A 16-year-old male came to clinic for his health supervision visit. He said he was a good student receiving A’s and B’s in accelerated classes. He also played basketball and baseball and participated in other outside activities. He reported no health problems but said that he often went to sleep between midnight and 1 AM because of needing to finish his homework. He got up at 6:30 AM to be able to start school at 8 AM. He said on the weekends he would try to sleep later but even then it was difficult because of weekend activities. The past medical history showed a sprained ankle and overuse shoulder injury in the past two years. The family history was negative for any sleep disorders including obstructive sleep apnea.
The pertinent physical exam showed a healthy male with growth parameters in the 50 to 75th percentile. The rest of his physical examination was normal. The diagnosis of a healthy male with sleep deprivation was made. The pediatrician discussed with the patient and his father some of the difficulties of not having enough sleep and provided more information about sleep hygiene. The pediatrician emphasized that inadequate sleep had negative effects on academic achievement and had increased accident risks especially when operating an automobile.
In humans, sleep is regulated by two systems. The first is the homeostatic sleep drive which assumes that the longer the person is awake the more pressure there is to fall asleep. The second process is the circadian system which controls periods of activity and inactivity throughout the day. The circadian rhythm is slightly longer than 24 hours in humans and is controlled by the hypothalmic suprachiasmatic nucleus. When the circadian system and the external environment are misaligned, such that sleep occurs outside of normal times, a circadian rhythm sleep disorder can occur.
During adolescence, there is a normal physiologic change of the homeostatic and circadian systems such that there is a shift to a later sleep phase for adolescents. Adolescents also commonly have inadequate sleep that occurs on an ongoing basis because of societal norms. These adolescents normally have sleep onset later but need to get up in the morning for school and other activities resulting in inadequate sleep amount. Adolescents, if left alone without external influences, will sleep slightly more than 9 hours. However, 45% of adolescents sleep < 8 hours and 31% sleep between 8-9 hours on school nights. Adolescents may "catch-up" their sleep on the weekends, but the problems of inadequate sleep during the school week may not be mitigated with the additional weekend sleep.
Adolescents in addition to the normal physiologic change can have circadian rhythm sleep disorders. Delayed sleep phase disorder (DSPD) is the most common in this group a the prevalence of 7-16%. DSPD delays sleep onset by 3 to 4 hours compared to usual normative evening time (i.e. 10-11 PM). If left alone, the sleep is normal in quality and duration. Sleep wakening is then necessarily delayed causing problems with social needs (e.g. not getting up in time to go to school). The adolescent then has inadequate sleep which then leads to poor sleep hygiene which helps to change the intrinsic circadian rhythm which continues to cause the delayed sleep onset. Overtime, DSPD develops. DSPD is treated using good sleep hygiene but other interventions may be necessary.
- Chronotherapy delays sleep onset progressively over several days until the normal sleep onset time is achieved and then anchors that new time with post-sleep morning light.
Light therapy especially in the morning can be helpful.
- Light in the evening delays sleep onset and light in the morning advances it (i.e. makes it earlier in the evening the next night). Light intensity between 2500-10000 lux will advance circadian rhythms.
- Melatonin is a chronobiotic that can be used to help sleep onset. Melatonin is given ~5 hours before desired sleep onset. Once consistent sleep onset is achieved, a smaller dose given 2 hours before desired sleep onset helps to establish the circadian pattern.
The opposite of DSPD can occur called advanced sleep phase disorder. It is not common in adolescence. The sleep onset occurs early in the evening despite trying to stay awake until normal times with typical wakening in the early AM (e.g. between 2 and 5 AM).
Good sleep hygiene includes:
- Consistent sleep onset and waking times
- Limited caffeine and food in the evenings before bedtime
- Limited exercise before bedtime
- Limited computer, television and other screen time to limit evening light exposure
- Bed and bedroom with comfortable temperature, no or low level lighting. Bed not used for activities associated with mental alertness such as homework, electronic screens, etc.
Psychophysiologic insomnia is a sleep-onset disorder and is not a circadian rhythm sleep disorder.
Overall, good sleep amounts and patterns have positive health benefits while poor sleep amounts and patterns have negative health benefits. Many of these problems are dose response related and can be reciprocal. For example inadequate sleep can lead to depressive symptoms and depressive symptoms can lead to poor sleep.
Problems associated with inadequate sleep include:
- Mental health
- Attention problems
- Depression (strongly associated with poor sleep)
- Suicidal ideation
- Poor perceived mental health
- Poor perceived physical health
- Low self esteem
- Poor psychosocial functioning
- Fatigue and tiredness
- Physical health
- Pain (in females only)
- Cardiovascular problems
- Cardiometabolic problems
- Overweight and obesity
- Health risks
- Accidents and injuries particularly automobile accidents
- Aggression (being in fights, weapons carrying, etc.)
- Use of cigarettes, alcohol and drugs
- Unprotected sexual activity
- Poor academic achievement (especially in older adolescents)
Questions for Further Discussion
1. How is psychophysiological insomnia diagnosed and treated?
2. What are indications for referral to a sleep medicine specialist?
3. What are other sleep disorders and how are they defined?
- Disease:Sleep Disorders
- Symptom/Presentation: Sleep Disturbance
- Specialty: Developmental Disabilities | General Pediatrics
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Sleep Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Bartlett DJ, Biggs SN, Armstrong SM. Circadian rhythm disorders among adolescents: assessment and treatment options. Med J Aust. 2013 Oct 21;199(8):S16-20.
Reiter J, Rosen D. The diagnosis and management of common sleep disorders in adolescents. Curr Opin Pediatr. 2014 Aug;26(4):407-12.
Shochat T, Cohen-Zion M, Tzischinsky O. Functional consequences of inadequate sleep in adolescents: a systematic review. Sleep Med Rev. 2014 Feb;18(1):75-87.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital