Idiopathic and Posttrauma Nightmares in a Clinical Sample of Children and Adolescents: Characteristics and Related Pathology

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1 Journal of Child & Adolescent Trauma, 3: , 2010 Copyright Taylor & Francis Group, LLC ISSN: print / X online DOI: / Idiopathic and Posttrauma Nightmares in a Clinical Sample of Children and Adolescents: Characteristics and Related Pathology TERA J. LANGSTON, 1 JOANNE L. DAVIS, 2 AND RACHAEL M. SWOPES 2 1 Private Practice, Panama City, FL 2 University of Tulsa Nightmares occur commonly during childhood and adolescence as a part of normal childhood development and in response to a traumatic event. Although nightmares are known to be associated with psychological distress, few studies have examined potential differences between idiopathic nightmare sufferers and those whose nightmares began after exposure to a traumatic event (posttrauma). The present study examined such differences in 47 trauma-exposed children and adolescents attending an outpatient treatment facility. It was hypothesized that individuals with posttrauma nightmares would have increased posttraumatic stress disorder symptoms, anxiety, depression, and decreased sleep quality versus those with idiopathic nightmares or no nightmares. Results found that, in general, nightmares are associated with increased distress and impairment, and those with posttrauma nightmares fared worse on several measures of distress than those with idiopathic nightmares or no nightmares. Implications of the current study and suggestions for future research are discussed. Keywords nightmares, sleep disturbance, trauma, posttraumatic stress disorder More than five million children in the United States are estimated to be exposed to some form of extreme traumatic event each year (Pfefferbaum, 1997). Similar to adult victims of trauma, child victims commonly display sleep disturbances including problems falling or staying asleep and nightmares in the aftermath of the traumatic event (e.g., Avery, Massat, & Lundy, 2000; Cuffe & Shugart, 2001). Increasingly, sleep disturbances are thought to be a primary source of developing and maintaining problems posttrauma (Ross, Ball, Sullivan, & Caroff, 1989). At the same time, however, a certain level of sleep problems is considered developmentally normal for children (e.g., Schredl, Fricke-Oerkermann, Mitschke, Wiater, & Lehmkuhl, 2009a). At this point, it is unclear to what extent sleep problems in trauma-exposed children can be attributed to traumatic events versus normal childhood development. And although sleep problems and nightmares can be disruptive and impairing regardless of their origin, it is unknown whether sleep problems that began prior to a traumatic event differ in any clinically or empirically meaningful ways from those that began following a traumatic event for children and adolescents. This study focuses on the Submitted March 7, 2010; revised May 23, 2010; accepted May 26, Address correspondence to Joanne L. Davis, Department of Psychology, University of Tulsa, 800 South Tucker Drive, 308G Lorton Hall, Tulsa, OK joanne-davis@utulsa.edu 344

2 Idiopathic and Posttrauma Nightmares 345 experience of nightmares and examines differences between individuals whose nightmares began prior to a traumatic event (idiopathic nightmares) and those whose began after a traumatic event (posttrauma nightmares). Nightmares are defined as frightening dreams that arouse the person from sleep, with the individual typically being able to describe the dream content and sequence upon awakening (e.g., Singareddy & Balon, 2002). The prevalence of idiopathic nightmares, or nightmares of unknown origin, is believed to be strongly influenced by age with the prevalence highest in young children and decreasing with age (Carlson & Cordova, 1999). There is little agreement among studies regarding specific prevalence rates (American Academy of Sleep Medicine, 2005) likely due to different definitions, age ranges, and methodology utilized across studies. Mindell and Dahl (1998) reported that nightmares occur in 10% to 50% of children between the ages of 3 and 6. No specifications were discussed regarding the frequency of occurrence. Schredl et al. (2009a) surveyed 851 parents and 808 children; parents estimated that approximately 2.5% of children had nightmares often, and 27% had them sometimes. Children s self-report was 3.5% often and 40% sometimes. The authors determined that over the two-year span of the study, the total nightmare frequency of the sample significantly decreased, suggesting a natural, developmental course. The decrease in nightmares appeared to begin around the age of 10. Trauma exposure was not assessed in this study. Hartmann (1996) postulated that virtually all trauma victims experience posttrauma nightmares following the event. For the majority, these nightmares are experienced for a brief period of time. However, for a minority of trauma victims, the nightmares may become chronic. In a review of literature on posttraumatic stress disorder (PTSD) and sleep problems in adults, Harvey, Jones, and Schmidt (2003) reported prevalence rates of nightmares ranging from 19% to 52% in individuals with PTSD, while Forbes, Creamer, and Biddle (2001) found rates of 88% in a veteran PTSD sample. Similar prevalence rates of posttrauma nightmares have been demonstrated for child trauma victims. For example, Mertin and Mohr (2002) examined a sample of 56 children between the ages of 8 and 16 who had resided in a shelter following exposure to domestic violence. Even though only 20% of the children met criteria for PTSD based on diagnostic interview, 61% reported experiencing recurrent distressing dreams (p. 560). Nightmares that occur following the experience of a traumatic event are often referred to as posttrauma nightmares and are found to be markedly different from idiopathic nightmares in the (mostly adult) studies that have been conducted. Although nightmares in general tend to occur during the second half of the night during rapid eye movement (REM) or active sleep (Maurer & Schaefer, 1998), studies have demonstrated that posttrauma nightmares occur during REM and non-rem in both adult (e.g., Kramer & Kinney, 1988) and child samples (e.g., Nader, 1996) and are more likely to occur in the early part of the sleep cycle (van der Kolk, Blitz, Burr, Sherry, & Hartmann, 1984). Adults suffering from posttrauma nightmares report greater episodes of awakening during the sleep cycle compared with idiopathic nightmare sufferers (Singareddy & Balon, 2002). Finally, Hartmann (1996) found that posttrauma nightmares were associated with muscular activity and partial arousal, while this is not found in idiopathic nightmares (Mindell & Dahl, 1998). Several studies that did not assess for trauma exposure have found that frequent nightmares are related to stress and anxiety (e.g., Nielsen et al., 2000). Schredl and colleagues (2009a) found that chronic nightmares in children were associated with emotional symptoms, hyperactivity-inattention, conduct problems, and peer problems. In another longitudinal study, Nielsen and colleagues examined 610 adolescents when they were 13 and 16 years old. The authors found that the frequency of nightmares was significantly related

3 346 T. J. Langston et al. to anxiety symptoms at age 13 and generalized anxiety disorder, separation anxiety, and overanxious disorder at age 16. Studies have also found greater occurrence of nightmares and nighttime awakenings in school-aged children following physical or sexual abuse (e.g., Sadeh et al., 1995), disasters (e.g., Vogel & Vernberg, 1993), and human violence (e.g., Pynoos et al., 1987). Thus, research has found some differences in sleep and nightmare characteristics between individuals based on trauma-exposure status. Additionally, nightmares in general, regardless of trauma-exposure status, appear to be related to increased distress. To date, few studies have evaluated differences in nightmares that started before a trauma (idiopathic nightmares) and those that started after a trauma (posttrauma nightmares) in a sample of trauma-exposed individuals. In a recent study of adult trauma victims seeking treatment, Davis, Pruiksma, Rhudy, and Byrd (in press) explored differences between individuals with idiopathic nightmares or posttrauma nightmares in terms of nightmare characteristics, related pathology, sleep quality, and treatment response. The authors found that those with posttrauma nightmares experienced greater symptoms of depression and PTSD, as well as poorer sleep quality. No differences were found between groups on other nightmare or sleep characteristics or in response to a cognitive behavioral treatment for chronic nightmares. The authors suggested that individuals with nightmares prior to a traumatic event may have developed coping strategies that provided some protection against posttrauma problems. This finding is contrary to that found by Mellman, David, Kulick-Bell, Hebding, and Nolan (1995). These investigators examined the relationship of sleep problems in adults before and after a hurricane who had PTSD and depression within a year of the hurricane. They found that sleep problems prior to the hurricane were associated with greater psychological problems afterward, suggesting that pretrauma sleep disturbances may be a vulnerability factor for posttrauma functioning. More research is needed among various samples to ascertain whether idiopathic sleep problems including nightmares serve as risk or protective factors for posttrauma problems. Hypotheses In the current study, we examined the following hypotheses: 1. Trauma-exposed children and adolescents who experience posttrauma nightmares will report greater severity of PTSD, anxiety, depression symptoms, and poorer sleep quality than those who experience idiopathic nightmares and those without nightmares. Exploratory analyses will examine differences in nightmare experience by number of traumatic events, type of trauma, and the participants thoughts and feelings during the traumatic event. 2. Of the children and adolescents who experience nightmares, those with posttrauma nightmares will report greater frequency and severity of nightmares, greater number of panic symptoms upon waking from a nightmare, and greater similarity of their nightmares to the traumatic event than those with idiopathic nightmares. Method Participants The current study was drawn from a larger project exploring trauma and sleep disturbances in two clinical samples of children and adolescents. The study was approved by the

4 Idiopathic and Posttrauma Nightmares 347 Table 1 Demographic characteristics of trauma-exposed children and adolescents (N = 47) Characteristic n % M (SD) Age (2.78) Children (9 12) Adolescents (13 17) School grade 6.81 (2.66) Gender Male Female Race Caucasian African American/Black American Indian/Alaskan Native Other Family income $25,000 or below $26,000 $40, $41,000 $60, $61,000 $80, $81,000 or above Psychiatric diagnosis Yes No Taking medication Yes No institutional review boards of a Midwest university and two outpatient facilities. Inclusion criteria for this study included being between the ages of 9 and 17. Exclusion criteria included lack of fluency in the English language, presence of a developmental delay, or active psychosis. If a participant had difficulty reading the questionnaires, the study administrator was allowed to read them to him or her, but no participant required this. There were no restrictions on socioeconomic status, race, or ethnic background. Seventy-three participants were recruited for this study from two outpatient facilities. Based on developmental differences in sleep characteristics, participants were originally grouped into a children s group (ages 9 12) or an adolescent s group (ages 13 17). Specific demographic information is shown in Table 1. Overall, the sample was mostly female and Caucasian, with an average age of approximately 12. Nearly 75% had a psychiatric diagnosis, and almost half were being prescribed medications. Measures A packet of self-report measures was administered to each child participant. Parents were not queried about their children s experiences, as several studies on sleep and nightmares

5 348 T. J. Langston et al. have found that parent and child scores differ considerably and that parents underestimate nightmare occurrence (e.g., Schredl et al., 2009a; Schredl, Fricke-Oerkermann, Mitschke, Wiater, & Lehmkuhl, 2009b; Schredl, Pallmer, & Montasser, 1996). The following description of measures is drawn from the larger study (Langston, Davis, & Swopes, 2010). UCLA PTSD Reaction Index for DSM-IV (Child and Adolescent Versions). The Child Version (for ages 9 12) and Adolescent Version (for ages 13 17) of the UCLA PTSD Reaction Index for DSM-IV (Pynoos, Rodriquez, Steinberg, Stuber, & Frederick, 1998) were included to assess for symptomatology specific to the trauma experience. The UCLA PTSD Reaction Index is a self-report measure that consists of several sections. The initial section comprises a brief screen for lifetime trauma exposure to 12 different events, such as a natural disaster, car accident, serious illness, physical abuse, sexual assault, and witnessing physical abuse of others. The child is also afforded the opportunity to include any other traumatic event that was not included on the list. If the child indicates more than one traumatic experience, he or she is asked to indicate which event was the most bothersome. Next, the child indicates whether specific feelings, such as being scared, upset, or confused, were experienced during or right after the event. Responses to these questions allow for a structured appraisal of the objective and subjective aspects of the event to assist in determining whether the event meets diagnostic criteria as a trauma. The child and adolescent version contain identical items for this section. In order to be categorized into the trauma group, a participant has to endorse experiencing an event as well as the objective and subjective aspects required by the diagnostic criteria. In the next section, the child rates the frequency with which specific posttrauma stress symptoms were experienced in the previous month using a 5-point Likert-scale ranging from 0 (none of the time) to4(most of the time). Convergent validity is supported by the agreement of cut scores with a diagnosis of PTSD. Convergent validity is reported to be good (e.g.,.82 in comparison with the Clinician Administered PTSD Scale for Children and Adolescents; Newman et al., 2004). When detecting PTSD by using a cut score of 38, sensitivity is reported at.93, and specificity is reported to be.87. Test retest reliability ranges from good to excellent (.84.94). For the current study, the overall severity score of posttraumatic symptoms was used in analyses. For analyses examining the relationship between nightmares and posttraumatic stress symptoms, two items ( dreams about what happened or other bad dreams and trouble going to sleep or waking up during the night ) were omitted when computing the severity score in order to provide an estimate of PTSD symptoms that was not influenced by items related to sleep or confounded by questions regarding nightmares. Children s Depression Inventory. The Children s Depression Inventory (CDI; Kovacs, 1992) was included in order to assess for possible mood symptoms present in the participants. The CDI consists of 27 groups containing three sentences each describing various feelings and ideas. The child is instructed to pick the sentence from each group that best describes him or her for the previous two weeks. The profile produces an overall score and subscale scores for negative mood, interpersonal problems, ineffectiveness, anhedonia, and negative self-esteem. These scores are then converted to T-scores according to the respondents age and gender. Good internal consistency for the CDI has been demonstrated in various samples with reported coefficients ranging from.71 to.88 (Kovacs, 1992). For the current study, the total T-score was used to determine the degree of depressive symptoms reported. For analyses examining the relationship between the presence, frequency, and

6 Idiopathic and Posttrauma Nightmares 349 severity of nightmares and depressive symptoms, two item groupings regarding having trouble sleeping and feeling tired were omitted when computing the T-score in order to provide an estimate of depressive symptoms that was not influenced by items related to sleep and not confounded by questions regarding nightmares. Multidimensional Anxiety Scale for Children. The Multidimensional Anxiety Scale for Children (MASC; March, 1999) was included to assess for possible anxiety reactions in the child. The MASC consists of 39 items distributed across four major factors, three of which can be divided further into two subfactors. Main and subfactors include physical symptoms (tense/restless and somatic/autonomic), social anxiety (humiliation/rejection and public performance fears), harm avoidance (perfectionism and anxious coping), and separation anxiety. Respondents rate each of the items based on how they are thinking, feeling, or acting recently using a 4-point Likert-scale format. The response options range from 0 (never true about me) to3(often true about me). The MASC was normed on a nonclinical sample of 2,698 children and adolescents. It is intended for use with children and adolescents between the ages of 8 and 19 and has a fourth-grade level of readability. The MASC factor structure is stable across gender and age and shows excellent internal reliability. Convergent validity with the Social Anxiety Scale for Adolescents and the Social Phobia & Anxiety Inventory for Children was indicated to be.84 and.80, respectively (March, Parker, Sullivan, Stallings, & Conners, 1997). For the current study, the total MASC T-score, which is computed based on the respondents total score, age, and gender, was used to determine the degree of anxiety symptoms reported. Trauma-Related Nightmare Survey (Child Version). The Trauma-Related Nightmare Survey (Child Version; Langston & Davis, 2008) is a brief self-report measure that assesses current sleep quality, frequency, severity, and duration of nightmares, as well as cognitions, emotions, and behaviors related to nightmares. The measure is a modified version of the Trauma-Related Nightmare Survey (TRNS; Davis, Wright, & Borntrager, 2001), which was created as a self-report measure for an adult population. Adjustments made to the original measure involved language modifications in order to achieve a fourth-grade level of readability. Psychometric properties for the adult version of the scale indicate adequate test retest reliability (r =.64.77) and convergent validity with daily records of nightmares and sleep activity (r =.45.82; Davis, Byrd, Rhudy, & Wright, 2007). No psychometric properties are available for the child version of the scale. For the current study, participants were considered to be currently experiencing nightmares if they reported bad dreams at least once per month from which they awoke. The TRNS-Child was used to assess aspects of sleep quality for the previous one-month period and frequency of any nightmare experiences during the past week and month. Given the retrospective nature of their reports, the reported frequency of nightmare experiences for the prior week was used in the analyses. Severity of nightmares experienced was rated using a 5-point Likert scale format. A physiological arousal severity score was obtained by totaling the number of the 14 physiological symptoms the participant reported experiencing upon awakening from a bad dream. Pittsburgh Sleep Quality Index (Modified). The Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) is a self-report measure of quality of sleep and degree of sleep difficulties designed to assess seven components of sleep (i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction). Adjustments made to the original measure involved language modifications in order to achieve a fourth-grade level

7 350 T. J. Langston et al. of readability and the inclusion of a series of five questions designed to assess for the timing of and the participants reaction to reported nightmares. The child responds to 27 items by either filling in the blank or using a Likert scale format. Responses produce seven component scores, which are then summed to achieve a global score ranging from 0 to 21. A PSQI global cut score over 5 adequately differentiates sleep-disordered patients from healthy sleepers, with higher scores indicating worse sleep. Demographic Information. Information regarding each child s current age, level of education, racial and ethnic identification, gender, any known diagnoses, and any medications being taken including sleep medications was requested in order to accurately describe the characteristics of the sample. Due to the scope of the information requested, this form was completed by the parent or caregiver. Procedure Flyers describing the study were posted and provided to children and adolescents receiving services at one of the two participating clinics. Children who met study criteria were invited to participate in the study. Interested parties could inquire about participation either to their therapist or to the investigator listed on the flyer. Additionally, therapists were allowed to mention the study when they deemed participation appropriate. A parent or legal guardian provided informed consent for their child/adolescent while the child/adolescent provided assent. Questionnaire data collection took place in a private setting within the referring agencies. Each participant was compensated with a $5 gift card to a local department store or was able to choose from a selection of gifts of comparable value in lieu of the gift card. Data Analysis Comparisons were made between the collection sites and age cohorts on all dependent variables to determine whether groups could be combined for analyses. Chi-square and one-way analysis of variance were conducted to determine differences on dependent variables by type of nightmares. Results Preliminary Analyses Overall, 64.3% (n = 47) of participants reported having experienced a traumatic event. Only these individuals were included in subsequent analyses (see Table 1 for demographic information). Groups (site and age cohort) were compared on all demographic variables and the presence and severity of nightmares. No differences were found by site or age cohort, and the groups were combined. The most frequently reported traumas were witnessing domestic violence (34%), physical abuse in the home (26%), and sexual abuse (15.1%). Of the trauma-exposed individuals, 28% (n = 13) reported idiopathic nightmares, 23% (n = 11) reported posttrauma nightmares, and 49% (n = 23) reported no nightmares. Hypothesis 1 The first hypothesis, that trauma-exposed children and adolescents who experience posttrauma nightmares would report greater severity of PTSD, anxiety, depression symptoms,

8 Idiopathic and Posttrauma Nightmares 351 and poorer sleep quality than those who experience idiopathic nightmares and those without nightmares, was partially supported (see Table 2). Specifically, the posttrauma nightmare group scored significantly higher than the no nightmare group on fear of sleep, feeling sad when waking, depression, PTSD severity, and poorer global sleep quality. The idiopathic nightmare group reported greater fear of sleep than the no nightmare group. More participants were categorized as poor sleepers in the posttrauma group (100%) and idiopathic group (100%) than the no nightmare group (65%). Exploratory analyses were conducted to determine if presence or type of nightmare was affected by number of traumas, type of trauma, or nature of the trauma. No relationship was found for number of traumatic events with nightmare experience. Of the 13 types of trauma assessed by the UCLA PTSD Index, only sexual abuse was associated with the experience of nightmares. Specifically, more individuals with posttrauma nightmares (55%) than no nightmares (9%) reported experiencing sexual abuse, χ 2 (1, N = 34) = 8.69, p <.01. Several aspects of the worst or only traumatic experience were also related to the experience of nightmares. Specifically, individuals with posttrauma nightmares and those with idiopathic nightmares were more likely to report that during the traumatic event they were scared of dying, χ 2 (2, N = 47) = 6.88, p <.05; scared of being hurt, χ 2 (2, N = 47) = 15.16, p <.001; felt very scared, χ 2 (2, N = 47) = 14.99, p <.001; and felt unable to stop what was happening, χ 2 (2, N = 47) = 13.26, p <.001. Additionally, individuals with posttrauma nightmares were more likely to report actually being hurt badly, χ 2 (2, N = 47) = 9.06, p <.01, and feeling disgusted by what they saw, χ 2 (2, N = 47) = 15.44, p <.001, than those with idiopathic nightmares and those without nightmares. Hypothesis 2 The second hypothesis was that, of the trauma-exposed children and adolescents who experience nightmares (n = 24), those with posttrauma nightmares would report greater frequency and severity of nightmares, greater number of panic symptoms upon waking from a nightmare, and more similarity of their nightmares to the traumatic event than those with idiopathic nightmares. This hypothesis was primarily not supported. The only difference found was for number of panic symptoms upon waking from a nightmare, F(1, 22) = 8.21, p <.01. Specifically, the posttrauma nightmare group reported more panic symptoms (M = 5.36, SD = 2.25) than the idiopathic nightmare group (M = 3.08, SD = 1.66). No differences were found in terms of similarity of the nightmare content to the traumatic event. Specifically, of the individuals with posttrauma nightmares, 73% reported that their nightmares were the same as the trauma, 18% reported that they were similar, and 9% reported that they were not at all like the trauma. Of those with idiopathic nightmares, 54% reported that their nightmares were the same as the trauma, 24% reported that they were similar, and 24% reported that they were not alike. Discussion Overall, this study found that half of the trauma-exposed children reported experiencing nightmares every week. This prevalence rate of frequent nightmares is similar to rates found in other studies of trauma-exposed children inquiring about recurrent distressing dreams (e.g., 61%; Mertin & Mohr, 2002) and much higher than prevalence rates of frequent nightmares in the general population (e.g., 3.5% by child self-report; Schredl

9 Table 2 Differences between trauma-exposed children and adolescents with idiopathic nightmares, posttrauma nightmares, or without nightmares Posttrauma Idiopathic None Dependent variables (n = 11) M (SD) (n = 13) M (SD) (n = 23) M (SD) F η 2 Sleep quality Total sleep time 6.95 (1.56) 7.00 (2.26) 7.57 (2.18) Time to get to sleep a 2.64 (1.12) 2.38 (0.87) 1.83 (0.72) Fear of sleep b 1.82 (1.25) 1.54 (1.45) 0.48 (0.85) Sad upon awakening a 2.18 (1.17) 1.38 (1.04) 1.04 (1.15) Rested upon awakening 1.27 (0.91) 1.69 (0.75) 1.96 (0.98) Global sleep quality a (4.56) 9.00 (2.86) 6.17 (3.87) PTSD a (9.35) (11.32) (11.04) Anxiety (9.99) (15.21) (14.58) Depression a (17.09) (13.72) (13.47) Note. Effect sizes were calculated using eta-squared (.01 = small,.06 = medium, and.14 = large; Cohen, 1988). The first five sleep variables are taken from the Trauma-Related Nightmare Scale, Child Version. Total sleep time, total hours of sleep per night; Time to get to sleep, total time spent falling asleep (1= less than 15 minutes; 2= 15 minutes to 1 hour; 3= 1 hour to 2 hours; 4= more than 2 hours); Fear of sleep, fear of falling asleep rated on scale of 0 (not at all) to4(a huge amount); Sad upon awakening, level of sadness upon awakening rated on 0 4 scale; Rested upon awakening, how rested one feels upon awakening on 0 4 scale; Global sleep quality, sleep quality as measured by the Pittsburgh Sleep Quality Index; PTSD, severity of posttraumatic stress disorder symptoms as measured by the UCLA PTSD Reaction Index for DSM-IV (Child and Adolescent Versions) with the sleep and nightmare items removed; Anxiety, global anxiety as measured by the Multidimensional Anxiety Scale for Children; Depression, global depression as measured by the Children s Depression Inventory. a Differences between posttrauma and none. b Differences between all three groups. p <.05. p <

10 Idiopathic and Posttrauma Nightmares 353 et al., 2009a). Of those individuals suffering from nightmares, 46% reported that their nightmares began after the traumatic event. No other studies that we are aware of have assessed whether nightmares began before or after a traumatic event for children, so we are unable to speak to whether this figure is typical in trauma-exposed samples of children. The main point of this study was to determine if there were differences in mental health difficulties based on nightmare status. The results suggest that, overall, nightmares are related to impairment and psychopathology and that, on several indices of difficulties, individuals with posttrauma nightmares fare worse. Specifically, both idiopathic and posttrauma nightmare groups reported greater fear of going to sleep than the no nightmare group. Further, every person in each of the nightmare groups was classified as a poor sleeper (score > 5 on the PSQI), compared to 65% of those in the no nightmare group. This is consistent with previous literature, which suggests that the presence of nightmares is associated with increased levels of distress (Levin & Fireman, 2002; Nielsen et al., 2000; Schredl et al., 2009a). It remains unclear, however, whether nightmares are a driving force for distress, reflection of distress, or some combination. Although numerous studies have indicated a link between nightmares and psychopathology and distress (e.g., Chivers & Blagrove, 1999; Levin, 1998), results of the current study suggest that this may be more salient for individuals who begin experiencing nightmares posttrauma. Only the posttrauma nightmare group scored significantly worse than the no nightmare group in terms of posttraumatic stress symptoms, global sleep quality index scores, depression, and feeling sad upon waking. These findings also match those found in the adult literature in suggesting that those with posttrauma nightmares report greater distress (Davis et al., in press). It is unclear why this is, however. One possibility may be that the nightmare groups differ on some important aspects of the traumatic event. Davis and colleagues found that posttrauma nightmares in adults were associated with a greater number of types of traumatic events; however, that was not found in this study. We did not explore the total number of traumatic events (including multiple incidents of any one type of trauma). However, a difference by type of trauma was found in the current study. Specifically, sexual abuse was higher in those with posttrauma nightmares than those without nightmares. Although the location of the sexual abuse activities was not assessed, the higher frequency of sexual abuse in those with posttrauma nightmares may reflect possible conditioning of fear to the bedroom environment in those individuals. It is also possible that the experience of sexual abuse accounts for some of the relationship between nightmares and indices of distress. Posttrauma nightmares were also related to characteristics of the traumatic event including suffering actual physical harm and feelings of disgust, both of which were found to be related to poorer functioning (Acierno, Resnick, Kilpatrick, Saunders, & Best, 1999; Olatunji, Babson, Smith, Feldner, & Connolly, 2009). It is also feasible that those with idiopathic nightmares developed a certain amount of tolerance or ways of coping with the nightmare-related distress that they were able to utilize following the trauma, resulting in lower reported distress. More information is needed about the nature, course, and etiological factors related to idiopathic nightmares (Mindell, 1993) to perhaps glean some understanding of their lower distress in the face of traumatic experiences. Finally, explorations of a potential differential response to nightmare treatments by etiology have yielded mixed results (Davis et al., in press; Germain & Nielsen, 2003; van der Kolk et al., 1984) in adult samples. It will be important going forth to explore whether etiology matters in the treatment of nightmares in children.

11 354 T. J. Langston et al. Limitations There are several limitations to the current study that should be acknowledged. Even though the study sample consisted of fairly even groups of male and female participants as well as child and adolescent participants, the majority of the sample was Caucasian. Additionally, the entire sample was composed of an outpatient, treatment-seeking population. As such, it is unclear to what extent the findings of this study can be generalized to the broader trauma-exposed population. This study also lacked the use of a structured interview or other diagnostic tool. Because instruments assessing nightmares and sleep quality in children were not available, modifications to adult measures were utilized for the present study. Finally, the small sample size did not allow us to examine the contribution of each of the variables to the outcomes. Conclusions The present study is one of the only available describing differences in nightmare experiences in outpatient trauma-exposed children and adolescents. This area of research may become increasingly important given the proposed importance of nightmares and sleep problems on the development and maintenance of posttrauma difficulties. Although much more information is needed about nightmares in trauma-exposed children and the nature of the relationship among nightmares and other indices of distress, it seems likely that children may benefit from directly assessing and addressing their nightmare experiences. References Acierno, R., Resnick, H., Kilpatrick, D. G., Saunders, B., & Best, C. L. (1999). Risk factors for rape, physical assault, and posttraumatic stress disorder in women: Examination of differential multivariate relationships. Journal of Anxiety Disorders, 13, American Academy of Sleep Medicine. (2005). International classification of sleep disorders (2nd ed.). Diagnostic and coding manual. Westchester, IL: Author. Avery, L., Massat, C. R., & Lundy, M. (2000). Posttraumatic stress and mental health functioning of sexually abused children. Child and Adolescent Social Work Journal, 17, Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, Carlson, C. R., & Cordova, M. J. (1999). Sleep disorders in childhood and adolescence. In S. D. Netherton, D. Holmes, & C. E. Walker (Eds.), Child and adolescent psychological disorders: A comprehensive textbook (pp ). New York, NY: Oxford University Press. Chivers, L., & Blagrove, M. (1999). Nightmare frequency, personality, and acute psychopathology. Personality and Individual Differences, 27, Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. Cuffe, S. P., & Shugart, M. (2001). Child abuse and psychic trauma in children. In H. B. Vance & A. J. Pumariega (Eds.), Clinical assessment of child and adolescent behavior (pp ). New York, NY: Wiley. Davis, J. L., Byrd, P., Rhudy, J. L., & Wright, D. C. (2007). Characteristics of chronic nightmares in a trauma exposed clinical sample. Dreaming, 17, Davis, J. L., Pruiksma, K. E., Rhudy, J. L., & Byrd, P. (in press). Nightmare characteristics, psychopathology, and treatment outcome in trauma-exposed individuals with and without pre-trauma nightmares. Dreaming. Davis, J. L., Wright, D. C., & Borntrager, C. (2001). The Trauma-Related Nightmare Scale. Tulsa, OK: University of Tulsa.

12 Idiopathic and Posttrauma Nightmares 355 Forbes, D., Creamer, M., & Biddle, D. (2001). The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy, 39, Germain, A., & Nielsen, T. (2003). Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients. Behavioral Sleep Medicine, 1, Hartmann, E. (1996). Who develops PTSD nightmares and who doesn t. In D. Barrett (Ed.), Trauma and dreams (pp ). Cambridge, MA: Harvard University Press. Harvey, A. G., Jones, C., & Schmidt, D. A. (2003). Sleep and posttraumatic stress disorder: A review. Clinical Psychology Review, 23, Kovacs, M. (1992). Children s Depression Inventory. New York, NY: Multi-Health Systems. Kramer, M., & Kinney, L. (1988). Sleep patterns in trauma victims with disturbed dreaming. Psychiatric Journal of the University of Ottawa, 13, Langston, T. J., & Davis, J. L. (2008). Trauma-Related Nightmare Survey - Child Version. Tulsa, OK: University of Tulsa. Langston, T., Davis, J. L., & Swopes, R. S. (2010). The impact of trauma on sleep and nightmares in a clinical sample of children and adolescents. Manuscript in preparation. Levin, R. (1998). Nightmares and schizotypy. Psychiatry, 61, Levin, R., & Fireman, G. (2002). Nightmare prevalence, nightmare distress, and self-reported psychological disturbance. Sleep: Journal of Sleep and Sleep Disorders Research, 25, March, J. S. (1999). Assessment of pediatric posttraumatic stress disorder. In P. A. Saigh & J. D. Bremner (Eds.), Posttraumatic stress disorder: A comprehensive text (pp ). Needham Heights, MA: Allyn & Bacon. March, J. S., Parker, J. D. A., Sullivan, K., Stallings, P., & Conners, C. (1997). The Multidimensional Anxiety Scale for Children (MASC): Factor structure, reliability, and validity. Journal of the American Academy of Child & Adolescent Psychiatry, 36, Maurer, K. E., & Schaefer, C. E. (1998). Assessment and treatment of children s nightmares: A review. Psychology: A Journal of Human Behavior, 35, Mellman, T. A., David, D., Kulick-Bell, R., Hebding, J., & Nolan, B. (1995). Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew. American Journal of Psychiatry, 152, Mertin, P., & Mohr, P. B. (2002). Incidence and correlates of post trauma symptoms in children from backgrounds of domestic violence. Violence and Victims, 17, Mindell, J. A. (1993). Sleep disorders in children. Health Psychology, 12, Mindell, J. A., & Dahl, R. E. (1998). Sleep. In R. T. Ammerman & J. V. Camp (Eds.), Handbook of pediatric psychology and psychiatry (pp ). Needham Heights, MA: Allyn & Bacon. Nader, K. (1996). Children s traumatic dreams. In D. Barrett (Ed.), Trauma and dreams (pp. 9 24). Cambridge, MA: Harvard University Press. Newman, E., Weathers, F. W., Nader, K. O., Kaloupek, D. G., Pynoos, R., Blake, D. D., et al. (2004). Clinician administered PTSD Scale for Children and Adolescents for DSM-IV Manual. Los Angeles, CA: Western Psychological Services. Nielsen, T. A., Leberge, L., Paquet, J., Tremblay, R. E., Vitaro, F., & Montplaisir, J. (2000). Development of disturbing dreams during adolescence and their relation to anxiety symptoms. Sleep, 23, Olatunji, B. O., Babson, K. A., Smith, R. C., Feldner, M. T., & Connolly, K. M. (2009). Gender as a moderator of the relationship between PTSD and disgust: A laboratory test employing individualized script-driven imagery. Journal of Anxiety Disorders, 23, Pfefferbaum, B. (1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 36, Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., ET al. (1987). Life threat and posttraumatic stress in school-age children. Archives of General Psychiatry, 44, Pynoos, R. S., Rodriquez, N., Steinberg, A. S., Stuber, M., & Frederick, C. (1998). The UCLA PTSD Reaction Index for DSM-IV (Revision 1). Los Angeles, CA: UCLA Trauma Psychiatry Program.

13 356 T. J. Langston et al. Ross, R. J., Ball, W. A., Sullivan, K. A., & Caroff, S. N. (1989). Sleep disturbance as the hallmark of posttraumatic stress disorder. American Journal of Psychiatry, 146, Sadeh, A., McGuire, J. P., Sachs, H., Seifer, R., Tremblay, A., Civita, R., et al. (1995). Sleep and psychological characteristics of children on a psychiatric inpatient unit. Journal of the American Academy of Child and Adolescent Psychiatry, 34, Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009a). Longitudinal study of nightmares in children: Stability and effect of emotional symptoms. Child Psychiatry and Human Development, 40, Schredl, M., Fricke-Oerkermann, L., Mitschke, A., Wiater, A., & Lehmkuhl, G. (2009b). Factors affecting nightmares in children: Parents vs. children s ratings. European Child & Adolescent Psychiatry, 18, Schredl, M., Pallmer, R., & Montasser, A. (1996). Anxiety dreams in school-aged children. Dreaming, 6, Singareddy, R. K., & Balon, R. (2002). Sleep in posttraumatic stress disorder. Annals of Clinical Psychiatry, 14, van der Kolk, B., Blitz, R., Burr, W., Sherry, S., & Hartmann, E. (1984). Nightmares and trauma: A comparison of nightmares after combat with lifelong nightmares in veterans. American Journal of Psychiatry, 141, Vogel, J. M., & Vernberg, E. M. (1993). Psychological responses of children to natural and humanmade disasters: I. Children s psychological responses to disasters. Journal of Clinical Child Psychology, 22,

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