Staff Perspective: Stress and Youth Sleep Solutions
This past week, I shared information on a treatment for posttrauma nightmares called Exposure, Relaxation, and Rescripting Therapy for Children on the Center for Deployment Psychology’s podcast, “Practical for your Practice”. Given this, I began thinking a lot about current potentially traumatic or stressful events that have been going on around the world; and the need for more trauma-informed sleep solutions for military youth experiencing stressors and subsequent sleep problems.
A colleague and I, Dr. Lisa DeMarni Cromer, presented a grand round on trauma-informed sleep solutions to providers associated with the Hawaii Psychological Association soon after the Maui fires. What I’m writing about here is what we decided to present given the recency of that disaster, understanding that stressors were still ongoing, but problems in sleep were being reported. Overall, we considered that the information presented could be helpful to other potentially traumatic or stressful situations associated with sleep problems in youth.
When youth experience stressful or upsetting events, disruptions in sleep are amongst the most common consequences. Sleep problems such as shorter sleep duration, difficulty falling asleep, frequent awakenings, nightmares, sleepless nights, and early-morning wakefulness are often reported (Geng et al., 2008; Pillar et al., 2000; Babson & Feldner, 2010, Charuvastra & Cloitre, 2009). These sleep problems could cause inadequate sleep in youth which may result in physical, behavioral, cognitive, and emotional problems. Therefore, intervening as early as possible is important in preventing or treating insufficient sleep and long-term problems (Charuvastra & Cloitre, 2009).
Prevalence rates of sleep disturbances among youth samples vary considerably. In general, 16% to 40% of children exhibit sleep disturbances. When children are exposed to trauma, this prevalence rate may increase to 71% (Giannakopoulos & Kolaitis, 2021). Adverse effects of childhood trauma on sleep have been found immediately as well as years after trauma and can still be demonstrated in adulthood.
When beginning to provide trauma-informed solutions for sleep, it is important to understand that there is no one size fits all procedure. Individual differences need to be considered and a caregiver’s comfort and willingness to provide the solutions should be considered. Different strategies can be taught so a parent has a range of strategies to use for different sleep problems. Feeling safe and loved is of the utmost importance after a youth has experienced trauma or a significant stressor. To help a youth feel this way, standard recommendations for sleep may need to be adapted temporarily, with the goal of returning to nighttime routines and sleep habits when feelings of love and safety have been achieved. If the changes have been too great and do not allow for this return, the establishment of a new routine and habits must occur. For example, if a youth has experienced a loss in the night and may feel that sleep is unsafe because they are not in control, enforcing good routines and sleep habits would be less effective at first and additional strategies and modifications would be needed. Allowing for some regression initially while providing lots of hugs, cuddles, and reading a story will help move a youth forward later.
As we start to work with youth and caregivers with sleep problems, we need to discuss the effects of trauma or stressors on sleep. Caregivers may not have an understanding about the effects of trauma or stress and may misinterpret their youth’s behavior and end up feeling frustrated and resentful. By gaining insight, a caregiver may gain empathy and compassion. A youth may not understand why they are feeling this way and that there are ways to improve sleep.
Trouble falling asleep is one of the most common sleep problems reported by caregivers. To improve this problem, caregivers can assist their youth by asking about their challenges with falling asleep and notice their behaviors. Once a youth’s challenge in falling asleep is understood a caregiver can do things like introducing calming activities such as reading a book, snuggling, and incorporating good sleep hygiene. If worries at night are the issue, it is important for caregivers to acknowledge the concern, have their youth write it down for the next day to problem solve, or be told that his or her caregiver will help them deal with this concern the next day.
When a youth is resisting sleep by doing things like asking for one more glass of water, a question, or tantrums, it is important to work with parents on not getting too caught up in these behaviors, but to validate the emotion and provide reassurance. If the resistance to fall asleep is due to not being tired, a caregiver can adjust a bedtime by starting at the time the youth is going to bed and move this time back in 15 minute increments. If a child is yelling or calling out to a parent at bedtime, he or she can be reminded that it is bedtime and or engage in check-ins that involve very little to no talking.
As for frequent awakenings, it is important to consider how tired a youth is. Being exhausted is associated with an increase in awakening during the night. Some strategies for frequent awakenings include making sure a youth’s bedroom at bedtime is comfortable, providing a security object for the youth to sleep with, and responding to the youth more frequently in the middle of the night and gradually responding less.
Nighttime fears are also common when a youth has experienced a traumatic event or stressor. Family conflict and parental anxiety can also play a role. To reduce these fears, youth need to be given the right amount of reassurance to ensure that he or she feels heard, but not so much that the youth feels there is something to fear. They could be told things like, “Mom and dad are across the hall to make sure you are safe.” These fears should never be dismissed or teased. Teaching coping skills and reinforcing the use of these strategies could also be helpful for some youth.
When nightmares occur, reassurance and education are often enough to reduce the occurrences of this sleep problem. Reassurance could take the form of holding and listening to a youth as they talk about the content of their nightmares. Education on nightmares may include a distinction between reality and dreams. It is recommended that caregivers refrain from letting their youth watch or hear about frightening things (e.g., movies, television shows, stories), reducing possible stressors from their youth’s life, promoting adequate sleep (e.g., regular sleep schedule, positive bedtime routine), allowing a security object at bedtime (e.g., blanket, stuffed animal), dimming the lights or providing a nightlight, and encouraging youth to use their imagination to get rid of nightmares (e.g., draw a picture of a nightmare and throw it away, create a positive ending to nightmares). For more severe nightmares, coping skills, guided imagery, and rescripting techniques could be used (Mindell & Owens, 2015).
Sleep problems are a natural response to stress, they often cause a lot of distress for parents and may cause considerable disruption in functioning for children. Although many of these sleep problems may improve on their own, intervening early with trauma-informed solutions could decrease distress and potentially reduce the risk of long-term challenges with sleep and behavior. If sleep problems persist, youth sleep problems should be further evaluated to determine if more directive care is needed (Belleville, et al. , 2011).
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Shantel Fernandez Lopez, Ph.D., is a Military Behavioral Health Child Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References:
Belleville, G., Guay, S., & Marchand, A. (2011). Persistence of sleep disturbances following
cognitive-behavior therapy for posttraumatic stress disorder. Journal of psychosomatic research,
70(4), 318-327.
Charuvastra, A. & Cloitre, M. (2009). Safe enough to sleep: Disruptions associated with trauma,
posttraumatic stress, and anxiety in children and adolescents. Child and Adolescent Psychiatric
Clinics of North America, 18(4), 877-891.
Connolly, D., McClowry, S., Hayman, L., Mahoney, L., & Arman, M. (2004). Posttraumatic stress
disorder in children after cardiac surgery. Journal of Pediatrics, 144, 480-484.
Giannakopoulos, G. Kolaitis, G. (2021). Sleep problems in children and adolescents following traumatic
life events. World Journal of Psychiatry, 11(2), 27-34. \
Mindell, J. A., Owens, J. (2015). A clinical guide to pediatric sleep: Diagnosis and management of sleep
problems, 3rd edition. Philadelphia, PA. Lippincott Williams & Wilkins.
Tang, W., Lu, Y., Yang, Y., & Xu, J. (2018). An epidemiologic study of self-reported sleep problems in a
large sample of adolescent earthquake survivors: The effects of age, gender, exposure, and
psychopathology. Journal Psychosomatic Research, 113, 22-29.
This past week, I shared information on a treatment for posttrauma nightmares called Exposure, Relaxation, and Rescripting Therapy for Children on the Center for Deployment Psychology’s podcast, “Practical for your Practice”. Given this, I began thinking a lot about current potentially traumatic or stressful events that have been going on around the world; and the need for more trauma-informed sleep solutions for military youth experiencing stressors and subsequent sleep problems.
A colleague and I, Dr. Lisa DeMarni Cromer, presented a grand round on trauma-informed sleep solutions to providers associated with the Hawaii Psychological Association soon after the Maui fires. What I’m writing about here is what we decided to present given the recency of that disaster, understanding that stressors were still ongoing, but problems in sleep were being reported. Overall, we considered that the information presented could be helpful to other potentially traumatic or stressful situations associated with sleep problems in youth.
When youth experience stressful or upsetting events, disruptions in sleep are amongst the most common consequences. Sleep problems such as shorter sleep duration, difficulty falling asleep, frequent awakenings, nightmares, sleepless nights, and early-morning wakefulness are often reported (Geng et al., 2008; Pillar et al., 2000; Babson & Feldner, 2010, Charuvastra & Cloitre, 2009). These sleep problems could cause inadequate sleep in youth which may result in physical, behavioral, cognitive, and emotional problems. Therefore, intervening as early as possible is important in preventing or treating insufficient sleep and long-term problems (Charuvastra & Cloitre, 2009).
Prevalence rates of sleep disturbances among youth samples vary considerably. In general, 16% to 40% of children exhibit sleep disturbances. When children are exposed to trauma, this prevalence rate may increase to 71% (Giannakopoulos & Kolaitis, 2021). Adverse effects of childhood trauma on sleep have been found immediately as well as years after trauma and can still be demonstrated in adulthood.
When beginning to provide trauma-informed solutions for sleep, it is important to understand that there is no one size fits all procedure. Individual differences need to be considered and a caregiver’s comfort and willingness to provide the solutions should be considered. Different strategies can be taught so a parent has a range of strategies to use for different sleep problems. Feeling safe and loved is of the utmost importance after a youth has experienced trauma or a significant stressor. To help a youth feel this way, standard recommendations for sleep may need to be adapted temporarily, with the goal of returning to nighttime routines and sleep habits when feelings of love and safety have been achieved. If the changes have been too great and do not allow for this return, the establishment of a new routine and habits must occur. For example, if a youth has experienced a loss in the night and may feel that sleep is unsafe because they are not in control, enforcing good routines and sleep habits would be less effective at first and additional strategies and modifications would be needed. Allowing for some regression initially while providing lots of hugs, cuddles, and reading a story will help move a youth forward later.
As we start to work with youth and caregivers with sleep problems, we need to discuss the effects of trauma or stressors on sleep. Caregivers may not have an understanding about the effects of trauma or stress and may misinterpret their youth’s behavior and end up feeling frustrated and resentful. By gaining insight, a caregiver may gain empathy and compassion. A youth may not understand why they are feeling this way and that there are ways to improve sleep.
Trouble falling asleep is one of the most common sleep problems reported by caregivers. To improve this problem, caregivers can assist their youth by asking about their challenges with falling asleep and notice their behaviors. Once a youth’s challenge in falling asleep is understood a caregiver can do things like introducing calming activities such as reading a book, snuggling, and incorporating good sleep hygiene. If worries at night are the issue, it is important for caregivers to acknowledge the concern, have their youth write it down for the next day to problem solve, or be told that his or her caregiver will help them deal with this concern the next day.
When a youth is resisting sleep by doing things like asking for one more glass of water, a question, or tantrums, it is important to work with parents on not getting too caught up in these behaviors, but to validate the emotion and provide reassurance. If the resistance to fall asleep is due to not being tired, a caregiver can adjust a bedtime by starting at the time the youth is going to bed and move this time back in 15 minute increments. If a child is yelling or calling out to a parent at bedtime, he or she can be reminded that it is bedtime and or engage in check-ins that involve very little to no talking.
As for frequent awakenings, it is important to consider how tired a youth is. Being exhausted is associated with an increase in awakening during the night. Some strategies for frequent awakenings include making sure a youth’s bedroom at bedtime is comfortable, providing a security object for the youth to sleep with, and responding to the youth more frequently in the middle of the night and gradually responding less.
Nighttime fears are also common when a youth has experienced a traumatic event or stressor. Family conflict and parental anxiety can also play a role. To reduce these fears, youth need to be given the right amount of reassurance to ensure that he or she feels heard, but not so much that the youth feels there is something to fear. They could be told things like, “Mom and dad are across the hall to make sure you are safe.” These fears should never be dismissed or teased. Teaching coping skills and reinforcing the use of these strategies could also be helpful for some youth.
When nightmares occur, reassurance and education are often enough to reduce the occurrences of this sleep problem. Reassurance could take the form of holding and listening to a youth as they talk about the content of their nightmares. Education on nightmares may include a distinction between reality and dreams. It is recommended that caregivers refrain from letting their youth watch or hear about frightening things (e.g., movies, television shows, stories), reducing possible stressors from their youth’s life, promoting adequate sleep (e.g., regular sleep schedule, positive bedtime routine), allowing a security object at bedtime (e.g., blanket, stuffed animal), dimming the lights or providing a nightlight, and encouraging youth to use their imagination to get rid of nightmares (e.g., draw a picture of a nightmare and throw it away, create a positive ending to nightmares). For more severe nightmares, coping skills, guided imagery, and rescripting techniques could be used (Mindell & Owens, 2015).
Sleep problems are a natural response to stress, they often cause a lot of distress for parents and may cause considerable disruption in functioning for children. Although many of these sleep problems may improve on their own, intervening early with trauma-informed solutions could decrease distress and potentially reduce the risk of long-term challenges with sleep and behavior. If sleep problems persist, youth sleep problems should be further evaluated to determine if more directive care is needed (Belleville, et al. , 2011).
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Shantel Fernandez Lopez, Ph.D., is a Military Behavioral Health Child Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References:
Belleville, G., Guay, S., & Marchand, A. (2011). Persistence of sleep disturbances following
cognitive-behavior therapy for posttraumatic stress disorder. Journal of psychosomatic research,
70(4), 318-327.
Charuvastra, A. & Cloitre, M. (2009). Safe enough to sleep: Disruptions associated with trauma,
posttraumatic stress, and anxiety in children and adolescents. Child and Adolescent Psychiatric
Clinics of North America, 18(4), 877-891.
Connolly, D., McClowry, S., Hayman, L., Mahoney, L., & Arman, M. (2004). Posttraumatic stress
disorder in children after cardiac surgery. Journal of Pediatrics, 144, 480-484.
Giannakopoulos, G. Kolaitis, G. (2021). Sleep problems in children and adolescents following traumatic
life events. World Journal of Psychiatry, 11(2), 27-34. \
Mindell, J. A., Owens, J. (2015). A clinical guide to pediatric sleep: Diagnosis and management of sleep
problems, 3rd edition. Philadelphia, PA. Lippincott Williams & Wilkins.
Tang, W., Lu, Y., Yang, Y., & Xu, J. (2018). An epidemiologic study of self-reported sleep problems in a
large sample of adolescent earthquake survivors: The effects of age, gender, exposure, and
psychopathology. Journal Psychosomatic Research, 113, 22-29.