Sleep Problems

Definitions

Sleep is the body and mind’s way of resting and renewing itself. A regular sleep schedule is an important part of wellness. How much sleep a person needs depends on several factors, including activity level, but getting the amount of sleep recommended for your age range is best. Getting either too much or too little sleep can indicate or cause other problems.

A lack of sleep may cause or contribute to the following:

• Poor coordination (e.g., tripping easily or running into things).
• Behavior and mood problems.
• Poor memory and concentration.
• Work or school performance problems.
• Stress and anxiety.
• Health problems, such as weight gain, hormone imbalance, or a weakened immune system.

Getting too much sleep may indicate the following:

• Depression.
• Substance use.
• Significant life transitions.
• Growth spurts.

Night terrors are frequent and recurring episodes of intense crying and fear while a child is sleeping. It is difficult to wake the child during a night terror, and it's generally best to allow the night terror to run its course. Children usually do not remember night terrors when they wake up in the morning. Night terrors may be caused by:

• Stressful life events and trauma.
• Fever.
• Sleep deprivation.
• Side effects to medication.

Nightmares refer to bad dreams that cause the person to experience fear, terror or anxiety. If they do not occur often, theseare considered to be a normal part of child development, and are more common in girls than boys. Beyond childhood, nightmares may be triggered by something serious such as a death, trauma, or stress at home, or they may occur even without recent adverse events. Individuals who have experienced trauma may try to avoid sleep in effort to avoid having a nightmare.

Sleep walking is a sleep disorder that causes people to get up and walk around while sleeping. Sleep walking is more common in children than adults and is more likely to occur when a person has not had enough sleep.

Sleep apnea is a medical condition that causes someone to stop breathing while sleeping. Sleep apnea may cause snoring at night and excessive drowsiness during the day. It can also have serious long-term health consequences or lead to death, especially when the person is using alcohol or drugs.

Encourage the client or family to engage in good sleep hygiene and habits. Clients with difficult, persistent, or serious sleep problems need to be referred to a medical provider.

Sleep is impacted by daily routines, especially routines near bedtime. Consistency supports good sleep. Help the client or the child's family to create consistent nightly routines.

Action movies or video games may negatively affect sleep, especially if they are used in the evening.

Sleep routines can be impacted by seasonal, family, or cultural activities. Some degree of variation based on these factors is normal, but clients still need to get enough sleep for their age range.

A desire to sleep more than usual or to not sleep at all may be symptomatic of a mood disorder. See Chapter D-8: Mood Disorders (Depression & Bipolar).

Sleep patterns can also be disrupted as a result of substances. See Chapter D-2: Substance Use and Abuse.

A fear of going to sleep can indicate adverse life events and/or that the person is under stress. Help the client to explore possible stressors and address them. If you suspect that sleep problems are related to abuse, see Chapter D-3: Abuse and Neglect. If the fear of sleep is associated with the avoidance of nightmares related to a traumatic event, see Chapter D-5: Trauma and Posttraumatic Stress.

In many cultures, it is common for children to report seeing or hearing things or feeling an energy presence (e.g., the boogie man or monsters under the bed). This is different than having a hallucination. See Chapter D-10: Hallucinations and Delusional Thoughts (Psychosis).

A sleep log can provide helpful information to you and the client. Encourage your client to keep track of bedtimes and wake up times, night wakings, occurrences of nightmares/night terrors, and other details.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to recent life events, recent wellness checks, or use of substances (including medications).

Treatment plan, including a history of presenting problem and recommended course of treatment.Review the DSM-5 for criteria on Depression or Substance Abuse.

Personal history

• Traumatic experiences
• Recent major transition, such as a move to a new home
• Longstanding or severe illness
• History of anxiety
• History of depression
• Substance use or abuse

Sleep routine

• Lacks consistency in bedtime routine
• Consumes food or beverages with sugar or caffeine before bedtime
• Eats large meals close to bedtime
• Gets excited or is involved in too much activity close to bedtime
• Uses screens in the hour before bedtime, such as:
  • Television
  • Video game
  • Computer
  • Smart phone

Sleep environment

• High noise levels or a lot of activity in the home during bedtime
• No curfew or their curfew is not regularly enforced (for a child)
• No consistent sleep and wake patterns
• Too much light in the room at night

These questions are written as though you speaking directly with the client. If the client is a minor, you can modify these questions to also get evaluation information from the parent.

Sleep patterns

• Do you have a consistent bedtime routine? What does that look like?
• Do you have a relaxing bedtime ritual?
• How often do you oversleep?
• Do you snore loudly through the night? Do you snore more when you are on your back?
• Have you ever stopped breathing for short periods of time while sleeping? Do you ever wake up startled or anxious because you stopped breathing?
• Are you able to sleep through the night?
• How often do you wake up during the night, unable to return to sleep?
• Do you sleepwalk, have night terrors, or have nightmares? How frequent and how severe are they?

Personal history

• Do you have excessive fears or past trauma ?
• Do you have any medical conditions ?
• Do you take any prescribed medications ?
• Do you take any vitamins, supplements, or herbs, such as melatonin?
• Do you use any over-the-counter medicines, such as sleeping aids or cold medication?
• Do you use any substances ? What kinds, how much, and how often?
• Do you use a laptop, smartphone, or other screen in the late evening or during the night?

Daily performance

• Are you often irritable or easily angered?
• Do you have poor nutrition? Do you eat unhealthy foods or not eat regularly ?
• Do you have difficulty staying awake during the day?
• Do you want or need naps during the day?
• Have you fallen asleep while doing tasks?
• Do you have unexplained problems with performance?
• Do you have a difficult time paying attention at work or school?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specifically, you may consider helping the client develop a consistent sleep routine, and good sleep hygiene:

• Waking up at the same time seven days a week.
• Exercise regularly.
• Reduce the amount of light and noise in the bedroom.
• Avoid reading, watching TV, or viewing bright screens while in bed.
• Eat at consistent times to avoid going to bed hungry; avoid greasy or heavy foods right before bed.
• Avoid excessive liquids at nighttime.
• Avoid caffeine and alcohol in the evening.
• Smoking or consuming nicotine can disturb sleep; avoid using them in the evening and at night.
• Avoid "taking problems to bed." Work through stressors and make a plan for the following day before getting into bed.
• Avoid "trying" to fall asleep. If you don't fall asleep within 20 minutes, get up and leave the bedroom to read or engage in a non-stimulating activity, then return to bed when sleepy.
• Put the clock somewhere it cannot be seen from bed.
• Avoid daytime naps, especially longer than 30 minutes.

Refer your client to a clinician for a mental health assessment if the sleep problems appear to be a symptom of anxiety, depression, or another mental health condition. If the sleep problems may be associated with substance use or abuse, see Chapter D-2: Substance Use and Abuse and consider referring the client for a substance use assessment. BHA/Ps certified at a level II or higher can provide substance use assessments and treatment.

Refer your client to a medical professional or local CHAP if any of the following apply:

• A history of stopping breathing for short periods of time while sleeping or of waking up startled or anxious because she stopped breathing.
• Your client has concerns about her sleep walking experiences or patterns.
• Your client reported longstanding problems related to sleep that have never been evaluated or treated by a medical professional.
• Your client says his sleep problems are due to nightmares related to past trauma; refer the client to a medical professional to evaluate the appropriateness of a prescribed sleep aid.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.