Adolescent Sleep Daniel S. Lewin, Ph.D., D,ABSM Associate Director, - PowerPoint PPT Presentation

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 3 Stage REM

Stage 3: Non REM Sleep Neurons of CCx firing is slow & synchronized Inhibition of centers of the RAS (Pons, Medulla & Raphae Nuclei), Serotonergic pathways from the RAS to thalamus & hypothalamus initiate delta activity in the cerebral cortex

REM Sleep Desynchronization of thalamacortical pathway broad activation of CCx Inhibition of the Raphae Activation of the and locus ceruleus pontine nucleus through cholinergic Hyperpolarization of and glutamic Motor neurons resulting pathways in broad atonia

Hypnogram Sleep Stage Distribution Wake REM Stage 1 Stage 2 Stage 3 Time 2200 2400 200 400 600 800 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 Population Study Age group National Institutes of Switzerland {Iglowstein, 2003 Health 13.9-14.2 hours Infants 16-18 hours (Birth -12 months) 11.4-13.5 hours Toddlers and Pre-school 11-12 hours 1-5 years 9.9-11 hours School Age >/=10 hours 6-10 years 8.1-9.6 hours Teenagers 8.5-10 hours 12-18 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 African American Children – Ages 6-18 (n=42) 490 480 Total Sleep Time (min) 470 460 450 440 430 420 Sun Mon Tue Wed Thu Fri Sat DAY Alfano C, et al. Sleep (2007) Abstract Supplement, 30: p. A96

Process Sleep Process Clock Sleep Academic Award, Gerald Rosen

Process S Sleep Reduced Homeostatic homeostatic drive 1 st sleep 2nd sleep Process C Circadian Sleep Academic Award, Gerald Rosen

Accidents by Time of Day Sleep Academic Award, Mark Muhowald

What Mediates Sleep Propensity and Wakefulness Bio-history of the sleep wake system Lifestyle choices Drugs/alcohol Light Social/workplace Vigilance

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, 3 rd 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

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

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 - Star sleep .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