Sleep Disorders in Adolescents Sujay Kansagra, MD

abstract Chronic sleep deprivation is a common, treatable condition among adolescents. Growing literature supports a myriad consequences that impact overall health, behavior, mood, and academic performance in this vulnerable age group during a time when there are rapid changes in physical development and emotional regulation. This article reviews the epidemiology and health effects of sleep deprivation in adolescents as well as common disorders leading to sleep loss and evidence to support treatment. Although a variety of important sleep disorders may disrupt quality of sleep in adolescents, such as obstructive sleep apnea, restless leg syndrome, and narcolepsy, this article will focus on common disorders that affect the quantity of sleep, such as poor sleep hygiene, circadian rhythm disorders, and insomnia.

Duke University Medical Center, Durham, North Carolina

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2019-2056I Accepted for publication Jan 29, 2020 Address correspondence to Sujay Kansagra, MD, Division of Pediatric Neurology, Duke University Medical Center, 10211 Alm St, Raleigh, NC 27617-8221. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2020 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 26, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 145, number s2, May 2020:e20192056I EPIDEMIOLOGY OF SLEEP DEPRIVATION Metabolism and obesity also correlate F–72°F) and free from noise, and IN ADOLESCENTS with sleep duration, although avoiding disruptors of sleep, such as The average sleep needed for an directionality is unclear. light and screen time. Observational studies in adults, adolescent to maintain proper health The recommendation to avoid light 1 children, and adolescents show an is 8 to 10 hours per night. This and screen time before bed is increase in weight with decreases in recommendation is based on the supported by numerous sleep time. In a meta-analysis of 12 American Academy of Sleep Medicine epidemiological studies that link studies looking at obesity in children, expert panel, which reviewed studies screen-based activities to sleep the odds ratio of short sleep duration on general health, cardiovascular disruption. A variety of habits and with obesity was 1.89.10 Changes in 2 health, metabolism, mental health, exposures are associated with hormones that regulate satiety, leptin, and longevity as they relate to sleep worsening sleep metrics, including and ghrelin, may play a role.11,12 duration. The duration applies to total increased social media use before sleep over a 24-hour span and is Cognitive performance is impaired bed, sleeping with a mobile device, irrespective of other important with chronic sleep restriction, which screen use in the late evening, and the aspects of sleep, such as circadian can affect academic performance. number of devices kept in the – timing and continuity. Attention span, particularly bedroom.17 20 A prospective study prolonged attention, suffers with that implemented a media use plan Sleep deprivation in adolescents is sleep deprivation in a dose- for families showed benefits in sleep, common. The Youth Risk Behavior dependent manner with no evidence indicating that the association Survey found that 72.7% of students of plateau over a 1-week period.13 between media and poor sleep is at , reported an average of 8 hours of Sleep restriction is associated with 21 2 least partly causal in nature. sleep on school nights. This is similar declining academic performance from to the National Sleep Foundation poll, middle school through the collegiate A study looking at body temperature – which reported that 62% of students level.14 16 and sleep regulation in adults found get ,8 hours of sleep on week nights. that the rate of decrease in body Seniors were the most sleep deprived, We are developing a better temperature correlates with more with 75% reporting ,8 hours of understanding of how sleep can affect sleep time in the early stages of sleep per night3; girls and African cardiovascular function, immune sleep.22 Similarly, warmer Americans may be disproportionately regulation, growth, risk-taking, and environments are found to impair affected.4 Subjective reports of sleep self-regulation in adolescents. A sleep quality.23 Caffeine is duration are typically less than complete discussion on the health problematic as early as middle school, objective measures, such as consequences of sleep deprivation are with an associated decrease in quality actigraphy; therefore, the prevalence beyond the scope of this article. of sleep observed as doses increase.24 of sleep deprivation may be more Poor sleep-hygiene practices appear severe than what is indicated by CAUSES OF SLEEP DEPRIVATION IN to be a contributor to sleep survey data.5 ADOLESCENTS disruption in children and 25,26 Apart from voluntary sleep adolescents. However, there is no restriction, there are a variety of sleep consensus as to which elements of HEALTH CONSEQUENCES OF SLEEP issues that can impact the quantity of sleep hygiene are critical nor which DEPRIVATION sleep. This article will discuss poor are necessary when implementing Lack of sleep is associated with sleep hygiene, circadian rhythm sleep-hygiene strategies for insomnia. multiple health and academic disorders, and insomnia as well as Similarly, data supporting the role of consequences. First, mood and risk of examine the data to support poor sleep hygiene in causing depression are correlated with sleep treatment strategies. insomnia, or good sleep hygiene duration. Self-reports of poor mood, preventing insomnia, are lacking. emotional regulation, and self-harm Poor Sleep Hygiene increase with sleep restriction.6,7 The Sleep hygiene refers to the behaviors Delayed Sleep-Wake Phase Disorder relationship between mood and sleep and environmental factors that can Pubertal onset corresponds with is complex and bidirectional because affect sleep; these factors are typically a biologically mediated shift in sleep poor mood and anxiety can worsen modifiable. Some aspects of good timing with a predisposition to a later insomnia and vice versa.8 However, sleep hygiene include following sleep-wake cycle. This shift is data support improvement in a nighttime routine, maintaining mediated by 2 distinct processes. depressive symptoms when sleep a consistent sleep schedule, keeping First, the homeostatic drive to sleep, time is extended.9 the sleeping environment cool (68° which increases with increased wake

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 145, number s2, May 2020 S205 time, accumulates slower during TABLE 2 Treatment of DSPD adolescence. This translates into Step 1: Avoid bright lights for 30 min before the target bedtime a longer time to fall asleep and easier Step 2: Shift the bedtime earlier; shift by 15–20 min earlier each d ability to stay awake at night when Step 3: Consider use of melatonin; small doses (0.5–1 mg) are effective. Melatonin should be given – comparing postpubertal and 4 6 h before the current sleep time 27 Step 4: Get early morning light; bright lights early in the morning help shift the circadian rhythm to an prepubertal teenagers. Second, earlier time point. The one caveat is with extreme delay in the circadian rhythm. If the adolescent melatonin secretion shifts to a later routinely wakes up 3 h later on a weekend than they do on weekdays, then bright lights first thing in time, causing a delay in the circadian the morning on a weekday should be avoided. The ideal timing to begin light exposure is 3 h before rhythm.28–32 A delay in circadian the time that the adolescent naturally wakes up on a weekend physiology predisposes to a mismatch Step 5: Keep the schedule for bedtime and wake time the same throughout the week between an adolescent’s preferred sleep time and social demands, such Treatment strategies for DSPD are became the first state to mandate as school. Delayed sleep-wake phase listed in Table 2. delayed start times for middle and high schools, with the goal being disorder (DSPD) is diagnosed when Light exposure is known to affect to implement this mandate this mismatch causes functional circadian timing, but studies by July 2022. impairment (see Table 1 for evaluating both late light avoidance diagnostic criteria). An adolescent and using bright light in the morning Delayed school start times present with DSPD has a normal quantity and are limited in adolescents. In a variety of logistic and social quality of sleep when allowed to sleep a randomized controlled trial of challenges, including transportation at will. However, when she or he adolescents with DSPD who received difficulties, decreased interaction sleeps at the wrong times on the basis early morning light exposure and between parents and adolescents, and of social demands, DSPD is common. sleep education, the average sleep extracurricular scheduling problems. Studies show a prevalence as high as More data are needed to continue to 33 latency decreased by 43 minutes and 14% in the adolescent population. sleep increased by 72 minutes push for this initiative. Data from compared with the control group. a 2017 Cochrane Review on this topic Treatment approaches mainly rely on Given low risk of using bright light suggest several possible benefits, but melatonin supplementation and therapy in the morning, this is higher-quality primary studies are timing of light exposure. A meta- a typical recommendation for needed.43 analysis reviewing the use of adolescents with DSPD.37 melatonin to advance sleep phase in Insomnia both adolescents and adults found A growing understanding of age- that use of exogenous melatonin dependent patterns of circadian Insomnia refers to a decrease in sleep fi advanced endogenous secretion of physiology are helping shape due to dif culty falling asleep, fi melatonin by 1.18 hours and education policy. An American dif culty staying asleep, or decreased average sleep latency by Academy of Pediatrics policy awakening too early. 23 minutes.34 The time of statement advocates for delayed Psychophysiological insomnia (PI) is administration of melatonin appears school start times for middle and high a common subtype of insomnia. It is to be more important than the dose, schools.38 There are increasing data characterized by the inability to fall with ideal timing ∼4 to 6 hours to support this initiative. Delayed asleep or stay asleep due to the 35 intrusion of anxious or stressful before habitual bedtime. The start times improve mood, increase 44 administration of melatonin is overall sleep time, decrease levels of thoughts while in bed. recommended in the practice daytime sleepiness, increase school Insomnia is common among parameters for DSPD by the American attendance, and reduce car adolescents, with rates ranging 36 – Academy of Sleep Medicine. crashes.39 42 California recently between 7% and 40% on the basis of – the criteria used.45 47 Those with PI often sleep better in novel TABLE 1 Diagnostic Criteria for DSPD environments, such as hotel rooms, Significant delay in the major sleep episode compared with wake time and sleep time that is desired or which can aid in narrowing the required differential. Negative associations Symptoms are present for .3mo with sleep can lead to progressive If allowed to choose sleep schedule, patients show improved sleep quality and duration but maintain anxiety with perpetuation of the a delayed phase in their sleep-wake cycle Sleep diary or actigraphy for 7–14 d shows delay in time of sleep insomnia. Unfortunately, chronicity of Sleep disturbance is not better explained by another cause PI is high in adolescents, with up to Adapted from American Academy of Sleep Medicine. The International Classification of Sleep Disorders: Diagnostic and 88% of those with a history of PI Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. reporting difficulties with ongoing

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