Pediatric Behavioral Health in Disasters
4. Recovery
4.1. Taking the Fear out of Children’s Dreams Following a Disaster: The Wonder of Imagery Rehearsal Therapy
Carolyn Ievers-Landis, Ph.D., DBSM, and Kimberly Burkhart, Ph.D.
Objectives
- Explain how a traumatic event can affect sleep.
- Identify three imagery rehearsal strategies that can improve sleep.
Consider what happens when children experience seemingly uncontrollable events during a disaster. They may see or hear things that are physically threatening and emotionally frightening. They may also experience losses, including the serious illness or death of a family member.
Children commonly spend considerable time thinking about these events and worrying about their own safety or the safety of others. Some children develop traumatic stress symptoms, including insomnia and nightmares.
How a Nightmare Cycle Develops
After a frightening dream, a child may run to a parent’s bedroom for comfort. The child may describe in vivid detail what they saw, heard, did, and felt in the dream. The parent listens, comforts the child, and may allow the child to remain in the parent’s bed for the rest of the night.
Parents may then begin regularly asking whether the child had any bad dreams or nightmares.
Repeatedly focusing on nightmares can prime a child to pay particular attention to frightening dreams.
When another nightmare occurs, the same pattern may repeat: the child has a frightening dream, runs to the parent’s room, describes the dream in detail, receives comfort, and returns to sleep.
As the pattern becomes established, the child may become distressed at bedtime and anticipate experiencing the same terror. The child may try to stay awake to avoid dreaming or want to begin the night in the parent’s bed to prevent the nightmare or receive comfort more quickly. This cycle can continue for weeks, months, or even years.
Imagery Rehearsal Therapy
Imagery Rehearsal Therapy (IRT) is a straightforward therapeutic technique that can help interrupt the nightmare cycle. Barry Krakow, M.D., originally developed the strategy for adults experiencing frequent, distressing nightmares that disrupted their sleep. Research indicates that IRT can also be effective for children.
Demonstrated benefits of IRT include improved sleep, reduced anxiety, increased confidence in handling frightening situations, and generalization of coping skills.
IRT interrupts the nightmare cycle by directing the child’s attention toward positive imagery and helping the child develop a sense of control over dream content.
IRT in Practice
- Stop rehearsing details of frightening dreams. Avoid repeatedly discussing frightening details, such as the appearance of a monster or details of a traumatic event.
- Ask the child what they would prefer to dream about. Ask, “What would you rather dream?”
Possible themes include:
- A beach
- Unicorns and rainbows
- Exploring a rainforest or mountains
- Camping
- Animals playing
- Develop the new dream using all five senses. Help the child make the positive image vivid by asking sensory questions.
- What do you see? White, puffy clouds or tree branches swaying in the wind.
- What do you hear? Wind chimes or music playing.
- What do you smell? Suntan lotion or melted butter from popcorn.
- What do you feel? Sand between the toes or the warmth of the sun on the skin.
- What do you taste? Cool water or salt and butter on crunchy popcorn.
- Schedule 10–15 minutes to practice during the day.
Possible practice times include:
- After school and before homework
- At dinnertime while a parent prepares food
- As part of the bedtime routine
- Use creative activities to practice the new dream.
The child might:
- Draw pictures
- Make crafts
- Use stickers
- Write a book
- Tell a story
- Set realistic expectations about dream recall. Explain that people remember only a small portion of their dreams. Children may be having the new dream without remembering it the next morning.
Remind children and parents that occasionally having an unpleasant dream is normal. Clinicians can follow up and help resolve challenges associated with practicing the new dream.
The child may need to choose a different positive image or create a new, reassuring ending to the upsetting dream—one in which the child has a sense of control. Depending on the child’s developmental level, a parent may need to prompt and assist with rehearsal.