Danielle Montgomery woke up in a panic, peering around her darkened bedroom. To the teenager's relief, she was still alive. Not like in the nightmare where her lifeless body lay under a black tarp as her family huddled around crying.
The dream interrupted her sleep again and again after the 15-year-old saw a dead body for the first time last year. While headed to the bus stop one morning on her way to school, she stumbled upon a crime scene. What she saw came to haunt her: Police milling around in a yard, a black tarp on the ground, and, underneath, a dead body.
It's not the only nightmare that wakens her feeling anxious and overheated. This summer Montgomery dreamed somebody set her family's house on fire, just like they did the local CVS pharmacy during April's riots after Freddie Gray died from injuries sustained in police custody. In another, the National Guard dispatched to the city to keep order during the unrest knocked down the door of her family's home in Reservoir Hill.
There are children across the city just like Montgomery. They live with fear and anxiety in violent and impoverished neighborhoods and experts are seeing the consequences. Many of these children suffer from a hidden and serious health condition: sleep disorders. Social workers, psychologists and primary care physicians report that many kids are not getting enough sleep and that's affecting their behavior and academic performance.
Kids who don't get enough sleep — at least 8 hours for teenagers and up to 11 for younger children — have trouble concentrating and staying awake during the day, sleep experts said. They may not do well in school and act out because they are irritable.
Montgomery said she could not concentrate on a test she had the day after she dreamed her house caught fire because she was too lethargic.
"We are designed just like most things in nature to have a period of rest," said Dr. Arethusa Kirk, a pediatrician with Total Health Care in Baltimore. "Our bodies and brains really need that. Children in particular who are going through these critical periods of development really need sleep in order to lay down memory, to restore their bodies, to restore themselves and to be able to function appropriately during the day."
The brain tends to clear itself out during sleep, flushing away harmful neurotoxins. At the same time, certain synaptic connections are strengthened and solidified, while the less important ones are discarded, said Dr. Emerson Wickwire, director of the insomnia program at the University of Maryland School of Medicine. Studies are underway to see if lack of sleep affects how the brain develops, he said. Sleep is also important for regulating the body's hormones.
Dr. Samuel L. Williams III, a psychiatrist with Total Health Care who treats Montgomery, estimates 70 percent to 75 percent of his patients have some kind of sleep problem.
They often come to him initially because they are misbehaving at school. Part of Williams' assessment of children examines whether they are getting adequate rest.
The kids he works with either have seen violence or are reminded constantly of it, whether it is a police helicopter flying over their neighborhood, the regular sound of sirens or what have become mundane conversations about people getting killed.
Many like Montgomery deal with flashbacks or troubling thoughts that make it hard to wind down at night, Williams said. Others are hypervigilant and never relax.
"For kids who have experienced some sort of violence, night time is troubling," Williams said. "It is so dark it doesn't feel safe. Even if they do sleep it's a more restless sleep and that can be interrupted by nightmares."
Another one of Williams' patients, 10-year-old Kyonte Summerville, often can't sleep at night and even jokes that he is a vampire. He said he has trust issues and doesn't like to go to sleep with others in the house.
His grandmother and legal guardian, Patrice Moses, said that when her grandson does manage to sleep, he thrashes and punches the air as if he is fighting someone. Most times he stays awake playing video games or listening to music. When he gets to school the next day, Kyonte can barely keep his eyes open and often naps at his desk.
Williams believes Kyonte's sleep problems stem from childhood trauma after his father murdered his mother when the boy was 2 years old. Kyonte was in the room when it happened.
"He doesn't really remember much, but it was internalized," Williams said.
When sleep is fragmented, sleep stages are altered and the brain can be unable to enter the deepest most restorative stages of sleep, Wickwire said.
Likewise, when the brain endures severe or chronic stress, certain regions of the brain appear unable to rest, he said. Its almost like certain networks within the brain remain awake during sleep. As a result, overall stress levels increase.
"Sleep and stress are incompatible," Wickwire said. "When there is trauma or environmental turmoil or when children perceive danger, there is not a question that it negatively impacts their sleep quality."
Other factors also can contribute to poor sleep in inner city children. Children living in poverty may not have a comfortable place to sleep, either sharing a bed or sleeping on a couch or a floor. Families may face financial hardships that land them temporarily without housing, and sleeping at a different friend or relative's house each night. Or parents might work the night shift, and kids may stay awake to make sure they get home safely.
"In some families it is not like they have a quiet sleep environment where kids are sleeping in a room by themselves," said Dr. Tina Cheng, at the Johns Hopkins Children's Center. "If you sleep with a lot of different people, that will interrupt your sleep."
There are ways that families can help their children sleep better, even in the most hectic environments, doctors said. Most important is a consistent regular routine.
"It doesn't really matter what you employ, just make it something you do every night, because in a chaotic world, this is their touchstone," Kirk said.
Doctors also tell their patients not to go to bed unless they are sleepy, to avoid too many daytime naps and to do something relaxing, such as taking a warm bath, before going to bed. Watching television or talking on the phone in bed can make it tougher to fall asleep.
Laurel Kiser, with the Family Informed Trauma Treatment Center at the University of Maryland School of Medicine, said children also can be taught how to change the narrative of their dreams in a way that can give them more control over their fears.
"If they are having a bad dream, how can they shift the image of that dream so they have more a powerful image?" Kiser asked. "If they are being chased by a monster can they turn around and pop the monster with a pin?"
Ultimately, the children need to deal with any trauma or stress in their lives.
Montgomery said therapy with Williams has helped. Talking to her grandmother about her day also eases some of her anxiety. She also recently took a sleep test and discovered she has sleep apnea, which she is having treated.
Kyonte also continues treatment, but his grandmother worries about him. She also has trouble sleeping because she is constantly checking on him in his room. She said she will do everything she can in hopes he eventually can get a good night's sleep.
"I would love to see him be able to rest and have fewer difficulties so that he will be able to grow up and go to college and be successful," she said.