Dr. Alanna Hare answers an email from a concerned parent, discussing the effect of sleep deprivation and delayed sleep phase disorder on teenagers.

Q & A with Dr. Alanna Hare – ‘My daughter can’t get to sleep before 5am’


For the past 12 months, my 14 year old daughter hasn’t been able to get to sleep before 5am. If left alone, she then sleeps until midday. This is particularly rare however, as she has to get to school by 9am each weekday morning.

My research suggests that she may have delayed sleep phase disorder. Do you think this is a possibility? I have desperately tried to get appointments at my local hospital via my GP, but so far, they have refused her an appointment, suggesting instead that she is treated in the local community. Even then however, our GP doesn’t seem to know what to do.

What options do we have?


 

Difficulties getting to sleep can be worrying and stressful, both for the individual experiencing the sleep problem, and for their families and partners.

The first thing to understand is that sleep changes during childhood and adolescence (and indeed, continues to change during adulthood). The proportion of REM (dream) sleep is reduced and there is a marked increase in non-REM deep sleep, which peaks just before puberty. These changes in sleep patterns during childhood are important for brain development.

Laptop on, in a dark room
According to NHS data from 2017, hospital attendances in England for children with sleep disorders has tripled in only 10 years

In addition, during early and late adolescence, important and significant changes in circadian rhythms take place. Whilst young children will fall asleep and wake up earlier than older children and adults, during puberty the timings shift, so much so that the vast majority of adolescents possess a rhythm which is generally shifted further forward than even their parents. This means that teenagers are often wide awake at 11pm, and may not begin to feel ready for sleep until midnight or later.

This shift means that teenagers are often inclined to still be sleeping at 7am, when their parents and teachers require them to be up and getting ready for the school day. This powerful biological drive to sleep later, and sleep more, can cause significant distress to both the adolescent and their parents. After all, the timing of the school day means that adolescents will often be enormously sleep deprived, as they can’t possibly fall asleep earlier, but must wake for the school day after only a few hours of sleep.

Nevertheless, in the case described above, there is a more significant shift in the sleep schedule than is usually expected, meaning that your daughter is experiencing a drastically reduced sleep opportunity, and is persistently having to get up just a few hours after she has fallen asleep. And then, when she is allowed to sleep at weekends, she naturally sleeps through until the late morning or early afternoon. This type of sleep pattern is referred to as delayed sleep phase disorder or DSPD.

Girl in bed, upset whilst holding cup of tea or coffee. Dr. Alanna Hare recommends scheduling "worry time" each evening, to prevent rumination before bedtime.
Sleep deprivation and depression and/or anxiety, will often work as part of a vicious circle, simply reaffirming the symptoms of one another. 

In this case, I would recommend keeping a detailed sleep diary for at least 2 weeks. Some good diaries can be downloaded from the internet, and there are numerous apps available for smartphones that can help with this. The diary should be completed as soon as possible after waking each day, to ensure an accurate record. In this diary, any and all medications taken should also be noted, along with their timings, and a note should be made of any intake of caffeine (which should be entirely avoided in young children!).

Some initial steps to take at home which may also be helpful in cases of delayed sleep are:

  1. Reducing screen time, particularly in the 60 minutes or so before bedtime. Smartphones and tablet devices in particular emit a blue wavelength of light which is a powerful inhibitor of the brain’s sleep-inducing hormone, melatonin. This can be very significant in terms of delaying sleep onset. I prefer to avoid these devices altogether before sleep, rather than use a “red-light filter” as the stimulation of browsing social media and emails can also mean that the brain is just too stimulated to sleep.
  2. Ensuring the bedroom is quiet, dark and cool. Light and noise can prevent sleep, and an overly warm bedroom can also impact on sleep quality. Blackout blinds may help, particularly in the summer months.
  3. Encouraging talking about any worries, particularly around school and friendships in this age group. This can be a challenging time, particularly for young girls, and anxiety can prevent decent, high-quality sleep. Scheduling in “worry time” away from bedtime and the bedroom can be helpful, as can writing down our worries or fears. If anxiety is troublesome, consider speaking to the school, your GP or requesting a referral for expert support.
  4. Encouraging some exercise in the daytime (but not within 2 hours of the desired bedtime).
  5. Getting some bright, ideally day-light, every morning, and encouraging dim-light conditions in the hour or so before bedtime to re-establish a more congruent circadian rhythm.

If despite all these measures, sleep is still not forthcoming until the early hours of the morning, it’s really important that expert advice is sought from a sleep physician as soon as possible. Treatment will usually involve the use of timed Bright Light Therapy (much brighter than our usual lightbulbs), as well as carefully-timed and adjusted melatonin, each of which have been proven to help readjust the circadian rhythms to more manageable schedules.

Dr. Alanna Hare is a Consultant in sleep and ventilation at Royal Brompton Hospital, and myza’s very own expert-in-residence, offering the very best in sleep tips on our Expert Advice page. 

If you want to ask Dr. Hare anything (and we mean, anything) about sleep, we would love to hear from you! Just send your questions to editorial@myza.co.

Author

Dr Alanna Hare

MA (Cantab) MB BS MEd MRCP Consultant Physician & Specialist in Sleep Medicine

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