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. ([email protected]) 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
