2. Dr. Colin M Shapiro MBBCh, PhD, MRC Psych. FRCP(C) Professor, Department of Psychiatry and Opthalmology University of Toronto Director, Sleep and Alertness Clinic Youthdale Child & Adolescent Sleep Centre

4. Adam and Oswald: Clinical Science 1983, 65, 561 In nocturnal animals peak rates of RNA and protein synthesis, RNA and protein content of cells, number of cells and growth rates occur at the time when sleep predominates i.e., during the light period. * * Each star represents a published report ****** **** **** ** **** **** **** * ******** ******** ****************** ************** ************************** Activity PeriodSleeping Period 1800h2400h0600h1200h1800h

5. LIFE - Cycle and Sleep Composition of Sleep 16 14 12 10 8 6 4 2 REM DEEP LIGHT Newborn 16 hrs. avg. Young Adult 8 hrs. avg. Adult 7 hrs. avg. Elderly 6 hrs. avg. 50% 25% 24% 1% 26% 19% 53% 2% 18% 5% 62% 5% WAKE 25% 11% 61% 3%

6. INSOMNIA  Difficulty Falling asleep  Can’t Stay asleep (keep waking up)  Wake up too Early in the morning  Sleep is not Refreshing INSOMNIA  Difficulty Falling asleep  Can’t Stay asleep (keep waking up)  Wake up too Early in the morning  Sleep is not Refreshing  Can affect up to as many as 1 in 5 teens  Signs: always Fatigued; Drinking too much Caffeine; Inattention; Irritable; Lack of Get-up and Go

7. Melatonin secreted by the pineal gland melatonin is produced to help our bodies regulate our sleep-wake cycles Darkness stimulates the release of melatonin and light suppresses its activity melatonin cycles are disrupted when we are exposed to excessive light in the evening or too little light during the daytime

8. Difficulty with sleep onset at desired time Once initiated, sleep is normal Most common CRSD referral Population data lacking Population estimates of prevalence of 0.17 – 0.25% Prevalence increases to >15% amongst adolescents Insomniacs: 10% Positive family history

9. Sleepiness in Seattle & Toronto You are here Your body clock is in Vancouver

10. Melatonin Bright Light Therapy Chronotherapy+ Behavioural Strategies

11. 1921Midnight369Noon Normal Sleep Phase DSPD Phase ADVANCE Melatonin “pulls” sleep time forward Light “pushes” it away/forward

12. Sleep Period Chronotherapy Light Application

13. Sleep Period PM Melatonin Administration AM Melatonin Administration

14. Lifestyle changes Sleep hygiene guidelines Changing attitude

18. Rahman, Kayumov,Casper & Shapiro Patient with phase delay are more likely to develop depression! 2010

22. School-related Symptoms of Youth Depression Poor performance in school, truancy, tardiness Withdrawal from school activities/peer groups Lack of enthusiasm, energy or motivation Globalized anger and rage Overreaction to criticism, increased self-criticism Indecision, lack of concentration or forgetfulness Restlessness and agitation Problems with authority Suicidal thoughts or actions (e.g., cleaning out locker, giving away items)

23. Fear of failure social rejection bodily sickness bullying or abuse childhood memories thoughts of a better life separation with family worries about the future

24. This booklet was distributed to parents, school boards, family doctors, group practice and social workers. Response was positive and helped families in particular to accept the diagnosis and initiate treatment specifically.

25. Parents and health professionals were able to recognize the behavior in the children after reading this booklet. This educational tool also helped in the early recognition, detection and assessment of depression in children and teenagers at the sleep clinic.

27. Active investigation into markers of circadian phase in humans Two currently utilized markers Core body temperature Dim light melatonin onset (DLMO)

28. Measurement of markers difficult Melatonin secretion very sensitive to light exposure Samples need to be obtained under dim light conditions Core body temperature altered by: ● activity ●food intake ●sleep

29. Melatonin (pg/ml) Time of Day Increase in levels begin between 6:00 pm & 9:30 pm (DLMO) Levels peak approximately 3:00 am & begin to decrease Lowest levels just before awakening

30. Melatonin pg/ml Time

31. Melatonin pg/ml Time

32. Melatonin pg/ml DSPD Normal Time

33. Melatonin pg/ml DSPD Approx 5 hours Melatonin DLMO

34. CT min approx 2hrs before habitual wake time HABITUAL WAKE UP TIME ( ~11:00 a.m.)

35. See also Ottawa slides on ADHD and Tourette’s Syndrome