Sleep occupies a crucial place in our lives. Although detailing the importance of sleep is beyond the scope of this article (see Markov and Goldman1 for an in-depth review), it is worthwhile to note that sleep is necessary for the maintenance of a number of brain and bodily functions. We need good and rejuvenating sleep, and when sleep is problematic it frequently becomes a primary clinical focus.2 Children's sleep disturbances are important because they make children more irritable, disturb the parent-child relationship, and lead to change in daytime functioning such as problematic peer interactions and difficulty learning. Sleep disturbance is an especially common symptom of traumatic stress.3 Trauma-related sleep disturbances may require different understanding and responses by parents than non–trauma-related sleep problems, and pediatricians can provide families with guidance and techniques to help children with trauma-induced sleep disturbances. Sleep disturbances after a traumatic experience are a key indicator of early difficulties that can worsen and result in longer-lasting psychiatric disorders such as posttraumatic stress disorder (PTSD) and depression.4 Pediatricians have a critical role in helping families with this central feature of traumatic disturbances. They know and are trusted by their patients and families, and pediatricians are most likely to see children experiencing sleep issues before anyone else.
Understanding and Classifying Trauma-Associated Sleep Problems
Disruptive Sleep as an Adaptation
Initial reactions of increased arousal after a traumatic experience are normal adaptive changes to danger5 and commonly wane over time as the child feels more safe and secure. This “on alert” behavior during the day may continue into the night and can interfere with sleep, resulting in sleep difficulties. Many factors determine whether or not sleep issues continue. A history of sleep problems, ongoing stresses, and the nature of the environment are just a few of these factors. However, our ability to predict who will develop chronic sleep problems is limited. Pediatricians should review the child's sleep history, identify the type of sleep difficulties present, and learn what interventions were successfully used previously.
Providing education that being “on alert” and having sleep difficulties is an expected response after trauma and providing information about other typical traumatic stress responses may be sufficient to promote recovery for many children. It is important to inform the child and parents that it will often take children some time to return to their previous sleep routine (even for transient sleep problems). However, equally important is the idea that sleep problems shouldn't become a new normal for the child and that a concerning history, severe exposure, and persistent or worsening sleep problems warrant further evaluation and intervention.
Classifying Trauma-Related Sleep Disorders
The first step when dealing with trauma-related sleep challenge is correctly identifying the specific sleep difficulty (Figure 1). Traumatized children are most likely to have pre-sleep (falling asleep), and within-sleep (middle of the night) problems.
Classifying and addressing sleep disorders in youth exposed to trauma. The figure depicts the three main categories of sleep difficulties (pre-sleep, within sleep, and waking unrested) as well as common subcategories that determine methods and interventions that can be used by the pediatrician and the family to help the child return to normal, pre-trauma sleep. PTSD, posttraumatic stress disorder.
Pre-sleep problems. Pre-sleep problems can be either volitional or avolitional, but usually both.
In an avolitional sleep problem, children simply cannot fall asleep while in a general state of hyperarousal—they are still in danger mode, and their hypervigilance in response to a perceived threat prevents them from falling asleep, even when they cognitively feel safe and want to sleep.
In a volitional sleep problem, children avoid sleep because of trauma reminders during the day or evening, or bedtime/sleeping itself is a reminder. These children feel vulnerable at night, and sleeping doesn't feel safe. Furthermore, many children become afraid of sleep as they don't want to have nightmares or night terrors. When children awaken with their heart racing in a significant state of hyperarousal, this can be so distressing that children become afraid to go to sleep.
Within sleep problems. Within-sleep problems include sleep that is disrupted and ineffective. Middle-of-the-night sleep problems include nightmares/night terrors and nighttime awakenings/restless sleep.
With nightmares, children experience the emotional distress of the nightmare and awaken with heightened sympathetic tone. These children awaken so aroused it may be difficult to go back to sleep, with nightmares occurring in both rapid eye movement (REM) and non-REM sleep.6 Night terrors may occur more frequently in younger children but are not atypical in older children and adolescents who have experienced trauma. These children with nightmares or night terrors can awaken with extremely elevated heart rates, making it difficult to go back to sleep. Parasomnias, including vocalizations at night and sleep walking, can also be observed.
Frequent nighttime awakenings (non-nightmare related) and restless sleep with increased motoric activity can also cause significant distress. Often, these children are experiencing increased startle while awake, a daytime manifestation of this same phenomena of increased alertness and reactivity. As a result, these children are not spending as much time in the restful stages of sleep and wake up tired, resulting in increased irritability and trouble with daytime learning.
Addressing Concerns Over Safety and Protection
A feeling of safety is essential for a child to effectively recover after a traumatic experience. If the child continues to live in unprotected surroundings, sleep difficulties are unlikely to be amenable to therapy.7 For example, consider a child experienced who a mudslide in the family home. When the family moves back home, but the hillside that allowed for the mudslide is not repaired, therapy is unlikely to be effective. Connecting the family with appropriate resources to fix the hillside may have the greatest impact on sleep. This is analogous to continued hypervigilance when still living with an abuser. It is almost impossible to adequately address sleep disturbances if the underlying real danger is not address.
Even when pediatricians think the environment is now safe, the child may not.8 For example, children who have gone through serial experiences of child abuse may have an underlying distrust in the parent's ability to protect, even when placed in a safe, protective setting. Understanding if the child feels safe can help evaluate if ongoing safety concerns are affecting the child's sleep and is essential to address when developing a treatment plan.
Furthermore, it is natural for children to desire proximity with the parent at night in the days and weeks after a traumatic event. The decision and approach to enhance feelings of safety through proximity (parents spending more time in the child's room around bedtime, child coming into the parent's bed, parent sleeping in the child's room) varies from family to family. However, it is critical that from the onset, parents make any changes as part of a broader negotiation with the child, validating the desire to be close and praising the child's ability to describe their feelings to the parent, and at the same time communicating that this increased proximity is to support the child's transient sleep difficulties and is only temporary. Renegotiation of sleep accommodations may be necessary if the child's sleep worsens after subsequent trauma reminders or additional traumatic events.
There is a natural ebb and flow of trauma-related sleep disturbances. Oftentimes, the worst nights are related to trauma reminders the child experienced during the day or evening. Parents tend to be more aware of and prepared for daytime reminders that are easily connected to the trauma (eg, first day back to school after school violence). The time of day or night of a trauma, or the day of the week or time of year the trauma occurred, could also affect the intensity of the reminder and its impact on sleep. In the evening, a television show that the family watches or a story that the parents read to the child at bedtime could be an unsuspected trauma reminder. Children and parents need to develop awareness of the connection between daytime or evening trauma reminders and poor sleep at night. Pediatricians can educate parents to attend to potential trauma reminders during the day or evening with the use of coping skills that help calm the child. If the trauma reminders also affect the parent, the parents may need their own support to increase their awareness of the trauma reminder's impact on the child and themselves.
It is helpful to start with how many good versus bad nights the child experiences, and what daytime or evening characteristics are predictive of good versus bad nights. Parents can learn to identify potential trauma reminders and provide additional support on those nights when their child is most likely to have sleep difficulties. For example, children who are picked up in the family car after being in a car crash are likely to experience distress. It is useful to anticipate this as well as spend some extra time at night calming the child before sleep.
Some youth experience constant reminders, which increases the risk of a chronic sleep disturbance. If there are constant reminders, pediatricians can work with parents to figure out how to practically deal with that issue. Families must do their best to buffer their children from ongoing reminders that are out of their control (eg, neighborhood issues, needing to resume riding a bus)
Often, the family may not have control over aspects of potential reminders and the family may need support in contextual discrimination (ie, the ability to tell the difference between trauma-reminder situations from the real, current situation). For example, if the trauma happened in the bedroom, the bedroom could be changed or rearranged to decrease the risk of reminders, or if the event happened at school it may be useful to change classrooms or ensure limited exposure to certain schoolmates if the trauma is related to bullying. Pediatricians can help the family make these discriminations and understand that just because there is a similar context to the traumatic event it is actually different. Parents can make concrete changes or point out the differences to the child to decrease the impact of the reminders.
Parenting the Child with Sleep Disturbance
Educating parents that sleep problems are common and not the result of bad parenting is essential. Encouraging the parents to go back to the strategies they have previously used to help their child learn to sleep empowers the importance of the parents' crucial role in helping their child recover. However, parents need to know that prior techniques that were successful may not be as effective under these new circumstances. For instance, the previously anxious child whose sleep improved with continued reassurance and structured sleep hygiene, but who now is highly aroused and more anxious, may not respond to those parenting techniques (Table 1).
Addressing Sleep in Children Exposed to Trauma: First Steps
When children experience trauma, parents often feel extremely guilty. Parents know that their primary function is to safeguard their child, and their inability to protect them is perceived as a failure. Their child's sleep problems are a constant reminder of self-perceived parental failure. A common problem with trauma-related sleep disturbances is that parents may not be able to “educate” their child out of them, which is a technique that generally works with good sleepers. For example, parents are often successful by discovering what is distressing and interfering with the child's sleep and will be able to reassure their child and demonstrate their erroneous thinking (eg, the common fear of monsters under the bed).
Unfortunately, the child who has experienced trauma is rarely reassured by parental education alone. It may take time to rebuild a sense of safety. Parents need to know about the course of trauma-related sleep problems and how to monitor their child's sleep appropriately. Pediatricians should invite parents to talk to their child regularly about their child's sleep. You want the parent and child to communicate and problem-solve about sleep rather than struggling over the child's sleep. Implementing structured and consistent sleep hygiene may cause conflict, and an open dialogue facilitated by the pediatrician is crucial to sleep improvement.
Children who were “bad sleepers” prior to a traumatic experience often will have an even worse time falling asleep. It is common for anxious and worried children to have difficulty going to sleep, as their increased worries and catastrophic thinking become more prominent at night. After a traumatic event, these thought patterns tend to worsen and increase their impact on sleep. The traumatic experience may validate the child's worries, and now the parent is faced with a child whose worries are confirmed, making sleep incredibly challenging and decreasing the child's capacity to accept reassurance from the parents. If children were anxious before the traumatic experience, pediatricians should continue to encourage good bedtime routine and the use of calming techniques. However, these children often will need treatment for their pre-trauma anxiety (ie, cognitive-behavioral therapy, selective serotonin reuptake inhibitors)9 or for sleep disturbances in the context of PTSD (ie, melatonin, prazosin).10
Sleep: The Canary in the Coal Mine
Approach to Mental Health Evaluation
Children with sleep problems related to trauma often wake up tired. Tired kids are typically irritable and have trouble with daytime attention and learning.2 These daytime issues might be the chief complaint, and parents and teachers often become concerned that the child has a psychiatric disorder such as attention-deficit/hyperactivity disorder (ADHD) or depression; however, this may be the result of poor sleep. The pediatrician will have to work backwards to uncover the underlying etiology of these symptoms and subsequently the cause of the sleep problem, and may suggest improving sleep first and then re-evaluating for other possible comorbidities.
Although chronic tiredness associated with poor sleep can mimic childhood disorders, sleep difficulties are often present in many childhood disorders as well as those related to the traumatic events. Common disorders to consider include PTSD, anxiety, depression, and ADHD. When sleep problems have been identified and continue even after a routine has been established and behavioral interventions have been implemented, it is important to evaluate for common disorders and screen for common stress-related reactions.
Common Disorders in Children Exposed to Trauma
PTSD. Sleep difficulties are a common antecedent to the development of PTSD in children. Although PTSD is comprised of four separate criteria after the experience of a traumatic event (intrusive symptoms, avoidance, negative distortions in cognition and mood, and increased arousal/reactivity), sleep challenges can manifest as both intrusive symptoms (nightmares) and increased arousal (sleep disturbances).11 Trauma reminders experienced by the child also cross these different criteria and are not just limited to intrusive symptoms. PTSD, or significant posttraumatic stress symptoms, are often underrecognized in children after trauma. However, many effective treatments for PTSD exist such as trauma-focused cognitive-behavioral therapy.12 As there is no pharmacologic intervention for PTSD in children approved by the US Food and Drug Administration (FDA), clinicians should be especially thoughtful when considering medication.
Anxiety. Children with anxiety have a hard time falling asleep, but once asleep they generally sleep through the night and do not awaken too early.8 It is hard for anxious children to fall asleep because they continue to have worried thoughts about general events that occurred that day or anticipation about what might happen tomorrow. Those worries are often focused on nontraumatic but potentially stressful events such as interactions with classmates, upcoming tests, or being apart from family. Trauma typically heightens these worries, and knowing if a child previously suffered from anxiety may be the only way to tease out anticipatory anxiety versus trauma induced hypervigilance.
Depression. Children with depression usually have sleep issues; however, these difficulties with sleep are often different than trauma-related sleep problems.13 Children with depression have early morning awakening, which is not common in sleep problems related to trauma. Both trauma-related sleep and depression-related sleep can be associated with daytime tiredness, but with children who have experienced trauma, it is because of restless sleep with numerous periods of nighttime awakening, whereas children with depression cannot get enough hours of sleep. It is important to note that trauma-focused psychotherapies have been demonstrated to be helpful for depressive symptoms in children with PTSD.12
ADHD. Children who are tired may appear to have ADHD. Paradoxically, children who are tired may be more hyperactive during the day in addition to being less focused and more prone to distraction. It is difficult to tease out ADHD-related versus trauma-related symptoms. A child with ADHD symptoms with sleep problems and a known history of trauma may respond to treatment that initially focuses on improving the child's sleep and engaging in trauma-focused therapy.14 A reassessment after sleep is improved may or may not be necessary for any lingering ADHD symptoms.
An accurate psychiatric diagnosis is critical for providing appropriate pharmacotherapy options in children with trauma-related sleep disturbances. There are no FDA-approved medications for sleep disturbances in children. The literature supports the use of melatonin in certain pediatric populations for sleep,14,15 and a variety of other medications are often used by pediatricians. Prazosin has been demonstrated to be effective for the treatment of nightmares and sleep disturbances in adults with PTSD,16 but evidence in youth is limited to data on safety and tolerability.17 Another medication to consider at night includes clonidine, which case reports suggest reduce exaggerated startle and reactivity to reminders, including heart rate reactivity at night, that can help children get back to sleep if they awaken in scary state.18
An important clinical decision when addressing known trauma symptoms and ongoing sleep difficulties is deciding what to address first. When possible, it is prudent to first address sleep, either with hygiene, behavior, or coping strategies, or when appropriate, through the use of medications. This may potentially limit the risk of polypharmacy by clarifying which symptoms (1) are directly related to sleep (and thus improve with improved sleep); (2) are directly related to trauma and amenable to evidence-based trauma psychotherapies; and (3) persist and clearly demonstrate manifestations of a diagnosis that, when moderate to severe, may be treated with additional pharmacotherapy.
Due to the complexity of applying pharmacotherapy to children exposed to trauma with sleep disruption, it may be helpful to consult with or refer to child psychiatry when available.19 Clinical scenarios of when to consider psychiatric referral include (1) inadequate response to primary sleep interventions; (2) sleep issues that are frequent or severe and/or worsening over time; (3) identification of a psychiatric comorbidity that has persisted after attempting to address sleep (PTSD, anxiety, depression, behavioral issues); and (4) if the child has chronic sleep disturbances resistant to treatment, even without a clear trauma history, as this may warrant a more comprehensive trauma evaluation.
Trauma routinely affects children, and sleep disturbances are a common and challenging clinical scenario among children exposed to trauma. Pediatricians are perfectly situated to address sleep difficulties related to trauma exposure and traumatic stress. Most strategies involve working with the parents and child to recognize the type of sleep disturbance, identification of association with trauma reminders and perceived or real safety concerns, and empowering the parents to use both previously successful and novel approaches to improve their child's sleep. Vigilance toward the development of ongoing and persistent psychiatric issues is also critical in this population.