A novel framework reveals why children have nightmares, and how building confidence and coping skills can help them gain control over their sleep.
Study: DARC-NESS: A mastery-based cognitive-behavioral model for treating chronic nightmares in youth.. Image Credit:Raw Pixel.com/Shutterstock.com
Nightmare disorder, characterized by the presence of chronic nightmares, can disrupt healthy sleep in childhood and adolescence, interfering with normal development. A recent paper in border in sleep Proposes a novel theory-driven, evidence-informed model for its treatment.
Nightmares disrupt the sleep cycle, reducing total sleep time and increasing the ability to wake up before the start of the next sleep cycle. When they become persistent, normal day-to-day functioning is affected, and the risk of mental health problems increases. Currently, both educational and cognitive behavioral therapy (CBT) interventions are used to improve sleep quality and duration, but their role in nightmare disorder is less studied. Nightmares are effectively managed in adults, but childhood interventions are less explored.
Nightmares vs. other nocturnal disorders
Chronic nightmares can have a significant impact on both mental and physical health, disrupting the sleep of not only the child but often family members as well. Although they can sometimes indicate an underlying mental health condition, nightmares are often thought of as secondary symptoms of disorders such as posttraumatic stress disorder (PTSD). However, emerging evidence suggests that directly addressing nightmares can meaningfully reduce symptoms, even when they are accompanied by other conditions.
Importantly, nightmares are distinct from other nighttime disturbances, including sleep terrors, nighttime anxiety, nocturnal panic attacks, and sleep-related breathing disorders. It is important to accurately differentiate between these conditions, as they differ in the underlying mechanisms and therefore require different treatment approaches.
Nightmares are traditionally classified as post-traumatic or idiopathic. Yet in children this difference may be less pronounced. Growing evidence suggests that trauma exposure and difficulties in fear extinction may interact along a continuum, leading to increased severity of nightmares as well as related symptoms such as depression and PTSD.
Hypotheses about nightmare cycles
Earlier theories suggest that nightmares persist from learned behavioral and cognitive responses to poor sleep, whether caused by insomnia or posttraumatic nightmares (PTN). An influential model, the “3P model”, identifies predisposing, precipitating, and perpetuating factors that interact to maintain sleep disorders.
Others propose that nightmares operate through reciprocal feedback processes where anxiety and overarousal associated with nightmares increase susceptibility to nightmares. The authors suggest that interventions may be more effective if they target a central component. Interactive processes.
In particular, some researchers believe that normal adaptive dreaming helps eliminate fearful memories by rewiring the brain to a fear-free environment. Conversely, with affect overload, a condition in which the child’s emotional distress exceeds the child’s ability to regulate emotions, this process can break down. Poor extinction of fear leads to repeated disturbing dreams that reactivate fear responses, making the child more likely to have nightmares.
DARC-NESS MODEL
The new model, called DARC-NESS, suggests that all nightmares, regardless of origin (posttraumatic or idiopathic), are sustained through a common set of interacting components that perpetuate nightmares. These include:
- dream (nightmare) content
- Appraisal (how the child interprets the experience)
- Resources for Regulation: Dealing with and Controlling Emotions
- Conditioned arousal: learned physiological activation in response to nightmares.
- Nightmare efficacy: child’s sense of control over nightmares
- Sleep hygiene and patterns
- sleep quality and quantity
Each of these can help maintain the cycle, but none are universal. For example, disturbing nightmare content sometimes reminds the child of a fearful memory, causing intense emotional disturbance, fear reactions, and frequent awakenings. This may contribute to reactivation of the fear network on consecutive nights. Importantly, the model is non-linear, meaning that children may enter or progress through these processes in different ways.
How the model works
Nightmare treatments operate primarily through several mechanisms, the most prominent of which is overcoming the nightmare. This is a central feature of the DARC-NESS model, which positions nightmare efficacy as the main mechanism driving change. The aim is to help affected children understand how the nightmare cycle is maintained and to help them change the pattern.
The model is designed as a flexible toolkit, enabling a modular, personalized approach that meets the needs of each child. The tools can be introduced in any order or combination depending on the situation and response. These tools aim to help children:
- discuss their nightmares
- Externalize the content of the nightmare through drawing or writing, helping children “get the nightmare out of their mind and onto paper.”
- Develop cognitive and emotional regulation skills: reassure them about the normality of nightmares, help them move through the fear through these skills
- Encourage experimentation with self-regulation tools without being discouraged by initial failures
- Improve their sleep patterns: often an early entry point
- Track nightmare patterns using a sleep and nightmare diary, thus monitoring changes and strengthening self-efficacy
During treatment, youth develop an increased sense of agency, believing that their actions can affect their sleep and nightmares.
The model encourages a collaborative approach, as children and their healthcare providers work together to identify the most relevant components for intervention.
The authors included a detailed case study to illustrate the clinical application of this model. They also report promising reductions in nightmares and improvements in mental health in early studies, and emphasize the need for voluntary participation to ensure the highest chance of success.
This modular approach may enable more individualized and efficient treatment of nightmare disorder in children.
