This document discusses sleep disorders in adolescents. It begins with an overview of common psychiatric conditions that are often comorbid with sleep problems like ADHD, autism, anxiety, and mood disorders. Next, it presents a clinical case of Maria, a 16-year-old with increasing truancy and indifference who is having trouble falling asleep and waking up. The document then provides theory on sleep-wake regulation and the functions of sleep. It describes the most common adolescent sleep disorders - insomnia and delayed sleep phase syndrome - and discusses diagnostic tools and treatment approaches like cognitive behavioral therapy and melatonin.

1. Reino Stoffelsen, child and adolescent psychiatrist (VUmcde Bascule, Amsterdam)
Anna van Spanje, senior policy officer (Dutch Knowledge Centre for Child and
Adolescent Psychiatry, Utrecht)
ESCAP, Madrid, June 20th 2015
Not getting out of bed…
A lazy adolescent, or…a sleep disorder?!

2. None
Conflicts of interest

3. • Ed de Bruin, clinical neuropsychologist and researcher,
University of Amsterdam (UvA)
• Jeannette Hop, child and adolescent psychiatrist, Altrecht
Thanks to

4. Introduction

5. Child psychiatry Sleep
ADHD
Autism
Anxiety
Eating disorder
Conduct disorder
Depression
Bipolar disorder
Psychosis
etc…
Insomnia
Hypersomnia
Circadian rhythm
sleep disorder
Breathing-related
sleep disorder
Parasomnias
Restless legs
etc…
?

6. Prevalence
In adolescents with…
…ADHD: 50-80% (Van der Heijden et al., 2005; Owens, 2008; Cortese et al., 2009)
…Autism: 50-80% (Richdale & Schreck, 2009)
…Mood disorders: one of the diagnostic criteria
…Anxiety disorders: 90% approx. (Cortese et al., 2014)

7. ADHD
Autism
Anxiety
Eating disorder
Conduct disorder
Depression
Bipolar disorder
Psychosis
etc…
Insomnia
Hypersomnia
Circadian rhythm sleep
disorder
Breathing-related sleep
disorder
Parasomnias
Restless legs
etc…
Child psychiatry Sleep
!
Corkum et al., 2011; Goodlin-Jones et al., 2009

8. Child psychiatry Sleep
Symptoms
Sleep disorder?
Depression?
Demoralised
adolescent?
* difficulty concentrating
* hyperactive behaviour
* worse school performance
* truancy
* loss of energy
* apathy
* depressed mood
* irritability
* nervousness
* fatigue

9. Today’s workshop
• Introduction
• Clinical case
• Theory: the two most common sleep disorders
in adolescence
• Diagnostics: tips & tricks
• Treatment
• Discussion

10. Clinical case: Maria
Discuss:
• Have you seen these symptoms in your own
clinical practice?
• What is your differential diagnosis?
• What would your next step be?

11. Summary clinical case
• Maria, age 16 years, increasing truancy,
indifferent attitude
• Since some months trouble falling asleep, hard
to awaken, doesn’t sleep in at weekends
• Tired, attention-concentration problems,
weaker performance
• Little interest in doing anything, irritable

12. Theory

13. Sleep-wake regulation
Sleep homeostasis and circadian rhythm (biological clock)
(nucleus suprachiasmaticus)
Process S – drive to sleep | Process C – drive to stay awake

14. Sleep-wake regulation
Sleep homeostasis and circadian rhythm (biological clock)
(nucleus suprachiasmaticus)
Process S – drive to sleep | Process C – drive to stay awake

15. Sleep-wake regulation
Sleep homeostasis and circadian rhythm (biological clock)
(nucleus suprachiasmaticus)
Process S – drive to sleep | Process C – drive to stay awake

16. Sleep-wake regulation
Sleep homeostasis and circadian rhythm (biological clock)
(nucleus suprachiasmaticus)
Process S – drive to sleep | Process C – drive to stay awake

17. Sleep-wake regulation
Sleep homeostasis and circadian rhythm (biological clock)
(Day-)light is very important in synchronising process C (biological clock)

18. Sleep stages
• Sleep cycle ~ 90 min.
• Beginning of the night: More deep sleep – rest, recovery, etc.
• End of the night: More REM sleep – processing, memory, etc.
• Deep sleep changes with time of falling asleep – REM does not
~ 90 min. ~ 90 min. ~ 90 min. …

19. The functions of sleep
• Rest (energy saving)
• Recovery (e.g., immune system): Necessary
for daily functioning and survival
• Growth (brain cells, body)
• Memory processes (brain reorganisation)

20. Hour of falling asleep
• Shifts in youth – starting at puberty – to a later
hour.
• Preference for later bedtime
• Get tired at a later hour
• Wake up at a later hour (!)
• Very prone to sleeplessness (insomnia)

21. Sleep and age
•Bed time shifts to later hours (more ‘evening
persons’)
•Less sleep during the day from birth to 5 years
•Starting at 50 years, more interruptions / light
sleep
•Decrease in sleep quantity
•Cultural differences?

22. Prevalence of sleep problems
(adolescents)
• 45% sleeps less than 8 hours per night,
9% less than 6 hours; even though sleeping a
minimum of 9 hours seems required for
functioning well during the day.
• 20% to 50% experiences sleepiness during the
day.
• 11% to 47% has trouble falling asleep and
staying asleep.

23. Consequences
• Behavioural problems (e.g. hyperactivity and ADHD,
impulsiveness, aggressive behaviour)
• Learning problems (e.g. attention, concentration, motivation)
• Emotional problems (e.g. irritability, anxiety, depression, mood
swings)
• Worse school performance
• Somatic complaints (e.g. fatigue, headache, stress)
• Other long term problems? (Still unclear – possible relations
with obesity and diabetes)
Sleep problems have consequences for the entire family
Astill et al., 2012; Dewald et al., 2010; Meijer et al., 2010; Bell & Belsky, 2008

24. Sleep disorders (DSM-5)
• Insomnia disorder
• Hypersomnolence disorder
• Breathing-related sleep disorders
• Circadian rhythm sleep-wake disorders
(Delayed sleep phase syndrome; DSPS)
• Parasomnias / PLMD (ICSD-2)

25. Insomnia disorder (DSM-5)
• Trouble falling asleep
• Trouble staying asleep (awake often and long
periods at night, wake up early and not fall
asleep again)
• Or: not feeling rested in the morning (sleep
quality)
• > 3 days /week and > 3 months

26. Circadian Rhythm Sleep-Wake Disorders (DSM-5)
Delayed sleep phase type
DSPS: delayed sleep phase syndrome
The sleep-wake rhythm and the environmental rhythm are
not in sync.
• Delayed sleep phase type (DSPS): internal circadian
pacemaker is delayed (> 2 hours later than average)
• Frequent in puberty (7% of adolescents)
• Changes in circadian rhythms (e.g. body temperature, melatonin
release) x social factors
• Week-weekend differences (jetlag-like symptoms)
• Similar to insomnia – much trouble falling asleep.
Difference: (being able to) sleep in until late

27. Circadian rhythm sleep disorder

28. Disrupted biological clock

29. Diagnostics

30. Diagnostics
• Anamnesis parents/child – age specific factors
• Sleep diary +/- actiwatch
• Questionnaires
• DLMO
• PSG / Video registration

31. History taking (screening)
History - screening: (answers: yes/no, and how often and how long?)
• Are there problems falling asleep?
• Are there problems staying asleep? (waking up often and/or having trouble falling
asleep after waking up)
• Waking up early and not being able to fall asleep again?
• Not feeling rested after sleeping?
• Unusual behaviour at night?
Impairments (fatigue, little energy, trouble with concentration / memory,
mood problems, behavioural problems, achieve less, social problems,
parent/child interaction problems)
If “yes”  proceed to profound consult
Assumption insomnia (DSM-5): if more than 3 nights per week, during
3 months

32. History taking (in-depth)
1. Quantitative:
• Sleep hours, rhythm, on weekdays / weekends / days off / holidays
• Moments awake at night?
• Naps during the day? Falling asleep suddenly during the day?
• Duration sleep problems? Developmental aspects? (e.g. separations /
magical thinking)
2. Subjective experience sleep (quality) +
functioning during the day (e.g. tired / irritable);
Subjective experience required sleep

33. History taking (in-depth)
3. Sleep hygiene, incl. aspects bedroom;
specifically gaming, internet, telephone, TV
4. Parasomnia (unusual behaviour at night)
• Nightmares, snoring, anxiety / anger, sleepwalking, talking, moving,
teeth grinding, wetting the bed
• Moment at night, memory, responsive yes/no
• Nightly epilepsy? (responsiveness / memory)

34. History taking (in-depth)
5. Activity pattern during the day? Hobbies
6. Family anamnesis (chronotype, other sleep
problems)
7. What has been tried, and did it work? (parents
and/or child)
What is the (further) parent/child interaction like?

35. History taking (in-depth)
8. Anxiety / stress / worry (sleep-related or not) /
mood / trauma
9. Somatic problems (current / previous)
10. Medication and substance use

36. Additional diagnostics
• Actigraphy
• Polysomnography
• Determine melatonin levels

37. Take home message
Child and
Adolescent
Psychiatry
Sleep

38. Diagnostics on both levels!
Child and
Adolescent
Psychiatry
Sleep

39. Treatment (1)

40. Cognitive Behavioural Therapy
for Insomnia (CBT-I)
• Behaviour: tackle habits and other behaviours that
disrupt sleep.
• Sleep hygiene, explain purpose and functioning of sleep
• Limit time spend in bed
• Stimulus control
• Cognition: tackle thoughts and sentiments that disrupt
sleep.
• Cognitive restructuring
• Stress reduction and relaxation
First choice for treatment insomnia, effective in both short and
long term (Morin, 1999; Morgenthaler et al., 2006; De Bruin et al., 2013)

41. Treatment of insomnia in adolescents
Sleep education
Explain functions of sleep (recovery, growth, energy, memory)
Explain structure of sleep, personal need, specifically for youth (melatonin)
Sleep hygiene
Context: temperature, sound, light.
Behaviour: bed time, naps during the day, exercise, caffeine, tobacco use, alcohol, food.
Sleep restriction / Sleep window – restrict time in bed
Sleep efficiency = (hours of sleep / time in bed)*100. For example, 8 hours in bed, 6 hours sleep: (6/8)*100 = 75% -
ideal is >90%.
Sleep window as aforementioned, e.g. go to bed at 23:00, get up at 5:30. Add 15-30 minutes with good sleep
efficiency.
Rationale: less time in bed, increasing sleep pressure, higher percentage of sleeping in bed, faith in sleep recovers.
Stimulus control
If more than 30 minutes awake in bed, get up, sit quietly in another room until sleepy, then go back to bed.
Rationale: disconnect association bed/bedroom and not sleeping.
Cognitive restructuring
Change dysfunctional cognitions (if I don’t sleep now, I have to cancel everything tomorrow) into functional ones (if I
don’t sleep now, I can still attend my appointments tomorrow), via thought schedule and challenging dysfunctional
thought (is it always true, does it happen to others, do others also think this applies to me, how bad is it if it is true some
time?)
Rationale: disrupting thoughts keep you awake, helping thoughts break tension and vicious worry-cycle.
Stress reduction/Relaxation For example body scan, progressive muscle relaxation, etc.

42. Treatment (2)

43. Treatment principles DSPS
3 pillars:
1. Zeitgebers: fixed times
2. Morning light >10.000 lux
3. Melatonin
• Sleep hygiene
• Much psycho education
• Discipline / Motivation

44. Melatonin
• Drug store: 0,1 mg
• Pharmacy: 1-5 mg
• Is being taken and prescribed
(too) much
• Know what you prescribe and
for which indication!

45. Melatonin: pharmacokinetics
• Tmax 1 hour
• Receptors ML 1 and ML 2
in SCN
• Hypnotic effect (30-60 min)
• Chronobiotic effect (5 hours
before DLMO)

46. Melatonin: phase response curve
Melatonin
10 hours after melatonin onset
Melatonin
5 hours before
melatonin onset
Lewy et al. (1980)
Science, 210:1267-9

47. Time of intake with DSPS
• 5 hours before DLMO: determine preferably
• In practice 18:00-20.00 hours
• Not: ½ hours AN
• Hypnotic effect
• Level too high in the morning
• Physiological dose 0,1 and 1 mg

48. Remember:
• Melatonin: timing is essential!
• <10 yrs: +/- 18.00 hours
• 10-16 yrs: +/- 19.00 hours
• >16 yrs: +/- 20.00 hours
• Start with low dosage
• <10 yrs: 0.5-1.0 mg
• 10-16 yrs: 1.0-2.0 mg to max. 3 mg
• >16 yrs: 1.0-3.0 mg to max. 5 mg
• Don’t go too high when the effect is insufficient!

49. Prescribe melatonin with /
without DLMO?
• Decide for yourself: no guideline
• Pragmatic
• Costs
• Logistics
• Be aware of your own actions:
• Off label
• No reimbursement
• Little research into long term side effects

50. Again:
Treatment principles DSPS
3 pillars:
1. Zeitgebers: fixed times
2. Morning light >10.000 lux
3. Melatonin
• Sleep hygiene
• Much psycho education
• Discipline / Motivation

51. Discussion
• Do you recognise the symptoms in your own
patients?
• Are there cultural differences in what people
consider ‘sleep problems’?

52. Anna van Spanje
a.vanspanje@kenniscentrum-kjp.nl
Reino Stoffelsen
r.stoffelsen@debascule.com