You Snooze, They Lose — How Sleep Disorders Affect Your Clients
By Jennifer Sisk, MA
Social Work Today
Vol. 6 No. 6 P. 48

Wake up! Don’t overlook sleep disorders that can seriously affect clients’ mental and physical health.

Every night, millions of Americans skimp on sleep to meet the demands of a busy lifestyle. For millions more, sleep disorders interfere with the quality and quantity of sleep. Despite the prevalence of sleep disorders and the recognition of chronic sleep deprivation as a national public health issue, most sleep disorders remain undiagnosed or misdiagnosed. Left untreated, a sleep disorder can severely affect overall quality of life, performance at school or work, daily functioning, and mental and physical health.

Richard Gelula, MSW, CEO of the National Sleep Foundation (NSF), is working to establish strategies to bring sleep to the forefront as a public health and safety concern. “We don’t recognize how much dysfunction, lack of motivation, and lack of energy can be attributed just to poor sleep habits,” he says. Gelula cites results from the NSF’s 2005 Sleep in America poll as an example. Approximately one half of the respondents reported symptoms of insomnia and 75% reported symptoms of a sleep disorder (eg, snoring, restless legs, sleep apnea) at least a few times per week, yet only 21% responded that they believed they had a sleep problem.

“We as a country do not value our sleep,” says Kim West, MSW, LCSW-C, a child and family therapist specializing in children’s sleep issues and disorders, and author of the book Good Night, Sleep Tight: The Sleep Lady’s Gentle Guide to Helping Your Child Go to Sleep, Stay Asleep and Wake Up Happy. Sleep is a basic biological need—the body needs approximately seven to eight hours per night to operate at peak functioning and alertness. It is highly unlikely that the average American would purposefully forgo food and water—two other basic needs—yet, most will not hesitate to cut short a good night’s sleep to finish an important work or school project, watch television, or surf the Internet. The Sleep in America poll confirmed this common public view that a good night’s sleep is not necessary: More than 50% of respondents agreed with the statement, “You can learn to function well over time with one or two fewer hours of sleep than you need.”

Unfortunately, this casual attitude toward the importance of sleep has not only created a sleep-deprived nation, but has also caused sleep to often be overlooked as a primary or secondary cause of medical or psychological problems. “Good sleep is not always realized as an important priority by either the clinician or the patient,” says Christopher L. Drake, PhD, DABSM, clinical psychologist at the Henry Ford Hospital Sleep Disorders and Research Center, assistant professor of psychiatry and behavioral neurosciences at Wayne State University School of Medicine in Detroit, and member of the NSF’s board of directors. “We in the field of sleep medicine hope to change that standpoint since sleep is an important factor in many illnesses, even those that are not primary sleep disorders.”

Recently, sleep deprivation was highlighted as a potential underlying cause of weight gain and obesity. Clinical studies have also linked sleep disorders with hypertension and other cardiovascular diseases and chronic mental health issues such as depression, anxiety, and stress. Individuals with sleep apnea have been shown to be at greater risk for hypertension, heart attack, and stroke. Studies have also found that sleep deprivation negatively affects cognitive functioning, such as memory, problem-solving, and learning.

Insomnia and Depression: A Reciprocal Relationship
For 60 million or more Americans suffering with insomnia, sleep is elusive, no matter how much they want a good night’s sleep. Insomnia, the most commonly diagnosed sleep disorder, is a risk factor for mental health conditions such as depression and anxiety. “Insomnia is comorbid with depression and anxiety,” says Gelula. “Not paying attention to insomnia increases the risk of developing depression.”

Vonnie Brown, MSW, LCSW, a private practitioner specializing in sleep, agrees. She works primarily with people with insomnia and accepts referrals from the Rocky Mountain Sleep Disorders Center Inc. in Montana and also refers clients to the facility. “Depression and anxiety are the most common psychiatric disorders and make up the majority of psychiatric diagnoses I see that are concurrent with insomnia,” she notes.

Establishing whether insomnia is a symptom or a consequence of depression and anxiety may be difficult and can determine the type of treatment. Brown administers a comprehensive psychiatric assessment that includes a depression inventory and anxiety index to evaluate the client’s psychosocial history and determine any life circumstances, stress, trauma history, or work history that may be contributing to insomnia. “Sometimes you find that the insomnia has some relationship to a trauma history,” Brown says. When insomnia is found to be secondary to another condition, antidepressants or antianxiety medication and counseling for psychological issues may, in turn, resolve the insomnia.

Just treating the insomnia itself may also improve mental health. “The treatment of poor sleep has been shown to have a positive impact on important mental health conditions such as depression,” says Drake. While most of the common sleep disorders have a certain behavioral component to their treatment, he says, behavioral therapy can be especially helpful for insomnia. “Specific behavioral treatments include sleep hygiene analysis, stimulus control, relaxation techniques, and cognitive-behavioral therapy,” Drake explains.

Brown’s role at the sleep center is to develop treatment plans for patients with insomnia, focusing on cognitive and/or behavioral changes. “The biggest factor in bringing about change and positively affecting insomnia is the client’s motivation to change,” Brown emphasizes. “Second is education regarding good sleep hygiene, which is essential.” She provides each client with a handout on sleep hygiene tips. “Discussing a client’s perceptions about sleep is important because some individuals may have unrealistic expectations about how much sleep they need, and others might have bad sleep habits, such as lying in bed awake for hours. These contribute to the insomnia problem,” Brown notes.

She helps clients identify sleep problems using a sleep diary (see sidebar). After two weeks of recording in the sleep diary, clients meet with her every two to three weeks over the course of several months to discuss treatment methods and improve sleep hygiene.

“For example, a sleep diary may reveal that the client is watching television or preparing for the next work day in the bedroom, just before going to bed. I would use stimulus control to change the sleep environment in the last hour before bedtime. Simply moving these activities out of the bedroom—removing an environmental stimulus—can make it easier to fall asleep,” Brown says. “Relaxation techniques such as relaxed breathing, progressive muscle relaxation, guided imagery, and soothing music might help a client reporting stress or difficulties winding down at the end of the day.” She suggests cognitive-behavioral therapy for clients who have anticipatory anxiety when trying to fall asleep.

Depending on the results of the psychiatric assessment and the sleep diary, a treatment plan may involve any or all of the aforementioned methods. “I help clients find as many ways as possible to improve their sleep,” says Brown. “When we utilize multiple treatment modalities, we can get a cumulative or synergistic effect, resulting in a greater increase in sleep quality and quantity.” Further into the treatment course, she recommends that clients repeat a two-week sleep diary. “It’s an important tool to track progress,” Brown emphasizes. Sleep diary comparisons are often helpful for clients who do not believe they are making progress and can improve the client’s desire to continue therapy. “We can go back and look at the first sleep diary and see that progress has been made in reducing insomnia,” she says.

Bedtime Behaviors: Children and Sleep Disorders
Like Brown, West also uses sleep diaries to identify the causes of sleep difficulties in children. Family sleep diaries often reveal that parents, not children, are disrupting sleep patterns, says West. “You’d be surprised how many parents interfere with their child’s sleep hygiene by keeping them up too late or allowing them too much caffeine or too much TV close to bedtime,” says West. Her training and experience as a social worker and family therapist are valuable in helping resolve sleep difficulties that involve both parents and children.

But, as America’s children and adolescents have become heavier, the prevalence of sleeping disorders, especially sleep apnea, have also begun to increase. “Sleep apnea is hugely underdiagnosed in children, as well as adults,” says West.

Gelula adds, “Children are already susceptible to sleep apnea because of enlarged tonsils and adenoids relative to the size of the airway from ages 3 to 10. With added body weight, there is an even greater risk of sleep apnea.” Unfortunately, sleep problems in this population are usually attributed to behavioral issues, even when there may be an underlying medical cause.

Over the past 10 years, West has worked with approximately 2,500 children and their families regarding sleep-related behaviors and disorders. In private practice as a family therapist, West found herself beginning to specialize in sleep after helping her brother’s children and friends’ children. Word of mouth about the success of her behavioral methods for finding sleep solutions for the children of exhausted parents, followed by recent local and national media exposure, led West to publish her book and create “The Sleep Lady” Web site. Now, she estimates that 98% of her social work practice focuses on sleep issues. For clients whose sleep problems do not stem from a sleep disorder or medical condition, West provides phone consultations on behavioral methods to gently remedy sleep difficulties.

West emphasizes that she is not a physician and does not diagnose sleep disorders in her clients. But, after having read more than 2,000 client histories and engaged in extensive self-study on sleep disorders, like Brown, West is often able to identify patterns in a child’s behaviors or other symptoms that may indicate a medical condition at the root of sleep problems. “Apnea, allergies, asthma, reflux—these can all contribute to loss of sleep,” West says. While pediatricians, gastroenterologists, and otolaryngologists often refer children and their families to her when they rule out medical conditions interfering with sleep. She has, in many cases, referred the same children back to a physician after her thorough history and evaluation of sleep habits highlights symptoms she believes may warrant a sleep study or further medical evaluation. “The parents don’t know what to look for, and the doctors don’t know what to ask for,” West says.

“Medical school curricula generally devote less than one or two lectures to sleep and sleep disorders, despite the large prevalence rates and increasing variety of treatment options,” Drake notes. Lack of education on sleep disorders may lead many child health professionals to assume that sleep problems are related strictly to behavioral issues.

“In a managed care environment, physicians just do not have time to spend on fully evaluating sleep issues in kids,” West adds. She spends 45 to 90 minutes on an initial history, using an eight-page form that includes detailed questions about sleep habits, physical and psychological symptoms, and sleep-related behaviors of both the child and parents.

Parents, too, are not well-informed about sleep disorders and possible medical causes. Bedtime behavioral issues are the primary reason parents seek out West’s help. When West is the first professional to evaluate a child’s sleep problems, she screens for potential medical conditions that could be interfering with the child’s ability to fall asleep and remain asleep. Often, the child’s behaviors mask an underlying medical cause for their sleep problems. In one of her recent cases, parents brought their 11/2-year-old child for a sleep evaluation for frequent waking during the night and crying. “Children can develop separation anxiety and other psychosocial issues associated with bedtime that interfere with sleep. Family behavioral therapy can help resolve such problems,” says West. The client’s intake history uncovered other symptoms, including dairy allergies, restless sleeping, sitting up during the night, and night sweating. “The sitting up and crying behaviors even continued when the child slept with his parents,” West says, which may suggest a sleep problem beyond separation anxiety. A sleep study revealed that the child had sleep apnea.

“Behavioral approaches might help somewhat, but they cannot resolve a medical condition,” she says. “My job is to take a thorough history in order to determine whether parents need to go to a pediatrician or another physician with specific questions or information about their child’s sleep problems.” After a comprehensive assessment, West decides whether to refer a child to his or her pediatrician or another specialist. Most of her referrals, she says, are to rule out sleep apnea or reflux.

As a testament to the importance of accurately diagnosing sleep apnea in children, West cites the example of a 5-year-old boy whose parents believed he had attention-deficit/hyperactivity disorder (ADHD) or a learning disability and were considering having him evaluated by a school psychologist and possibly administering medication because he was having problems learning the alphabet. “No one ever asked him any questions about his sleep habits and the quality of his sleep,” says West. Additional symptoms of bedwetting, night sweats, and mouth breathing led her to recommend checking for sleep apnea. He was diagnosed with obstructive sleep apnea due to enlarged tonsils and adenoids. “Within weeks after having those removed, his bedwetting, sweating, and mouth breathing resolved and he began to perform better in school,” says West. If a sleep study had not been performed, the boy may have been inappropriately medicated for ADHD and mistakenly placed in a special needs classroom.

Adding Sleep to Your Social Work Practice
Given the prevalence of sleep disorders and the frequency of underdiagnosis or misdiagnosis, how can social workers increase the likelihood of identifying sleep problems when working with clients? Knowing the right questions to ask in initial client interviews is essential, say Brown and West. “Any social worker in private practice needs to know how to look for a sleep disorder,” West says. “I encourage other therapists working with children [and adults] to add sleep-related questions to their psychosocial assessments [and] their intake evaluations.”

“I always ask about sleep when I do my initial intake assessment,” says Brown, even with clients who do not mention having sleep problems. Both Brown and West note that no training or certification on sleep disorders currently exists for social workers. Both are self-taught and the Homestead Schools Inc. CEU program “Insomnia, Sleep Apnea, Narcolepsy” is recommended as a learning resource. Information on sleep disorders and other sleep-related information are also available from the American Insomnia Association and the NSF.

“All social workers need to learn about sleep and its contribution to people’s health, safety, and well-being, particularly how it affects their daytime alertness and mood,” Gelula says.

Drake believes sleep specialists would welcome the addition of more social workers interested in sleep. “Since there is only a very small minority of sleep specialists and qualified psychotherapists who have been trained to treat sleep problems using behavioral strategies, social work could bring a large number of quality healthcare providers into the sleep specialty,” he says. “The fact is, sleep medicine needs help from diverse specialists to be able to meet the needs of the increasing numbers of patients with sleep disorders.”

In addition to helping patients with insomnia, social workers can also help patients diagnosed with sleep apnea, who may have compliance issues when prescribed a continuous positive airway pressure (CPAP) device. “The primary treatment for sleep apnea involves the use of a positive pressure mask to keep an individual from having episodes where the breathing stops throughout the night. Wearing the mask is often a difficult adjustment, which reduces patient compliance. Psychologists, and potentially social workers, could use desensitization techniques to help improve the patient’s ability to utilize the mask without feeling claustrophobic,” says Drake.

While most of Brown’s work is with insomnia, she does help patients with sleep apnea come to terms with their diagnosis and adjust to overnight CPAP therapy.

Her work on behavioral healthcare for individuals with psychophysiologic insomnia increased the awareness of the social worker’s role in counseling patients with sleep disorders. “Often, patients have a combination of medical and behavioral issues associated with sleep apnea and insomnia. I work on the behavioral issues while [the] patient undergoes medical treatment for their sleep disorder,” Brown says. Although their sleep center does not yet officially track success rates, she and David Anderson, MD, DABSM, medical director of the Rocky Mountain Sleep Disorders Center, Inc., estimate that they have helped 90% of their patients with a combination of medical treatments and social work.

Unfortunately, Drake says, most sleep medicine specialists do not work directly with social workers, even though they are becoming more involved in the treatment of sleep problems. “Given the importance of cognitive-behavioral therapy in treating many sleep disorders, social workers definitely have a role here,” says Gelula. “A social worker trained in cognitive-behavioral therapy could certainly create a practice supporting patients with sleep disorders and related problems.”

As a social worker himself, Gelula is interested in increasing the involvement of social workers in the NSF, which recently began the National Sleep Awareness Roundtable: a group of 25 different organizations dedicated to learning about sleep. “In partnership with the CDC [Centers for Disease Control and Prevention], we have created the roundtable as a forum for government agencies and professional societies to learn about sleep science and sleep medicine and how it applies to their concerns and target populations,” Gelula explains. “Social work would be a great field to have represented in the National Sleep Awareness Roundtable.”

— Jennifer Sisk, MA, is a suburban Philadelphia-based freelance writer with 15 years of experience as a writer and research analyst in the healthcare field. She has written on depression, attention-deficit/hyperactivity disorder, schizophrenia, mental wellness, and aging.

A typical sleep diary records information for two weeks at a time. In some cases, a sleep diary alone can be used to rule out a sleep disorder by revealing certain behaviors, foods, or medications interfering with sleep. For example, a sleep diary may highlight that a combination of after-dinner coffee and nightly asthma medication are causing difficulties falling asleep.

Information tracked in a sleep diary may include the following:

• bedtime and rise time;

• time required to fall asleep;

• number of times waking up at night;

• exercise activities and times;

• consumption of caffeine, alcohol, medications, foods;

• medication schedule;

• nap times;

• snoring; and

• feelings upon waking (eg, refreshed, exhausted).

For children with sleep problems, parents are asked to keep a sleep diary, and additional information tracked may include the following:

• bedwetting;

• number of crying incidents;

• night terrors;

• feeding times and amounts;

• teeth grinding;

• diaper changes; and

• presence of a pacifier, toy, blanket needed to fall asleep.

— JS

When to Refer for a Sleep Study
Knowing when to refer to a sleep center can be a difficult and complex decision, says Christopher L. Drake, PhD, DABSM, clinical psychologist at the Henry Ford Hospital Sleep Disorders and Research Center, assistant professor of psychiatry and behavioral neurosciences at Wayne State University School of Medicine in Detroit, and member of the National Sleep Foundation’s board of directors. He suggests the following informal guidelines for social workers in deciding when to refer a client to a sleep specialist:

• if the client reports excessive sleepiness, loud snoring, and is obese (“Sleep apnea should be considered in the differential diagnosis,” Drake says.);

• if a client reports chronic (more than one month) insomnia symptoms or symptoms of restless legs syndrome, but does not report other symptoms related to depression;

• if insomnia symptoms persist during or after treatment for depression (“In fact, poor sleep is the most common residual symptom following treatment of depression and is a major predictor of relapse in those who have had past episodes of major depression,” Drake says.); or

• if the client shows signs of debilitating sleepiness, such as drowsy driving, despite adequate sleep time (seven to eight hours).

— JS

Resources
American Insomnia Association
www.americaninsomniaassociation.org/aboutaia.htm

“Insomnia, Sleep Apnea, Narcolepsy.” Vijay Fadia, ed. Homestead Schools Inc.
www.homesteadschools.com

National Sleep Foundation
www.sleepfoundation.org