J. Paediatr. Child Health (1992) 28, 347-350
Annotation Night-time fears in children N. J. KING,’ B. J. TONGE2and T. H. OLLENDICK3 faculty of Education, School of Graduate Studies, Monash University, ‘Centre for Developmental Psychiatry, Monash Medical Centre, Clayton, Victoria, Australia and 3Deparfment of Psychology, Virginia Polytechnic lnstitute and State University, Blacksburg, Virginia, USA
Children’s night-time fears are part and parcel of normal development. Several authors have commented on the developmental progression of these ‘normal’ fears and have shown how they emanate from increasingly sophisticated cognitive development in the growing child.’,2 Infants and very young children show fear to things that occur in their immediate environment (e.9. loud noises, strangers, separation from parents). Their level of cognitive development limits the range of stimuli to which they can experience fear to those stimuli which are in the here and now and in their immediate presence. Preschool children, on the other hand, are capable of showing fear to more global and imaginary stimuli such as ghosts, monsters and the dark. Older children, able to differentiate ‘internal representations from objective reality’, begin to show more realistic and specific fears including fears related to physical injury, health and school performance.I This pattern in the types of fears children experience at different ages was illustrated in a study by Bauer in which he examined the fears of 4-6, 6-8, and 10-12 year old children.’ The children were interviewed individually and told that all children were afraid but that some children were more afraid of some things than others. They were then asked, ‘What are you afraid of most?’ and then allowed to draw a picture while describing their fears. Other questions probed the presence of night-time fears and scary dreams. Seventy-four per cent of the 4-6 year olds, 53% of the 6-8 year olds, but only 5% of the 10-12 year olds reported fears of ghosts and monsters; on the other hand, only 11% of the 4-6 year olds, but 53% of the 6-8 year olds and 55% of the 10-12 year olds described fears of bodily injury and physical danger. These age-related differences were also reflected in the description of scary dreams reported by the younger and older children. The younger children reported that the appearances of the monster itself (e.g. ‘His face looks ugly’ or ‘He has big ears‘) were sufficient to induce fear, while the older children imputed harmful actions to the monster (e.g. ’They wanted to cut my head off or ‘Guess he would have choked me or something’). Clearly, night-time fears are common although transient for most children.
Correspondence: Dr N. J. King, Faculty of Education, School of Graduate Studies, Monash University, Clayton, Vic. 3168, Australia. N. J. King, BA(Hons),DipEd, PhD, Senior Lecturer. B. J. Tonge. MB, BS, DPM, MRC Psych, FRANZP, Cent Child Psych, RANZCP, Professor and Head of Centre for Developmental Psychiatry. T. H. Ollendick, BSc, MA, PhD, Professor and Director of Clinical Training. Accepted for publication 5 December 1991.
However, other children experience night-time fears that become sufficiently intense to interfere with daily functioning as shown by these observations: In each family going to bed had become a highly emotional and disruptive nightly event, with delays and battles oflen beyond midnight. Crying and severe panic, crawling into parents’ and siblings’ beds, insisting upon bright lights, radios or TVs being lefl turned on in their rooms, restless nights continually interrupted in the early morning hours by frightened calling-out to the parents, and so on, were common events. Some of the children refused to visit relatives or friends overnight and others were becoming ashamed of their fears, increasingly secretive, lest their friends find out.. .The parents reported they had tried patience, reasoning, understanding, reassurance, rewards, and punishments, lectures, harangues, and ridicule. All of their previous attempts resulted only in a continuation of severe night time battles, leading many of them to eventually give up and allow the child to sleep all night sharing the parents’ or siblings’ beds, keeping lights on, or staying up very late hours, even on school nights. The children displayed fears in similar daytime situations, e.g. going alone into the basement or upper floors of their homes, occasional incidents of severe fear in school when they found themselves lefl alone, briefly, in a room or hall3
Such intense fears often result in parents advice from family doctors, paediatricians, psychologists and other health professionals. Severe night-time fears account for approximately 15% of the total referrals for treatment of childhood phobias.4~~ Excessively fearful or phobic children should be differentiated from another group of children who display behavioural problems through the night such as bedtime refusal and temper tantrums. These children are negativistic, hostile and defiant concerning household rules or parental commands (known as ‘oppositional-defiant disorder’)6 In this paper the causes, assessment and treatment of children’s excessive night-time fears are reviewed. Although there are several theoretical and applied perspectives of childhood behaviour disorders, this review is from a cognitive-behavioural stance.
CAUSES There is a dearth of scientific evidence on the causes of children’s night-time fears. However, along with other childhood fears, they are probably due to an interaction of several factors: biological, environmental and cogniti~e-mediational.~~~ Some researchers have speculated that we are ‘biologically
N. J. King eta/.
348
prepared’ to be fearful at an early age9 They argue that it is adaptive for the human young to have fears of potentially threatening stimuli. Darkness and the unknown would seem to represent situations that have the potential to endanger humans. The literature suggests the contribution of other factors, particularly in relation to the severe night-time fears of children. The family context is a significant factor as night-time fears often arise at times of parental illness or marital conflict. Rachman shows how fears can be learned or conditioned.” He points out three pathways of fear acquisition: direct conditioning (e.9. child showing fear of darkness after being locked in a dark room or closet), vicarious conditioning (e.9. child observing another family member who also has night-time fears) and information-giving (e.g. repeated warnings from parents about the dangers of being robbed or kidnapped at night). Also, children’s fears can be reinforced inadvertently by parents and siblings. On this issue, it is noteworthy that children with nighttime fears often bed-share with their parents. Not surprisingly, children who undergo these kinds of experiences come to lack confidence or belief in themselves to handle night-time fear-inducing situations. Such negative expectations are strengthened through any exposures to night-time situations that result in panic and humiliation. Consequently, children look to family members for solace or try other inappropriate means of coping through the night, which further verifies their feelings of inadequacy. Support for the influences of conditioning and cognitive-mediational processes is drawn from the clinical literature on children’s night-time
ASSESSMENT Clinicians and researchers utilize a multimethod. problemsolving approach to the assessment of children’s night-time fear^.^,'^ Typically, the assessment of children’s night-time fears includes a structured interview, completion of a fear survey schedule for children and home-monitoring on the part of parents. In addition, some researchers have used behavioural tests of darkness toleration.
Structured interviews Parents and children should be interviewed in order to identify the specific night-time fear or concern. As night-time fears are heterogeneous, it is necessary to clarify just what is feared (e.g. darkness, being alone, intruders, imaginary creatures, outside noises). Information can also be gathered on the history, duration and severity of the night-time fears. Friedman and Ollendick asked children and parents to rate the severity of night-time fears on a 1-10 point scale (1 = no problem; 10 = very severe problem).13 Asking specific rather than general questions, as well as concentrating on the ‘here and now’, enhance the reliability and validity of information gathered at interview.’*
Fear survey schedule lor children-revised (FSSC-R) This instrument is an 80-item inventory which requires children to rate their level of fear (none, some or a lot) to a range of ~ t i m u l i . Many ’~ items are related to night-time fears and comprise the Fear of the Dark Scale.l3 Children 7 years of age and upwards are usually capable of completing the FSSC-R. Given
that the scale was developed in America, adaptations have been made for use with Australian and British Finally, the FSSC-R has been well-researched in terms of its psychometric properties and shown to have adequate reliability and ~ a l i d i t y . ’ ~ ~ ’ ~
Home-monitoring Parents are provided with forms to complete each night or first thing in the m ~ r n i n g . ~ ~The ” ~ forms ’~ carefully specify the fear behaviours in question. For example, Friedman and O l l e n d i ~ k ’ ~ had parents rate their children on unwillingness to go to bed, fearless nights (absence of fearful behaviour) and number of minutes between the time a parent announced it was bedtime until the child was settled in bed. These recordings were completed each night and on the basis of direct observations of behaviour. Our experience indicates that parents often need preliminary instruction in home-monitoring to ensure that reliable information is obtained.
Darkness toleration tests Typically, this assessment procedure involves having the child (alone) stay in a darkened room for as long as can be tolerated.19,20 Of course, children should be familiarized with the room prior to testing and upper time limits for staying in the room need to be specified. Kanfer eta/.provided children with a rheostat so that they could increase the amount of illumination in the testing situation.*’ Movement of the rheostat dial was a useful indication of being afraid of the dark. Following exposure to darkness, children can be asked to rate the level of fear just experienced. For example, King et a/. had children rate how afraid they felt while in the dark on a ’fear thermometer’. This consisted of a 5-point Likert scale accompanied by behavioural descriptors and cartoon faces depicting various levels of fear.” However, on the basis of their findings, King et a/. questioned the clinical meaningfulness of darkness toleration tests and fear ratings obtained in this manner. (The behavioural avoidance tests seemed to be somewhat artificial and unrepresentative of night-time situations. Certainly darkness toleration tests lack an essential element of the anxiety evoking stimulus feared by the children, the factor of controllability. Children know that they have full licence to leave the testing room at any time. At bedtime, however, the contingencies are remarkably different as children are expected to stay in the bedroom.)
TREATMENT Children’s night-time fears have been successfully treated using behavioural procedures derived from the principles of respondent, vicarious and operant conditioning. In the application of behavioural procedures to children with night-time fears, we emphasize the need for therapy to be age-appropriate. Probably the most frequently used behavioural procedure in the treatment of excessive fears is systematic desensitizationz2 In its traditional form, fear-producing stimuli are presented imaginally (in order of least to most fear-producing) while the individual is deeply relaxed. While this procedure has been successful with adults, it can present difficulties for children. However, Lazarus and Abramovitz have reported a variant of systematic de-
Night-time fears in children
sensitization, especially for use with children.23 Known as emotive imagery, this procedure aims to induce a positive emotional state through the use of the child’s hero images in a narrative format. Once a positive emotional state has been produced, the therapist gradually introduces the fear-eliciting stimuli to the child. Jackson and King used emotive imagery in the treatment of a 5 year old child with extreme fears of darkness, noises and shadowsz4 Having determined that the child was fond of the comic character Batman, the therapists created a fear hierarchy and then asked the child to imagine that ‘he and Batman had joined forces and that he was appointed a special agent’. Next he was asked to close his eyes and to imagine the fearproducing stimuli in a graduated fashion, while accompanied by Batman. The following transcript illustrates the build-up of the imagery and the introduction of anxiety provoking items. The child’s active involvement in the treatment (shown here in bold) is also evident. Close your eyes - now I want you to imagine that you are sitting in the lounge room watching TV with your family. You’re dressed for bed and the last programme before bedtime has finished. Your mother tells you it’s time for bed but just then Batman. who you really wish you knew, appears out of nowhere and sits down next to you. Think about it as best you can. Can you see Batman in your head? Yes. Can you tell me what Batman’s wearing? What color are his clothes? He’s got black and red clothes and big shoes and a gun. Oh, you can see him with a gun? Yeah he needs i t for the Joker. That’s terrific M. Now I want you to imagine that Batman tells you he needs you on his mission to catch robbers and other bad people and he’s appointed you as his special agent. However, he needs you to get your sleep in your bedroom and he will call on you when he needs you. You’re lucky to have been chosen to help him. Yes. Now your mother puts you in your bed and leaves both the lights on and leaves the three blinds up. Batman is also there looking as strong as he always does. Think about it as clearly as you can. Can you see it? Yes, I can see mummy and Batman in my room and all the lights are 0nz4
After only four sessions of emotive imagery, the child showed considerable improvement. In this case, muscular relaxation had been attempted and was unsuccessful, leading the therapists to use the child’s favourite character as the fear-inhibiting agent. Other uncontrolled case studies have illustrated the potential efficacy of emotive imagery for anxious and fearful ~hildren.~.~~ King eta/. evaluated the efficacy of emotive imagery using a multiple baseline design across subjects.” Three clinic-referred children (6, 8 and 11 years old) with severe night-time fears participated in the study. These children also slept with their parents at night as a means of coping with their fear. For one of the children, excessive fear of darkness and worries about night-time creatures were apparently triggered by seeing the movie ‘Aliens’. Emotive imagery was directed towards fear of darkness and any associated fears expressed by the children. Between six and 13 sessions (30 min per session) of emotive imagery were provided to each of the children. Following emotive imagery, two of the chidren showed marked behavioural improvement and were able to sleep by themselves at night. Unfortunately, the child who slept most frequently with his mother did
349
not show any improvement in terms of night-time behaviour. Overall, these clinical research data show that it is possible to be creative and flexible with behavioural procedures in the treatment of children’s night-time fears. However, further controlled research is necessary on the efficacy of emotive imagery as treatment for children’s night-time fears. Contemporary behaviouraltreatment also addresses cognitivemediational processes. As we noted in our discussion of causes, cognitive processes play an important role in the maintenance of children’s night-time fears. Hence this broad-spectrum therapeutic approach is sometimes labelled ‘cognitive-behaviour modification’. Graziano et a/. conducted a series of studies?Bz6 which illustrate the cognitiveincluding a 2-3 year f~llow-up,~’ behavioural approach. In a controlled investigation, 40 children between 6 and 13 years of age were treatedz6 The children were severely night-time fearful, displaying panic behaviours (e.g. frequent crying and frightened calling out to the parents) that had disrupted the families nearly every night for a mean of 5 years. Children were randomly assigned to a treatment or waiting-list control group. Treatment involved teaching relaxation and verbal coping skills to the children to counter any feelings of being afraid through the night. [The children were required to: (i) lie down on a carpeted floor and relax their muscles with the assistance of the experimenter: (ii) choose and imagine a pleasant scene (e.9. riding a bicycle); and (iii) say the following ‘special’ words (adapted from Kanfer et ajz’): ‘I am brave. I can take care of myself when I am alone. I can take care of myself when Iam in the dark’. The children agreed to practice these exercises every night with their parents and whenever they started to become afraid.] Over the 3 week programme, parents played an important role in monitoring home practice and rewarding children for their progress. The children also received ‘bravery tokens’ that were exchanged for back-up reinforcement. Results clearly attested to the efficacy of the cognitive-behavioural treatment. Significant changes were noted for the treatment group on a host of variables including number o f minutes to get in bed and time to fall asleep, selfreported willingness to go to sleep and proportion of days that delay tactics (e.g. ask for water, light on) were used. Following treatment the waiting-list group was also treated. In total, 39 of the 40 children showed significant change in behaviour as judged against a strict criterion: 10 consecutive nights of fearless night-time behaviours. Long-term follow-up information was obtained 2-3 years after treatment from 34 of the 40 families using a mail questionnaire and extensive telephone contacts. Maintenance of improvement was noted for 31 of the 34 children. More recently, these findings have been replicated by Ollendick eta/. in a programme for children with severe nighttime fears.** In this study, Ollendick et a/. also dismantled the cognitive-behavioural approach by examining its treatment components (relaxation training, self-monitoring, verbal self-instruction and contingency management) in an attempt to determine which components were most effective. Using an additive design, the more cognitive components (self-instruction training and self-monitoring) were administered first, followed by the more behavioural components (contingent reinforcement on sleeping in own bed). They found that the more cognitive components alone were only moderately effective in reducing the night-time fears; only when the behavioural component (reinforcement) was added did the fears subside. The need for this added component perhaps should not have been unexpected. As noted earlier by Meichenbaum, it is frequently necessary to use reinforcement to ensure correspondence between what children
350
verbalize in self-instructional training and what they actually do in p r a ~ t i c e . 'Of ~ course, it is unclear whether reinforcement for sleeping in bed alone would have been effective since the procedures were implemented in an additive and sequential
N.J. King ef a/.
10 Rachman S. The conditioning theory of fear acquisitions: a critical examination. Behav. Res. Ther. 1977; 15: 375-87. 11 King N. J., Cranstoun F., Josephs A. Emotive imagery and children's nighttime fears: A multiple baseline design evaluation. J. Behav. Ther. Exp. Psychiatry 1989; 20: 125-35. fashion. 12 Poznanski E. 0. Children with excessive fears. Am. J. Orthopsychiat. Finally, mention should be made of parent-assisted pro1973; 43: 428-38. grammes designed to reduce night-time fears in ~ h i l d r e n . ~ - ~ ~13 Friedman A. G., Ollendick T. H. Treatment programs for severe nightIn these programmes,parents are taught cognitive-behavioural time fears: A methodological note. J. Behav. Ther. Exp. Psychiatry strategies to deal with their children's night-time fears. For 1989; 20: 171-8. example, in a study reported by McMenamy and Katz, children 14 Ollendick T. H., Cerney J. A. Clinical Behavior Therapy and Children. Plenum Press, New York. 1981. and parents were taught h o w to handle fears with the aid of a 15 Ollendick T. H. Reliability and validity of the Revised Fear Survey short story the parents read to the children which described t w o Schedule for Children (FSSC-R). BehaK Res. Ther. 1983; 21: 685-92. young children w h o experienced night-time fears and the 16 King N. J., Ollier K., lacuone R. et a/. Fears of children and methods they used to overcome them.3' The children in the adolescents: A cross-sectional Australian study using the Revisedstory used relaxation and self-instruction training (coping stateFear Survey Schedule for children. J. Child Psychol. Psychiatry ments) to deal with their fears. At the end of treatment, the 1989; 30: 775-84. children were given a 'ghostbuster' t-shirt and praised for the 17 Ollendick T. H., Yule W., Ollier K. Fears in British children and their progress they made. Other research has shown that cognitiverelationship to manifest anxiety and depression. J. Child Psycho/. behavioural procedures are acceptable ways of treating chilPsychiatry 1991; 32: 321-31. 18 Ollendick T. H.. King N. J., Frary R. B. Fears in children and dren's fears, as judged by children and caregivers in both adolescents. Reliability and generalizability across gender, age and community survey and clinical s t u d i e ~ . " ~ ~ ~ ~ ~ ~ nationality. Behav. Res. Ther. 1989; 27: 19-26. In summary, a variety of treatment programmes has been 19 Kelley C. K. Play desensitization of fear of darkness in preschool used to assist children with night-time fears. Although wellchildren. Behav. Res. Ther. 1976; 14: 79-81. controlled outcome studies have yet to be conducted, pro20 Leitenberg H., Callahan E. J. Reinforced practice and reduction of cedures such as emotive imagery, relaxation, self-instructional different kinds of fears in adults and children. Behav. Res. Ther. training and reinforcement appear highly promising. Further, 1973; 11: 19-39. these procedures appear effective when used with children 21 Kanfer F. H.. Karoly P., Newman A. Reduction of children'sfear of the directly or when taught to parents w h o subsequently administer dark by competence-related and situational threat-related verbal cues. J. Consult. Clin. Psychol. 1975; 43: 251 -8. them. 22 Wolpe J. Psychotherapy by reciprocal inhibition. Stanford University Press, Stanford, CA. 1958. 23 Lazarus A. A,, Abrarnovitz A. The use of 'emotive imagery' in the treatment of children's phobias. J. Mental Sci. 1962; 108: 191-5. 24 Jackson H. J., King N. J. The emotive imagery treatment of a child's REFERENCES trauma-induced phobia. J. Behav. Ther. Exp. Psychiatry 1981; 12: 325-8. Bauer D. H. An exploratory study of developmental changes in 25 Morris R. J., Kratochwill T. R. Treating Children'sFears and Phobias. children's fears. J. Child Psychol. Psychiatry 1976; 17: 69-74. A BehavioralApproach. Pergamon Press, New York. 1983. Ferrari M. Fears and phobias in childhood: Some clinical and 26 Graziano A. M.. Mooney K. C. Family self-control instruction for developmental considerations. Child Psychiatry Human Dev. 1986; children's nighttime fear reduction. J. Consult. Clin. Psycho/. 1980; 17: 75-87. 48: 206-13. Graziano A. M., Mooney K. C.. Huber C., lgnasiak D. Self-control 27 Graziano A. M., Mooney K. C. Behavioral treatment of 'nightfears' in instructions for children's fear reduction. J. Behav. Ther. Exp. children: maintenance of improvements at 2% to 3-year follow-up. J. Psychiatry 1979; 10: 221-7. Consult. Clin. Psychol. 1982; 50: 598-9. Graziano A. M.. De Giovanni I. S. The clinical significance of child28 Ollendick T. H., Hagopian L. P., Huntzinger R. M.Cognitive-behavior hood phobias: A note on the proportion of child-clinic referrals for therapy with nighttimefearful children. J. Behav. Ther. Exp. Psychiatry treatment of children's fears. Behav. Res. Ther. 1979; 17: 161-2. 1991; 22:113-21. Graziano A. M.,De Giovanni I. S., Garcia K. Behavioral treatment of 29 Meichenbaum D. H. Cognitive-behavior Modification. Plenum Press, children's fears: A review. Psychol. Bull. 1979; 86: 804-30. New York. 1977. American Psychiatric Association. Diagnostic and Statistical Manual 30 Giebenhain J. E., O'Dell S. L. Evaluation of a parent-training manual of Mental Disorders, 3rd edn. American Psychiatric Association, for reducing children's fear of the dark. J. Appl. Behav. Anal. 1984; Washington, DC. 17: 121-5. King N. J., Hamilton D. I., Ollendick T. H. Children's Phobias: A 31 McMenamy C., Katz R. C. Brief parent-assisted treatment for chilBehavioural Perspective. John Wiley, Chicester. 1988. dren's nighttime fears. J. Dev. Behav. Pediatr. 1989; 10: 145-8. Ollendick T. H. Fear reduction techniques with children. In Hersen M., 32 Weymouth J., Hudson A,. King N. The management of children's Eisler R. M., Miller P. M. eds. Progress in Behaviour Modification. nighttime behaviour problems: Evaluation of an advice booklet. Academic Press, New York. 1979; 8: 127-68. Behav. Psychother. 1987; 15: 123-33. Seligman M. E. P. Phobias and preparedness. Behav. Therapy. 1971; 33 King N. J., Gullone E. Acceptability of fear reduction procedures with 2: 307-20. children. J. Behav. Ther. Exp. Psychiatry 1990; 21: 1-8.
Annotation Night-time fears in children N. J. KING,’ B. J. TONGE2and T. H. OLLENDICK3 faculty of Education, School of Graduate Studies, Monash University, ‘Centre for Developmental Psychiatry, Monash Medical Centre, Clayton, Victoria, Australia and 3Deparfment of Psychology, Virginia Polytechnic lnstitute and State University, Blacksburg, Virginia, USA
Children’s night-time fears are part and parcel of normal development. Several authors have commented on the developmental progression of these ‘normal’ fears and have shown how they emanate from increasingly sophisticated cognitive development in the growing child.’,2 Infants and very young children show fear to things that occur in their immediate environment (e.9. loud noises, strangers, separation from parents). Their level of cognitive development limits the range of stimuli to which they can experience fear to those stimuli which are in the here and now and in their immediate presence. Preschool children, on the other hand, are capable of showing fear to more global and imaginary stimuli such as ghosts, monsters and the dark. Older children, able to differentiate ‘internal representations from objective reality’, begin to show more realistic and specific fears including fears related to physical injury, health and school performance.I This pattern in the types of fears children experience at different ages was illustrated in a study by Bauer in which he examined the fears of 4-6, 6-8, and 10-12 year old children.’ The children were interviewed individually and told that all children were afraid but that some children were more afraid of some things than others. They were then asked, ‘What are you afraid of most?’ and then allowed to draw a picture while describing their fears. Other questions probed the presence of night-time fears and scary dreams. Seventy-four per cent of the 4-6 year olds, 53% of the 6-8 year olds, but only 5% of the 10-12 year olds reported fears of ghosts and monsters; on the other hand, only 11% of the 4-6 year olds, but 53% of the 6-8 year olds and 55% of the 10-12 year olds described fears of bodily injury and physical danger. These age-related differences were also reflected in the description of scary dreams reported by the younger and older children. The younger children reported that the appearances of the monster itself (e.g. ‘His face looks ugly’ or ‘He has big ears‘) were sufficient to induce fear, while the older children imputed harmful actions to the monster (e.g. ’They wanted to cut my head off or ‘Guess he would have choked me or something’). Clearly, night-time fears are common although transient for most children.
Correspondence: Dr N. J. King, Faculty of Education, School of Graduate Studies, Monash University, Clayton, Vic. 3168, Australia. N. J. King, BA(Hons),DipEd, PhD, Senior Lecturer. B. J. Tonge. MB, BS, DPM, MRC Psych, FRANZP, Cent Child Psych, RANZCP, Professor and Head of Centre for Developmental Psychiatry. T. H. Ollendick, BSc, MA, PhD, Professor and Director of Clinical Training. Accepted for publication 5 December 1991.
However, other children experience night-time fears that become sufficiently intense to interfere with daily functioning as shown by these observations: In each family going to bed had become a highly emotional and disruptive nightly event, with delays and battles oflen beyond midnight. Crying and severe panic, crawling into parents’ and siblings’ beds, insisting upon bright lights, radios or TVs being lefl turned on in their rooms, restless nights continually interrupted in the early morning hours by frightened calling-out to the parents, and so on, were common events. Some of the children refused to visit relatives or friends overnight and others were becoming ashamed of their fears, increasingly secretive, lest their friends find out.. .The parents reported they had tried patience, reasoning, understanding, reassurance, rewards, and punishments, lectures, harangues, and ridicule. All of their previous attempts resulted only in a continuation of severe night time battles, leading many of them to eventually give up and allow the child to sleep all night sharing the parents’ or siblings’ beds, keeping lights on, or staying up very late hours, even on school nights. The children displayed fears in similar daytime situations, e.g. going alone into the basement or upper floors of their homes, occasional incidents of severe fear in school when they found themselves lefl alone, briefly, in a room or hall3
Such intense fears often result in parents advice from family doctors, paediatricians, psychologists and other health professionals. Severe night-time fears account for approximately 15% of the total referrals for treatment of childhood phobias.4~~ Excessively fearful or phobic children should be differentiated from another group of children who display behavioural problems through the night such as bedtime refusal and temper tantrums. These children are negativistic, hostile and defiant concerning household rules or parental commands (known as ‘oppositional-defiant disorder’)6 In this paper the causes, assessment and treatment of children’s excessive night-time fears are reviewed. Although there are several theoretical and applied perspectives of childhood behaviour disorders, this review is from a cognitive-behavioural stance.
CAUSES There is a dearth of scientific evidence on the causes of children’s night-time fears. However, along with other childhood fears, they are probably due to an interaction of several factors: biological, environmental and cogniti~e-mediational.~~~ Some researchers have speculated that we are ‘biologically
N. J. King eta/.
348
prepared’ to be fearful at an early age9 They argue that it is adaptive for the human young to have fears of potentially threatening stimuli. Darkness and the unknown would seem to represent situations that have the potential to endanger humans. The literature suggests the contribution of other factors, particularly in relation to the severe night-time fears of children. The family context is a significant factor as night-time fears often arise at times of parental illness or marital conflict. Rachman shows how fears can be learned or conditioned.” He points out three pathways of fear acquisition: direct conditioning (e.9. child showing fear of darkness after being locked in a dark room or closet), vicarious conditioning (e.9. child observing another family member who also has night-time fears) and information-giving (e.g. repeated warnings from parents about the dangers of being robbed or kidnapped at night). Also, children’s fears can be reinforced inadvertently by parents and siblings. On this issue, it is noteworthy that children with nighttime fears often bed-share with their parents. Not surprisingly, children who undergo these kinds of experiences come to lack confidence or belief in themselves to handle night-time fear-inducing situations. Such negative expectations are strengthened through any exposures to night-time situations that result in panic and humiliation. Consequently, children look to family members for solace or try other inappropriate means of coping through the night, which further verifies their feelings of inadequacy. Support for the influences of conditioning and cognitive-mediational processes is drawn from the clinical literature on children’s night-time
ASSESSMENT Clinicians and researchers utilize a multimethod. problemsolving approach to the assessment of children’s night-time fear^.^,'^ Typically, the assessment of children’s night-time fears includes a structured interview, completion of a fear survey schedule for children and home-monitoring on the part of parents. In addition, some researchers have used behavioural tests of darkness toleration.
Structured interviews Parents and children should be interviewed in order to identify the specific night-time fear or concern. As night-time fears are heterogeneous, it is necessary to clarify just what is feared (e.g. darkness, being alone, intruders, imaginary creatures, outside noises). Information can also be gathered on the history, duration and severity of the night-time fears. Friedman and Ollendick asked children and parents to rate the severity of night-time fears on a 1-10 point scale (1 = no problem; 10 = very severe problem).13 Asking specific rather than general questions, as well as concentrating on the ‘here and now’, enhance the reliability and validity of information gathered at interview.’*
Fear survey schedule lor children-revised (FSSC-R) This instrument is an 80-item inventory which requires children to rate their level of fear (none, some or a lot) to a range of ~ t i m u l i . Many ’~ items are related to night-time fears and comprise the Fear of the Dark Scale.l3 Children 7 years of age and upwards are usually capable of completing the FSSC-R. Given
that the scale was developed in America, adaptations have been made for use with Australian and British Finally, the FSSC-R has been well-researched in terms of its psychometric properties and shown to have adequate reliability and ~ a l i d i t y . ’ ~ ~ ’ ~
Home-monitoring Parents are provided with forms to complete each night or first thing in the m ~ r n i n g . ~ ~The ” ~ forms ’~ carefully specify the fear behaviours in question. For example, Friedman and O l l e n d i ~ k ’ ~ had parents rate their children on unwillingness to go to bed, fearless nights (absence of fearful behaviour) and number of minutes between the time a parent announced it was bedtime until the child was settled in bed. These recordings were completed each night and on the basis of direct observations of behaviour. Our experience indicates that parents often need preliminary instruction in home-monitoring to ensure that reliable information is obtained.
Darkness toleration tests Typically, this assessment procedure involves having the child (alone) stay in a darkened room for as long as can be tolerated.19,20 Of course, children should be familiarized with the room prior to testing and upper time limits for staying in the room need to be specified. Kanfer eta/.provided children with a rheostat so that they could increase the amount of illumination in the testing situation.*’ Movement of the rheostat dial was a useful indication of being afraid of the dark. Following exposure to darkness, children can be asked to rate the level of fear just experienced. For example, King et a/. had children rate how afraid they felt while in the dark on a ’fear thermometer’. This consisted of a 5-point Likert scale accompanied by behavioural descriptors and cartoon faces depicting various levels of fear.” However, on the basis of their findings, King et a/. questioned the clinical meaningfulness of darkness toleration tests and fear ratings obtained in this manner. (The behavioural avoidance tests seemed to be somewhat artificial and unrepresentative of night-time situations. Certainly darkness toleration tests lack an essential element of the anxiety evoking stimulus feared by the children, the factor of controllability. Children know that they have full licence to leave the testing room at any time. At bedtime, however, the contingencies are remarkably different as children are expected to stay in the bedroom.)
TREATMENT Children’s night-time fears have been successfully treated using behavioural procedures derived from the principles of respondent, vicarious and operant conditioning. In the application of behavioural procedures to children with night-time fears, we emphasize the need for therapy to be age-appropriate. Probably the most frequently used behavioural procedure in the treatment of excessive fears is systematic desensitizationz2 In its traditional form, fear-producing stimuli are presented imaginally (in order of least to most fear-producing) while the individual is deeply relaxed. While this procedure has been successful with adults, it can present difficulties for children. However, Lazarus and Abramovitz have reported a variant of systematic de-
Night-time fears in children
sensitization, especially for use with children.23 Known as emotive imagery, this procedure aims to induce a positive emotional state through the use of the child’s hero images in a narrative format. Once a positive emotional state has been produced, the therapist gradually introduces the fear-eliciting stimuli to the child. Jackson and King used emotive imagery in the treatment of a 5 year old child with extreme fears of darkness, noises and shadowsz4 Having determined that the child was fond of the comic character Batman, the therapists created a fear hierarchy and then asked the child to imagine that ‘he and Batman had joined forces and that he was appointed a special agent’. Next he was asked to close his eyes and to imagine the fearproducing stimuli in a graduated fashion, while accompanied by Batman. The following transcript illustrates the build-up of the imagery and the introduction of anxiety provoking items. The child’s active involvement in the treatment (shown here in bold) is also evident. Close your eyes - now I want you to imagine that you are sitting in the lounge room watching TV with your family. You’re dressed for bed and the last programme before bedtime has finished. Your mother tells you it’s time for bed but just then Batman. who you really wish you knew, appears out of nowhere and sits down next to you. Think about it as best you can. Can you see Batman in your head? Yes. Can you tell me what Batman’s wearing? What color are his clothes? He’s got black and red clothes and big shoes and a gun. Oh, you can see him with a gun? Yeah he needs i t for the Joker. That’s terrific M. Now I want you to imagine that Batman tells you he needs you on his mission to catch robbers and other bad people and he’s appointed you as his special agent. However, he needs you to get your sleep in your bedroom and he will call on you when he needs you. You’re lucky to have been chosen to help him. Yes. Now your mother puts you in your bed and leaves both the lights on and leaves the three blinds up. Batman is also there looking as strong as he always does. Think about it as clearly as you can. Can you see it? Yes, I can see mummy and Batman in my room and all the lights are 0nz4
After only four sessions of emotive imagery, the child showed considerable improvement. In this case, muscular relaxation had been attempted and was unsuccessful, leading the therapists to use the child’s favourite character as the fear-inhibiting agent. Other uncontrolled case studies have illustrated the potential efficacy of emotive imagery for anxious and fearful ~hildren.~.~~ King eta/. evaluated the efficacy of emotive imagery using a multiple baseline design across subjects.” Three clinic-referred children (6, 8 and 11 years old) with severe night-time fears participated in the study. These children also slept with their parents at night as a means of coping with their fear. For one of the children, excessive fear of darkness and worries about night-time creatures were apparently triggered by seeing the movie ‘Aliens’. Emotive imagery was directed towards fear of darkness and any associated fears expressed by the children. Between six and 13 sessions (30 min per session) of emotive imagery were provided to each of the children. Following emotive imagery, two of the chidren showed marked behavioural improvement and were able to sleep by themselves at night. Unfortunately, the child who slept most frequently with his mother did
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not show any improvement in terms of night-time behaviour. Overall, these clinical research data show that it is possible to be creative and flexible with behavioural procedures in the treatment of children’s night-time fears. However, further controlled research is necessary on the efficacy of emotive imagery as treatment for children’s night-time fears. Contemporary behaviouraltreatment also addresses cognitivemediational processes. As we noted in our discussion of causes, cognitive processes play an important role in the maintenance of children’s night-time fears. Hence this broad-spectrum therapeutic approach is sometimes labelled ‘cognitive-behaviour modification’. Graziano et a/. conducted a series of studies?Bz6 which illustrate the cognitiveincluding a 2-3 year f~llow-up,~’ behavioural approach. In a controlled investigation, 40 children between 6 and 13 years of age were treatedz6 The children were severely night-time fearful, displaying panic behaviours (e.g. frequent crying and frightened calling out to the parents) that had disrupted the families nearly every night for a mean of 5 years. Children were randomly assigned to a treatment or waiting-list control group. Treatment involved teaching relaxation and verbal coping skills to the children to counter any feelings of being afraid through the night. [The children were required to: (i) lie down on a carpeted floor and relax their muscles with the assistance of the experimenter: (ii) choose and imagine a pleasant scene (e.9. riding a bicycle); and (iii) say the following ‘special’ words (adapted from Kanfer et ajz’): ‘I am brave. I can take care of myself when I am alone. I can take care of myself when Iam in the dark’. The children agreed to practice these exercises every night with their parents and whenever they started to become afraid.] Over the 3 week programme, parents played an important role in monitoring home practice and rewarding children for their progress. The children also received ‘bravery tokens’ that were exchanged for back-up reinforcement. Results clearly attested to the efficacy of the cognitive-behavioural treatment. Significant changes were noted for the treatment group on a host of variables including number o f minutes to get in bed and time to fall asleep, selfreported willingness to go to sleep and proportion of days that delay tactics (e.g. ask for water, light on) were used. Following treatment the waiting-list group was also treated. In total, 39 of the 40 children showed significant change in behaviour as judged against a strict criterion: 10 consecutive nights of fearless night-time behaviours. Long-term follow-up information was obtained 2-3 years after treatment from 34 of the 40 families using a mail questionnaire and extensive telephone contacts. Maintenance of improvement was noted for 31 of the 34 children. More recently, these findings have been replicated by Ollendick eta/. in a programme for children with severe nighttime fears.** In this study, Ollendick et a/. also dismantled the cognitive-behavioural approach by examining its treatment components (relaxation training, self-monitoring, verbal self-instruction and contingency management) in an attempt to determine which components were most effective. Using an additive design, the more cognitive components (self-instruction training and self-monitoring) were administered first, followed by the more behavioural components (contingent reinforcement on sleeping in own bed). They found that the more cognitive components alone were only moderately effective in reducing the night-time fears; only when the behavioural component (reinforcement) was added did the fears subside. The need for this added component perhaps should not have been unexpected. As noted earlier by Meichenbaum, it is frequently necessary to use reinforcement to ensure correspondence between what children
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verbalize in self-instructional training and what they actually do in p r a ~ t i c e . 'Of ~ course, it is unclear whether reinforcement for sleeping in bed alone would have been effective since the procedures were implemented in an additive and sequential
N.J. King ef a/.
10 Rachman S. The conditioning theory of fear acquisitions: a critical examination. Behav. Res. Ther. 1977; 15: 375-87. 11 King N. J., Cranstoun F., Josephs A. Emotive imagery and children's nighttime fears: A multiple baseline design evaluation. J. Behav. Ther. Exp. Psychiatry 1989; 20: 125-35. fashion. 12 Poznanski E. 0. Children with excessive fears. Am. J. Orthopsychiat. Finally, mention should be made of parent-assisted pro1973; 43: 428-38. grammes designed to reduce night-time fears in ~ h i l d r e n . ~ - ~ ~13 Friedman A. G., Ollendick T. H. Treatment programs for severe nightIn these programmes,parents are taught cognitive-behavioural time fears: A methodological note. J. Behav. Ther. Exp. Psychiatry strategies to deal with their children's night-time fears. For 1989; 20: 171-8. example, in a study reported by McMenamy and Katz, children 14 Ollendick T. H., Cerney J. A. Clinical Behavior Therapy and Children. Plenum Press, New York. 1981. and parents were taught h o w to handle fears with the aid of a 15 Ollendick T. H. Reliability and validity of the Revised Fear Survey short story the parents read to the children which described t w o Schedule for Children (FSSC-R). BehaK Res. Ther. 1983; 21: 685-92. young children w h o experienced night-time fears and the 16 King N. J., Ollier K., lacuone R. et a/. Fears of children and methods they used to overcome them.3' The children in the adolescents: A cross-sectional Australian study using the Revisedstory used relaxation and self-instruction training (coping stateFear Survey Schedule for children. J. Child Psychol. Psychiatry ments) to deal with their fears. At the end of treatment, the 1989; 30: 775-84. children were given a 'ghostbuster' t-shirt and praised for the 17 Ollendick T. H., Yule W., Ollier K. Fears in British children and their progress they made. Other research has shown that cognitiverelationship to manifest anxiety and depression. J. Child Psycho/. behavioural procedures are acceptable ways of treating chilPsychiatry 1991; 32: 321-31. 18 Ollendick T. H.. King N. J., Frary R. B. Fears in children and dren's fears, as judged by children and caregivers in both adolescents. Reliability and generalizability across gender, age and community survey and clinical s t u d i e ~ . " ~ ~ ~ ~ ~ ~ nationality. Behav. Res. Ther. 1989; 27: 19-26. In summary, a variety of treatment programmes has been 19 Kelley C. K. Play desensitization of fear of darkness in preschool used to assist children with night-time fears. Although wellchildren. Behav. Res. Ther. 1976; 14: 79-81. controlled outcome studies have yet to be conducted, pro20 Leitenberg H., Callahan E. J. Reinforced practice and reduction of cedures such as emotive imagery, relaxation, self-instructional different kinds of fears in adults and children. Behav. Res. Ther. training and reinforcement appear highly promising. Further, 1973; 11: 19-39. these procedures appear effective when used with children 21 Kanfer F. H.. Karoly P., Newman A. Reduction of children'sfear of the directly or when taught to parents w h o subsequently administer dark by competence-related and situational threat-related verbal cues. J. Consult. Clin. Psychol. 1975; 43: 251 -8. them. 22 Wolpe J. Psychotherapy by reciprocal inhibition. Stanford University Press, Stanford, CA. 1958. 23 Lazarus A. A,, Abrarnovitz A. The use of 'emotive imagery' in the treatment of children's phobias. J. Mental Sci. 1962; 108: 191-5. 24 Jackson H. J., King N. J. The emotive imagery treatment of a child's REFERENCES trauma-induced phobia. J. Behav. Ther. Exp. Psychiatry 1981; 12: 325-8. Bauer D. H. An exploratory study of developmental changes in 25 Morris R. J., Kratochwill T. R. Treating Children'sFears and Phobias. children's fears. J. Child Psychol. Psychiatry 1976; 17: 69-74. 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