Night Terrors and Nightmares

Dreaming and nightmares occur in REM sleep and night terrors occur during non-REM (rapid eye movement) sleep. These two types of sleep disruptions are called sleep disturbances.

Night or sleep terrors are episodes of fear or agitation, panic and confusion with repetitive behaviors. They can occur in children and adults. During a night terror (pavor nocturnus) the child often seems partially awake and frantic. It often begins with a panicked scream and is associated with signs of fear and autonomic arousal. Speech may be difficult to understand or words and phrases may be repeated over and over. The child is not responsive to efforts to comfort the child. There may be some sleep walking and talking and children during a night terror are difficult to arouse. When the child wakes up they do not remember a dream or nightmare.

Night terrors are usually benign in nature and no specific treatment is required other than education and trying to keep a consistent bedtime routine. Children who are overtired are more prone to night terrors. The best management focuses on allowing the child to pass through the night terror without trying to wake the child up. Night terrors are most common in children between the ages of 3 and 12 years and most occur within 1-2 hours of falling asleep.

Children who are having a “bad” dream wake much easier and usually recall the dream. The best treatment is support and reassurance. Most nightmares occur in the second half of the night. Nightmares tend to decrease after age 10 years. Children under stress in or out of the home or children with separation anxiety and attachment difficulty are more prone to nightmares.


What is Keratosis Pilaris?

This is a common problem where small bumps like “goose bumps” appear on your skin. It is a disorder of keratinization where small papule (bumps) form with occasional redness around the bumps. It is commonly seen and felt on the anterior thighs, triceps area and cheeks. It is commonly seen in children who previously were diagnosed as having atopic dermatitis. Up to 10% of all children may experience this rash. It is commonly seen in children and teens and can be seen in infants.

The cause is not clearly known. There appears to be a familial pattern. Under a microscope plugs of skin cells (keratin) with one or more twisted hairs block hair follicle openings. The most common complaint is “rough and raised” bumps on the skin. It increases during the winter months and seems to be worsened by friction from clothing. Although it often persists into adulthood it usually improves after the teen years. It may increase during pregnancy.

Patience, lubrication and time are usually the best treatments. Emollients and topical keratolytic medications containing lactic acid, salicylic acid or urea can help soften the plugs. They do not help with any surrounding redness. A common preparation has 2% salicylic acid in 20% urea cream. It must be applied consistently for several weeks to see a benefit.

If your child does not respond to the above treatment then topical retinoids such as tretinoin 0.05% cream or adapalene 0.1% cream may be used. These usually require 2-3 months of treatment to see benefits. If there is redness and signs of inflammation then a topical low to medium strength corticosteroid can be used for several weeks.

Acetaminophen and Asthma

Although acetaminophen has been used for many years there is evidence to suggest the liberal use of it is not healthy. It can lead to the development of wheezing disorders and can exacerbate wheezing and asthma symptoms in children known to have asthma.

Some drug manufacturers point to the association of viral infections with the use of acetaminophen and say the respiratory problems are due to the viral infection and not the medication but studies do not support this.

At the present time it is best to avoid using acetaminophen by all children with asthma or at risk to develop asthma and use an alternative medication such as ibuprofen when possible. In general, for all children over age 3 months who do not have an allergy to ibuprofen the substitution of ibuprofen for acetaminophen is reasonable.

Future studies will provide more information about the safety of acetaminophen. Until then, caution is the best policy as is limiting the use of acetaminophen to clinical situations where no alternative is available.

Sibling Rivalry for Preschoolers & Toddlers

In this age group the arrival of a new baby is often accompanied by jealousy and competition for affection and attention. Toddlers and preschoolers often respond with behavior and mood changes to replace what they perceive as lost attention. This is why it is very important for parents to prepare children for the arrival of a new infant who will require parental attention which previously was directed elsewhere.

Most of these issues can be prevented by taking the time to provide love, attention, affection and a sense of security for the displaced child. A secure attachment engenders trust and eliminates the fear of loss which drives many of the behavior problems that accompany sibling rivalry for the younger child.

It is also important schedules, routines and rituals be continued. Mealtime and bedtime routines should not be changed. Toddler and preschool aged children depend on these routines to anchor their daily schedule. In addition, bedtime and playtime rituals such as story time, bath time, meal time, going on walks and various playtime activities must be continued.  Your child is looking to your behavior as a sign that he or she is still loved and important. By continuing prior behaviors you can prevent sibling rivalry from evolving into negative behavior.

The arrival of a new infant in the household is a perfect time to support the older child’s independence. By giving your toddler the freedom and encouragement to explore the world you will soften the anxiety and potential sense of loss that a new infant can symbolize. It is also a time when your toddler can learn how to respect others. Toddlers and preschoolers both need to learn they should not try to control the behavior of another. When a toddler does not respect a parent or a sibling, future behavior issues are certain to follow. It is also important to encourage and help direct your preschooler to name these competitive and jealous feelings and by praising and rewarding his or her strengths you will encourage the development of good feelings which can replace bad feelings.

For the preschooler a new sibling provides the added opportunity to feel deserved and approved of. By focusing on the individuality and unique strengths of the older child you will be supporting and acknowledging the importance of a positive and supportive relationship between you both. It is important you are always fair and never compare children.  Beware of words or actions that can be interpreted by the older child as showing the new arrival to the family is your favorite. Allow your love to show you have no favorites.

Obsessive Compulsive Disorder (OCD)

Obsessive Compulsive Disorder (OCD) is highly variable in terms of symptoms. The obsession is the thought and the compulsion is the behavior.  Although some OCD patterns are common such as touching, counting and repeating, obsessive and compulsive behaviors can be very unique. When a behavior causes social, emotional, educational or occupational dysfunction then therapy and intervention are necessary.  In most cases OCD can be treated successfully.

The first step in treatment is identification and finding a professional who is willing and able to help you find a successful treatment regimen. The most common treatments include behavior therapy or medication.  Choose a physician or a mental health professional you feel comfortable with.  Your ability to engage with the therapist really does matter.  Ask for a no charge “get to know” visit where you can meet the therapist for a few minutes to talk about the type of care you are seeking. If you begin seeing a therapist and there is not a therapeutic reciprocal alliance then ask for a referral to another therapist. Engagement does matter.

Cognitive Behavior Therapy (CBT) is the most common type of behavior therapy used in OCD.  The goal of CBT is to identify and confront fears in order to reduce anxiety through exposure and response prevention exercises without progression to the compulsive behavior. Obsessions that cause the least anxiety are dealt with first and then each obsession is pursued in a serial fashion progressing up to the most anxiety associated obsession.

Medication can also be used to decrease the intensity of OCD symptoms. Medication is often used in conjunction with CBT to reduce anxiety and improve patient compliance and success.  The most common medication is an antidepressant such as Anafranil, Prozac, Paxil or Zoloft.

Support groups, exercise, calming activities such as meditation and yoga and other strategies such as guided positive imagery and progressive relaxation techniques can also be helpful.

How the Brain Works

Your brain contains about 100 billion neurons. Each neuron is connected to other neurons like rose bushes planted close to one another. When the branches touch and overlap networks of neurons are formed. These connections are electrochemical synapses. Many hormones are released in the brain and support the growth and survival of these brain networks. Some of these hormones are released due to stressful or emotionally significant experiences while others are released due to new learning experiences or damaging brain events.

How you learn and remember is based on the strengthening and weakening of these neuronal circuits. This process allows the brain to respond and change and provides the basis for the word plasticity which is often used when discussing brain function. Brain neurons are able to adapt but there are limits to this adaptation beyond which cell death and brain damage do occur.

Your brain is able to self-organize and adapt to a changing environment. Stress, trauma, novelty and learning do affect brain structure and function. When stress hormones are released by your brain your ability to form new memories is affected. If a certain area of your brain is damaged by physical trauma or a lack of oxygen or blood flow your brain also has the ability for other undamaged populations of neurons to take over the job of the damaged neurons. This process involves the growth of new supportive networks that can perform the function of lost neurons and increase the performance and function of remaining working neurons.

Your brain is dynamic. The adult brain is not largely fixed and stable. Your ability to respond to brain stress through enhancement or rerouting of function is only now being understood. Old models that described the brain as being a hard wired circuit are not accurate. This capability allows you to continue an unending learning process throughout your life and provides hope for new treatments for those who are developmentally disabled, brain injured and for those who have psychological disorders.

Halloween Tricks and Treats

Halloween can be a very special but difficult holiday. Parents have numerous opportunities before and during this holiday to support healthy behaviors and to share important health and safety information with their child. Sugar laden treats and “scary” costumes are learning opportunities for your child. During the Halloween season remember to see things through the eyes of your child. This requires an understanding of your child’s perception and development.

Infants and toddlers become fearful when appearances suddenly change. This can happen when a mask or costume is worn by someone they love or trust or when they see a garden hose coiled like a snake. For a preschool child certain categories and themes are common causes of fearful thoughts and behavior. These include darkness, thunderstorms, loud or unexpected noises, animals, robbers and hidden monsters. Children do not develop the ability to separate fantasy from reality until about five years of age. For older children fear is heightened when there is a social element such as group fear or social isolation.

Begin to prepare your child for the sights and sounds of Halloween long before the holiday. Become a follower of your child. Help your child substitute imagination and creativity for confusion and fear. Always listen to your child and take all fears seriously. For the school aged child it is important you show your concern. Never dismiss or disavow the way your child interprets symbols. Start by naming and discussing specific fears. Discuss calming strategies and techniques. Use rational and reasonable explanations to help your child re-interpret the emotions that are being experienced. Your ongoing support will decrease associated anxiety and bolster your child’s ability to self-manage future feelings and emotions. This type of empowerment allows your child to focus on the creative and imagination benefits of this holiday and not react with fear and anxiety.

When shopping with your child or discussing costumes for Halloween never choose or direct your child to choose a certain costume. Allow your child to be led by her own comfort level and interest. By recognizing and understanding your child’s needs you will be better able to interpret and respond to difficult emotional responses while avoiding feelings and emotions your child is not yet prepared to address.

Halloween also provides opportunities to discuss issues of health and safety. Choose a costume that is reflective, brightly colored and flame resistant. Avoid sharp accessories and facial masks that obscure your child’s vision or increase the risk of tripping or hurting oneself or another. Always test any make-up on a small area of your child’s skin before it is applied to the face.  Talk about food and nut allergy risks. Discuss safe and courteous behaviors including the use of a flashlight, avoiding candles and stairs, traveling in a protective group, never entering a house alone and not running between houses or across a street. Making eye contact and graciously saying thank-you are also important as are proper hand washing, general food safety techniques and proper inspection of all “treats” before they are eaten.

On this holiday take the time to discuss with your child the importance of healthy treats and how much sugar is healthy. Talk about balance and view this holiday as a tasting “buffet” opportunity for your child. Avoid becoming the “sugar policeman.” By including sugar education in your daily lives long before Halloween your child will know ahead of time the importance of limiting sugar intake. Help provide what and when guidelines for sugar intake for the younger child and for the older child avoid critique and criticism about sugar intake. Show by example how you limit your own sugar intake. You are your child’s greatest teacher. Children should eat no more than 16 grams of sugar a day and an adult no more than 32 grams. A can of juice or soda contain about 40 grams of sugar and a single starburst about 4 grams. Make food label awareness and healthy food choice a part of your everyday life.

Halloween can be filled with magic and learning for every child.

The Importance of Exercise

Exercise is an essential component of a healthy lifestyle and leads to good physical health.  There is no single best activity but keeping your exercise routine fresh, exciting and social improves your chance to continue exercising.  Everyone should exercise from infancy through adulthood.

Exercise must always be done in a safe environment. Make sure you drink enough water and always warm up before you begin moderate to strenuous activities. Appropriate flexibility and strength must be present before many activities should be pursued. This includes core strength and an adequate base of muscle, bone, heart and lung strength. Lastly, equipment, pace and duration must always be considered.

The benefits to exercise are both physical and psychological. Physical benefits include improved lean body mass, improved heart and lung function and strong bones and muscles.  Psychological benefits include improved sleep and learning, enhanced self-esteem and a healthier general sense of well-being.  Exercise decreases stress and aides in the restoration of balance to our daily lives.

Exercise is a learned behavior and must be linked to a nutritious diet and adequate sleep and recovery. It must be started at an early age and become part of your daily activities. It must be inexpensive and readily available. It is best to include 60 minutes of a combination of moderate and vigorous exercise in your daily routine.

In recent years physical inactivity has become our standard. This has many causes including our use of automobiles rather than walking or biking, the deep penetration of labor-saving devices into our daily lives and the prevalence of electronic games and other devices that distract and support “sitting” behaviors. Even school schedules have changed with many physical education classes now being cancelled. In many urban areas children are afraid or not allowed to play outside due to safety concerns.

Children under age two years should not watch TV and children from age two to six years should watch less than two hours a day. Older children should keep screen and electronic device time under two to four hours a day. Most teens in the US spend more time with electronic devices than they do sleeping.

For infants the focus should be on developmentally appropriate motor skills. These types of exercise should be lively, consistent and spontaneous. Exercise that is imbedded within tummy time, diaper changing and dressing is best.  Peek-a-Boo , So-Big and Patty Cake are great choices.  Be cautious about the amount of time your infant spends in swings, bouncy chairs and car seats.

For the toddler to pre-school aged child the joy of movement is the focus. Children during these ages need to gain a sense of physical control over their bodies. They become stronger and leaner. They learn about spatial relationships in terms of hand-eye and foot-eye coordination.  They learn how to manipulate more than one object at a time and they develop a sense of stability and rhythm.  Walking, hopping, galloping, skipping, marching, running and obstacle courses are all perfect activities for this age.

As a child enters the school age years between five and ten years there is a transition to activities that have flexible rules and basic instructions.  Teamwork and the integration of motor and cognitive skills become increasingly important.

During the teen years personal interests and socialization opportunities are the focus. Team activities increase and vigorous exercise is common. Some risk-taking behaviors become incorporated into exercise and competition becomes more important. Throughout this period it is important to support in your child the importance of effort rather than outcome.

For more information check out my discussion on WJET.

Obstructive Sleep Apnea

This disorder is both frequent and serious. Numerous health problems are associated with obstructive sleep apnea syndrome (OSAS) in childhood. It is estimated that 2-3% of children have OSAS and the most common cause is enlarged tonsils and adenoids. When obesity is also present the risk for associated health problems is increased further.

The most common cause of OSAS is airway blockage. The windpipe is restricted or collapses when your child breathes in during inspiration.   Enlarged tonsils and adenoids are often the cause and this obstruction occurs during sleep when there is a decrease in body tone and general awareness.  Symptoms can be mild or severe. Usual symptoms include restless sleep, snoring, noisy breathing apnea, paradoxical chest movements, labored breathing and chest retractions and sweating. Some children complain of frequent waking and nightmares.

If the obstruction is nasal then mouth breathing is often seen. This allows your child to compensate for being unable to breathe through the nose. Other children will hyper extend their neck and assume a nose up sniffing position. This often decreases the snoring noises.  Daytime symptoms can include quality of life issues including mouth breathing, hyperactivity, moodiness, sleepiness, and headaches and learning problems. Moderate obstruction can lead to neurobehavioral, cardiovascular and metabolic consequences. Severe cases can lead to pulmonary hypertension, systemic hypertension, failure to thrive and developmental delay.

OSAS is more commonly seen in children who are overweight and in children with small jaws, muscles weakness, craniofacial syndromes or Down syndrome.

A comprehensive history and physical examination by your pediatrician is the first step to obtain this diagnosis. Your child may also need to see a lung specialist (pulmonologist) or an ear, nose and throat (ENT) physician. Further diagnostic evaluations may be needed including an overnight sleep study (polysomnography) and an evaluation of the upper airways either through direct visualization or through X-rays and other imaging studies.

OSAS treatment depends on the cause. When enlarged tonsils or adenoids are the cause then removal is necessary. This involves an adenoidectomy and/or a tonsillectomy. If other structural or weight issues are present then these issues need to be addressed. When surgery is not helpful then treatment with continuous positive airway pressure (CPAP) is often the option of choice.

If your child has surgery and continues to have symptoms then close follow-up and continued treatment is necessary.

DSM 5 Changes in Common Pediatric Mental Health Issues

General Information

Published  5/2013.

Lack of physiologic understanding/ categories are artificial.

DSM 1952/ DSM II 1968/ DSM III 1980/ DSM IV 1994/ DSM IV-TR 2000  (text revision)

American Psychiatric Association

Gold standard for the description of mental illness

Insurers and service providers use it to determine eligibility for services

Last update about 20 years ago.

Goal: improve accuracy of diagnosis

Risk: misdiagnosis/ over diagnosis/ medicalization of normal behavior


  • single axis not multi-axis format
  • Simplify use by clinician
  • Age/ gender/ culture are now considered factors when making a diagnosis
  • Just starting the science of psychiatry (3 sections: introduction/ outline of categorical diagnosis/ conditions that require further research)
  • “Unclear what we know and what we do not know”


Notable Changes            

Neurocognitive Disorders: Major neurocognitive disorder (dementia): memory impairment is not essential/ ex. frontotemporal dementia has personality changes early and memory changes later.

Mild neurocognitive disorder: mild cognitive decline beyond normal forgetfulness of aging. 1-2 SD below norm on NC testing.

Intellectual Disabilities:  

  • MR is removed
  • Based on cognitive and adaptive function
  • Mild/ moderate/ severe/ profound are eliminated
  • Specifiers are now used
  • Severity is determined by adaptive functioning not IQ score


Autism Spectrum Disorder:     

  • Replaces PDD: AD/ AS/ CDD/ Rett’s syndrome/ PDD(NOS)
  • autistic disorder/ PDD(NOS)/ AS are joined
  • Specifiers: language delay or intellectual disability
  • Primary focus is on strengths and weaknesses
  • Mild/ moderate/ severe are eliminated
  • Defined in terms of level of support required
  • New specifier: ASD is associated with a known medical/ genetic/ environmental factor. (ex: FAS/ Fragile X syndrome/ epilepsy)
  • Benefits: improve diagnosis in girls
  • Unsolved: minority access to services delays diagnosis
  • Dual diagnosis of ADHD and ASD now allowed
  • 2 domains:         
    • deficits in social communication and social interaction
    • RR (restricted repetitive) behaviors, interests and activities


Social Communication Disorder               

  • new diagnostic category/ outside of ASD
  • Lack RR behaviors
  • Children with severe ADHD and social skill deficits
  • Allows a new group of patients


Somatic Symptom Disorders  

  • Somatoform diagnosis is eliminated: this focused on medically unexplained symptoms.
  • Somatic symptom disorder: medically unexplained is not central to this diagnosis. (lowers the risk of alienating patients by imaginary context)
  • Focus on symptoms lasting longer than 6 months that are associated with disproportionate thoughts, feelings and behaviors such as extreme anxiety.



  • Reverse of most psychiatric conditions that are defined in adults and modified for use in children.
  • Limits social, academic or occupational functioning
  • At least six symptoms from either or both of two symptom domains: inattention and hyperactivity/ impulsivity.  Over 17 years need only five symptoms.
  • Inattention:  Careless mistakes/ difficulty with sustained attention/ not listen/ not follow instructions/ difficulty organizing/ poor sustained tasks/ loses things/ easily distracted/ forgetful.
  • Hyperactivity and Impulsivity:  Not due to oppositional behavior/ defiance/ hostility or lack of understanding instructions.  Fidgets, squirms or taps/ leaves seat/ runs and climbs when not appropriate/ lack of quiet play/ unable sit still/ talks excessively/ blurts out answers/ difficulty waiting turn/ interrupts or intrudes.
  • Several symptoms must be seen in each setting rather than more than one setting involved as the past criteria.
  • Levels: mild (few symptoms and minor impairment)/ moderate (between mild and severe)/ severe (many symptoms and marked impairment in social or occupational functioning)
  • Age of onset increased to 12 years from age 7 years since some issues with inattention do not manifest until a child is older.
  • 314.00 Predominantly inattentive
  • 314.01 Combined
  • 314.01 Predominantly hyperactive/ impulsive


Communication Disorders

  • language disorder: previously called expressive and mixed receptive-expressive language disorders.
  • Speech sound disorder: previously called phonological disorder.
  • Childhood-onset fluency disorder: previously called stuttering


Specific Learning Disorder    

  • Includes reading disorder/ mathematics disorder/ disorder of written expression/ learning disorder (NOS).
  • Coded specifiers for the deficit types


Joseph Barber, MD