Children with epilepsy have a higher risk of also having autism spectrum disorder (ASD). A new study in Developmental Medicine & Child Neurology examined factors associated with the co-occurrence of autism and epilepsy in a large population-based group.
For the study, investigators at the Mayo Clinic compared the prevalence of autism spectrum disorder in children with and without epilepsy based on medical records, and they evaluated associated factors including sex, age at autism identification, and intellectual disability. The study included 30 490 children in the Olmsted County, Minnesota birth cohort, of whom 257 (0.84%) had epilepsy diagnosed before 19 years of age.
Autism prevalence was significantly higher among children with epilepsy as compared with children without across all three research and clinical definitions assessed (21.4% versus 3.2% using broad research criteria, 14.0% versus 1.6% using stricter research criteria, and 7.9% versus 0.7% for clinical diagnosis).
Children with epilepsy and autism were more likely to have intellectual disability (56.5% versus 15.4%), were more often female (38.2% versus 25.8%), and were identified with autism at a younger age (7.4 versus 8.7 years) compared with those without autism.
“These observations highlight clinically relevant differences within this group and underscore the importance of early recognition of developmental concerns,” said lead author Mariya Saify. MBBS.
Senior author Elaine C. Wirrell, MD added that although children with epilepsy are at an elevated risk of autism, recognition can be delayed. “Our findings emphasise the importance of screening for autism in this population to support earlier diagnosis and timely intervention, both of which are key to improving long-term outcomes.”
In many households in Mabopane and Soshanguve – townships on the northern outskirts of South Africa’s City of Tshwane that are marked by high poverty, unemployment and informal economic activity – evenings follow a familiar pattern.
When electricity cuts occur or power becomes unaffordable, families turn to gas stoves, paraffin heaters, or wood and coal fires to cook meals and keep warm. These energy sources contribute to air pollution, but the most harmful exposure often happens indoors, where children spend much of their time. These choices, though often unavoidable, put young children’s health at risk.
Children are particularly vulnerable to air pollution. Their lungs are still developing, their airways are narrower, and they breathe faster than adults.
In 2021, exposure to air pollution was linked to more than 700 000 deaths of children under five years old globally.
They are exposed by inhaling polluted air, swallowing contaminated dust or food, and through skin contact. Household fuel combustion releases tiny particles and harmful gases that irritate the lungs and airways. These pollutants can also damage the skin, triggering immune responses that worsen allergic conditions such as eczema and asthma.
As public health specialists, we examined the association between household air pollution and eczema and severe asthma symptoms among children aged seven years and younger in Mabopane and Soshanguve. We found that the use of polluting household fuels and gas was associated with an increased likelihood of eczema, followed by severe asthma symptoms.
Eczema and its impact
Eczema, or atopic dermatitis, is a chronic skin condition that causes itching, redness and inflammation.
It can significantly affect a child’s life by disrupting sleep and increasing the risk of skin infections. It also raises the likelihood of developing asthma, hay fever, or food allergies later. Visible rashes can equally affect confidence, social interactions and participation in school or play. Exposure to cigarette smoke inside the home further increases the risk of developing or worsening eczema, especially when mothers or female caregivers smoke.
Severe asthma and its impact
Asthma is a long-term condition affecting the lungs and airways, making breathing difficult. Symptoms include wheezing, coughing, chest tightness and shortness of breath. Global asthma prevalence ranges from 9.1% to 9.5% for children.
Severe asthma refers to frequent, hard-to-control, and sometimes life-threatening symptoms. Children with severe asthma may struggle to speak during attacks and are far more likely to need emergency care or hospitalisation. Young children are particularly vulnerable because their lungs, skin barrier and immune systems are still developing. Exposure to indoor air pollution during these early years increases the risk of long-term health problems.
Our study
To understand how household environments affect children’s health, we studied preschool-aged children in Mabopane and Soshanguve, in South Africa’s largely urban Gauteng province, between January 2022 and March 2023.
We randomly selected 42 preschools and collected health and household information from caregivers of 1840 children, including details on eczema, asthma symptoms, household fuel use, and exposure to cigarette smoke inside the home.
What we found
About one in eight children had experienced eczema at some point, and a similar proportion were currently experiencing symptoms. We also found that children from households using electricity for cooking and with no tobacco smoke exposure were less likely to have eczema than those who were exposed.
Children living in homes using open fires – such as paraffin, wood, or coal – for cooking or heating were more likely to have eczema. Exposure to cigarette smoke inside the home further increased this risk, particularly when mothers or female caregivers smoked.
Severe asthma symptoms were also common, affecting about one in six children. The use of gas for cooking or heating was strongly linked to severe asthma symptoms, even though gas is often viewed as a cleaner alternative during power cuts. Poor ventilation can increase indoor pollution, making these energy sources harmful to children.
The use of combined building materials in homes increased the likelihood of having eczema and corrugated iron significantly increased the likelihood of developing its symptoms. The frequency of trucks passing near the preschool children’s residences on weekdays was found to be associated with eczema and current symptoms. There was a significant association observed when trucks passed the children’s residences almost all day on weekdays. Children who walked to preschool had an increased risk of severe asthma symptoms compared with those using other modes of transport.
Why this matters
Although nearly 89% of residents in the study area have access to electricity, many households cannot rely on it consistently. Rising electricity costs and scheduled power cuts force families to use alternative fuels. These coping strategies, while understandable, increase children’s exposure to indoor air pollution during the most vulnerable stage of their development.
Our study confirmed that children in poorer communities face higher health risks due to their living environments, not just genetics. Susceptible groups, such as children, should be prioritised to reduce the adverse health effects of both outdoor and indoor air pollution.
What needs to change
Protecting children’s health requires more than asking parents to make better choices, as many families do not have safe, affordable alternatives.
Public health education on the dangers of cigarette smoke is crucial. Education campaigns, smoking cessation support and community-level interventions can help reduce children’s exposure to environmental tobacco smoke.
Stronger action on indoor and household air pollution is urgently needed. Evidence from this study can support the South African government in fast-tracking regulations and enforcing ambient air quality laws. It can also help in promoting safer household energy options.
Cleaner air inside homes is not a luxury. For South Africa’s children, it is a public health necessity.
Accelerated continuous theta burst stimulation (a-cTBS) may be a “viable and scalable therapeutic option” say researchers
Photo by Emily Wade on Unsplash
A new non-invasive brain stimulation technique known as accelerated continuous theta burst stimulation (a-cTBS) improves social communication at one month follow up and has a favourable safety profile in children with autism, finds a trial from China published by The BMJ today.
The researchers say the findings suggest that a-cTBS may be “a viable and scalable therapeutic option for children with autism spectrum disorder.”
Preliminary results from a recent pilot study suggest that a-cTBS is safe and effective for enhancing social communication in children with autism. A key advantage of a-cTBS is its shorter sessions compared with conventional brain stimulation, making it more suitable for children.
To build on this work, the researchers investigated the effectiveness and safety of a five day a-cTBS protocol in improving social communication among children with autism, including younger children and those with intellectual disability.
The trial involved 200 children (167 boys and 33 girls) aged 4-10 years with autism recruited from three academic hospitals in China from July 2023 to October 2024, half of whom also had intellectual disability.
The children were randomised to receive either active a-cTBS (intervention) or sham (control) treatment for five consecutive days (10 sessions each day). The stimulation targeted the brain’s left primary motor cortex, which is linked to movement, language, and social cognition.
The researchers used the Social Responsiveness Scale (SRS-2) to measure changes in social communication impairment from baseline to post-intervention and from baseline to one month follow-up. Language improvements were also assessed using three recognised measures.
A total of 193 participants completed the full five day intervention course. Compared with the sham group, the a-cTBS group showed significantly greater improvements in social communication from baseline to post-intervention and from baseline to one month follow-up, with mean difference impairment score reductions of -6.25 and -6.17, respectively.
The a-cTBS group also showed greater improvements in language abilities. This finding was supported by a small effect size (Cohen’s d) ranging from 0.12 to 0.47, representing the difference between the two group means.
Adverse events were more frequent in the a-cTBS group than in the sham group (54.5% v 29.3%), with restlessness and scalp discomfort being the most common. All adverse events were mild to moderate and resolved spontaneously.
The researchers acknowledge some limitations with the SRS-2 measure and potential bias from greater treatment expectancy in the intervention group. The trial also had a short one-month follow-up and more than 80% of participants were boys.
However, they point out that the inclusion of young children and those with intellectual disability supports the protocol’s broad applicability, and consistent effects across sensitivity analyses provides greater confidence in their conclusions.
As such, they say their results suggest that a-cTBS may be “a feasible, effective, and scalable therapeutic option for children with autism spectrum disorder, including those with intellectual disability” and their protocol “represents a major advancement towards equitable autism care worldwide.”
In a linked editorial, researchers in Hong Kong agree that the findings show promise, but advocate for cautious optimism.
They note that while “a-cTBS should not replace psychosocial support or educational adaptation,” it “may become an important component of a multimodal pathway for children with autism with significant social communication difficulties,” provided it is “further replicated and integrated thoughtfully with behavioural care.”
Ahead of World Malaria Day on 25 April, the World Health Organization (WHO) has announced a significant step forward in the fight against malaria with the prequalification of the first treatment developed specifically for newborns and young infants weighing between two and five kilograms. The prequalification designation indicates that the medicine meets international standards of quality, safety and efficacy, and will help to expand access to quality-assured treatment for one of the most underserved patient groups.
The newly prequalified treatment, artemether-lumefantrine, is the first antimalarial formulation designed specifically for the youngest malaria patients. Until now, infants with malaria have been treated with formulations intended for older children, which increase the risk of dosing errors, side effects and toxicity. WHO prequalification will enable public sector procurement, contributing to closing a long-standing treatment gap for some 30 million babies born each year in malaria-endemic areas of Africa.
“For centuries, malaria has stolen children from their parents, and health, wealth and hope from communities,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “But today, the story is changing. New vaccines, diagnostic tests, next-generation mosquito nets and effective medicines, including those adapted for the youngest, are helping to turn the tide. Ending malaria in our lifetime is no longer a dream – it is a real possibility, but only with sustained political and financial commitment. Now we can. Now we must.”
New prequalified tests
On 14 April 2026, WHO also prequalified three new rapid diagnostic tests (RDTs) designed to address emerging diagnostic challenges for malaria. The most common malaria RDTs for P. falciparum parasite work by detecting the protein, known as HRP2. But based on reported studies and surveys in 46 countries, some strains of the malaria parasite have lost the gene that makes this protein – so they become “invisible” to HRP2-based RDTs, leading to false-negative results. In countries in the Horn of Africa, up to 80% of cases were missed, leading to delayed treatment, severe illness, and even death.
The new tests address this issue by targeting a different parasite protein (pf-LDH) that the malaria parasite cannot easily shed. They provide a reliable, quality-assured alternative where HRP2-based tests are failing. WHO now recommends that countries switch to these alternative RDTs when more than 5% of cases are missed due to pf-hrp2 deletions. This ensures accurate diagnosis, appropriate treatment, and protects hard-won malaria control gains – especially for the most vulnerable communities.
Adopted children who have grown up in more favourable family environments than their siblings are at lower risk of mental health issues, criminality and social problems – benefits that, in some cases, extend to the next generation. These are the findings of a new study of Swedish siblings published in The BMJ.
Children who grow up in difficult family circumstances are at greater risk of experiencing problems later in life. These may include mental health issues, difficulties at school or criminal behaviour.
To determine the extent to which these factors can be influenced, researchers at Karolinska Institutet studied pairs of siblings in Sweden where one sibling was adopted away from a high-risk family while the other remained with and grew up with their biological parents. This allowed them to compare the long-term effects of different family environments while taking genetic factors into account.
“Our study shows that a more favourable home environment can make a big difference, particularly for children who start life with clear risk factors,” says Erik Pettersson, associate professor at the Department of Medical Epidemiology and Biostatistics at Karolinska Institutet.
Followed over 12 000 siblings
The study is based on Swedish population registers and covers just over 12 000 full and half-siblings born between 1950 and 1980. All come from families where at least one parent had experienced some form of psychiatric or social issue, such as mental illness, criminality or attempted suicide, and where at least one child had been given up for adoption before the age of ten. Families who took in adopted children often had greater resources and higher socio-economic status.
The results show that the adopted children had a lower risk of mental illness, criminality and dependence on social security benefits as adults, compared to their siblings who grew up with their biological parents. They also performed better at school and, on average, attained a higher level of education. Furthermore, men who had been adopted performed better during military conscription, both on intelligence tests and in interviews measuring stress resilience and social adaptability.
May affect the next generation
The researchers also investigated whether these differences were passed on to the next generation. In total, nearly 22,000 children of the sibling pairs were studied.
On average, the children of adopted siblings displayed higher functioning than their cousins, for example a lower risk of criminality and financial problems. The effects were weaker than in the previous generation, but pointed in the same direction.
“This suggests that improved living conditions benefit not only the individual, but also the next generation,” says Erik Pettersson.
Value of support measures
He emphasises that the results should not be seen as an argument for adoption, which is currently uncommon in Sweden. However, he believes the study highlights the value of interventions for children in vulnerable environments.
“Research into the effects of various support measures aimed at giving children a better upbringing is both limited and fragmented,” he says. “Some studies show significant long-term benefits; others show little or none at all. Our study suggests that the potential is considerable, even though we cannot say which measures are most important.”
A major study, led by researchers at Children’s Hospital of Philadelphia, Nemours Children’s Health, and Children’s National Hospital, found that different types of crystalloid fluid resuscitation were equally effective for staving off the most serious adverse kidney events after the treatment of paediatric patients with suspected septic shock. The findings of this large clinical trial are detailed in a study published by The New England Journal of Medicine and are being presented at the Pediatric Academic Societies (PAS) Meeting in Boston.
Sepsis is a life-threatening response to infection that causes organ failure. The combination of the body’s immune system and the infection together cause an abnormal response, which can prevent different organ systems from working normally. While many decades of research and improvements in clinical care have significantly improved outcomes for paediatric sepsis patients, about 1 in 10 children in the US with sepsis or septic shock are still at risk of dying.
In some previous multi-centre studies, researchers found that critically ill adults who received balanced crystalloid fluid – an intravenous (IV) treatment meant to exhibit similar properties to human plasma – resulted in lower risk of complications and death compared with a standard 0.9% saline IV solution. This prompted researchers to explore whether a similar study could determine whether one fluid treatment was superior for pediatric sepsis patients.
“We knew we were going to need thousands of patients to answer this question, which we knew would be a challenge,” said co-lead author Fran Balamuth, MD, PhD, an attending physician and Division Chief of Emergency Medicine at CHOP. “Yet we were excited to proceed because these fluids are inexpensive and universally available around the world, meaning that we wouldn’t have decades of waiting to take action once the study was complete; we could be pragmatic and take immediate action based on the results that we found.”
Because suspected cases of sepsis are uncommon among the general population, Balamuth, co-lead author Scott L. Weiss, MD, attending physician and Division Chief of Critical Care at Nemours Children’s Hospital, Delaware, and their colleagues required the collaboration of many hospitals to achieve the data standards needed for meaningful conclusions. For this, they collaborated with Nathan Kuppermann, MD, Executive Vice President and Chief Academic Officer of Children’s National Hospital and Director of the Children’s National Research Institute, who has a history of running successful clinical trials in acutely ill children, and served as the senior author.
“This trial demonstrates the power of large collaborative research networks to answer important clinical questions for children,” Kuppermann said. “By enrolling thousands of patients across multiple countries, we were able to provide the kind of evidence clinicians need to guide care for children with suspected septic shock.”
In the end, a total of 47 emergency departments across five countries were represented in the study, with more than 9000 patients enrolled who received either balanced fluid or 0.9% saline.
The primary outcome of the study was Major Adverse Kidney Events by 30 days (MAKE30), an important outcome for kidney injury that accounts for death, new renal replacement therapy or persistent renal dysfunction. The researchers found that MAKE30 occurred in 3.4% of patients enrolled in the balanced fluid group and 3.0% in the 0.9% saline ground. The study found biochemical differences in children treated with the two fluids, including a higher frequency of elevated blood chloride levels in the 0.9% saline group, and higher lactate levels in the balanced fluid group. Both groups had 23 median hospital-free days of 28, and there were no differences in mortality or other safety outcomes or adverse events.
“This trial confirms that either balanced fluid or 0.9% saline are effective and safe for the initial resuscitation of children with suspected septic shock, and that a fluid strategy that reduces hyperchloraemia does not necessarily translate to improved patient outcomes,” said Weiss, an attending physician and Division Chief of Critical Care at Nemours Children’s Hospital, Delaware. “We also did not identify differences across subgroups. However, despite the large number of participants, it is important to note that we cannot exclude the possibility of benefit of one fluid or the other in a subset of children with the most severe illness.”
“A large trial like this definitively answers a question we’ve had in our field for many, many years,” Balamuth said. “In an emergency department with a child with suspected sepsis, you can treat the child with whichever fluid is readily available. And we think that’s great news for children around the world.”
With proper assessment and monitoring, the risk of serious heart events during physical activity may be lower than previously believed for children and adolescents with certain heart conditions, according to a new American Heart Association scientific statement
Photo by Annie Spratt on Unsplash
Physical activity in children and teenagers with cardiomyopathy (conditions that affect the heart muscle’s structure and function, impairing its ability to pump or fill effectively), as well as children with implantable cardioverter-defibrillators (ICDs) may be safer than previous research suggested, according to a new scientific statement from the American Heart Association, published today in the Association’s flagship peer-reviewed journal Circulation.
While physical activity and exercise are essential for childhood development and long-term health, they have been traditionally discouraged among children and adolescents with cardiomyopathies and ICDs (implantable devices that detect life-threatening abnormal heart rhythms and deliver electrical shocks) due to concerns that they could worsen heart function or lead to sudden cardiac death.
“While safety is always paramount, halting all physical activity among children with cardiomyopathy or ICDs has at times led to unintended consequences. The latest research indicates that restricting children’s movement can negatively affect their heart health, physical fitness levels, mental well-being and social development, and quality of life,” said Jonathan B. Edelson, MD, MSCE, chair of the scientific statement writing group, an associate professor of paediatrics and medical director of the sports cardiology program and heart transplant and ventricular assist device programs in the division of cardiology at Children’s Hospital of Philadelphia.
What do parents and caregivers need to know?
Ensuring safe participation in physical activity requires thoughtful, individualized planning and ongoing collaboration among clinicians, families and patients.
Personalised approach: Tailored risk assessments based on diagnosis, risk profile, genetic profile and clinical evaluations are critical to better guide decisions about prescribing physical activity for children with different types of cardiomyopathies. Various diagnostic screening tools, such as echocardiograms, cardiac imaging and exercise stress tests, can be used to assess symptoms at rest and with activity. Genetic testing and family screening can also be helpful to assess individual risk.
Shared decision-making: Clinicians, families and (when developmentally appropriate) children or adolescents with cardiomyopathy and/or ICDs can work together to balance a patient’s risk, patient- and family-tailored goals and values. It is important for clinicians to disclose when risk evidence is based on adult data.
Close follow-up and reassessment: Ongoing monitoring is important to track potential shifts in risk, assess if symptoms progress and evaluate if heart function improves or deteriorates. The recommendations for safe physical activity must evolve as the child grows, activities change and the disease progresses.
Close follow-up and reassessment: Ongoing monitoring is important to track potential shifts in risk, assess if symptoms progress and evaluate if heart function improves or deteriorates. The recommendations for safe physical activity must evolve as the child grows, activities change and the disease progresses.
What types of activities can be considered?
The new scientific statement aims to shift from adopting a one-size-fits-all approach to physical activity limitations to considering ways for youth with heart conditions or an ICD to safely participate in physical activities – from low-intensity daily activities to high-intensity training and sports in select cases – after a detailed individualised risk assessment.
Light-to-moderate intensity exercise (such as walking, light cycling or swimming) may be appropriate to maintain physical fitness, social development and quality of life, with regular monitoring of their condition. Structured physical activity, such as fitness classes, strength training, running, biking, hiking or organised sports programs, may be reasonable for some children and adolescents with heart conditions. For some carefully selected paediatric patients with certain cardiomyopathies, participation in physical activity including competitive sports may be reasonable after expert assessment and shared decision-making discussion about the risks and benefits. Emergency action plans, including AED (automated external defibrillator) access and bystanders trained in CPR, are essential during organised sports. Additional guidance for specific types of cardiomyopathies are detailed in the manuscript.
“Children with cardiomyopathy should not automatically be sidelined from participating in physical activity, including recreational or competitive sports,” Edelson said. “Most children should be physically active – with individualised evaluation, monitoring and planning. Physical activity is important for their long-term health, physical and social development.”
The statement notes more research is needed about childhood cardiomyopathies because most of the findings in the statement are based on observational studies in adults; therefore, findings should be applied cautiously to a paediatric population. In addition, outstanding questions remain, such as how moderate or vigorous exercise may affect the long-term progression and how risk varies across different types of cardiomyopathies.
Despite new diagnostic methods and expanded vaccination programmes, many children in Uganda continue to suffer from severe brain infections. This is shown in a new study from Karolinska Institutet, published in The Lancet Regional Health – Africa. The researchers’ analysis highlights simple clinical signs that can help healthcare providers more quickly identify children at high risk of death.
The study followed 212 children aged 0 to 12 who were treated for suspected central nervous system infections at two hospitals in southwestern Uganda. Fifteen per cent of the children died during hospitalisation, and 18 per cent were discharged with neurological disabilities such as seizures or muscle weakness. Malaria and the bacterium Streptococcus pneumoniae were the most commonly identified causes.
Simple observations can provide crucial information
“Our results show that even in settings where advanced diagnostics are not always available, simple clinical observations can provide crucial information about which children are in greatest need of rapid care,” says Phuthumani Mlotshwa, doctoral student at the Department of Global Public Health and the study’s first author.
The infections were caused by several different microorganisms. Malaria was detected in 20 per cent of the children, and bacteria in the cerebrospinal fluid in 11 per cent. For nearly half of the cases, no specific pathogen could be identified, which the researchers say underscores the need for improved diagnostic tools.
“The combination of high mortality and significant disabilities among survivors shows that we need to strengthen prevention, diagnostics, and follow-up,” says Giulia Gaudenzi, researcher at the same department and the study’s senior author.
Most children with a severely broken wrist can be treated without surgery, according to a major NIHR-funded UK trial led by researchers at the University of Oxford. The findings suggest that a non-surgical, cast-first approach delivers similar long-term recovery while reducing the risks associated with surgery and costs.
Broken wrists are among the most common injuries in children accounting for about half of children’s fractures. Severely displaced distal radial fractures, where the bones move out of place, are often routinely treated with surgery. However – unlike adults – children have a remarkable ability to straighten broken bones, in a process called remodelling.
Researchers questioned whether a plaster cast would achieve the same long-term result without exposing children to the risks of an operation.
Professor Matt Costa, senior author and Professor, Orthopaedics Trauma Surgery at the Kadoorie Institute, University of Oxford said: ‘These fractures can look very severe on an X-ray, which has traditionally led to surgery to straighten the bone. But because children’s bones are still growing, they have a remarkable capacity to heal. Until now, there has been limited high-quality evidence on whether surgery was always necessary.’
The CRAFFT trial (Children’s Radius Acute Fracture Fixation Trial) was funded by the National Institute for Health and Care Research (NIHR) and supported by the NIHR Biomedical Research Centre: Oxford. It recruited 750 children aged 4–10 from 49 hospitals across the UK. Participants were randomly assigned to receive either surgical fixation or treatment with a plaster cast.
Patients were measured at regular intervals against a set of criteria. At three months, children who had surgery reported slightly better arm function, but the difference between groups was very small. By six and 12 months, there was no difference in recovery, suggesting that early advantages with surgery do not persist.
There were complications following surgery, including infections, scarring and nerve irritation. Non-surgical treatment, which avoids anaesthesia and operative intervention, was shown to reduce NHS costs by around £1,600 per patient on average.
The trial was designed with input from families, who helped define what level of improvement would be meaningful enough to warrant surgery. The observed difference between treatments fell below this threshold.
Professor Dan Perry, NIHR Research Professor and Children’s Orthopaedic Surgeon at Alder Hey Children’s Hospital and the University of Liverpool, and lead author, said: ‘It is astonishing that children have the ability to grow bent, broken bones straight again. It really is a superpower that is unique to children. From both a clinical and health system perspective, these findings are important. Adoption of these results could reduce the number of children exposed to the risks of anaesthesia and surgery, and ease pressure on healthcare services without compromising recovery.’
The results, published in The Lancet, support wider adoption of a cast-first approach for most children with these injuries.
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 centre 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,” said Lisa Cromer, PhD., a professor of psychology at the University of Tulsa and a volunteer child psychiatry faculty member at the OU School of Community Medicine in Tulsa. “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.”
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, MD, an associate professor at the OU School of Community Medicine in Tulsa. “What’s unique about the model is that it’s customisable 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 behaviour.”
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.”
“A nightmare is a bad dream that you wake up from,” Cromer said. “If you don’t wake up, then the brain is doing its job of resolving the fear of the dream. But if a child does wake up, they’re trying to escape the nightmare. And when a child wakes up, they’re not able to resolve the nightmare, which actually exacerbates the problem. That’s why nightmares are so important to treat.”
