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Rapid treatment of nocturnal anxiety in children
I I, pp. I.
1. Behav. Ther. & Exp. Psychim. Vol. 9-l Perpamon Press Ltd.. 1980. Printed in Great Britain
c‘
ooo5-7908/80/0301axws02.00/0
RAPID TREATMENT OF NOCTURNAL ANXIETY IN CHILDREN JONATHAN
KELLERMAN
Children’s Hospital of Los Angeles, University of Southern California School of Medicine, Department of Pediatrics Stlmmary-Night fears and slccplcssncss in three children of varying ages arose from an initial anxious rcacrion to a realistic stimulus combined with its subsequent reinforcement because of its avoidance properties and of parental attention. Treatment using incompatible response training based on the principle of reciprocal inhibition and self-paced exposure along with operant rcinforcemcnt of appropriate sleep behavior was associated with the elimination of problem behavior within three or four sessions for all three children. Extended follow-up revealed maintenance of thcraocutic gains accompanied by improvement in other areas of psychological functioning. _ same evening. This did not recur, however, until two weeks later, when, while experiencing a fever due 10 chicken-pox, D spontaneously reported “seeing Dracula”. From that time on, nightmares occurred from two to seven times a week, and the child’s anxiety had gcneralizcd to his refusing to visit his maternal grandmother because it was in her house that he had seen the Dracula movie. For several months bcforc referral, D’s parents had allowed him to sleep in their bed. Intcrestingly, several weeks after the chronic nightmares began, the child had requested to purchase a toy Dracula cape. His parents, adopting a protective stance, had rcfuscd and had assiduously scrccncd potentially anxiety-provoking t&vision material from his view.
Fear of sleeping alone and nightmares are common problems in children. The relationship between conditioned anxiety and disturbances of sleep has been discussed by several authors (Christozov and Dascalov, 1970; Persikoff and Davis, 1971; Handler, 1972; Taboada, 1975; Kellerman, 1979; Cellucci and Lawrence, 1978) and behavioral approaches aimed at reducing anxiety have proved effective. In the current report, a combined behavioral approach was effective in rapidly eliminating nocturnal anxiety in three children of different age levels. Behavioral analysis was used to specify stimuli that elicited, maintained and followed anxiety, and incompatible response training was used to achieve anxiety reduction. Operant reinforcement of appropriate nighttime behavior was used to overcome the deviant nocturnal behavior.
METHODS The assumption was made that the nightmares rcprcscntcd an anxiety reaction to a frightening film. In addition, inappropriate sleep behavior had been positively reinforced by allowing the child to slap with his parents and the child’s verbalized fear was followed by a great deal of parental attention. Consequently, the trcatmcnt plan dcviscd had several facets. (1) D was told that he could not be afraid and angry at the same time and that being angry at Dracula could make him feel better. During one individual session, he practiced repeatedly drawing Dracula and displaying anger, including tearing up the drawing and throwing it away. Angry verbal responses were displayed by the author and D was encouraged to imitate them. By the end of the session D was clearly enjoying this and was told that he could practice at home when he felt afraid. (2) D’s parents were instructed not to protect him from what they felt wcrc fearful stimuli as this tcndcd to co&m to the child that characters on television or the movies were to
CASE HISTORY D, a five-year-old boy, presented with a seven month history of nightmares accompanied by nocturnal anxiety. These episodes were behaviorally similar to those common in classical night terrors (sudden waking, motility, scrcaming, no memory of the event; Kellerman. 1979). D’s parents reported that their child had viewed a frightening Dracula movie on television and had experienced a nightmare that
Requests for reprints should be addressed IO Dr. Jonathan Kellerman, Director, Psychosocial Program, Hematology-Oncology, Children’s Hospital of Los Angeles, P.O. Box 54700, Los Angeles, CA 90054. 9
Division of
JONATHAN KELLERMAN
10
be feared. D’s verbalized fear regarding Dracula was to be followed by the statement, “You can handle it” and the suggestion that he get angry at Dracula. (3) D was instructed that he would no longer be able to sleep in his parents’ room and that if he slept in the proper place he would be rewarded. Wiih D’s participation it was agreed that during the first week he could sleep anywhere in the house except his parents’ room; after that he would be required to sleep in his room. Through discussion with D several counter-anxious behaviors, in addition to anger, were obtained (turning on a night light, going to the refrigerator for a snack, turning on the radio next to his bed, looking through a favorite picture book) and D was instructed to use these if he began to feel frightened. He was told to engage in these incompatible responses the minute he felt just a little afraid and not to wait until the anxiety intensified. Going into his parents’ room was specitIcaRy excluded as an acceptable anxiety-reducing activity. Appropriate sleep behavior was to be recorded and positively reinforced with money (5 cents). Reinforcement was given on the morning fotlowing a full night of appropriate sleep. D asked if he could use his money to buy a Dracula cape and was told that he could. (4) D’s parents were given examples of asserdve behaviors, particularly those related to mastery over fearful stimuli, and were instructed to look out for these and verbally praise them.
RESULTS The night following the initial session D tried to gain entry to his parents’ room and upon being refused permission to do so had a tantrum. His parents successfully extinguished this behavior by ignoring it. D then curled up outside their door and slept, with no subsequent nightmares. Throughout the remainder of the first week he slept on a couch in the living room and was monetarily and verbally reinforced. Two nightmares occurred during the first week. During the second week D slept in his own room and experiencea no nightmares. He eventuarly earned enough money to purchase a Dracula costume. After four weeks, during which nightmares did not occur, monetary reinforcement for appropriate sleep behavior was faded out. Follow-up 18 months later revealed maintenance of therapeutic gains, as did a second follow-up at 24 months. D’s mother reported that he occasionally talked about Dracula but that it didn’t seem to bother him. An increase in general assertiveness was noted. Total treatment occurred over three hourly sessions. Two other cases were successfully treated using similar methods. An eight-year-old girl
with a four year history of separation anxiety, school phobia, fear of the dark and anxiety about going to sleep was found to have fears focusing upon kidnappers breaking into her house at night. She drew a picture of a kidnapper, was given an explanation regarding the incompatibility of anger and fear, and was encouraged to practice getting angry at the intruder the moment she felt anxious. Appropriate nocturnal behavior was positively reinforced with money. During the first week she reported feeling less frightened at night and slept in her room uneventfully. After two weeks complete cessation of nocturnal anxiety was reported. Monetary reinforcement was faded out. Follow-up at 16 months revealed maintenance of therapeutic gains. A 13-year-old girl was referred due to a five year history of anxiety associated with being alone at night or in the dark. She spent the night in her younger brother’s room and experienced intermittent nightmares. Anxiety centered around being molested by a cat burglar or rapist and was reported to have increased following several stranglings that occurred near her neighbourhood. A pattern of escape behavior had been learned in which she tried to stay in her room at night, experienced anxiety, waited until the level of discomfort rose to an intolerable level and then left for an alternative sleeping place. Steps were taken to deal with reality issues that contributed to the anxiety (e.g., purchasing opaque drapes for bedroom windows, making sure that the family house was adequately secure). Several counter-anxious behaviors (watching television, reading, turning on a night light and getting a snack) were used contingent upon threshold anxiety. Appropriate night-time behavior was monetarily reinforced. Within two weeks she was sleeping comfortably in her room and reporting no anxiety, monetary reinforcement was faded out. Follow-up at nine months revealed stability of relaxed pre-sleep and sleep behavior. DISCUSSION Three cases of successful rapid treatment of nocturnal anxiety and related problems in
RAPID TREATMENT OF NOCTURNAL ANXIETY IN CHILDREN
children of varying ages have been presented. All three of these cases had in common realistic occurrences that led to subsequent learning of disruptive, anxious associations. Treatment elements included careful behavioral analysis aimed at specifying the stimuli with which anxiety was associated, handling of reality factors that contributed towards maintenance of anxious behavior, instruction in practice of counter-anxious behaviors and reversal of familial patterns of positive reinforcement of anxious behavior. Speculation is offered here, that while most children are exposed to numerous fearful stimuli throughout their childhood, pediatric phobias are not ubiquitous because children naturally engage in self-curative behavior. Mainly self-paced repeated exposure to fearful stimuli. Parental protectiveness may serve to intensify rather than reduce the child’s anxiety by restricting the opportunity to engage in counter-anxious behavior. In addition, parental attention offered contingent upon fearfulness may very well contribute toward chronicity of problematic anxiety. It is possible that the implementation of a reward system may, in itself, have anxiety-reducing properties in that it offers the child a cognition (thinking about earning a reward) that is relaxing and therefore incompatible with anxiety. In the three cases cited, fearful stimuli could be avoided or escaped. Where a fearful response follows a repeated aversive stimulus that cannot be avoided, treatment may be more prolonged. An example of this is the case of a chronically ill child who is confronted with repeated, uncomfortable medical procedures. There is evidence, however, that similar behavioral Acknowledgement-The manuscript.
11
methods may be used in reducing conditioned anxiety in such instances (Kellerman, 1979). It is not useful to conceptualize pediatric anxiety reactions in terms of syndromes or disease states in which the essential organizing criterion is the setting or time in which the fearful behavioral occurs. Thus, thinking of all instances of nocturnal anxiety or nightmares as equivalent is not helpful in terms of developing treatment plans. Rather, a careful behavioral analysis aimed at eliciting the stimulus antecedents and consequences specific to individual cases paves the way’to developing ways of helping patients develop counter-anxious strategies. It is precisely this need for individualized functional analysis, as opposed to standardized, packaged treatment that has been so eloquently addressed by Phillips (1978). The rapidity and durability of therapeutic gains reported in the present study lend further credence to this notion. REFERENCE.5 Cellucci A. J. and Lawrence P. S. (1978). The efficacy of systematic desensitization in reducing nightmares, J. Behav. Ther. % Exp. Psychiat. 9,109-144. Christozov C. and Dascalov D. (1970) Correlation between clinical and EEG findines in children with ni&tt terrors and somnambulism, Acta Poedopychiotr. 3?, 61. Handkr L. (19f2) The amelioration of niahtmarcs in children, P&hoiher. Ther. Res. Pratt. 9.54: Kellerman J . (I 979) Single case study: Behavioral treatment of night terrors in a child with acute leukemia, J. Nem. Ment. Db. 167, 182-185. Pcrsikoff R. B. and Davis P. C. (1971) Treatment of pavor noctumus and somnambulism in childhood, Am. J. Psychiat. 128,778. Phillips L. W. (1978) The soft underbelly of behavior therapy: Pop behavior mod, J. Behav. Ther. & Exp. Psych&. 9,139-M. Taboada E. L. (1975) Night terrors in a child treated with hypnosis, Am. J. C/in. Hypn. 17,270.
author wishes to thank MS Lourdes V. Centeno for assistance in the preparation
of this
1. Behav. Ther. & Exp. Psychim. Vol. 9-l Perpamon Press Ltd.. 1980. Printed in Great Britain
c‘
ooo5-7908/80/0301axws02.00/0
RAPID TREATMENT OF NOCTURNAL ANXIETY IN CHILDREN JONATHAN
KELLERMAN
Children’s Hospital of Los Angeles, University of Southern California School of Medicine, Department of Pediatrics Stlmmary-Night fears and slccplcssncss in three children of varying ages arose from an initial anxious rcacrion to a realistic stimulus combined with its subsequent reinforcement because of its avoidance properties and of parental attention. Treatment using incompatible response training based on the principle of reciprocal inhibition and self-paced exposure along with operant rcinforcemcnt of appropriate sleep behavior was associated with the elimination of problem behavior within three or four sessions for all three children. Extended follow-up revealed maintenance of thcraocutic gains accompanied by improvement in other areas of psychological functioning. _ same evening. This did not recur, however, until two weeks later, when, while experiencing a fever due 10 chicken-pox, D spontaneously reported “seeing Dracula”. From that time on, nightmares occurred from two to seven times a week, and the child’s anxiety had gcneralizcd to his refusing to visit his maternal grandmother because it was in her house that he had seen the Dracula movie. For several months bcforc referral, D’s parents had allowed him to sleep in their bed. Intcrestingly, several weeks after the chronic nightmares began, the child had requested to purchase a toy Dracula cape. His parents, adopting a protective stance, had rcfuscd and had assiduously scrccncd potentially anxiety-provoking t&vision material from his view.
Fear of sleeping alone and nightmares are common problems in children. The relationship between conditioned anxiety and disturbances of sleep has been discussed by several authors (Christozov and Dascalov, 1970; Persikoff and Davis, 1971; Handler, 1972; Taboada, 1975; Kellerman, 1979; Cellucci and Lawrence, 1978) and behavioral approaches aimed at reducing anxiety have proved effective. In the current report, a combined behavioral approach was effective in rapidly eliminating nocturnal anxiety in three children of different age levels. Behavioral analysis was used to specify stimuli that elicited, maintained and followed anxiety, and incompatible response training was used to achieve anxiety reduction. Operant reinforcement of appropriate nighttime behavior was used to overcome the deviant nocturnal behavior.
METHODS The assumption was made that the nightmares rcprcscntcd an anxiety reaction to a frightening film. In addition, inappropriate sleep behavior had been positively reinforced by allowing the child to slap with his parents and the child’s verbalized fear was followed by a great deal of parental attention. Consequently, the trcatmcnt plan dcviscd had several facets. (1) D was told that he could not be afraid and angry at the same time and that being angry at Dracula could make him feel better. During one individual session, he practiced repeatedly drawing Dracula and displaying anger, including tearing up the drawing and throwing it away. Angry verbal responses were displayed by the author and D was encouraged to imitate them. By the end of the session D was clearly enjoying this and was told that he could practice at home when he felt afraid. (2) D’s parents were instructed not to protect him from what they felt wcrc fearful stimuli as this tcndcd to co&m to the child that characters on television or the movies were to
CASE HISTORY D, a five-year-old boy, presented with a seven month history of nightmares accompanied by nocturnal anxiety. These episodes were behaviorally similar to those common in classical night terrors (sudden waking, motility, scrcaming, no memory of the event; Kellerman. 1979). D’s parents reported that their child had viewed a frightening Dracula movie on television and had experienced a nightmare that
Requests for reprints should be addressed IO Dr. Jonathan Kellerman, Director, Psychosocial Program, Hematology-Oncology, Children’s Hospital of Los Angeles, P.O. Box 54700, Los Angeles, CA 90054. 9
Division of
JONATHAN KELLERMAN
10
be feared. D’s verbalized fear regarding Dracula was to be followed by the statement, “You can handle it” and the suggestion that he get angry at Dracula. (3) D was instructed that he would no longer be able to sleep in his parents’ room and that if he slept in the proper place he would be rewarded. Wiih D’s participation it was agreed that during the first week he could sleep anywhere in the house except his parents’ room; after that he would be required to sleep in his room. Through discussion with D several counter-anxious behaviors, in addition to anger, were obtained (turning on a night light, going to the refrigerator for a snack, turning on the radio next to his bed, looking through a favorite picture book) and D was instructed to use these if he began to feel frightened. He was told to engage in these incompatible responses the minute he felt just a little afraid and not to wait until the anxiety intensified. Going into his parents’ room was specitIcaRy excluded as an acceptable anxiety-reducing activity. Appropriate sleep behavior was to be recorded and positively reinforced with money (5 cents). Reinforcement was given on the morning fotlowing a full night of appropriate sleep. D asked if he could use his money to buy a Dracula cape and was told that he could. (4) D’s parents were given examples of asserdve behaviors, particularly those related to mastery over fearful stimuli, and were instructed to look out for these and verbally praise them.
RESULTS The night following the initial session D tried to gain entry to his parents’ room and upon being refused permission to do so had a tantrum. His parents successfully extinguished this behavior by ignoring it. D then curled up outside their door and slept, with no subsequent nightmares. Throughout the remainder of the first week he slept on a couch in the living room and was monetarily and verbally reinforced. Two nightmares occurred during the first week. During the second week D slept in his own room and experiencea no nightmares. He eventuarly earned enough money to purchase a Dracula costume. After four weeks, during which nightmares did not occur, monetary reinforcement for appropriate sleep behavior was faded out. Follow-up 18 months later revealed maintenance of therapeutic gains, as did a second follow-up at 24 months. D’s mother reported that he occasionally talked about Dracula but that it didn’t seem to bother him. An increase in general assertiveness was noted. Total treatment occurred over three hourly sessions. Two other cases were successfully treated using similar methods. An eight-year-old girl
with a four year history of separation anxiety, school phobia, fear of the dark and anxiety about going to sleep was found to have fears focusing upon kidnappers breaking into her house at night. She drew a picture of a kidnapper, was given an explanation regarding the incompatibility of anger and fear, and was encouraged to practice getting angry at the intruder the moment she felt anxious. Appropriate nocturnal behavior was positively reinforced with money. During the first week she reported feeling less frightened at night and slept in her room uneventfully. After two weeks complete cessation of nocturnal anxiety was reported. Monetary reinforcement was faded out. Follow-up at 16 months revealed maintenance of therapeutic gains. A 13-year-old girl was referred due to a five year history of anxiety associated with being alone at night or in the dark. She spent the night in her younger brother’s room and experienced intermittent nightmares. Anxiety centered around being molested by a cat burglar or rapist and was reported to have increased following several stranglings that occurred near her neighbourhood. A pattern of escape behavior had been learned in which she tried to stay in her room at night, experienced anxiety, waited until the level of discomfort rose to an intolerable level and then left for an alternative sleeping place. Steps were taken to deal with reality issues that contributed to the anxiety (e.g., purchasing opaque drapes for bedroom windows, making sure that the family house was adequately secure). Several counter-anxious behaviors (watching television, reading, turning on a night light and getting a snack) were used contingent upon threshold anxiety. Appropriate night-time behavior was monetarily reinforced. Within two weeks she was sleeping comfortably in her room and reporting no anxiety, monetary reinforcement was faded out. Follow-up at nine months revealed stability of relaxed pre-sleep and sleep behavior. DISCUSSION Three cases of successful rapid treatment of nocturnal anxiety and related problems in
RAPID TREATMENT OF NOCTURNAL ANXIETY IN CHILDREN
children of varying ages have been presented. All three of these cases had in common realistic occurrences that led to subsequent learning of disruptive, anxious associations. Treatment elements included careful behavioral analysis aimed at specifying the stimuli with which anxiety was associated, handling of reality factors that contributed towards maintenance of anxious behavior, instruction in practice of counter-anxious behaviors and reversal of familial patterns of positive reinforcement of anxious behavior. Speculation is offered here, that while most children are exposed to numerous fearful stimuli throughout their childhood, pediatric phobias are not ubiquitous because children naturally engage in self-curative behavior. Mainly self-paced repeated exposure to fearful stimuli. Parental protectiveness may serve to intensify rather than reduce the child’s anxiety by restricting the opportunity to engage in counter-anxious behavior. In addition, parental attention offered contingent upon fearfulness may very well contribute toward chronicity of problematic anxiety. It is possible that the implementation of a reward system may, in itself, have anxiety-reducing properties in that it offers the child a cognition (thinking about earning a reward) that is relaxing and therefore incompatible with anxiety. In the three cases cited, fearful stimuli could be avoided or escaped. Where a fearful response follows a repeated aversive stimulus that cannot be avoided, treatment may be more prolonged. An example of this is the case of a chronically ill child who is confronted with repeated, uncomfortable medical procedures. There is evidence, however, that similar behavioral Acknowledgement-The manuscript.
11
methods may be used in reducing conditioned anxiety in such instances (Kellerman, 1979). It is not useful to conceptualize pediatric anxiety reactions in terms of syndromes or disease states in which the essential organizing criterion is the setting or time in which the fearful behavioral occurs. Thus, thinking of all instances of nocturnal anxiety or nightmares as equivalent is not helpful in terms of developing treatment plans. Rather, a careful behavioral analysis aimed at eliciting the stimulus antecedents and consequences specific to individual cases paves the way’to developing ways of helping patients develop counter-anxious strategies. It is precisely this need for individualized functional analysis, as opposed to standardized, packaged treatment that has been so eloquently addressed by Phillips (1978). The rapidity and durability of therapeutic gains reported in the present study lend further credence to this notion. REFERENCE.5 Cellucci A. J. and Lawrence P. S. (1978). The efficacy of systematic desensitization in reducing nightmares, J. Behav. Ther. % Exp. Psychiat. 9,109-144. Christozov C. and Dascalov D. (1970) Correlation between clinical and EEG findines in children with ni&tt terrors and somnambulism, Acta Poedopychiotr. 3?, 61. Handkr L. (19f2) The amelioration of niahtmarcs in children, P&hoiher. Ther. Res. Pratt. 9.54: Kellerman J . (I 979) Single case study: Behavioral treatment of night terrors in a child with acute leukemia, J. Nem. Ment. Db. 167, 182-185. Pcrsikoff R. B. and Davis P. C. (1971) Treatment of pavor noctumus and somnambulism in childhood, Am. J. Psychiat. 128,778. Phillips L. W. (1978) The soft underbelly of behavior therapy: Pop behavior mod, J. Behav. Ther. & Exp. Psych&. 9,139-M. Taboada E. L. (1975) Night terrors in a child treated with hypnosis, Am. J. C/in. Hypn. 17,270.
author wishes to thank MS Lourdes V. Centeno for assistance in the preparation
of this