Children's nighttime fears

Clinical

Psychology

Pergamon

Review, Vol. 17, No. 4, pp. 431-443, 1997 Copyright 0 1997 Elsevier Science Ltd Printed in the USA. All righu reserved 0272-7358/97 $17.00 + .OO

PI1 so272-7358(97)000147

CHILDREN’S

NIGHTTIME Neville

Faculty

of Education,

FEARS

King Monash

University

Thomas H. Oliendick Department

of Psychology,

Virginia

Polytechnic

Institute

and State University

Bruce J. Tonge Centre

for Developmental

Psychiatry,

Monash

Medical

Centre

ABSTRACT. Some children experience persistent night-time fears that interfere with their daily Initially, we present deoelupmental considerations necessary to an understanding of

functioning.

severe night-time fears. We postulate that severe night-time fears are pobably due to a complex interaction of biological, environmt?ntal, and cognitive-mediational processes. Several assessment procedures are outlined: behavioral interviews, diagnostic interviews, fear survey schedules for children, home monitoring on the part of parents, behavioral interventions,

and darkness toleration tests. Traditional

and more recent cognitive-behavioral interventions,

terms of their research foundations.

Cognitive-behavioral

are evaluated in

strategies appear to have the more

empirical support, although we draw attention to several methodological limitations. 0 1997 Elsevier Science Ltd

INTRODUCTION CHILDREN’S authors

NIGHTTIME

have commented

fears are part and parcel of normal

on the developmental

and have shown how they emanate

progression

from increasingly

development.

sophisticated

ment in the growing child (Bauer, 1976; Ferrari, 1986). children show fear to things that occur in their immediate

Several

of these “normal” cognitive

fears

develop

Infants and very young environment (e.g., 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 Correspondence should be addressed to Neville King, Faculty of Education, Monash University, Clayton, Victoria 3168, Australia. 431

432

in the here other

and B. J, Tonge

N. King, II: H. Olhdick,

and now and in their

hand, are capable

ghosts,

monsters

sentations

from

including

those

immediate

of showing

related

Preschool

children,

fear to more global and imaginary

and the dark. Older objective

presence.

reality,”

children,

begin

to physical

able to differentiate

to show more

injury,

health,

realistic

and school

on the

stimuli such as “internal

and

repre-

specific

performance

fears (Bauer,

1976). This

pattern

in the types of fears children

trated in a study by Bauer

(1976))

10 to 12-year-old

The children

children others.

children.

were afraid

but that some

They were then

draw a picture nighttime

and 55%

physical danger. scary dreams

These

reported

that the appearances were

actions

to the monster

hand,

of the

questions

percent

age-related

differences

by the younger to induce (e.g.,

probed

reported

“They

me or something”).

described

while

wanted

to

the presence

of

53% of

but 53% of the 6- to

fears

of bodily

injury

and

in the description

Younger

children

of

reported

“His face looks ugly” or “He has big the

older

children

imputed

to cut my head off” or “Guess

Clearly,

than

allowed

fears of ghosts and

were also reflected

itself (e.g.,

things

and then

of the 4 to 6-year-olds,

and older children.

fear,

to 8, and

and told that all

of some

only 11% of the 4 to 6-year-olds, lo- to 12-year-olds

ages was illus-

nighttime

fears

are

harmful he would

common

although

for most children.

However, tense

sufficient

choked

Seventy-four

of the monster

ears”)

transient

Other

afraid

of most?”

but only 5% of the lo- to 12-year-olds

on the other

8-year-olds

individually

were more

are you afraid

their fears.

fears and scary dreams.

monsters;

children

at different

the fears of 4 to 6,6

were interviewed

“What

while describing

the 6- to 8-year-olds,

have

asked,

experience

in which he examined

other

to interfere

children

experience

nighttime

with daily functioning

fears

that become

as shown by these

sufficiently

in-

observations.

In each family going to bed had become a highly emotional and disruptive nightly event, with delays and battles often beyond midnight. Crying and severe panic, crawling into parents’ and siblings’ beds, insisting upon bright lights, radios or TVs being left turned on in their rooms, restless nights continually interrupted frightened

in the early morning hours by

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 punish-

ments, lectures, harangues, and ridicule. All of their previous attempts resulted only in a continuation

of severe nighttime 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 left alone, briefly, in a room or hall. (Graziano,

Mooney, Huber, & Ignasiak,

1979, pp.

221-222)

Such

intense

fears often

result

in parents

seeking

advice from

doctors, pediatricians, and other health professionals. Severe for approximately 15% of the total referrals for treatment

psychologists,

family

nighttime fears account of childhood phobias

(Graziano & De Giovanni, 1979). Excessively fearful or phobic children differentiated from another group of children who display behavioral

should be problems

Children S Nighttime Fears

433

through the night, such as bedtime refusal and temper tantrums. These children are negativistic, hostile, and defiant about household rules or parental commands; such behaviors are consistent with “oppositionaldefiant disorder” (American Psychiatric Association, 1994). In this paper, the etiology, assessment, and treatment of children’s excessive nighttime fears are reviewed. Although there are several theoretical and applied perspectives of childhood behavior disorders, this review is written from a behavioral perspective.

ETIOLOGY There is a dearth of scientific evidence on the causes of children’s nighttime fears. However, along with other childhood fears, they are probably due to an interaction of several factors: biological, environmental, and cognitive-mediational (Graziano, DeGiovanni, & Garcia, 1979; King, Hamilton, & Ollendick, 1988; Ollendick, 1979). Some researchers have speculated that we are “biologically prepared” to be fearful at an early age (Seligman, 1971). They argue that it is adaptive for 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 nighttime fears of children. The family context is a significant factor as nighttime fears often arise at times of parental illness or marital conflict. Rachman (1977) shows how fears can be learned or conditioned. He points out three pathways of fear acquisition: direct conditioning (e.g., child showing fear of darkness after being locked in a dark room or closet), vicarious conditioning (e.g., child observing another family member who also has nighttime 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 (Graziano, Mooney et al., 1979; King, Cranstoun, 8c Josephs, 1989). Not surprisingly, children who undergo these kinds of experiences come to lack confidence or belief in themselves to handle nighttime fear-inducing situations. Such negative expectations are strengthened through any exposures to nighttime 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 (Graziano, Mooney et al., 1979; King et al., 1989; Mooney, Graziano, & Katz, 1985). Recently, we attempted to empirically validate Rachman’s analysis of fear acquisition with school-aged Australian children (Ollendick & King, 1991). In this investigation, vicarious and instructional factors were reported to be the most influential (56% and 89%, respectively) by a majority of the children. However, these sources of fear were often combined with direct conditioning experiences, This latter finding is consistent with the notion that childhood fears, including nighttime fears, are “multidetermined” and “overdetermined” (see King et al., 1988; Ollendick, 1979). Clearly more research is needed on the etiology and maintenance of children’s nighttime fears, Focusing on the family context, particularly child-parent interactions, is likely to be fruitful in terms of understanding the development of severe nighttime fears and anxieties (cf. Kendall et al., 1992).

434

N. King, ?: H. Ollendick, and B. J. Timge

ASSESSMENT

Clinicians and researchers utilize a multi-method, problem-solving approach to the assessment of children’s nighttime fears (King et al., 1988). Typically, assessment of children’s nighttime fears should include a behavioral interview, diagnostic interview, completion of a fear survey schedule for children, and home-monitoring on the part of parents. In addition, some researchers have used behavioral tests of darkness toleration. The reader is referred to other sources for more detailed information on the assessment of childhood fears (King et al., 1988; Morris & Kratochwill, 1984; Ollendick, King, & Yule, 1994). Behavioral Interview Parents and children should be interviewed in order to identify the specific nighttime fear of concern. As nighttime fears are heterogeneous, it is necessary to clarify just what is feared (e.g., darkness, being alone, intruders, imaginary creatures, outside noises). Also, information can be gathered on the history, duration and severity of nighttime fears. Friedman and Ollendick (1989) asked children and parents to rate severity of nighttime fears on a lo-point scale (1 = no problem and 10 = very severe problem). Parental management issues should be explored at interview since excessive reassurance, bed-sharing, and other forms of over-protectiveness can be powerful maintenance factors. 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 (Ollendick & Cerney, 1981). Diagnostic Interview The diagnostic status of the child with severe nighttime difficulties should be considered in a comprehensive psychological assessment. Typically, children with severe nighttime fears meet DSM-n/diagnostic criteria for specific phobia (American Psychiatric Association, 1994). However, it should be emphasized that nighttime fears can also be a feature of more pervasive anxiety disorders, such as separation anxiety disorder, generalized anxiety disorder, and posttraumatic stress disorder. There are now many structured diagnostic interviews available to clinicians and researchers interested in the diagnosis of childhood fears and anxieties, such as nighttime fears. Many of these diagnostic interview schedules have both child and parent versions. Representative of these instruments are the Anxiety Disorders Interview Schedule for Children (ADISC; Silverman 8c Nelles, 1988), the Interview Schedule for Children (ISC; Kovacs, 1978) and the Diagnostic Interview Schedule for Children and Adolescents (DISCA; Herjanic & Reich, 1982). Of these, we recommend the ADIS-C because its specialist nature as well as promising reliability and validity (Silverman, 1994; Silverman & Eisen, 1992). Fear Survey Schedule There are a number of fear survey schedules suitable for use with children (see James, Reynolds, & Dunbar, 1994; Morris & Kratochwill, 1983) These assessment devices are helpful in identifying specific fear producing stimuli for the child. The Fear Survey Schedule for Children (FSSGR, Ollendick, 1983) has proven to be particularly useful in the assessment of children with nighttime fears. The FSSGR is an 80-item inventory that requires children to rate their level of fear (none, some or a lot) to a range of

Children’s Nighttime Fears

435

stimuli. Many items are related to nighttime fears and have been used to form a Fear of the Dark Scale (Friedman & Ollendick, 1989). Children 7 years of age and older are usually capable of completing the FSSC-R. Given that the instrument was developed in America, adaptations have been made for use with Australian and British children. Finally, the FSSC-R has been well researched in terms of its psychometric properties and shown to have adequate reliability and validity (James et al., 1994; King & Ollendick, 1992; Ollendick, 1983).

Home Monitoring Parents are usually provided with forms to complete on a daily basis, aimed at providing information about nighttime fear behavior (Friedman & Ollendick, 1989; Graziano,Mooney et al., 1979). The forms carefully specify the fear behaviors in question. For example, Friedman and Ollendick (1989) had parents rate their children on unwillingness to go to bed, fearless nights (absence of fearful behavior), 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 behavior. Drawing on data gleaned from home monitoring forms, researchers often set behavioral criteria to assist in making judgments about treatment effectiveness for the individual child. Thus, Graziano and his colleagues specified 10 consecutive fearless nights in their research on the assessment and treatment of children’s nighttime fears (Graziano, Mooney et al., 1979; Graziano & Mooney, 1980). Our experience indicates that parents often need preliminary instruction in home monitoring to ensure that reliable information is obtained. In general, home monitoring has proven to be a useful procedure in the assessment of nighttime fears (Friedman & Ollendick, 1989; Graziano & Mooney, 1982; King et al., 1989).

Darkness To/era tion Tests Typically, this assessment procedure involves having the child (alone) stay in a darkened room for as long as can be tolerated (Kelley, 1976; Leitenberg & Callahan, 1973). 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, Karoly, and Newman (1975) 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 al. (1989) 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 behavioral descriptors and cartoon faces depicting various levels of fear. However, on the basis of their findings, King et al. questioned the clinical meaningfulness of darkness toleration tests and fear ratings obtained in this manner. The darkness toleration tests seemed to be somewhat artificial and unrepresentative of nighttime situations. Certainly darkness toleration tests lack an essential element of the anxiety evoking stimulus feared by the children: controllability. Children know that they have full license 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. Consequently, we have reservations about the clinical utility and ecological validity of darkness toleration tests.

436

N. King, T H. Ollmdick, and B. J Tonge

INTERVENTION We now describe and evaluate advances in the treatment of children experiencing severe nighttime fears. We have deliberately excluded those studies in which children have questionable levels of clinical fear (e.g., Kanfer et al., 1975; Kelley, 1976; Leitenberg & Callahan, 1973). Children’s fears have been successfully treated using behavioral procedures derived from the principles of respondent, vicarious and operant conditioning. Probably the most frequently used behavioral procedure in the treatment of excessive fears is systematic desensitization. In its customary form, fear producing stimuli are presented imaginally (in order of least to most fear-producing) while the individual is deeply relaxed (Wolpe, 1958). While this procedure has been successful with adults, it can present difficulties for children. However, Lazarus and Abramovitz (1962) had reported a variant of systematic desensitisation, especially for use with children. 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. Several uncontrolled case studies have illustrated the potential efficacy of emotive imagery for childhood anxieties, including nighttime fears (reviews by King et al., 1988; Morris & Kratochwill, 1983). For example, Jackson and King used emotive imagery in the treatment of a 5-year-old child with extreme fears of darkness, noises, and shadows. 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 fear-producing stimuli in a graduated fashion, while accompanied by Batman. The following transcript illustrates the build-up of imagery and introduction of anxiety-provoking items. The child’s active involvement in the treatment is also evident. Therapist: 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 program 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? Child: Yes. Therapist: Can you tell me what Batman’s wearing? What color are his clothes? Child: He’s got black and red clothes and big shoes and a gun. Therapist: Oh, you can see him with a gun? Child: Yeah he needs it for the Joker. Therapist: 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

Children’s Nighttime Fears

437

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. Child: Yes. Therapist: 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? Child: Yes. I can see mummy and Batman in my room and all the lights are on. After only four sessions of emotive imagery, the child showed considerable improvements. In this case, muscular relaxation had been attempted and was unsuccessful, leading the therapists to use the child’s favorite character as the fear-inhibiting agent. An l&month follow-up showed that therapy gains had been maintained. King et al. (1989) evaluated the efficacy of emotive imagery using a multiple baseline across subjects design. Three clinic-referred children (6, 8- and 11-year-old) with severe nighttime fears participated in the study. These children also slept with their parents at night as a means of coping with their fears. For one of the children, excessive fear of darkness and worries about nighttime creatures were apparently triggered by seeing the movie “Aliens.” Emotive imagery was directed toward fear of darkness and any associated fears expressed by the children. Between 6 and 13 sessions (30 minutes per session) of emotive imagery were provided to each of the children. Following emotive imagery, two of the children showed marked behavioral improvement and were able to sleep by themselves at night. Unfortunately, the child who slept most frequently with his mother did not show any improvement in terms of nighttime behavior. Overall, these clinical research data show that it is possible to be creative and flexible with behavioral procedures in the treatment of children’s nighttime fears. However, further controlled research is necessary on the efficacy of emotive imagery as treatment for children’s nighttime fears. An early investigation reported by Miller and his colleagues is of particular interest, as it evaluated the relative efficacies of systematic desensitization and psychotherapy compared to a waiting-list control condition (Miller, Barrett, Hampe, & Noble, 1972). The children (6-15 years) had various clinical fears including nighttime fears. Both the systematic desensitization and psychotherapy groups received 24 sessions of individual treatment over a Smonth period. Muscle relaxation training and construction of fear hierarchies were completed during the first four sessions of the systematic desensitization group. In the following sessions the child was instructed to imagine progressively greater fear-eliciting stimuli while remaining relaxed, and when all items of the hierarchy could be imagined without fear, an in uiuo assessment was scheduled. If results of this assessment were negative, imaginal desensitization was resumed. Parents assisted in development of alternative responses for children to fear and anxiety and assisted in the desensitization process. The desensitization condition also included contingency management and assertiveness training depending on the needs of the individual case. In the psychotherapy group, young children were seen for play therapy, while older children were seen for interview therapy. Both older and younger children were encouraged to explore their hopes, fears and conflicts. As in the desensitization condition, parents also received counseling for improved contin-

438

N. King, 7: H. Ollendick, and B. J. Tonge

gency management at home. Thus, the “psychotherapy” contained many aspects of “behavioral” treatment, even though children did not specifically undergo systematic desensitization. Dependent variables in this study included clinician- and parent-ratings of fear severity. On clinician ratings, neither treatment condition was superior to the waitinglist control condition. However, when age was examined, it was found that younger children in both treatment groups significantly improved over the waiting-list controls. Thus, younger children appear to have been more responsive to treatment. Therapist experience, sex of the child, IQ or chronicity of fears had no significant impact on outcome. Ratings of parents on the Louisville Behavior Checklist (Miller et al., 1971) and Louisville Fear Survey for Children (Miller, Barrett, Hampe, & Noble, 1972) showed significantly greater improvements for both treatment groups compared to the waiting list control group. However, the two treatment groups did not differ on parent ratings. Results for each of the measures were maintained at a &week follow-up. Therapeutic gains were still evident at l- and 2-year follow-ups (Hampe, Noble, Miller, 8c Barrett, 1973). Unfortunately, this study has several methodological limitations. As already noted, not all of the sample of children experienced nighttime fears. From the information on the nature of the presenting phobias provided by the researchers, it appears that there were in fact a minority of children with nighttime fears. Criticism has also been forthcoming about measures used in the study, it being noted that the researchers did not include any specific behavioral measures of the children’s overt fears. We also observed a confounding of the treatment conditions, thus making is impossible to draw any conclusions about the comparative effectiveness of systematic desensitization and psychotherapy. Contemporary behavioral treatment also addresses cognitive-mediational processes, (Kendall et al., 1992). Graziano and his hence “cognitive-behavior modification” colleagues have conducted a series of studies on the cognitive-behavioral treatment of children’s nighttime fears including a 2- to 3-year follow-up (Graziano, Mooney et al., 1979; Graziano & Mooney, 1980, 1982). In their preliminary investigation, Graziano et al. applied cognitive-behavioral treatment to five boys and two girls (S-12 years) with severe nighttime fears. The families were seen once a week for 5 weeks (2 weeks for assessment and 3 weeks for treatment), with children and parents being seen in separate groups. The children were instructed in relaxation, pleasant imagery and special words (adapted from Kanfer et al., 1975) - “I am brave. I can take care of myself when I am alone. I can take care of myself when I am in the dark.” The children were told to practice the exercises every night with their parents and whenever they started to become afraid. The children were also given “bravery tokens” for how well they did each exercise and for being brave both going to bed and through the night. The bravery tokens could be cashed for a McDonald’s party. Each child was given a booklet that contained written instructions for daily practice and space to record the number of tokens earned each night. This provided a self-monitoring record of progress. The rationale of the program was explained to parents, it being emphasized that family cooperation was crucial to the success of the program. Hence, a verbal contract was agreed to between the experimenters and parents and between parents and their children. At the child’s bedtime, the parents were instructed to prompt and supervise the home practice of the self-control exercises, and apply the bravery tokens plus verbal praise. The most important finding was that all children reached the

Children’s Nighttime Fears

behavioral occurred

criteria of 10 consecutive over the Smonth,

&month,

439

fearless nights. No new fears or other problems and l-year follow-ups.

In view of their initial success in overcoming children’s nighttime fears using cognitive-behavioral strategies, Graziano and Mooney (1980) then conducted a controlled evaluation of their intervention package. Thirty-three children, 6 to 13 years of age, participated in the study. All children experienced severe and long-term nighttime fears. Children were randomly assigned to a treatment or waiting-list control group. Similar to the pilot investigation, treatment involved teaching relaxation and verbal coping skills to the children to counter any feelings of being afraid through the night. Over the 3-week program, parents played an important role in monitoring home practice and rewarding children for their progress. Results clearly attested to the efficacy of the cognitive-behavioral treatment. After 3 weeks of cognitive-behavioral intervention, the treatment group had significantly less nighttime fear than the control group on a host of variables including the number of minutes to get in bed and time to fall asleep, self-reported willingness to go to sleep, and proportion of days that delay tactics (e.g., ask for water, light on) were used by the children. Follow-ups at 2,6, and 12 months were conducted by telephone with parents of the children in the treatment group. At the time of the 1Bmonth follow-up, only 1 of the 17 children in the experimental group failed to meet the behavioral criterion of 10 consecutive “fearless” and “perfect” nights. Following treatment of the experimental group, the control group was provided with the same program. A similar improvement occurred with nearly all children reaching the behavioral criterion. Long-term follow-up information was obtained 2 to 3 years after treatment on children using a mail questionnaire and extensive telephone contact with parents. Maintenance of improvement was noted in nearly all children (Graziano & Mooney, 1982). It should be noted that Graziano and Mooney’s work has been replicated with younger children troubled by severe nighttime fears (Giebenhain & O’Dell, 1984; McMenamy 8c Katz, 1989). For example, using a multiple baseline design across subjects, McMenamy and Katz evaluated effectiveness of cognitive-behavioral strategies with five 4 to 5-year-old children and their parents. The children were taught relaxation skills, pleasant imagery, and self-instructions to reduce anxiety; the parents were trained to positively reinforce compliance and reductions in their children’s fearful behavior. Given the age of the children, however, some creative innovations were necessary. Children were taught how to handle fears with the aid of a short story. Read to the children by their parents, the story described two young children who experienced nighttime fears and the methods they used to overcome them. The children in the story used relaxation and self-instruction training (coping statements) to deal with their fears. At the end of treatment, the children were given a ‘ghostbuster” t-shirt and praised for the progress they made. Nightly ratings of the children’s bedtime behavior (e.g., crying spells, getting out of bed, the time it took to fall asleep) were completed by the parents. Relative to baseline scores, the mean reduction in fearful behaviors at the end of the 3week treatment phase was 40%. Six weeks later, it increased to 48%. Telephone interviews with the parents at a 6month follow-up suggested continued improvement. Pre- and post-ratings on the Child Behavior Checklist showed significant improvement in the children’s behavior at the end of treatment, as well as at a 6week follow-up. Marked improvements in family functioning were also observed, thus attesting to the generalization of treatment effects.

440

N. King, i? H. Olltmdick, and B. J. Tonge

METHODOLOGICAL

AND THEORETICAL

ISSUES

Although nighttime fears are troublesome, they appear to respond to various treatment modalities in a relatively short period of time. Cognitive-behavioral strategies appear to be the most effective and cost-efficient interventions. As noted, Graziano, Mooney et al. (1979) and Graziano and Mooney (1980) used a combination of cognitive self-instruction, relaxation, and reinforcement to reduce the intensity, frequency, and duration of nighttime fears in children. Typically the children reached a criterion of 10 fearless nights with five treatment session. McMenamy and Katz (1989) reported success with a similar treatment procedure for younger children experiencing severe nighttime fears; all of the children exhibited marked improvements after 3 weeks of treatment. Such changes in nighttime fears have persisted for up to 2 l/2 to 3 years (Graziano & Mooney, 1982). In the light of the duration and severity of the children’s fears, the rapid behavioral changes reported in these studies are very impressive. Unfortunately, the methodologies used in these studies preclude identification of the specific mechanisms responsible for such changes. For example, Graziano, Mooney et al. (1979) utilized an uncontrolled multiple case study approach. The lack of appropriate controls makes the results difficult to interpret. Although Graziano and Mooney (1980) employed a control group design, they used a waiting list rather than a placebo control group. Consequently, changes related to nonspecific factors, such as enrolling in a treatment program and expectancies for change, cannot be ruled out as being responsible for changes which were attributed to treatment. McMenamy and Katz (1989) used an extended multiple baseline design, but they did not report equating therapist contact with the children and their families across baseline and treatment conditions. Consequently, change attributed to introduction of treatment may have been due to reactivity to contact with the therapist or to active participation in a treatment program. In response to these issues, Friedman and Ollendick (1989) conducted a study designed to examine more closely efficacy of a multicomponent treatment program similar to that employed by Graziano, Mooney et al. (1979). A multiple baseline design across subjects was used to examine efficacy of a treatment package consisting of relaxation, reinforcement, and cognitive self-instruction in the reduction of severe nighttime fears in six children. This study equated amount of contact with therapists and the clinic across baseline and treatment conditions. A placebo treatment session was utilized for children on extended baselines to control for reactivity to the demands associated with beginning treatment. During the placebo session, children drew pictures and discussed their favorite activities while parents were reminded about home monitoring. Although the disruptive bedtime behaviors of five of the six children were reduced, the multiple baseline analysis revealed that changes were not solely due to treatment. For children with extended baselines, improvement preceded treatment. Contact with a therapist was sufficient to produce improvements on such variables as minutes to go to bed and disruptive fear behavior through the night. Friedman and Ollendick (1989) acknowledge that it is unlikely that reactivity alone is responsible for the maintenance of improved nighttime behavior, as reported in their study as well as in the Graziano studies (Graziano, Mooney et al., 1979; Graziano 8c Mooney, 1980) and in McMenamy and Katz (1989). Typically, nonspecific treatment effects dissipate over time (Lob& 8cJohnson, 1975). Initial changes in the children’s behavior may have served to produce changes in their reinforcement contingencies at

Children 5 Nighttim

Fears

441

home and the children’s own beliefs about their ability to remain in the dark and/or facilitated the development of adaptive coping strategies. These changes may then have led to maintenance of improvement. Nonetheless, future studies should attempt to control for the reactive effects of participation in a treatment program. Until this is done the role of what Graziano and his colleagues considered to be the active treatment ingredients - relaxation, selfinstruction, and reinforcement - remains less clear. Of course, there are other methodological issues that should also be addressed. For example, none of the studies we reviewed reported information on the diagnostic status of the children. Future studies should attempt to address this omission. As well as providing important clinical information about the sample of children, diagnostic status can be used as a dependent variable in the evaluation of treatment (cf. Kendall, 1994). SUMMARY

AND CONCLUSIONS

Our review has shown that nighttime fears are experienced by nearly all children during the normal course of development. These fears are transient and not of sufficient magnitude to be problematic. However, some children experience nighttime fears of much greater intensity and duration. Severe nighttime fears cause considerable personal distress and interfere with family functioning. These fear problems should not be confused with behavioral problems, such as noncompliance and oppositional behavior. Of course, it must be recognized that some children may experience genuine fear problems as well as behavioral difficulties (comorbidity). As with children’s clinical fears in general, severe nighttime fears are probably due and cognitive-mediational to a complex interaction of biological, environmental factors. We recommend a multi-method, hypothesis testing approach to the assessment of children’s severe nighttime fears, including a behavioral interview, diagnostic interview, completion of a fear survey schedule by the child, and home monitoring on the part of parents. Although darkness-toleration tests are often used by clinicians and researchers, we are critical of their clinical utility and ecological validity. Traditional behavioral treatment procedures, such as systematic desensitization and its variants (emotive imagery), have been successfully used in the management of children’s severe nighttime fears. More recently, cognitive-behavioral interventions have become popular in the treatment of children’s severe nighttime fears. Typically, these interventions involve self-instruction, relaxation, and reinforcement. Controlled investigations have shown that cognitive-behavioral strategies are remarkably efficient in the treatment of severe nighttime fears. However, these investigations have generally not controlled for a possible placebo effect, which we see as a major methodological limitation. Nonetheless, it would appear that promising advances have been made in the assessment and treatment of children’s severe nighttime fears. REFERENCES American Psychiatric Association. (1994). Dingnostir and stati.&& mnnual c~f’manta1 di.wrdms (4th ed.). Washington, DC: Author. Bauer, D. H. (1976). An exploratory study of developmental changes in children’s fears. ,~ournnl o/Child Prychology and Psychiatry, 17, 69-74. Ferrari, M. (1986). Fears and phobias in childhood: Some clinical and developmental considerations. Child l3ychiatry and Human Development, 17, 75-87. Friedman, A. G., & Ollendick, T. H. (1989). Treatment programs for severe night-time fears: A methodological note. Journal of Behavior Thm& and Experimental Psychiatry, 20, 171-178.

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