Adolescent Sleep

Daniel S. Lewin, Ph.D., D,ABSM Associate Director, Pediatric Sleep Medicine

Children’s National Medical Center Associate Professor of Pediatrics George Washington University

School of Medicine

February 16, 2017

What is sleep? “Sleep is a reversible

behavioral state of perceptual disengagement from and unresponsiveness to the environment. It is also true that sleep is a complex amalgam of physiological and behavioral processes ”.

(Carskadon & Dement)

Awake

Drowsy

Stage 1

Stage 2

Stage REM

Stage 3

Stage 3: Non REM Sleep

Inhibition of centers of the RAS (Pons, Medulla & Raphae Nuclei),

Neurons of CCx firing is slow & synchronized

Serotonergic pathways from the RAS to thalamus & hypothalamus initiate delta activity in the cerebral cortex

REM Sleep

Inhibition of the Raphae and locus ceruleus Activation of the

pontine nucleus through cholinergic and glutamic pathways

Desynchronization of thalamacortical pathway broad activation of CCx

Hyperpolarization of Motor neurons resulting in broad atonia

Wake

REM

Stage 1

Stage 2

Stage 3

Time

2200 2400 200 400 600 800

Hypnogram Sleep Stage Distribution

NonREM Stage 3 is dominant during the first half of night Sleep stage REM is dominant during the second half of night

Estimate Norms: Sleep Duration Age group National Institutes of

Health

Population Study Switzerland {Iglowstein, 2003

Infants

(Birth -12 months)

16-18 hours 13.9-14.2 hours

Toddlers and Pre-school

1-5 years

11-12 hours 11.4-13.5 hours

School Age

6-10 years

>/=10 hours 9.9-11 hours

Teenagers

12-18

8.5-10 hours 8.1-9.6 hours

Table 1. Estimated Normative Values for Total Sleep Time Form Birth to 18 years. * https://www.nhlbi.nih.gov/health/health-topics/topics/sdd/howmuch

Child and Adolescent Sleep Patterns

420

430

440

450

460

470

480

490

Sun Mon Tue Wed Thu Fri Sat

DAY

Tota

l Sle

ep T

ime

(min

)

African American Children – Ages 6-18 (n=42)

Alfano C, et al. Sleep (2007) Abstract Supplement, 30: p. A96

Sleep Academic Award, Gerald Rosen

Process Sleep

Process Clock

Sleep Academic Award, Gerald Rosen

Process S Sleep Homeostatic

Process C Circadian

Reduced homeostatic drive

1st sleep

2nd sleep

Accidents by Time of Day

Sleep Academic Award, Mark Muhowald

What Mediates Sleep Propensity and Wakefulness

Bio-history of the sleep wake system

Light

Lifestyle choices Drugs/alcohol

Vigilance

Social/workplace

Sleep and Circadian Health Effects

• Metabolic regulation and energy expenditure

• Physical restoration • Tissue repair • Neuronal recalibration • Memory consolidation

MS – Sleep and Start Times

Presenting Complaints

• He never sleeps and does not nap during the day

• The F*bit Confirms she never sleeps

• He is exhausted and falls asleep during the day but sleep 11 hours at night

• Her Sleep Quality is terrible!

Insomnia: Essential Features

“Frequent and persistent difficulty initiating or maintaining sleep that results in general sleep dissatisfaction…despite adequate sleep opportunity” International Classification of Sleep Disorders, 3rd Edition., American Academy of Sleep Medicine, Darien, Illinois (2014), p. 23

Daytime Impairment

• Daytime impairment: – Adults – fatigue, decreased mood or

irritability, general malaise, cognitive impairment, social and vocational impairment and poor quality of life

– Children - poor school performance, impaired attention and behavioral disturbance

Differential Diagnosis

• Delayed Sleep Phase Syndrome (DSPS) ability to sleep during preferred phase

• Environmental cause • Insufficient Sleep Syndrome • Other sleep disorders • Rule out medical causes

Sleep Hygiene

– Establish Sleep as a priority (time limited) – Regular bed & wake times – Regulate napping – Eliminate or regulate caffeine habit – Eliminate stimulating behavior before bedtime – No electronic media use within a half hour of

bedtime • Negotiation point

– Quiet time & close time – Establish an early evening worry time

Sleep Education

– Optimal sleep duration by age 6-8:10.5-11h; 9-11: 10-11h; 12-14 9.5-10.5h; 15-18: 8.5-10h.

– Optimal sleep schedule by age 6-8:7:30-8:30; 9-11: 8:00-9:30; 12-14 9:00-10:30; 15-18: 10:00-11:30.

– Two process model of sleep – Regulation of napping – Sleep continuity

http://www.bbc.com/news/magazine-16964783

Stimulus Control

• Dissociate stimulus (e.g., bed) associated with frustration/activation

• Modifications for children and teens – Thoughtful planning – Analysis of cues (extrinsic – clock, bed, light) – Analysis of cues (intrinsic – Anxiety,

rumination, faulty assumptions) • Side of the bed test (sleep state

misperception)

Cognition

– Address sleep-related misconceptions, predictions, and myths

– Tools to decrease cognitive arousal • Cognitive therapy (recording, neutralizing and

topping thoughts) • Mindfulness based interventions • Byron Katie the Little book (4 questions: True? If

not true then? Turn it around. Who would you be without that thought)

– PASS (Positive Affect Stimulation Sustainment) or Savouring (McMack, 2015; Harvey, AG

Sleep Restriction

–Limit TST to weekly average –Setting a fixed sleep window

Relaxation Therapy

– Tools to decrease physiological and cognitive activation • Breathing

–Active and passive • Sensate focusing

– Investigate different channels • Progressive muscle relaxation • Guided imagery • Physically active and physically quiet practices

(yoga, Tai Chi, Karate, running, meditation prayer)

Circadian Rhythm Disorder Delayed Sleep Phase Syndrome

• Definition: A shift of the sleep phase to a later period that conflicts with academic and work schedules & social norms

• Prevalence: affects 7% of adolescents

Social Jetlag

• Sleeping in on weekends does not “make up” for weekday sleep loss • School day function is not improved • Circadian bio-rhythms cannot adjust

• The result is a permanent state of “jet lag” Adjustment takes 1 day/time zone crossed Effects persist up to 3 days Associated with daytime sleepiness, poor academic performance, depressed mood

Case 1 - Recomendations

Session1 • Education • Schedule sleep 12am-8am WD and 1am-

9am WE • No electronics in bedroom • Sleep restriction – 8.5 hours • 15 minute cat naps only! • Eliminate Caffeine after noon • Stimulus control

Mid-sleep time= TST/2 = bedtime ~5am Average TST = 8.9hrs Estimated DLMO – 11pm-12am

Circadian Rhythm Disorder, Delayed Sleep Phase Syndrome: Treatment

• Contract for at least 2 weeks (optimally 6). • Modify involvement in highly rewarding activities at

bedtime • Eliminate naps • Regulate sleep wake Schedule (Social Jet Lag) • Chronotherapy (phase – advance/delay; acute

sleep debt) • Light and temperature • Melatonin • Regular daily schedules

Sleep Aides

Sedative Hpypnotics Antihystamines Anit-depressant Natural Sleep Aids

THANK YOU

Danny Lewin, Ph.D. (Dlewin@CNMC.org) Children’s National Medical Center Department of Pulmonary and Sleep Medicine

Top Sleep Tips • No electronic media in the bedroom and

within an hour of bedtime • Use bed and bedroom for sleep • Regular bedtime routines • Quiet and together time before bedtime • Regular bedtime routine • Comfortable sleep environment • Cut out Caffeine • NEVER DRIVE SLEEP DEPRIVED!

Sleep Resources • National Institutes of Health -

Starsleep.nhlbi.nih.gov • National Sleep Foundation - Sleepfoundation.org • American Academy of Sleep Medicine - AASM.org • A Clinical Guide to Pediatric Sleep: Diagnosis and

Management of Sleep Problems (Jodi Mindell & Judith Owens)

• Sleeping Through the Night – Jodi Mindell • Solve Your Child’s Sleep Problems - Richard

Ferber