A child's sense of control over life and health outcomes as well as perceptions of the world as fair, equal, and just are significantly influenced by his or her social experiences and environment. Unfortunately, the social environment for many children of color includes personal and family experiences of racial discrimination that foster perceptions of powerlessness, inequality, and injustice. In turn, these perceptions may influence child health outcomes and disparities by affecting biological functioning (eg, cardiovascular and immune function) and the quality of the parent-child relationship and promoting psychological distress (eg, self-efficacy, depression, anger) that can be associated with risk-taking and unhealthy behaviors. In this article we review existing theoretical models and empirical studies of the impact of racial discrimination on the health and development of children of color in the United States. On the basis of this literature, a conceptual model of exposure to racial discrimination as a chronic stressor and a risk factor for poor health outcomes and child health disparities is presented. Pediatrics 2009;124:S176-S186

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Trauma-related nightmares and insomnia, and other sleep disorders, are frequently reported among trauma survivors. The roles of fear of sleep, REM density, and decreased parasympathetic activity are beginning to inform the relationship between trauma exposure and sleep difficulties. Additionally, the potential adaptive role of sleep loss immediately following a traumatic experience is being recognized. Interventions targeting these sleep disturbances show promise in reducing symptoms. Research in understanding the role of sleep on the development, course, and treatment of PTSD is expanding. Longitudinal investigations are needed to further elucidate these relationships and identify treatments most effective in ameliorating symptoms.

Lucid dreaming (LD) is a distinct behavioral state characterized by an awareness of dreaming while a dream occurs and, at times, an ability to, during dreaming, control dream events and/or purposefully awaken from a dream. LD and its potential role as a mechanism of action of Imagery Rehearsal therapy (IR) were investigated in military veterans with posttraumatic stress disorder and recurrent nightmares. This study reports on the nature of LD constructs in 33 treatment-seeking Iraq and Afghanistan combat veterans participating in a larger clinical trial of 6 sessions of 1 of 2 therapies: components of Cognitive-Behavioral Therapy for Insomnia (cCBT-I) or IR ϩ cCBT-I. Participants completed questionnaires regarding sleep and nightmares, other PTSD symptoms, and LD before and after treatment. Before treatment, veterans demonstrated a LD profile characterized by high dream awareness and low dream content control. After IR ϩ cCBT-I treatment, control of dream content, but not lucid awareness, increased more than after cCBT-I treatment (ES ϭ .68).

Sleep disturbances are among the most commonly endorsed symptoms of post-traumatic stress disorder (PTSD). Treatment modalities that are effective for the waking symptoms of PTSD may have limited efficacy for post-traumatic sleep problems. The aim of this review is to summarize the evidence for empirically supported and/or utilized psychotherapeutic and pharmacological treatments for post-traumatic nightmares and insomnia. While there are few controlled studies of the applicability of general sleep-focused interventions to the management of the sleep disturbances in PTSD, evidence is growing to support several psychotherapeutic and pharmacological treatments. Future investigations should include trials that combine treatments focused on sleep with treatments effective in managing the waking symptoms of PTSD.

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Posttraumatic stress disorder (PTSD) is associated with cognitive deficits in attention, executive control, and memory, although few studies have investigated the relevance of cognitive difficulties for treatment outcomes. We examined whether cognitive functioning and history of traumatic brain injury (TBI) were associated with response to cognitive-behavioral therapy (CBT) for PTSD-related sleep problems. In a randomized controlled trial of Imagery Rehearsal (IR) added to components of CBT for Insomnia (IR + cCBT-I) compared to cCBT-I alone for PTSD-related recurrent nightmares, 94 U.S. veterans completed a battery of cognitive tests. TBI was assessed via structured clinical interview. Mixed-effects models examined main effects of cognitive functioning and interactions with time on primary sleep and nightmare outcomes. Significant verbal immediate memory by time interactions were found for nightmare distress, nightmare frequency, and sleep quality, even after controlling for overall cognitive performance and depression. TBI exhibited main effects on outcomes but no interactions with time. Findings indicated that individuals with lower verbal memory performance were less likely to respond to treatment across two sleep interventions. Veterans with TBI displayed greater symptoms but no altered trajectories of treatment response. Together with prior literature, findings suggest that verbal memory functioning may be important to consider in PTSD treatment implementation.

Chronic insomnia and recurrent nightmares are prominent features of posttraumatic stress disorder (PTSD). Evidence from adult research indicates that these sleep disturbances do not respond as well to cognitive-behavioral therapies for PTSD and are associated with poorer functional outcomes. This study examined the effect of prolonged exposure therapy for adolescents versus client-centered therapy on posttraumatic sleep disturbance, and the extent to which sleep symptoms impacted global functioning among adolescents with sexual abuse-related PTSD. Participants included 61 adolescent girls seeking treatment at a rape crisis center. The Child PTSD Symptom Scale-Interview (Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess PTSD diagnosis and severity of symptoms, including insomnia and nightmares. The Children's Global Assessment Scale (Shaffer et al., 1983) was used to assess global functioning. There were significant main effects of time and treatment on insomnia symptoms. Additionally, there was a main effect of time on nightmares. Results also showed that insomnia and nightmares significantly predicted poorer global functioning posttreatment (R = .21). Despite significant improvements in posttraumatic sleep disturbance, there were still clinically significant insomnia symptoms after treatment, suggesting that additional interventions may be warranted to address residual sleep disturbance in PTSD.