NIGHT NURSE
Eeasing the Sleep of Troubled Children and
Teens.
By Carol Glod
Sometimes when faced with the challenges of my
work, I ask myself, "why I am doing this?" It's in usually in
those moments when things aren't going very smoothly. But then I think
about the patients I'm with, realize their struggles, and face their pain.
If I give up, I give up on them.
According to a recent survey of thousands of high
school students in Massachusetts, nearly one in four students has considered
suicide
in the past year, and
one in ten has actually tried to harm himself or herself. Although I work
with these children and adolescents every day, I was shocked to see the
enormity of the problem. And more than that, I was scared. If twenty-four
percent of adolescents are suicidal, then someone has to step in.
I became interested in tackling depression in
childhood and adolescence after years of studying adults with similar problems,
and after following up on an observation made by nurses working with children
who had been hospitalized on a psychiatric unit at McLean Hospital. A core
group of children had tremendous sleep difficulties, no matter what the
nursing staff tried. We diagnosed these children as suffering from either
depression or posttraumatic stress disorder (PTSD) because of childhood
abuse. Since no one had yet investigated the sleep patterns of abused children,
we launched a major study with funding from the National Institute of Nursing
Research and the National Institute of Mental Health, along with several
foundations.
We discovered that, as we predicted, abused children
suffered severely disturbed sleep patterns. In fact, compared with a group
of normal children and a control group of depressed children who had not
been abused, the abused children took three times as long to fall asleep
and experienced much more nighttime activity. We were one of the first
research groups to document and characterize the sleep problems in abused
children. We went on to report that these children displayed hyperactivity
during the day and disturbances in their circadian rest-activity cycle,
which may have accounted for their sleep pattern disruption. Their activity
cycle was "phase-delayed"-that is, it was shifted later into
the day, with the peak of activity occurring about one hour later than
the peak in the control group of "normal" children. That shift
could have accounted for their delayed sleep onset. This groundbreaking
work led to several awards, including recognition from the national honor
society for nursing, Sigma Theta Tau International.
Since our initial studies looked only at younger
children, we wondered what happened to the sleep patterns of abused children
during their adolescence, that time of hormonal storms and attempts at
independence. With funding for some preliminary work from the provost's
research fund at Northeastern and subsequently from the National Alliance
for Research on Schizophrenia, we embarked on a study of adolescents. Our
initial results were disappointing; we found no differences in sleep between
the abused group with PTSD and the depressed and normal groups.
Being taught to persevere in data analysis, however,
we soon found that things were even more complicated than we had guessed.
It turned out that there were two subgroups of depressed adolescents: one
with insomnia and one with hypersomnia (sleeping too much). The picture
that emerged was not surprising to us. Adolescents with an insomniac form
of depression, as well as those with PTSD because of physical or sexual
abuse, experienced more sleep disruption than those with hypersomniac depression
or the normal control group. We are now following up on these findings;
an undergraduate honors student at N.U. is exploring whether the adolescents'
self-reporting of their symptoms differs between the groups.
From there I faced a critical juncture: should
I continue to research underlying neurobiological disturbances such as
circadian rhythm disregulation, sleep disruption, and other problems in
pathophysiology, or focus instead on outcome studies? One of my first interests
in this series of studies had been to help children and adolescents improve
their sleep. As a pragmatist and a nurse, I was nagged by the desire to
do something about their symptoms. Following this impulse, I decided to
pursue intervention studies-that is, to determine how to alleviate their
sleep problems. To make a difference in the lives of children and adolescents.
With funding from a pharmaceutical company, my
team then began a clinical trial of an antidepressant, bupropion (Wellbutrin),
to determine its dosage, safety, and efficacy in adolescent depression.
I initially received, and still do hear, comments from colleagues like,
"You want to study drugs in kids? But you're a nurse!" For a
nurse to design, execute, and complete a clinical drug trial in psychiatry
is virtually unheard of. But nurse practitioners and their counterparts
in psychiatry, clinical nurse specialists, have graduate degrees, and in
Massachusetts (like every other state) have the ability to prescribe medications.
For two years now, we have been screening adolescents
for depression and enrolling them in the trial. We have chosen a very difficult
group: adolescents who fail to recognize their depressive symptoms or who
may blame their problems on others. About half of our subjects who enter
the trial decide they will not even begin the medication. As a colleague
of mine said, "It becomes a sport for a depressed kid to say no. No
to treatment. No to anything."
Despite the many obstacles, we have persevered.
Our preliminary results are so promising that we have decided to end the
open trial early and try to find funding for a double-blind controlled
study-the gold standard in our field for drug trials. By comparing a group
of subjects who take medication with a group that unknowingly receives
placebos, double-blind controlled studies provide the strongest evidence
possible of whether a treatment program works. At the same time, our society
is struggling with the ethical issues surrounding the use of placebos in
clinical trials. As I wrote the latest grant, I once again became overwhelmed
with all of the obstacles. Would we get the necessary number of subjects?
How would we convince these teens and their parents to participate? Should
we include a placebo? Is there a better research design?
In the midst of these questions, I taught my class
at N.U. on psychopharmacology, gave a talk on teen depression to seventy
teachers at a local high school, and saw a severely depressed sixteen-year-old
who had come all the way from upstate New York for a medication consultation.
As I busily ran from one task to the next, I realized why I was doing what
I was doing. We have so little information to guide clinical practice,
particularly in the psychopharmacologic treatment of children with psychiatric
disorders, yet these children have to face their problems. They continue
to receive medications, even in the absence of research data. Untreated
depression will lead them to contemplate and perhaps attempt suicide.
What do we tell these children and their parents
and teachers? It is the true nature of a nurse to promote health-in this
case, the mental health of our youth. It is part of the essence of research-based
clinical practice to have hard data to guide the decisions we make for
patients in need. It is also part of our mission to serve the disadvantaged
and underserved, by advocating for the best and most effective interventions,
both pharmacologic and nonpharmacologic, to help them lead productive lives
and reach their highest potential. I tell them that this is why I do what
I do.
Carol Glod is an associate professor of nursing
and a certified specialist in child and adolescent psychiatricmental
health nursing.
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