The Teenage Clock: Discussion of Sleep Disorders in Adolescents
After reading this article and answering the review questions, the reader will be able to:
- List the differential diagnoses of daytime sleepiness in an adolescent
- Explain the diagnosis and treatment of a circadian rhythm sleep disorder
- Reinforce the secondary health issues of sleep deprivation and irregular sleep cycle
A 14-year-old girl presents to your office with a 2-year history of difficulty falling asleep and daytime sleepiness. Her complaints today include more frequent headaches and increased drowsiness. Her parents believe that her headaches are related to insufficient sleep, especially noted during this school year. She has been tardy to school at least five times per month during this past year. She reports that she sometimes falls asleep in the first two periods of school and generally feels more alert in the afternoon.
Her past medical history is significant only for headaches treated with ibuprofen as needed. She drinks one large cup of coffee in the morning in addition to one or two cans of caffeinated soda, usually before suppertime. Occasionally she will consume an energy drink. She denies tobacco, marijuana, or alcohol use. She denies any symptoms of anxiety, irritability, or changes in her mood. She states that she enjoys spending time with her friends.
She has her own room in which she has a bed, TV, computer, overhead light, digital clock, and bedside lamp. After supper, she goes to her room and works on her laptop computer. She usually uses the computer while sitting on her bed. She turns off the lights, TV, and computer between 10:30pm and 11pm. She is not able to fall asleep until at least 1am, but often later. Once she falls asleep, she sleeps until she is awakened in the morning, which occurs at 6:45am for her to be at school by 7:30am. She is very difficult to awaken in the morning. She will take a nap after school from 3pm to 5pm about three times a week. The time of the day that she feels most alert is after supper.
On Friday and Saturday nights, she is usually in bed by 1:30am or 2am and falls asleep quickly, within about 15-30 minutes. She sleeps in until noon on Saturday and has to be awake by 10am on Sunday for church. She feels slightly more rested on the weekends.
She denies restless leg symptoms, growing pains, snoring, or dry mouth. She does have occasional morning headaches, especially noted during the school week. She had onset of menarche 2 years ago and has regular menstrual cycles. She denies symptoms of cataplexy (an abrupt partial or complete loss of muscle tone triggered by a strong positive emotion such as laughter), sleep paralysis (inability to move or speak at the time of falling asleep or waking up), or hypnagogic or hypnopompic hallucinations (vivid visual, auditory, or sometimes tactile experiences on falling asleep or waking up). She denies persistent symptoms of fatigue such as decreased energy level or lack of motivation.
A sleepy teenager or a teen having trouble falling asleep is a patient that commonly presents to a primary care office; the evaluation can be challenging. Obtaining the following historical information is most helpful in evaluating this type of patient:
- The patient's symptoms or concerns that prompted evaluation for sleepiness versus fatigue: sleepiness is the tendency to doze off or actually fall asleep, in contrast to fatigue, which is associated with subjective feelings of low energy and low motivation. Fatigue tends to be associated with a medical or psychiatric disorder. There may be significant overlap between these two symptoms.
- Assessment of sleep pattern: ideally the use of a sleep diary for at least 1-2 weeks can better document time spent in bed, time to fall asleep once in bed, number of nighttime awakenings, time spent awake after initially falling asleep, and total sleep time both on weekdays and on weekends. An example of one sleep diary is listed under Resources.
- Detailed description of sleep hygiene: bedtime routine, caffeine, alcohol or drug use, exercise habits, and the patient's sleep environment.
- Assessment for co-morbid psychiatric problems.
- Assessment of other psychological and emotional factors that may be contributing to symptoms, such as school avoidance or environmental stressors.
The differential considerations for this patient include:
- Delayed sleep phase syndrome
- Restless leg syndrome (an urge to move the extremities or an uncomfortable sensation in the legs that is worse with inactivity)
- Poor sleep hygiene (use of caffeine, cigarettes , alcohol, or too much electronic media exposure close to bedtime, etc.)
- Circadian preference (a tendency towards being a "night owl" but doesn't have the same intractable quality or persistence)
- School avoidance or refusal
- Psychiatric disorders (such as bipolar disorder or depression)
This patient's most likely diagnosis is delayed sleep phase syndrome. However, there are other issues that are interfering with her sleep that are important to address. These include caffeine intake, irregular sleep schedule (school compared to non-school days), and too many electronic devices in her room. Additionally, she suffers from insufficient sleep as a consequence of her delayed sleep pattern with an early morning school start time.
Chronic sleep deprivation has significant long-term health effects, including the potential for accidents when driving, impaired regulation of behavior, irritability, worsening mood disorders, increased headaches, and poor school performance; in addition, there may be increased use of caffeine and other stimulants. Insufficient sleep also effects appetite and metabolic control, which may lead to increased weight gain and risk for diabetes.
Delayed Sleep Phase Syndrome
Delayed sleep phase syndrome is a circadian rhythm sleep disorder. It is defined by a delay in the phase of the major sleep period in relation to the desired sleep time and wake time. There is a chronic or recurrent complaint of inability to fall asleep at a desired conventional bedtime along with the inability to awaken at a desired and socially acceptable time. When allowed to choose their preferred schedule, patients will exhibit normal sleep quality and normal sleep duration for age and maintain a delayed but stable 24-hour sleep-wake pattern. It is more common in adolescents, with a prevalence of 7%-16% in this age group.
To better understand sleep and wakefulness, it is important to review the basics of the homeostatic sleep process and the circadian sleep rhythm. The homeostatic sleep process regulates the length and depth of sleep. As one is awake longer, the "pressure" to sleep increases. Conversely, the closer one is to having slept, the less pressure there is to sleep. The circadian sleep rhythm is an oscillator that varies between increased propensity for sleep or wakefulness throughout a 24-hour period. The circadian troughs occur in the mid to late afternoon and towards the early morning hours. The two periods of alertness are in the mid-morning and in the mid-to-late evening, with the maximum period of alertness in the evening - the "second wind effect."
During adolescence, there is a predictable delay in the circadian alerting system in which the normal evening alertness time occurs later. The delay in the bedtime preference tends to follow pubertal development. Accordingly, because girls enter puberty earlier than boys, the delay in bedtime is usually noted at an earlier age in girls.
Additionally, adolescents may be less sensitive to the "pressure" to sleep, which increases their actual ability to stay up later. The ability to stay up late combined with increased evening activities and increased use of TV, computers, and handheld electronic devices, especially at night, can all contribute to increased difficulty falling asleep and a later bedtime.
Treatment Options for Delayed Sleep Phase Syndrome
Treatment goals for delayed sleep phase syndrome include shifting the sleep-wake cycle to an earlier time and then maintaining a regular sleep cycle. As one can imagine, this treatment requires the motivation of the adolescent in addition to support by the family. For the treatment to be successful, a multifactorial approach is often needed.
Table 1: Summary of Treatment Options for Delayed Sleep Phase Syndrome
Phase advancement is one treatment option that may be used when the difference between the current sleep onset time and the target earlier sleep time differs by less than 3 hours. The bedtime and wake times are shifted earlier by about 15 to 30 minutes every day until the desired timing is achieved. The pace of the shift can be dependent on the child. Chronotherapy, or phase delay, is another treatment approach, but is more difficult and generally reserved for more challenging cases. This may be necessary if the current sleep time and the target sleep time differ by more than 3 hours.
The strategy is to delay the bedtime and wake times by 2-3 hours daily to actually achieve the desired timing. For example, a patient sleeping from 4:30am until 12:30pm, with a target time to fall asleep of 11pm, may need chronotherapy. For this example, the patient would shift the sleep period to falling asleep at 7:30am and awakening at 3:30pm and then falling asleep at 10:30am with awakening at 6:30pm and so on. This always requires family involvement to keep the teen awake at continually shifting times and then maintaining the schedule.
Phototherapy with bright light exposure of at least 30-60 minutes in the morning can also be helpful in shifting the circadian clock. Light therapy is measured in lux, with 2,500 to 10,000 lux as the usual treatment range recommended for the light boxes that are used. Additionally, maintaining dim light exposure in the evening is also important with some experts even suggesting the use of sunglasses. Because light therapy may be difficult for many patients to do on a regular basis, melatonin can also be used. However, it does not have as potent of an effect on the circadian cycle as light exposure. Although melatonin is not FDA-approved for circadian rhythm disorders, suggested initial dosing may include 1-5 mg given about an hour before sleep onset.
Sleep onset refers to the time that the patient is falling asleep and not the time the patient gets into bed. For example, in the above case, the patient is usually falling asleep around 1am or 2am, so the melatonin administration would be recommended around midnight. As the patient falls asleep at earlier times, the dosing of melatonin is also changed to an earlier time in 15-30 minute increments. Other studies have demonstrated a dosing range of 0.5-3 mg about 4-5 hours prior to sleep onset to be effective.
As mentioned initially, addressing sleep hygiene and lifestyle issues (outlined below) will be important factors in successful treatment. Because long-term changes and habits may be difficult to maintain, working with a behavioral therapist can be helpful. Another potential adjunct to therapy is considering a delayed school start time, at least until the sleep cycle is stabilized.
Table 2: Instructions for Patients with Delayed Sleep Phase Syndrome
For the 14-year-old patient in our case, my initial recommendations would include phase advancement in combination with sleep hygiene, melatonin, and/or light therapy. From her history, she was awake in bed for almost 2 hours on school nights before falling asleep at 1am.
Ideally, she should be able to fall asleep within 15-30 minutes of getting into bed. For that reason, initially she should try getting into bed later, at midnight to 12:30am on school days. Then she should move the time earlier, to a target bedtime of around 10:30pm, in 15-30 minute increments on a daily basis depending on how successful she is at falling asleep. She should maintain approximately the same wake-up time (within an hour or so) on school days and weekends. Initially she may be more tired on this schedule, but that should improve as the schedule is maintained and the bedtime is earlier.
Treatment should also address issues of sleep hygiene, such as avoiding all caffeine and napping as well as removal of the TV, computer, and cell phone from the bedroom. A trial of melatonin starting at a dose of 1.5-3mg 30-60 minutes before her bedtime can be included in the phase advancement plan outlined above. In this case, with the new initial trial of a bedtime of midnight to 12:30am, melatonin should be administered at about 11:30pm. Light boxes can be purchased on the Internet for $100-$200. Close follow-up is also recommended.
If you are concerned that a patient may have a sleep disorder that is beyond the scope of your practice, Wisconsin Sleep evaluates infants, children, and adolescents with a wide range of problems including delayed sleep phase syndrome, insomnia, obstructive sleep apnea, behavioral sleep disorders, restless legs, and parasomnias such as sleepwalking and night terrors. More information is available on http://www.wisconsinsleep.org/, including a requisition form for consultation and contact information.
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- Online sleep diary: http://www.sleepeducation.com/pdf/sleepdiary.pdf
- Adolescent Sleep Needs and Patterns; Research report and resource guide, 2000 available at http://www.sleepfoundation.org/sites/default/files/sleep_and_teens_report1.pdf
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