized children and adolescents reported a higher frequency of nightmares and more intense nightmares, with an average of 9.7 nightmares per month, compared to the non-traumatized comparative group (1.7 nightmares per month). Participants with a trauma history reported more themes of helplessness and violent dreams compared to the control group (Ossa et al. 2013).

There is limited research on nightmare prevalence associated with different trauma types, but specific trauma types have been studied separately in regard to nightmares. For example, a study examining medical traumas in children, specifically burn injuries, indicated that bad dreams and nightmares were reported in the pediatric burn unit settings immediately after the injury (Stoddard et al. 1996). Another qualitative study explored exposure to domestic violence as a particular type of trauma in relation to youth nightmares (Humphreys et al. 2009). Mothers affected by domestic violence reported general sleep disturbances and nightmares in their children exposed to domestic violence (Humphreys et al. 2009). Additionally, sleep problems are associated with child sexual abuse (Hébert et al. 2017) and motor vehicle accidents are associated with an increase of nightmares in children (Jones and Peterson 1993; Wittmann et al. 2010).

The current literature is limited in its exploration of nightmares in children (particularly from the child’s perspective), nightmare associations by trauma type, and nightmare frequency associated with cumulative trauma exposure. Moreover, research is lacking related to treatment-seeking populations, which provides useful information for improving clinical practice. This study will address these significant gaps in the literature by examining the following research goals within a large, treatment-seeking sample of youth with a history of trauma: (1) understand the association between nightmare frequency and trauma type, (2) explore how cumulative trauma exposure predicts nightmare frequency, and (3) explore the relationship between nightmares and other symptoms of PTSD. These results will aid in the clarification of symptom presentation for children who have been exposed to various forms of trauma and help to identify and successfully target treatment in which children may be at higher risk for experiencing nightmares subsequent to trauma exposure.

Methods

Background

The Arkansas Legislature approved funding in 2009 to address the psychological impact of childhood trauma by improving screening, monitoring, and continuity of care for children in the state of Arkansas. This funding was utilized to create the Arkansas Building Effective Services for Trauma (ARBEST) program, with the mission of improving outcomes for traumatized children and families across systems in Arkansas. Among other activities, the ARBEST program provides training in evidence-based trauma treatments and trauma symptom assessment to mental health professionals (MHPs) and child advocates within the state’s 13 Child Advocacy Centers (CACs) serving children following an allegation of abuse (most often sexual abuse, which was the largest sample in the current study). A web-based data collection system was designed to support MHPs in their implementation of trauma symptom assessment. Data from this system were utilized in this study (see Measures section). All data collection activities were approved by the University of Arkansas Institutional Review Board. There was no conflict of interest in the current study.

Participants

Participants in the study were children and adolescents (N = 4440) who presented for services at a CAC or other treatment facility across the state. We utilized data entered into the ARBEST website by 2235 MHPs or child advocates serving youth who experienced trauma, including both registration and child assessment data. Participants were excluded from the current study if they were outside of the 7–18 year age range due to the age cutoffs on the assessment tool included in this study (see below for a description of measures) (see Table 1).

Table 1.

Participant characteristics

Demographics (N = 4440) Percentage
Gender
   Female 70.8%
Reporter Type
   Child-report (ages 7–12 years) 28.3%
    Adolescent-report (ages 13–18 years) 71.7%
Race
    Caucasian 74.3%
    African American 13.5%
    Bi-racial 5.8%
    Other 6.4%
Ethnicity
    Hispanic 7.9%
Location of services
    Community Mental Health Center 22.8%
    Private/Group Provider 28.6%
    Academic Medical Center 10.4%
    Child Advocacy Center 38.1%
Open in a new tab

Measures

Trauma Exposure and Posttraumatic Stress Symptoms

The ARBEST web-based system provided access to the UCLA PTSD Reaction Index for DSM-IV, a tool that assesses trauma exposure and PTSD symptoms in children and adolescents (Steinberg et al. 2013; Steinberg et al. 2004). It includes parent-report and self-report versions. On the measure, informants are asked to indicate whether the child has been exposed to twelve different traumatic events and also includes an option to describe additional traumatic events not already queried. It subsequently asks individuals to identify the current most impairing event and asks questions about the child’s reactions during or directly after exposure to that event. Finally, it assesses PTSD symptom frequency on a 5-point Likert scale (from “none” to “most”) within the past month. The symptoms of PTSD are separated into three categories based on the DSM-IV criterion (note that some criterion names and associated symptoms have changed within updated DSM-5 criteria). On the form utilized within the current study (that assesses DSM-IV criteria) Criteria B includes re-experiencing symptoms, such as intrusive thoughts, flashbacks, bad dreams/nightmares, and psychological and/or physiological reactivity to trauma reminders. Criteria C includes avoidance symptoms, such as avoidance of thoughts, feelings, activities, or people that illicit trauma reminders; forgetting aspects of the traumatic event; diminished interest; detachment; and/or affect restriction. Criteria D includes symptoms of increased arousal, such as sleep problems, irritability, concentration difficulties, hypervigilance, and/or an exaggerated startle response. For the purposes of this study, when scoring Criterion B, we removed item 5 (“bad dreams/nightmares”), since we were exploring the relationship between that item and other symptoms of PTSD including on Criterion B.

The ARBEST web-based system houses all three versions of the UCLA PTSD Reaction Index: parent-report, child-report (ages 7–12 years), and adolescent-report (ages 13–18 years). Clinicians can elect which forms to use with families, with the parent form being optional for children above the age of 12 years. Only the child-report and adolescent-report forms were utilized within the current study to determine type of trauma exposure, nightmare frequency, and PTSD symptoms from the child’s perspective. Moreover, analyzing only youth self-report data allowed for the creation of a consistent dataset with no missing data, given that the parent-report form is optional for adolescents. Similar to the current internal consistency rates for the UCLA PTSD Reaction Index (Steinberg et al. 2013; Steinberg et al. 2004), each scale demonstrated good to adequate internal consistency within our sample. Specifically, the alpha reliability coefficients (Cronbach’s alpha) for the UCLA PTSD Reaction Index youth self-report were .80, .70, and .70 for Criteria B, C, and D respectively.

Trauma Type Variable

Trauma type variables were created from the UCLA PTSD Reaction Index trauma exposure items. Items that queried for similar traumatic events (e.g., “seeing someone in your town beaten or shot,” or “seeing a dead body in your town”) were grouped together to form a single trauma type (e.g., “community violence”). Children were given a score of “1” for a trauma type if they endorsed any item within the group or a score of “0” if they did not endorse any item within the group. Table 3 includes which traumatic experiences on the UCLA PTSD Reaction Index were grouped together for each trauma type variable. Additionally, a cumulative trauma exposure variable was created for each youth by summing their scores for each trauma type.

Table 3.

Prevalence rates of cumulative trauma exposure

Trauma Types Percentage
One trauma type 18.2%
Two trauma types 20.7%
Three trauma types 20.2%
Four trauma types 12.3%
Five trauma types 12.3%
Six trauma types 7.1%
Seven trauma types 2.2%
Open in a new tab

Nightmare Frequency Variable

Nightmare frequency was assessed on a 5-point Likert scale (0–4), ranging from “none - never”, “little – twice a month”, “some – once or twice a week”, “much – twice or three times a week”, and “most – almost every day” within the past month on the UCLA PTSD Reaction Index. Participants who endorsed that nightmares were experienced “much” or “most” within the past month (a score of 3 or 4) were coded as having clinically-significant nightmares, as is recommended by the measure.

Analysis Plan

The analysis plan for this study includes specific strategies to target each research goal, as follows: (1) we ran frequencies between each trauma type and nightmare frequency to understand how nightmares vary by trauma type; (2) a logistic regression was conducted to explore how cumulative trauma exposure predicts nightmare frequency. In the logistic regression, a significant beta weight (b) and Wald demonstrates statistical significant and allows for the rejection of the null hypothesis. The odds ratio (OR) determines how nightmare frequency shifts for every one unit increase in trauma type; (3) Pearson correlations were conducted between nightmare frequency and overall symptom count for Criterion B, C, and D on the youth self-report UCLA PTSD Reaction Index for DSM-IV to explore the relationship between nightmares and other symptoms of PTSD.

Results

Participant Characteristics

A total of 4440 participants were included in the analysis; the majority (70.8%) were female. The participants chosen for this analysis were between the ages of 7 to 18 years (M = 12.9; SD = 2.85). Based on age, most participants (71.7%) completed the adolescent self-report form, while the remainder completed the child self-report form. A majority of the participants were Caucasian (74.3%) and 13.5% were African American, 5.8% Bi-racial, and 6.4% identified as “Other.” Additionally, 7.9% of participants identified as Hispanic. Minority status was ascribed to clients who identified as African American, Bi-racial, Hispanic, and/or Other. See Table 1 for sample descriptives. Regarding trauma types, 37.9% of the sample experienced physical abuse, 59.9% experienced sexual abuse, 47.5% experienced community violence, 39.1% experienced a natural disaster, 49.6% experienced death/illness, 26.8% experienced a medical trauma, and 45.5% experienced domestic violence. It should be noted that participants can endorse more than one type of trauma. It should be noted that all variables met the assumptions for the following analyses and no outliers were present in the data.

Research Results

Preliminary Analyses

All analyses were completed using SPSS version 25. A total of 2969 participants (66.9%) reported either no nightmares or sub-clinical nightmares and 1471 participants (33.1%) reported clinically-significant nightmares. All participants endorsed at least one form of trauma. A total of 79.1% of the sample had experienced more than one trauma type, with an average of 3.06 (SD = 1.68) trauma types endorsed. 44.2% of participants indicated on the UCLA PTSD Reaction Index, sexual abuse as their most bothersome trauma.

Clinically-Significant Nightmares Differentiated by Trauma Type

Addressing research goal 1, results from cross-tab frequencies run between most bothersome trauma type and clinically-significant nightmares are reported in Table 2. Results indicated that experiences of sexual abuse (21.1%) were most commonly associated with clinically-significant nightmares and medical trauma (10.2%) was least associated with clinically-significant nightmares.

Table 2.

Trauma type definitions and relationship to nightmares

Trauma type endorsed UCLA PTSD Reaction Index Items Clinically-Significant Nightmares
Physical Abuse “being hit kicked or punched” 14.6%
Sexual Abuse “adult older than you touch private parts” 21.1%
Community Violence “war going on around you,” or “beaten up or shot in your town,” or “seeing someone in your town beaten or shot,” or “seeing dead body in your town” 18.7%
Natural Disaster/Accident “being in an earthquake damaged building,” “another kind of disaster,” or “being in bad accident” 15.6%
Death/Illness “hearing about death or serious injury of loved one” 18.5%
Medical Trauma “having painful scary medical treatment” 10.2%
Domestic Violence “seeing family member hit kicked or punched” 16.8%
Open in a new tab

Clinically-Significant nightmares: Nightmares endorsed at least 2–3 times per week on the UCLA PTSD Reaction Index

Nightmares Predicted by Cumulative Trauma

Addressing research goal 2, a total cumulative trauma type variable, named “cumulative trauma,” was created to understand the number of trauma types each participant had experienced on the youth self-report data. The correlation between youth self-report of cumulative trauma and nightmare frequency was r = .22, p < .01. Table 3 shows the percentage of participants who endorsed having clinically-significant nightmares for each added trauma type endorsed. A logistic regression was conducted to analyze the relationship between frequency of youth self-reported nightmares and cumulative trauma. Age, gender, and minority status were controlled for in the logistic regression. Cumulative trauma was a significant predictor of clinically-significant nightmares, (OR = 1.26, Wald χ2 = 137.58, p < .001) when controlling for age, gender, and minority status. Gender was also a significant predictor of clinically-significant nightmares (OR = 1.48, Wald χ2 = 27.50, p < .001), with females endorsing more frequent nightmares. Overall, for every type of trauma added, the odds of experiencing clinically-significant nightmares increased by 1.3 times, (CI 95% 1.21–1.30) (see Table 4).

Table 4.

Logistic regression predicting clinically-significant nightmares

Variable B SE B Wald χ2 OR 95% CI OR
Age −.01 .01 .85 .98 .96–1.10
Gender .39*** .07 27.50*** 1.48*** 1.27–1.71
Minority status −.06 .07 .80 .93 .80–1.08
Cumulative trauma .23*** .02 137.58*** 1.26*** 1.21–1.30
Open in a new tab

* p < .05, ** p < .01, *** p < .001. Minority status was used as the reference group. Female gender was used as the reference group

Nightmare Associations with Other PTSD Symptoms

Regarding research goal 3, results from Pearson correlations between nightmare frequency and PTSD Criteria scores on the UCLA PTSD Reaction Index indicated significant positive relationships between nightmare frequency and Criterion B (Re-experiencing), r = .58, p < .001; Criterion C (Avoidance), r = .64, p < .001; and Criterion D (Increased Arousal), r = .55, p < .001.

Discussion

The current study represents an important addition to the current literature on child trauma exposure and the experience of nightmares. The first research question examined the prevalence of clinically-significant nightmares reported by youth, based on the type of trauma experienced. Children and adolescents who had been sexually abused were the most likely to report clinically-significant nightmares (21.1%) in relation to other trauma types. This is in contrast to children who experienced medical trauma, who were about half as likely to report clinically-significant nightmares. It is important to note that the prevalence rates reported are not specific to only one trauma type (i.e., a child that was sexually abused may have also been exposed to community violence). The majority of our sample endorsed multiple traumas (79.1%), therefore examining prevalence related to those who only experienced each specific trauma would not be useful or generalizable for this population. Although exposure to multiple trauma types has been estimated to be 14% of the population in the United States (U.S. Department of Health and Human Services 2017), our results highlight that youth who have experienced one type of trauma and present for clinical services have likely experienced several types of trauma. Of note, a large proportion of participants for this study were referred from CAC’s (38.1%) which specialize in child sexual abuse assessment, which may account for the large percentage of our sample that had been exposed to sexual abuse (59.9%).

The second research question examined the likelihood of children reporting clinically-significant nightmares related to their cumulative trauma exposure. Children were 1.3 times more likely to report clinically-significant nightmares for every additional trauma type experienced.

The third research question examined the relationship between each DSM-IV PTSD symptom cluster/criterion (re-experiencing, avoidance, and arousal) and the frequency of nightmares reported by youth. There were strong positive relations found between all PTSD symptom clusters and nightmare frequency, with the strongest relationship found between avoidance and nightmares.

In summary, our findings demonstrated that clinically-significant nightmares are experienced by approximately one out of every five youth who have been sexually abused, compared to one out of every ten youth who experienced a medical trauma (with other trauma types falling in between). We also found that as the number of trauma types experienced by youth increases, the likelihood of youth reporting clinically-significant nightmares increases with each new type of trauma experienced. Finally, we found that nightmare frequency was strongly associated with other PTSD symptoms.

Strengths and Limitations

This is the first study to utilize a treatment-seeking population of youth to study the relationship between trauma exposure and nightmares. Another strength of this study was the use of a large state wide sample of youth with over 4000 participants in the current study. The sample ranged across ages, gender, and ethnicity. Additionally, this population was a treatment-seeking population with a history of trauma, which was a unique strength of this study. The current study also utilized a high quality measure to assess for trauma exposure and symptomatology through self-report data on the UCLA PTSD Reaction Index. There are some limitations to the current study that deserve mention. This study relied upon a retrospective account of nightmares; therefore, findings are specific to the participating youth’s memories of nightmares from the prior month. This measurement could be improved with prospective measurement, as developmental research has reported caution related to the accuracy of child retrospective time estimations (Bisson et al. 2012). However, this could have been largely circumvented by the older average age of our participants. This study included a cumulative trauma variable which represented how many different types of trauma were experienced by children; however, it is unknown how many specific instances each child experienced within each specific type (e.g., how many distinct episodes of physical abuse). To increase clinical utility in relation to cumulative trauma, nightmares were specified as either clinically-significant (occurring two or more times per week) or non-clinical (occurring less than two times per week); however, examining this variable as dichotomous rather than continuous might attenuate the strength of some relations. Additionally, the study is correlational and therefore cannot make causal or temporal inferences. Nightmare frequency prior to trauma exposure is unknown; therefore, we can establish that clinically-significant nightmares and cumulative trauma co-occur, but cannot assess whether nightmares increased following a youth’s traumatic experiences. Lastly, the current study included several important demographic covariates (age, gender, and minority status); however, there may be other variables that relate to both exposure to multiple trauma types and nightmare frequency. Future research in this area should continue to be mindful regarding relevant covariates to be included when examining these variables, such as including other mental health symptoms or general sleep difficulties.

Clinical Implications and Future Directions

This study assessed the relationship between nightmare frequency and trauma characteristics in a large sample of youth who reported on their own symptoms and trauma exposure. Our results underscore the importance of clinicians assessing nightmare frequency and severity in youth who have experienced trauma. Sexual abuse was most common with clinically-significant nightmares than other trauma types, followed by exposure to violence (in the community or at home). Unfortunately, cumulative trauma exposure was the rule versus the exception in treatment-seeking youth within our sample; indeed, approximately 80% of our sample endorsed experiencing more than one trauma type. Finally, clinically-significant nightmares demonstrated strong correlations with all other PTSD diagnostic criterion, suggesting substantial relationships between experiencing nightmares and other impairing posttraumatic stress symptoms. When assessing for nightmares, clinicians should also be thoughtful of associated impairments, including disrupted sleep, which can have significant impacts on a child’s ability to engage in relationships and participate in the learning environment (Dewald et al. 2010). When treating youth with frequent and distressing nightmares, clinicians should be aware of trauma exposure, the impact of nightmares across clinical domains, and evidence-based treatments for treating nightmares (Krakow et al. 2001; Pruiksma et al. 2018). This study adds to our current understanding of nightmares in children and adolescents exposed to traumatic events. Nevertheless, there are several opportunities for additional research that would continue this expansion of knowledge. First, the mean age of our sample was 12.9 years; additional research in younger populations would clarify whether the association between nightmares and trauma characteristics varies in different developmental stages. Children ages 5–10 may be especially helpful to explore further, given that this developmental period has previously been associated with the greatest frequency of nightmares in youth. Similar to adult samples, our study demonstrated significant gender differences in the prevalence of nightmares, with females reporting greater frequency of nightmares. However, our sample was almost three-quarters female. Additional work examining nightmare characteristics in males would be helpful. Moreover, our sample was largely Caucasian, with only one quarter of our sample identifying as a minority. Symptom presentation and impairment may demonstrate ethnic or racial differences and research that includes more diverse populations is needed.

Our study utilized the UCLA PTSD Index that was developed for the DSM-IV. These results should be replicated utilizing measures that focus on DSM-5 symptom criteria, particularly given the changes for children under the age of 6 years. This study also did not examine impairment associated with experiencing clinically-significant nightmares apart from their association with other symptoms of posttraumatic stress. It would be helpful for future studies to include measures of other areas that may be impaired by disrupted sleep (e.g., sleep quality, academic performance, peer relationships). Finally, given that PTSD is most often co-morbid with other psychiatric disorders (Brady et al. 2006), future work should examine if nightmare characteristics vary by diagnostic profile.

Overall, this study demonstrated the prevalence rates of clinically-significant nightmares in a large sample of treatment-seeking youth, exploring nightmare associations with trauma type and cumulative trauma exposure. Future research should continue to expand upon these finding to provide quality assessment and treatment for youth suffering from clinically-significant nightmares in relation to their trauma backgrounds.

Compliance with Ethical Standards

Conflict of Interest

Authors declare that they have no conflicts to report.

Ethical Standards and Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation [institutional and national] and with the Helsinki Declaration of 1975, as revised in 2000. These data were collected as part of a program evaluation of ARBEST approved through the UAMS IRB. The UAMS IRB approved a waiver of informed consent for this study.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

  1. Agargun MY, Kara H, Ozer OA, Selvi Y, Kiran U, Kiran S. Nightmares and dissociative experiences: The key role of childhood traumatic events. Psychiatry & Clinical Neurosciences. 2003;57:139–145. doi: 10.1046/j.1440-1819.2003.01093.x. [DOI] [PubMed] [Google Scholar]
  2. American Academy of Sleep Medicine . The international classification of sleep disorders, second edition (ICSD-2) Westchester: American Academy of Sleep Medicine; 2005. [Google Scholar]
  3. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5™. 5th ed. Arlington: American Psychiatric Publishing, Inc. 10.1176/appi.books.9780890425596
  4. Bisson N, Tobin S, Grondin S. Prospective and retrospective time estimates of children: A comparison based on ecological tasks. PLoS One. 2012;7:e33049. doi: 10.1371/journal.pone.0033049. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bjorvatn B, Grønli J, Pallesen S. Prevalence of different parasomnias in the general population. Sleep Medicine. 2010;11(10):1031–1034. doi: 10.1016/j.sleep.2010.07.011. [DOI] [PubMed] [Google Scholar]
  6. Brady K, Killeen T, Brewerton T, Lucerini S. Comorbidity of psychiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry. 2006;61(7):22–32. [PubMed] [Google Scholar]
  7. Breslau N. Epidemiologic studies of trauma, posttraumatic stress disorder, and other psychiatric disorders. Canadian Journal of Psychiatry. 2002;47:923–929. doi: 10.1177/070674370204701003. [DOI] [PubMed] [Google Scholar]
  8. Briere J, Elliott D. Prevalence, characteristics and long-term sequelae of natural disaster exposure in the general population. Journal of Traumatic Stress. 2000;13(4):661–679. doi: 10.1023/A:1007814301369. [DOI] [PubMed] [Google Scholar]
  9. Carter KA, Hathaway NE, Lettieri CF. Common sleep disorders in children. American Family Physician. 2014;89(5):368–377. [PubMed] [Google Scholar]
  10. Dalenberg CJ, Straus E, Carlson EB. Defining trauma. In: Gold SN, Gold SN, editors. APA handbook of trauma psychology: Foundations in knowledge. Washington, DC: American Psychological Association; 2017. pp. 15–33. [Google Scholar]
  11. Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bögels SM. The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: A meta-analytic review. Sleep Medicine Reviews. 2010;14(3):179–189. doi: 10.1016/j.smrv.2009.10.004. [DOI] [PubMed] [Google Scholar]
  12. Duke LA, Allen DN, Rozee PD, Bommaritto M. The sensitivity and specificity of flashbacks and nightmares to trauma. Journal of Anxiety Disorders. 2008;22(2):319–327. doi: 10.1016/j.janxdis.2007.03.002. [DOI] [PubMed] [Google Scholar]
  13. Floress MT, Kuhn BR, Bernas RS, Dandurand M. Nightmare prevalence, distress, and anxiety among young children. Dreaming. 2016;26(4):280–292. doi: 10.1037/drm0000034. [DOI] [Google Scholar]
  14. Hébert M, Langevin R, Guidi E, Bernard-Bonnin AC, Allard-Dansereau C. Sleep problems and dissociation in preschool victims of sexual abuse. Journal of Trauma & Dissociation. 2017;18:507–521. doi: 10.1080/15299732.2016.1240739. [DOI] [PubMed] [Google Scholar]
  15. Humphreys C, Lowe P, Williams S. Sleep disruption and domestic violence: Exploring the interconnections between mothers and children. Child & Family Social Work. 2009;14(1):6–14. doi: 10.1111/j.1365-2206.2008.00575.x. [DOI] [Google Scholar]
  16. Jones RW, Peterson LW. Post-traumatic stress disorder in a child following an automobile accident. The Journal of Family Practice. 1993;36(2):223–225. [PubMed] [Google Scholar]
  17. Kales A, Soldatos CR, Caldwell AB, Charney DS, Kales JD, Markel D, Cadieux R. Nightmares: Clinical characteristics and personality patterns. The American Journal of Psychiatry. 1980;137:1197–1201. doi: 10.1176/ajp.137.2.268-a. [DOI] [PubMed] [Google Scholar]
  18. Krakow B, Hollifield M, Johnston L. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: A randomized controlled trial. JAMA. 2001;286(5):537–545. doi: 10.1001/jama.286.5.537. [DOI] [PubMed] [Google Scholar]
  19. Krakow, B., Haynes, P. L., Warner, T. D., Melendrez, D., Sisley, B. N., Johnston, L., & … Lee, S. (2007). Clinical sleep disorder profiles in a large sample of trauma survivors: An interdisciplinary view of posttraumatic sleep disturbance. Sleep and Hypnosis, 9(1), 6–15.
  20. Langston TJ, Davis JL, Swopes RM. Idiopathic and posttrauma nightmares in a clinical sample of children and adolescents: Characteristics and related pathology. Journal of Child & Adolescent Trauma. 2010;3:344–356. doi: 10.1080/19361521.2010.523064. [DOI] [Google Scholar]
  21. Leskin GA, Woodward SH, Young HE, Sheikh JI. Effects of comorbid diagnoses on sleep disturbance in PTSD. Journal of Psychiatric Research. 2002;36:449–452. doi: 10.1016/S0022-3956(02)00025-0. [DOI] [PubMed] [Google Scholar]
  22. Nader K. Children's traumatic dreams. In: Barrett D, Barrett D, editors. Trauma and dreams. Cambridge: Harvard University Press; 1996. pp. 9–24. [Google Scholar]
  23. Ossa FC, Bering R, Pietrowsky R. Prevalence and intensity of nightmares in traumatized and nontraumatized children and adolescents. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie. 2013;41(5):309–317. doi: 10.1024/1422-4917/a000246. [DOI] [PubMed] [Google Scholar]
  24. Perry BD, Azad I. Posttraumatic stress disorder in children and adolescents. Current Opinion in Pediatrics. 1999;11:310–316. doi: 10.1097/00008480-199908000-00008. [DOI] [PubMed] [Google Scholar]
  25. Petrov ME, Lichstein KL, Baldwin CM. Prevalence of sleep disorders by sex and ethnicity among older adolescents and emerging adults: Relations to daytime functioning, working memory and mental health. Journal of Adolescence. 2014;37(5):587–597. doi: 10.1016/j.adolescence.2014.04.007. [DOI] [PubMed] [Google Scholar]
  26. Pfefferbaum B. Posttraumatic stress disorder in children: A review of the past 10 years. Journal American Academy Child Adolescent Psychiatry. 1997;36:1503–1511. doi: 10.1016/S0890-8567(09)66558-8. [DOI] [PubMed] [Google Scholar]
  27. Pruiksma KE, Cranston CC, Rhudy JL, Micol RL, Davis JL. Randomized controlled trial to dismantle exposure, relaxation, and rescripting therapy (ERRT) for trauma-related nightmares. Psychological trauma: theory, research, practice and policy. 2018;10(1):67–75. doi: 10.1037/tra0000238. [DOI] [PubMed] [Google Scholar]
  28. Punama¨ki R-L. Determinants and mental health effects of dream recall among children living in traumatic conditions. Dreaming. 1997;7:235–263. doi: 10.1037/h0094481. [DOI] [Google Scholar]
  29. Ross RJ, Ball WA, Sullivan KA, Caroff SN. Sleep disturbance as the hallmark of posttraumatic stress disorder. The American Journal of Psychiatry. 1989;146(6):697–707. doi: 10.1176/ajp.146.6.697. [DOI] [PubMed] [Google Scholar]
  30. Schredl M, Reinhard I. Gender differences in nightmare frequency: A meta-analysis. Sleep Medicine Reviews. 2011;15(2):115–121. doi: 10.1016/j.smrv.2010.06.002. [DOI] [PubMed] [Google Scholar]
  31. Schredl M, Kleinferchner P, Gell T. Dreaming and personality: Thick vs. thin boundaries. Dreaming. 1996;6:219–223. doi: 10.1037/h0094456. [DOI] [Google Scholar]
  32. Schredl M, Fricke-Oerkermann L, Mitschke A, Waiter A, Lehmkuhl G. Longitudinal study of nightmares in children: Stability and effect of emotional symptoms. Child Psychiatry and Human Development. 2009;40:439–449. doi: 10.1007/s10578-009-0136-y. [DOI] [PubMed] [Google Scholar]
  33. Secrist, M., Dalenberg, C.J., Gevritz, R. (2018). Contributing factors to nightmares in children: Trauma, anxiety, dissociation and emotion-regulation. Psychological trauma: Theory, research, practice, and policy. Washington, DC: American Psychological Association. 10.1037/tra0000387. [DOI] [PubMed]
  34. Steinberg AM, Brymer M, Decker K, Pynoos RS. The UCLA PTSD reaction index. Current Psychiatry Reports. 2004;6:96–100. doi: 10.1007/s11920-004-0048-2. [DOI] [PubMed] [Google Scholar]
  35. Steinberg AM, Brymer MJ, Kim S, Ghosh C, Ostrowski SA, Gulley K, Pynoos RS. Psychometric properties of the UCLA PTSD reaction index: Part 1. Journal of Traumatic Stress. 2013;26:1–9. doi: 10.1002/jts.21780. [DOI] [PubMed] [Google Scholar]
  36. Stoddard FJ, Chedekel DS, Shakun L. Dreams and nightmares of burned children. In: Barrett D, Barrett D, editors. Trauma and dreams. Cambridge: Harvard University Press; 1996. pp. 25–45. [Google Scholar]
  37. Terr LC. Childhood traumas: An outline and overview. American Journal of Psychiatry. 1991;148:10–20. doi: 10.1007/978-1-4899-1034-9_18. [DOI] [PubMed] [Google Scholar]
  38. Tierens M, Bal S, Crombez G, Van de Voorde P, Rosseel Y, Antrop I, Deboutte D. The traumatic impact of motor vehicle accidents in high school students. Journal of Pediatric Psychology. 2012;37(1):1–10. doi: 10.1093/jpepsy/jsr058. [DOI] [PubMed] [Google Scholar]
  39. U.S. Department of Health & Human Services (2017). Child maltreatment - 2015. Administration for Children & Families. Children’s Bureau, Washington, D.C. Retrieved September 20, 2017 from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2015.
  40. Wittmann L, Zehnder D, Schredl M, Jenni OG, Landolt MA. Posttraumatic nightmares and psychopathology in children after road traffic accidents. Journal of Traumatic Stress. 2010;23(2):232–239. doi: 10.1002/jts.20514. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Child & Adolescent Trauma are provided here courtesy of Springer

RESOURCES