Coping With the Sleep Disorders Expected After the Sandy Hook Shooting

Since the news first burst onto America's screens last week, all of us are sleepwalking our way through a uniquely American nightmare. Central to every American's thoughts are the families who lost loved ones in the massacre at Sandy Hook Elementary School and the entire community of Newtown, Conn. violated in such a brutal and shocking manner. The disaster upends all that is good about America, a country where children can safely deliver newspapers on their bicycles and wave their parents goodbye on their way to happy and secure schools. Of all the shooting massacres in recent American history, this disaster more than any other violates our core belief that here in America we can keep our children secure, and shakes at our sense of American identity.

While our national and regional political leadership confront their responsibilities and opportunities in protecting Americans by force of legislation, Newtown and the surrounding Connecticut community must confront a new world where nothing feels safe, and nothing remains sacred.

Without doubt, parents, teachers, neighbors, first responders and all of the bereaved are likely already dealing with acute sleep disorders, including insomnia, as the shock of the event fades into insurmountable grief; but even those not immediately affected may experience sleep disruption. During an event of such national sorrow that brings our own president to tears, many of us are sleeping uneasily. Feeling safe, feeling secure and ultimately the ability to abandon self-vigilance are central to healthy sleep. All parents and children around the country, all teachers and principals responsible for children and colleagues, need our help to quickly regain this sense of safety -- if not during the day, then at least during the few hours of sleep they will be trying to get.

Though the initial shock will eventually pass, and the acute insomnia -- both trouble falling asleep and difficulty staying asleep -- in the days and weeks after the event affecting those immediately impacted by the shooting may be evident, and ultimately, if treated quickly, short-lived, children show their psychological disturbances differently and often in a more delayed fashion. Without the ability to express their feelings as readily as adults can verbally, children's trauma may emerge in various behaviors, including in their patterns and behaviors during sleep as well as their imaginary play.

Children are innately programed to sense safety, and for every child their central harbor of safety is their nuclear family -- their parents, their siblings, their home and often the family pet. It is not unusual to notice children asking their parents about the safety and security of the home at times of such crisis, especially if the child is old enough to be aware of the atrocities, but even younger children may actively demonstrate their sense of insecurity.

One young patient of mine, age 7, began sleepwalking shortly after he was an inadvertent witness to his father's intimidation by a criminal. The patient's father was an active-duty detective in a unit prosecuting narcotics crime, and unfortunately one day a known criminal intruded onto the detective's private property, threatening his well-being within earshot of his child. While the family was physically safe, the child had witnessed a loss of security and a threat to the kingpin of the family's safety -- his father. Shortly after, the 7-year-old began asking his father to see if the doors and windows to the property were locked to "keep the bad man out." This became part of his bedtime ritual before the patient came to me for treatment. However, after falling asleep normally, the child began sleepwalking, a "parasomnia" of "slow-wave sleep" or "deep sleep" that occurs normally in the first third of the night. These parasomnias are common in young children up until the age of 12, but can become more pronounced after trauma such as the Sandy Hook shootings. Treatment for this child will include individual psychotherapy with a child psychologist, as well as expert behavioral sleep therapy for the sleepwalking and family therapy to counsel the whole family. In this instance, the child's confidence in the ability of his parents to protect him was a necessary beginning when embarking on healing. Parents could rapidly institute simple measures that included safeguarding the sleeping environment by removing objects that the child could bump into, removing rugs he might trip over in his sleep, locking windows and balconies, and removing sharp-edged furniture from the bedroom. Many of the surviving schoolchildren from Sandy Hook may experience similar parasomnias, which can include the sleepwalking described above and also night terrors, which can be particularly frightening for parents to witness.

During night terrors the child will appear to wake up suddenly from sleep, screaming in a frightening way (so much so that sometimes neighbors can become concerned for the safety of the child). Parents will find their child with eyes wide open, inconsolable and exhibiting signs of intense fear, sometimes with sweating and a rapid heart rate. The child, however, will not recognize the parents, and may not seem responsive even though he appears to be awake and screaming. The key is to understand that the child needs to be safeguarded, gently reassured with verbal and physical contact, and supported until the episode passes. Waking the child up to full alertness is difficult and usually unhelpful because this can increase sleep deprivation, which can make these episodes more frequent. Ensuring the child is safe and settled before leaving the bedroom is all that is required, and in the morning the child will have no recall of the event. Parents are often more shaken than the child about this the next day, and a properly educated parent will be able to cope with this more easily than one who is not informed.

Even the smallest children can sense distress in a home, including emotional distress of grieving parents. Exquisitely sensitive, the child will often respond by not wishing to leave the parent, especially during bedtime, and a return of what we term "stalling" behavior may appear. Stalling is commonly seen in preschool children who want "one more story" or "one more drink of water" before saying goodnight, and is an expression of neediness and a test of the limit setting of the parents. At a time like this, parents are encouraged to provide additional reassurance and indulgences to their children, both to avert the child's sense of vulnerability and in this time, likely more so, to soothe the parent's own sense of wellbeing. "Limit-setting behavior disorder," as we term it in sleep medicine, is very commonly seen and normally readily treated with simple behavioral strategies, but in these first days after Sandy Hook shootings these behaviors should be indulged, in my opinion, until both parents and children feel a returning sense of normalcy. In times of heinous violence it may actually not be unusual for small children to begin co-sleeping with their parents or vice versa, but if it can be avoided and the child made to feel safe in his or her room, this would be preferable to avoid establishing new behaviors that would need to be unlearned later.

In some instances, small children will also demonstrate a renewed fear of monsters, and ask for the parents to check in the closet or check under the bed. Parents should comply and make thorough checks to reassure their children. It is reasonable to consult a sleep specialist for what parents will consider a "regression" of behavior. Often when these children come to me for advice, I prescribe a "make-believe monster spray" that only the child can spray with a gesture before bedtime as a means of restoring a sense of power and control to the child. But this I recommend along with more tangible symbols of safety, including a bedtime nightlight or night lamp and a special blanket, perhaps even a protective toy -- items that the child will collaborate in choosing with the parents as an added emotional investment in his or her sleep environment. These strategies are acceptable and not to be frowned upon, even if parents feel their child is too old for a toy or a nightlight to allow this at a time of distress.

In some occasions with very distressed children, I even go against standard practice and with the permission of the parents, allow the child to co-sleep with a treasured pet if there is one in the home. One of my pediatric patients who was 8 told me about the "incredible feeling of safety" he felt sleeping when he was allowed to go to bed with his big tabby cat. This should be allowed at a time of insecurity and fear. While co-sleeping with pets is considered poor sleep hygiene and can leave to real loss of sleep when the pet disturbs the child or the adult, as a soothing measure -- especially if the pet is beloved -- this can be an enormous source of solace.

We are already seeing interviews of parents describing not only their experiences but also their management of information to their children's awareness of the massacre. These parents are to be commended and admired for putting their children's needs above all other needs. But perhaps a salient recommendation is to avoid or minimize television exposure as much as possible. Broadcast media and repetitive images may embed memories and intensify the experiences of trauma; this data has been replicated in many instances, including in the response of Pakistani children to drone attacks, which can elicit the same response in children whether they witness an event live or on television. Unquestionably, children should be shielded from violent images by parental safeguards on television, and wherever possible allowing the children-only movies or cartoons that will not be interrupted with unpredictable news flashes.

Over time, even these dark days will gradually fade and a new normalcy will arrive, but in the interim, parents and principals and teachers must be aware that support is here for them, too. They, too, could potentially develop their own sleep disorders, which can include significant trouble falling asleep or staying asleep, and waking up earlier than desired. Daytime hours may seem more difficult and distracted, and emotional lability can be widespread, with unexpected tears and difficulty controlling tempers and maintaining attention. Early intervention with doctors and mental health providers can help greatly. Whereever possible, seek out board-certified sleep specialists at an American Academy of Sleep Medicine accredited center that is experienced in the management of sleep disorders. While many Americans have aversions to sleeping medicine, under supervision these medicines may be exactly what is needed to help the parent function in the difficult weeks to months that will follow.

Each of us is dealing with a profoundly violated community, overwhelmed with the sadness and sorrow that each of us experience personally, whether or not we have a direct connection to these events. Bear in mind all of us are especially vulnerable to a loss of faith in humanity and an assault on the safety and goodness of our society.

No matter how grown up we are, we each need reassurance and affirmation that society continues to be secure and safe and a harbor for our lives. Expect some fallibility in ourselves as the days go forward and know that we are all vulnerable to disrupted sleep at such a time. This is true both of us as members of the wider community in the tristate area and as parents and professionals across the nation.

Perhaps most forgotten are members of the media who are especially at risk as they perform their duties gathering the stories that they must bring to America, and articulating our collective shock and horror.

As the days turns to weeks, consider seeking medical attention if trouble falling asleep or staying asleep persists after four weeks or a sense of desolation sets in and fails to leave. Our sleep disturbances are intimate mirrors to the anguish of our daytime distress and none of us must fear seeking assistance as readily for ourselves as we would for our children.

The community returning to Sandy Hook school is going through a unique adjustment that the rest of the nation is witnessing but not experiencing. All of us must support Sandy Hook and the first responders supporting Sandy Hook at this time so that Newtown may once more regain some semblance of peace, both in their long waking hours ahead and the brief respite their private hours of sleep can give them. Until those distant days, know that many professionals are available to help in order to ease at least a fragment of our collective suffering and stand by to assist whether with information, counseling, active treatment, or what America does best: a sense of shared solidarity.

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