Sleep quantity and quality are essential for emotional, cognitive, and physical development, yet a frequently overlooked barrier to restorative sleep in childhood and adolescence is chronic nightmares. Chronic nightmares can be responsive to treatments, but when they persist, cause sleep fragmentation, disrupt sleep continuity and total sleep time, and elevate pre-sleep arousal, all of which undermine daytime functioning and overall well-being (Gauchat et al., 2020). Although occasional nightmares are common and typically benign, persistent and distressing nightmares represent an understudied malleable contributor to poor sleep health across development (Cromer et al., 2022; El Sabbagh et al., 2023) and may amplify risk for broader mental health problems (Gieselmann et al., 2019; Gill et al., 2023). As the field advances educational and cognitive-behavioral interventions to promote sleep, chronic nightmares remain insufficiently integrated into models of sleep quality and intervention, despite being modifiable. There is considerable evidence that nightmare treatments are effective in adults (Gieselmann et al., 2019). The current manuscript presents the theoretical basis for a brief evidence-based treatment for youth (Cromer et al., 2024). In a recent systematic review, Gill et al. (2023) expressed an “urgent need” (p. 280) for rigorously conducted clinical trials targeting nightmares in youth. This gap underscores the importance of a strong theoretical framework to guide intervention development. In line with this need, the current manuscript presents a nightmare maintenance model (i.e., factors that sustain nightmares over time) that identifies nightmare efficacy as a central, developmentally relevant mechanism. Nightmare efficacy refers to the belief in one's ability to control, cope with, or reduce nightmares, whereas mastery reflects the accumulation of successful experiences using skills to positively impact nightmares and sleep. Thus, efficacy represents a central cognitive mechanism that supports engagement in skill-based practice and the development of mastery over time. The model has been refined through several pilot studies and a clinical trial demonstrating promising reductions in nightmares and improvements in mental health (Cromer et al., 2024). These findings serve as the theoretical foundation for transdiagnostic treatment for improving nightmares and sleep in youth ages 6–17 years. By articulating the model and illustrating its clinical application, this manuscript aims to support clinical applications in the short term as well as the next phase of research.

Nightmares can be symptomatic of other mental health diagnoses, but when they cause sufficient distress and impairment, they may be independently diagnosed and treated. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) definition of nightmare disorder includes, “repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security or physical integrity” (American Psychiatric Association, 2022, p. 457). A defining feature of a nightmare is that an individual becomes rapidly alert upon waking and has significant distress and/or functional impairment. Modifiers are mild (<1 per week), moderate (one or more per week) and severe (nightly; American Psychiatric Association, 2022).

Chronic nightmares have deleterious effects on mental and physical health (American Psychiatric Association, 2022, p. 460) and nightmare treatment can improve other threat-related disorders and possibly depression (Sheaves et al., 2023). Further, children's nightmares can disrupt household members' sleep (Li et al., 2011). Although sleep health has gained increasing attention in recent decades, nightmares, particularly in youth, remain understudied, underdiagnosed and rarely treated (Cromer et al., 2022; Nadorff et al., 2015). Nightmares are often conceptualized as secondary symptoms of other mental health conditions [e.g., posttraumatic stress disorder (PTSD)] despite evidence that standalone treatments are effective (Gieselmann et al., 2019; Gill et al., 2023).

Differential diagnosis is essential for treatment planning because most conditions that mimic nightmares will not respond to a unified protocol for nightmare treatment. Diagnosis relies on clinical evaluation involving the child and caregiver that considers the child's recall of the episode, the timing of the event, and behavioral observations. Below, we highlight common differential diagnoses relevant to clinical assessment.

Nightmares should be distinguished from non-rapid eye movement (NREM) sleep arousal disorders, such as sleep terrors (Leung et al., 2020). NREM disorders of arousal occur in slow-wave sleep (i.e., N3), which predominates the first third of the night. Nightmares typically occur during REM, with episodes more frequently observed in the second half of the sleep period. Recall is a critical differentiator; unlike nightmares, episodes of NREM disorders of arousal are not recalled. Behaviorally, in contrast to nightmares, NREM disorders of arousal are characterized by the dreamer appearing disoriented or partially asleep rather than fearful and oriented upon awakening.

Nightmares should also be distinguished from nighttime anxiety, nocturnal panic attacks, and sleep-related breathing disorders [most commonly obstructive sleep apnea (OSA); American Psychiatric Association, 2022, p. 460]. While these conditions may cause significant nocturnal distress, they lack vivid imagery recall. For example, OSA may be mistaken for nightmares when a child awakens suddenly gasping for breath because of an apneic event; in this case, fear arises from physiological distress, rather than dream content. Similarly, nocturnal panic attacks involve abrupt awakenings with intense distress and physiological arousal without dream recall (American Psychiatric Association, 2022, p. 460; American Academy of Sleep Medicine, 2014, p. 261). Nighttime anxiety in children is driven by environmental or situational fears (e.g., darkness, separation) and may lead to bedtime resistance or nighttime awakenings, whereas insomnia is characterized by fear of not sleeping, in contrast to nightmares, which are characterized by fear of sleep.

Nightmares have been categorized as either posttraumatic or idiopathic, a distinction derived primarily from research with adults (Youngren et al., 2024). Posttraumatic nightmare (PTN) onset occurs following a traumatic event; content can vary from replicative of the trauma to not bearing any similarity to a precipitant (American Psychiatric Association, 2022, p. 458). PTNs are associated with an inability to initiate the fear extinction process (McNamara et al., 2021), contributing to the development and maintenance of PTSD. In contrast, idiopathic nightmares have no identifiable precipitating cause and are theorized to initiate the fear extinction process; however, fear extinction is disrupted when the dreamer wakes prematurely (McNamara et al., 2021). In this way, idiopathic nightmares become negatively reinforced.

Evidence from pediatric samples is limited, but existing studies have explored whether nightmare etiology is associated with symptom severity and distress. Langston et al. (2010) found that youth with PTNs had more severe depression and PTSD symptoms compared to youth with idiopathic nightmares. Within a sample of youth with PTN, replicative nightmares were associated with more PTSD symptoms but not higher nightmare distress than were non-replicative nightmares (Gray and Cromer, 2018). Recently, Tett et al. (2025) extended this work to a broader sample of youth aged 6–17 years with either PTNs or idiopathic nightmares and found comparable nightmare distress and themes across groups. These findings raise the possibility that, in the developing brain, nightmares may represent a more unitary phenomenon, with trauma exposure and fear learning interacting along a continuum rather than constituting distinct etiological categories. This theoretical distinction is revisited in the next section on mechanisms of chronic nightmare maintenance.

A theoretical breakthrough in behavioral sleep medicine was introduced by Spielman et al. (1987), who reconceptualized insomnia from a transient symptom to a learned, self-perpetuating disorder. Their model emphasized that behavioral and cognitive responses to poor sleep, such as compensatory sleep-interfering habits and worry about sleep, can maintain insomnia long after the initial precipitant has resolved. This work evolved into a 3P model to acknowledge predisposing, precipitating, and perpetuating factors in the development and maintenance of insomnia.

(Davis 2009, p. 63) extended Spielman's conceptual framework to explain PTN development and maintenance, highlighting the similar roles for predisposing vulnerabilities, precipitating or triggering events, and ongoing behavioral and cognitive perpetuating factors in the onset and maintenance of chronic PTN. (Davis 2009, p. 63) identified key perpetuating factors for nightmares including sleep deprivation and REM disruption, daytime distress and arousal, anticipatory anxiety, avoidance, and maladaptive sleep habits.

More recently, Sheaves et al. (2023) drew on network approaches to illustrate how nightmares may participate in reciprocal symptom-symptom interactions. The authors conceptualized nightmares as part of a broader system of feedback loops (e.g., nightmares increasing anxiety and hyperarousal, which in turn increase vulnerability to further nightmares) that may contribute to comorbidity. The authors suggested that treatment approaches may be more effective if they target central components within a network. By identifying and modifying feedback loops, interventions may disrupt the broader network that sustains nightmares. Nevertheless, there remains a need for a mechanism-focused framework that explains how symptom loops develop and clarifies which processes can be directly targeted to reduce chronic nightmares across etiologies.

Nightmare distress is an important contributor to nightmare maintenance. Belicki (1992) observed that negative daytime affect following a nightmare predicted poor psychological functioning. Levin and Nielsen (2007) proposed a model in which one's emotional load (i.e., cumulative emotional distress and ability to regulate it) becomes too great, causing a nightmare. Drawing on classical conditioning principles, they argued that adaptive dreaming ordinarily facilitates fear extinction: the feared memory (conditioned stimulus) is repeatedly reactivated in the absence of threat (unconditioned stimulus), leading to fear extinction. However, when affect load is high, this extinction process becomes disrupted, increasing the likelihood of a nightmare. The resulting nightmares then heighten next-day distress, especially in individuals with high dispositional stress sensitivity.

Gieselmann et al. (2020) applied a transactional model of stress and coping to understand nightmare distress. Primary appraisal involves evaluating whether a nightmare is threatening to one's well-being, followed by a secondary appraisal of one's coping potential. They found that individuals with higher nightmare distress engaged in more daytime coping efforts, suggesting more attempts to manage distress. Notably, greater distress was also reported among participants who believed they knew the cause of their nightmares, which the authors suggested may reflect heightened emotional salience of nightmares linked to identifiable stressors, such as traumatic experiences.

Rousseau and Belleville (2018) conducted a systematic review to explore the hypothesized mechanisms underlying psychological treatments for nightmares. They identified six mechanisms to explain treatment efficacy: increased sense of mastery, emotional processing and fear-structure modification, belief restructuring, restoration of sleep functions, reduction of physiological arousal, and prevention of avoidance behaviors. Among these, the enhancement of mastery, or patients gaining control over their nightmares, emerged as the most frequently cited mechanism. Notably, while mastery has been discussed in relation to treatment response, it has been less explicitly examined as a mechanism underlying the maintenance of nightmares. The remaining mechanisms fit with existing transactional models of stress (e.g., restoring sleep functions, reducing physiological arousal, preventing avoidance) and cognitive models, including 3P frameworks (e.g., fear-structure modification, belief restructuring).

Nightmares may arise from a variety of precipitating factors, including psychological stress (Nielsen and Levin, 2007), traumatic experiences (American Psychiatric Association, 2022, p. 458), pharmacologic influences, and psychiatric or medical comorbidities (such as sleep fragmentation from sleep related breathing disorders). However, the current model posits that while the precipitant might differ, once nightmares emerge, their persistence is driven by shared learning mechanisms. The etiological distinction is an interesting theoretical question because treating PTN may be akin to a trauma exposure; however, from a learning theory perspective, nightmare-related fear sustains avoidance-based cycles for both idiopathic and PTN. Furthermore, at least in youth, preliminary findings suggest that there are no functional differences between idiopathic nightmares and PTNs (Tett et al., 2025).

Building on prior theoretical approaches, the DARC-NESS model integrates elements of the 3P formulation (Davis, 2009, p. 63; Spielman et al., 1987), affect-load theory (Nielsen and Levin, 2007), transactional stress concepts (Gieselmann et al., 2020), and network perspectives (Sheaves et al., 2023) to explain how nightmares are maintained across etiologies. DARC represents the core maintaining processes, D: Dream (or nightmare) content, A: Appraisal, R: Regulation resources, C: Conditioned arousal, while NESS represents the central mechanism of Nightmare Efficacy and sleep-related maintaining factors including, S: Sleep hygiene and patterns, and S: Sleep quantity and quality. While nightmares themselves are understood as avoidance or escape from distressing dream content (Levin and Nielsen, 2007), nightmare maintenance is conceptualized as arising from dynamic interactions among cognitive, emotional, behavioral, and physiological processes that may be activated differently across individuals (Sheaves et al., 2023).

Consistent with Davis (2009), the model highlights perpetuating cognitive, behavioral, emotional, and physiological processes, but extends these ideas by allowing multiple entry points, rather than a single ordered sequence. This flexibility reflects a network-informed perspective in which processes interact non-linearly and vary across individuals (Sheaves et al., 2023). Drawing from Levin and Nielsen's (2007) conceptualization of affective overload, as well as work on coping resources in nightmare treatment (Gieselmann et al., 2020), affect overload is represented in the model as insufficient regulatory capacity relative to emotional demands. Finally, influenced by Rousseau and Belleville (2018), the model centers nightmare efficacy as the core mechanism underpinning the other components.

The current model proposes that in clinical practice, helping children understand how nightmares are maintained is a critical therapeutic task. Nightmares are often experienced as confusing, uncontrollable, and frightening events (American Psychiatric Association, 2022), and children (and their caretakers) may not connect how daytime experiences, emotions, and sleep-related behaviors contribute to nightmare recurrence. Below, the DARC-NESS model is described both as a theoretical framework and a psychoeducational tool that can be used collaboratively with youth to explore how nightmares are maintained and how they can be changed; Figure 1 includes example clinician prompts that may be used to guide the process. The model provides a shared language for discussing nightmares, externalizes the nightmare pattern from the child, and allows clinicians and youth to identify which processes are most relevant for a given individual, rather than assuming a one-size-fits-all pathway. This interactive process guides collaborative treatment planning.

The DARC-NESS Model in Figure 1 is depicted as a circular, multi-component system; clinically, this serves to help youth identify their personal cycle based on these pathways. The clinician should note, however, that the pathways are functionally non-linear, and not all youth may experience each component; this variability is represented with dashed lines. Youth may enter the cycle at any point and may bypass one or more components entirely, depending on the developmental level and individual experiences.

Each component of the DARC-NESS model represents a distinct process that can contribute to nightmare maintenance. Dream (nightmare) content maintains nightmares when they are emotionally salient or repetitive, increasing affect load, fear activation, and the likelihood of awakening to escape distress, as well as reactivation of fear networks across nights. Appraisals of nightmares as dangerous, uncontrollable, or indicative of personal vulnerability heighten perceived threat and anticipatory anxiety, promoting avoidance of sleep or premature awakening. Resources for regulation influence maintenance when a youth has limited capacity to manage emotions or physiological arousal, increasing vulnerability to affective overload and reducing tolerance of distressing dream content. Conditioned arousal reflects learned physiological reactivity to sleep-related cues which interferes with sleep initiation. The NESS components represent downstream processes that sustain nightmares by shaping both sleep processes and perceived agency, including nightmare efficacy, sleep hygiene and patterns, and sleep quality and quantity.

The components of the model represent common but not universal processes, and the core mechanism—nightmare efficacy—interacts dynamically with those processes. Nightmare efficacy reflects the individual's sense of agency, control, and belief in their capacity to cope with nightmares (Rousseau and Belleville, 2018). It functions as a central amplifying or buffering mechanism; low nightmare efficacy amplifies several interconnected maintaining processes, described below.

For clarity, treatment components are described below in the order of the DARC-NESS mnemonic rather than the order in which they are introduced in therapy.

This case was selected to demonstrate the treatment model and its clinical application, given the adolescent's engagement in therapy and the breadth of nightmare content addressed through rescripting. In addition, the case illustrates common clinical challenges, including variable homework adherence (e.g., pillow case and reading the new dream narrative), the need to discontinue or modify ineffective strategies (i.e., PMR), and the adaptability of the intervention in the context of significant life changes, such as relocation. The therapy modules represent a range of therapeutic activities that can be implemented flexibly and non-linearly in response to individual needs and circumstances.

A thoughtfully constructed case formulation enables clinicians to design a treatment plan that targets the theorized mechanisms of change (Eells, 2025). The multi-component model of nightmare maintenance is a valuable framework for guiding case formulation of nightmares and thus treatment of nightmare disorder. A detailed sleep and nightmare assessment is critical for identifying the relevant components in a child's case formulation. A clinical interview with both the child and caregiver can reveal which components are most relevant to the child's nightmare maintenance. It is important for the clinician to get a detailed picture of evening routines, sleeping environment, caregiver responses to the child's nighttime behaviors, as well as typical sleep schedule parameters including time in bed, sleep onset latency, wake after sleep onset, wake time, and daytime sleep (Mindell and Owens, 2015). Sleep and nightmare diaries are invaluable for supporting assessment and monitoring change. Additionally, as demonstrated with Alex, that data can then serve as a tool for reinforcing a child's self-efficacy by connecting cognitive-behavioral changes to observed changes in outcome. Standardized assessments may also be useful depending on the clinical setting; for example, broad screening tools such as the Structured Clinical Interview of Sleep Disorder in Children (Rischard et al., 2024), can help identify comorbid medical sleep disorders (e.g., OSA) that require further evaluation.

Once an initial formulation is developed, it is important to share this working understanding with the child in a developmentally appropriate way. In our work treating nightmare disorder, we have found that a visual (like the example in Figure 1) and describing a “vicious cycle of nightmares” is helpful. During this discussion, the clinician presents the cycle and the components most relevant to the child, emphasizing that the cycle can be broken at multiple points with the use of tools or coping skills learned in treatment. This discussion helps cultivate hope and motivation for change by underscoring choice in selecting from multiple pathways to improvement.

With a shared and discussed case conceptualization, clinicians can then identify relevant interventions based on the theorized components relevant for the child. Selected interventions are aimed at addressing the underlying mechanism of the relevant component. For example, when addressing conditioned arousal, the relevant intervention technique can include introducing the child and caregiver to stimulus control principles (Spielman et al., 1987; Perlis et al., 2005). These strategies can be implemented developmentally; for instance, psychoeducation about conditioning paired with creating a pillowcase with positive reminders can serve as a helpful cue for children that the bed is a place for sleep and relaxation. Table 1 summarizes model components alongside corresponding intervention targets and is intended as a flexible, non-exhaustive guide highlighting evidence-based strategies for treating nightmare disorder.

After identifying relevant components and corresponding interventions, the sequence of modular components may be tailored to the child's presentation. This modular approach is flexible: interventions may be delivered sequentially, concurrently, or iteratively depending on factors such as nightmare severity, treatment goals, readiness, and comorbid conditions. For example, in an integrated behavioral health setting such as a pediatric sleep clinic, it may be appropriate to begin by addressing hyperarousal with relaxation techniques or implementing a bedtime routine before engaging with nightmare exposure. Conversely, a child being seen in a more traditional behavioral health setting that may already have an established therapeutic rapport may be able to engage in nightmare exposure earlier.

Clinicians should view nightmare case conceptualization as a hypothesis, meaning it is testable and modifiable, modeling an empirical stance of curiosity and openness. Progress monitoring is essential for examining treatment response as well as for building self-efficacy by linking behavioral changes to improvements in sleep and nightmares (Craske et al., 2014; Rousseau and Belleville, 2018). If core components do not reduce nightmare frequency or distress, it is important to revisit the initial formulation and consider other factors, such as co-occurring medical sleep disorders.

Not all youth experience complete remission of nightmares; however, most show meaningful improvements, with gains continuing beyond treatment completion. If nightmare frequency or distress does not improve after addressing the youth's identified maintenance factors and completing two rescripting sessions, a referral for medication treatment of the nightmares may be warranted. Our team has found that nightmare rescripting has not caused iatrogenic effects. That said, while youth may need rewards and motivations to do hard things like facing a nightmare and rescripting, participation should always be voluntary. Exposure-based interventions may undermine learning or increase avoidance when they are implemented without sufficient collaboration or perceived control (Craske et al., 2014).

Using the multi-component model of nightmare maintenance as a framework for case conceptualization offers several advantages. The DARC-NESS model supports a collaborative, modular approach in which intervention components are flexibly selected and sequenced based on the child's presentation. This approach also allows clinicians to personalize treatment by targeting the most relevant maintaining processes, promoting clinical efficiency across settings.