Sleep Deprivation in Adolescents

Oct 08, 2020

Causes:

1. Delayed melatonin release
2. Electronic devices
3. Chronic illness
4. Psychiatric diseases
5. Sleep disorders
6. Academic/Social obligations

Consequences:

1. Mood disorders
2. Obesity
3. Cognitive dysfunction
4. MVA’s

Treatment of DSPD:

1. Sleep Diary
2. Melatonin
3. Morning waking
4. Morning exercise
5. Limiting electronic devices
6. Blue blocker glasses/filters

Insufficient Sleep in Adolescents

The incidence of insufficient sleep in teenagers varies in research articles from 35% to 75% making this problem a modern epidemic. The consequences of sleep deprivation in teenagers can be severe and the high incidence mandates that a comprehensive sleep history be taken on every adolescent attending primary care. Research indicates to achieve optimal daytime alertness in adolescents this requires 9 hours of sleep. In reality, this is rarely achieved.

There are a number of reasons for insufficient sleep in teenagers. Electronic devices occupy the bedroom of almost every teenager in advanced countries. LED screens inhibit melatonin release thus delaying sleep onset. It has been demonstrated in research articles that melatonin release is already somewhat delayed in teenagers.

Mood disorders and chronic disease can lead to sleep disruption as well as insomnia. Adolescents with sleep disorders (sleep apnoea, periodic limb movement disorder and narcolepsy among others) are more likely to have insomnia and fragmented sleep and these need to be excluded.

Teenagers have academic and social obligations that impact on sleep. Often, they have homework, sports training and part time work occupying their evenings. Add social activities to this and pressure on sleep onset and duration is marked.

The consequences of sleep deprivation in adolescents can be severe. There are very high rates of anxiety and depression in teenagers with delayed sleep phase disorder (DSPD). OCD also often accompanies sleep deprived teenagers. Sleep deprivation can lead to increased risk-taking behaviour and sleeping less than 8 hours per night is associated with a threefold increase in attempted suicide. Obesity is consequence for sleep deprivation and may lead to diabetes, high blood pressure, fatty liver disease and polycystic ovarian syndrome. A study in 2002 estimated that for each sleep hour lost the odds of obesity increased 80%.

There is a direct correlation between sleep deprivation and cognitive dysfunction. It has been estimated that grades will fall by 5% for every hour of sleep lost. Sleep deprivation leads to decreased concentration and impaired working memory leading to lowered academic outcomes. In many countries school starting times for high school children are being delayed to offset this problem. Grades improve in these schools who institute this change.

DSPD is extremely common in teenagers. In many cases the management is reasonably straight forward. Initially a sleep diary needs to be completed for at least one week. To make the diagnosis sleep onset needs to be delayed by 3-6 hours compared to usual timing of around 10 pm. Sleep onset is often at the same time. Once the person has fallen asleep it needs to be normal in length and quality, but is severely delayed. The teenager, on history, has difficulty falling asleep and waking. This is most pronounced during the week when they need to get up for school. In children with severe DSPD waking at a normal time can be very difficult or even impossible. They are often, in effect, in sleep mode until about lunchtime. They often sleep in on weekends and feel more refreshed on those days.

There are various ways of treating DSPD. A sleep diary is vital. Melatonin should be used at a starting dose of 0.5 mgs (needs to be made by compound chemist) and is given either 10 hours prior to the midpoint of sleep on free days (weekends or holidays) or 6 hours before mean sleep onset time. Each week these times should be reassessed as the sleep schedule changes. The dose of melatonin can be slowly increased to 2 mgs if there isn’t the expected response. The commonest errors with melatonin in this problem is giving too much. The dose to phase shift is generally much lower than that used for the hypnotic effect. It is also usually given too late.

Chronotherapy should also be instituted. Sleep can be walked forwards or backwards. The latter is more practical. The waking time should be brought back by 15-30 minutes each week. For example, if the waking time is 11 am on weekends, then this is brought back to 10.30/10 etc until a time is reached that is socially acceptable.

After waking the patient needs to get up and go outside to exercise in the sun as soon as possible. The exercise needs to be in the sunshine (swimming is not useful as the eyes re underwater) and last for about 15-20 minutes. Results are usually significant within about four weeks. The new schedule is then maintained without Melatonin by maintaining the morning regime.

Electronic devices may be used until 2 hours prior to bedtime and should then be outside the bedroom. LED screens prevent Melatonin release. If they are needed for homework in the evening blue blocker glasses or filters should be used. The sunset settings on computers etc are not as effective.

I try to use Melatonin for short periods in children as long-term usage in children has received little research. It is safe short term. The main issue from my perspective is that the ovaries and testicles have Melatonin receptors. What does Melatonin do in the long term to the gonads of children? We know Melatonin acts on them as it is used as a fertility drug in animals and I have, at times, noted IVF clinics using it on women attending their clinics. There is no research that proves definitively that long term use is completely safe.

Dr Terry Sands
Sleep Physician & Paediatrician
P: 02 4226 6376

References

1. Journal of Thoracic Disease 2018 Jan 10(Suppl 1) S103-S111
2. Insufficient sleep in teenagers and young adults: An update on causes and consequences. Judith Owens Paediatrics 2014, 134, e921

Downloads:

1. Adolescent sleepiness questionnaire
2. Sleep Diary
   1. yoursleep.aasmnet.org/pdf/sleepdiary.pdf
   2. http://sleepcouncil.org.uk/sleep-diary/