DARC-NESS model offers insights into persistent nightmares in children

Recently published research from the University of Oklahoma and the University of Tulsa proposes a new model to explain why nightmares can persist over time in children and how therapy can be designed to break that cycle.

The study, published in Frontiers in Sleep, introduces the DARC-NESS model, a mnemonic for the factors that can keep a child stuck in chronic nightmares. At the center of the model is "nightmare efficacy," or the idea that children can learn skills to rid themselves of nightmares and restore good sleep.

The DARC-NESS model looks at the mechanisms of what is maintaining nightmares, as well as the mechanisms that can break the cycle of nightmares. It's a child's response to a nightmare that causes the chronic nightmares to happen, which means if we can learn to respond to nightmares differently, then we can interrupt that cycle. It's empowering to understand that we can take steps to master our dreams."

Lisa Cromer, Ph.D., professor of psychology, University of Tulsa and volunteer child psychiatry faculty member at the OU School of Community Medicine in Tulsa

Rather than focusing only on the content of a nightmare, the model encourages clinicians to consider a broader set of factors, including how a child interprets the dream, worries about going to sleep, experiences anxiety at bedtime and copes after waking.

That information can help guide a personalized treatment plan instead of a one-size-fits-all approach. For some children, treatment may focus on reducing bedtime anxiety. Others may benefit from improving sleep habits or participating in exposure-based therapy, such as describing, writing about or drawing the nightmare and then working with a clinician to "rewrite" it.

"We believe we have created a way to conceptualize why nightmares persist and how we can better treat them in kids," said OU Health child and adolescent psychiatrist Tara Buck, M.D., an associate professor at the OU School of Community Medicine in Tulsa. "What's unique about the model is that it's customizable to what the patient needs, and it focuses on what the patient can control. We look for the potential intervention points and target those in a collaborative way with patients and their families."

Unlike insomnia, in which people fear they won't sleep, children with chronic nightmares are afraid they will sleep. According to Buck, helping children build confidence in their ability to address nightmares can have benefits far beyond sleep.

"Self-efficacy is at the heart of the model," she said. "When children feel empowered to do something about the nightmares, they begin to see how things are interconnected – because they're sleeping better, they have more energy, they go to school more consistently and their parents report improved behavior."

The model is designed for use by a range of clinicians, including therapists and pediatricians. For many years, health care providers either assumed that nightmares couldn't be treated or that they would go away if an underlying trauma or mental health condition were addressed. However, that's not always the case.

"We've worked with children who have been in mental health treatment for a long time and their nightmares are still persistent," Buck said. "There is a need for a nightmare treatment model to help children when their nightmares are recurrent and distressing."