1. Adolescents and Sleep David Y. Huang, M.D.
Tallahassee Pulmonary Clinic, P.A.
April 8, 2010

2. Goals
Provide scientific and medical background regarding adolescents and sleep
Allow the community’s educators to look at innovative ideas regarding better sleep for our adolescent students
Provide sleep education in schools
Improve opportunity for students to get adequate sleep each night

3. Disclosures I am a Sleep Medicine Physician I am 6’ 4”
I am married to a beautiful wife and am the father of 4 children
9th grader at Sail
2 sons in middle school
Daughter in elementary school
I am a Leon County Taxpayer
I receive no compensation for being here today
I am not affiliated with the Leon School Board, SAC, or DAC
I realize that these are tough times for all county school budgets
I am a concerned citizen of Leon County and am an Advocate for the 5,000 high school students in Leon County

4. Terminology Adolescent: 13-22 years old Teenager: 13-19 years old
Insufficient sleep syndrome =
Chronic sleep deprivation
Insomnia = difficulty initiating or maintaining sleep = DIMS
Delayed sleep phase syndrome = DSPS (going to bed very late and sleeping very late)

5. Sleep Needs Vary as We Age - Ideal Sleep Times
Newborns/Infants ( months):
hours
Toddlers/Children (12 mo - 12 years):
hours
Adolescents
hours
Young Adults
7 - 9 hours
Older Adults
7 - 8 hours
Sleep needs vary as a function of age.1
Infants or newborn babies (up to 2 months) need hours over a 24-hour cycle. Sleep is definitely a priority for new babies and they need a lot of sleep to grow and develop. Although sleep patterns will change, establishing a regular schedule at this time and putting babies to bed early in the evening helps them get all the sleep they need. From months, the average baby requires hours of sleep. From months, most sleep will occur at night; from months, a baby will be taking 2 naps a day and by 18 months, only 1 nap. Naps are independent of nighttime sleep and just as important.
Around 18 months and during the toddler or pre-school age, children need around hours of sleep. When children reach the age of 5 they need 10 hours at night. Most children give up a nap by the age of 5.
Recent research indicates that adolescents need about as much sleep as when they were younger, a minimum of 8 ½ hours to an average of 9 ¼ hours. Although teens are often involved in more activities that deprive them of sleep and experience a lot of daytime sleepiness, sleep is just as important to their development.
Adults perform best with hours although most adults get between 4 and 10 hours of sleep. Allow yourself to sleep naturally and without waking to an alarm clock, and then observe how you function during the day. You need enough sleep to perform optimally during the day.
Contrary to a common myth, older adults need just as much sleep as younger adults; however, they often have more medical or sleep problems, they often do not sleep as efficiently due to pain, discomfort or disruptions and may not experience as much deep sleep as they age.
1. Mindell J, Owens JA. A clinical guide to pediatric sleep. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003.

6. Adolescents Experience a Shift to a Later Sleep-Wake Cycle
The biological clock of children shifts during adolescence, which drives them to a later bed time (11:30 pm or later) and a natural tendency to wake up later in the morning. Bright light at night can worsen this problem.
This delayed sleep onset (delayed sleep phase) can place them in conflict with their schedules – particularly early school start times.
Contributing to the physical changes that occur as adolescence approaches, teens also experience a biological shift to a later sleep-wake cycle. Interestingly, this biological process is supported by measures of melatonin, a natural hormone secreted in the brain that induces sleep naturally, in teens at different times throughout the day. It was found that, in teens, melatonin is secreted later in the evening – around 11:30 pm or later – and then drops sharply later in the morning. This sleep tendency to later times, often called a “sleep phase delay” puts teens into conflict with typical schedules, particularly early school start times.3
3. Carskadon MA, Wolfson AR, Acebo C, Tzischinsky O, Seifer R. Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep 1998;21(8):

7. Whose Fault Is It?
Thomas Edison
The Light Bulb
The Big Three

8. Adolescent Sleep-Wake Cycle
Childhood circadian phase
Adolescent - Delayed circadian phase
Morning sleepiness and difficulty awakening from sleep
Alert in the evening Delayed sleep onset
Adolescents have a later sleep-wake cycle than young children. They often report difficulty falling asleep and difficulty awakening at the times required by school or work schedules. When responsibilities no longer dictate an early sleep schedule (e.g., summer vacation), the patient has no difficulty sleeping and waking. The preferred scheduling of the major sleep episode is delayed.
The desire to go to bed later and to sleep in later in the morning is related to a shift in internal biological time, as represented by the delay in the timing of the circadian melatonin rhythm (dashed line). This delay in circadian timing is associated with and may be the primary cause of sleep onset insomnia (i.e., patients attempt to go to sleep at a biological time when the circadian clock is promoting wakefulness) and morning sleepiness (i.e., patients awaken at a biological time when the circadian clock is promoting sleep). The phase delay in circadian timing maybe related to biological (circadian physiology) and behavioral (e.g., social activities, increased light exposure in the evening, earlier school start times) changes that occur during adolescence.8
3. Carskadon MA, Wolfson AR, Acebo C, Tzischinsky O, Seifer R. Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep 1998;21(8):
5. Millman RP. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics 2005;115(6):
8. Carskadon MA, Harvey K, Duke P, Anders TF, Litt IF, Dement WC. Pubertal changes in daytime sleepiness. Sleep 1980;2(4):
Normal sleep time
Later Sleep-Wake Cycle

9. Adolescent Sleep-Wake Cycle
Normal circadian melatonin phase
Later circadian melatonin phase
Morning sleepiness difficulty awakening from sleep
Alert in the evening Sleep onset insomnia
Patients with DSPS report difficulty falling asleep and difficulty awakening at the times required by school or work schedules. When responsibilities no longer dictate an early sleep schedule (e.g., summer vacation), the patient has no difficulty sleeping and waking. The preferred scheduling of the major sleep episode is delayed.
The desire to go to bed later and to sleep in later in the morning is related to a shift in internal biological time, as represented by the delay in the timing of the circadian melatonin rhythm (dashed line). This delay in circadian timing is associated with and may be the primary cause of sleep onset insomnia (i.e., patients attempt to go to sleep at a biological time when the circadian clock is promoting wakefulness) and morning sleepiness (i.e., patients awaken at a biological time when the circadian clock is promoting sleep). The phase delay in circadian timing maybe related to biological (circadian physiology) and behavioral (e.g., social activities, increased light exposure in the evening, earlier school start times) changes that occur during adolescence.8
DSPS combined with early school start times is thought to contribute to poor school performance and reduced sleep during the week (open box).3 Inadequate sleep in adolescents is reported to contribute to increase risk of automobile accidents and increased use of caffeine, nicotine and alcohol.5
3. Carskadon MA, Wolfson AR, Acebo C, Tzischinsky O, Seifer R. Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep 1998;21(8):
5. Millman RP. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics 2005;115(6):
8. Carskadon MA, Harvey K, Duke P, Anders TF, Litt IF, Dement WC. Pubertal changes in daytime sleepiness. Sleep 1980;2(4):
Normal sleep time
Delayed sleep time and reduced sleep duration ▬► during the school week
Restricted sleep time with delayed phase
NL sleep time with delayed phase

10. Insufficient Sleep Syndrome
Social pressures
Delayed sleep phase
School start times
Sleep Time
Genetic predisposition
Risk taking behavior including the use and abuse of recreational legal and illegal drugs and alcohol is extremely common in adolescence.11 These behaviors often contribute to problems with daytime sleepiness and are also an additive risk factor for Motor vehicular accidents. Forty percent have tried an illicit drug. Ninety percent of high school students have tried alcohol. Sleep problems are significantly more common in individuals using illicit drugs, alcohol and nicotine. There are an enormous variety of intrinsic and extrinsic factors that influence daily sleep amounts in the adolescent. These factors can affect not only the development of sleep disturbance, but also the development of a variety of awake behavioral problems and psychiatric illness in this population.12
11. Johnson EO, Breslau N. Sleep problems and substance use in adolescence. Drug Alcohol Depend 2001;64(1):1-7.
12. Halbower AC, Marcus CL. Sleep disorders in children. Curr Opin Pulm Med 2003;9(6):471-6.
Substance abuse
Hormonal influence, obesity

11. Trying to Get Enough Sleep
Late bedtime
Sleep restricted
during school
week
Afternoon
napping
Problem with
daytime
alertness
Problem with
daytime
alertness
Adolescent Vicious Cycle
With such busy schedules, the attempt to make up for sleep loss can become a vicious cycle. Adolescents are frequently sleepy in the morning because they wake early for school or other commitments. Sleep inertia causes difficulty becoming alert in time for school or other activities. By afternoon, accumulated sleepiness may result in a nap, which reduces sleep drive. This reduces the drive to sleep, so that adolescents are not sleepy again until later in the evening. As a result, they go bed later, resulting in less sleep. Sleeping in late on Saturday and Sunday morning reduces sleepiness, resulting in even later bedtimes on Sunday night; again causing sleep deprivation at the beginning of the school week. Thus, the vicious cycle continues.
Graphic courtesy of Helene Emsellem, MD, George Washington University.
Sleep restricted
during school
week
Sleep longer on
weekends
Difficulty
initiating sleep
Graphic courtesy of Helene Emsellem, MD, George Washington University.

12. Consequences of Sleep Deprivation
Impaired cognitive, social and behavioral performance.
Poor athletic performance, poor school performance, lower grades
Tardiness and absence from school
Difficulty remaining alert, difficulty being able to focus and concentrate (worse ADHD)
Irritability, impaired mood, and depression.
Increases in substance abuse and in obesity
Drowsy driving, injury, and possibly death.
How many hours of sleep do the Rickards basketball players get each night?
Sleep deprivation has serious consequences for persons of any age.9 Cognitive, social and behavioral performance is impaired and it takes more effort for teens to remain alert, concentrate, make wise decisions and achieve academically. In general, teens that have academic problems or report lower grades tend to sleep less and have irregular sleep patterns. Recent studies indicate that during a good night’s sleep following a learning task, memory is consolidated and performance is improved as compared to those who get less sleep.10 Teens who do not get enough sleep also find it particularly difficult to pay attention during tedious, routine or boring tasks; increasingly so over a longer time period. The drive to remain alert decreases and errors are more likely to be made. Tardiness and absences are sometimes the result of having difficulty getting up in the morning.5
5. Millman RP. Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics 2005;115(6):
9. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003;26(2):
10. Stickgold R, Walker MP. Memory consolidation and reconsolidation: what is the role of sleep? Trends in Neurosciences 2005;28(8):

13. Drowsy Driving and Auto Accidents
Sleep-related crashes are a universal problem33-35 and are most common in young people, who tend to stay up late, sleep too little, and drive at night. A study of fall-asleep crashes using data from North Carolina indicated that in 55% of the crashes the drivers were under the age of 26 and predominantly male. The peak age of occurrence for these crashes was Per mile driven, 16 year olds are 10 times more likely to be involved in a fatal car crash than 30 to 59 year old drivers. Graduated drivers licensing programs have been successful in reducing the rate of fatal crashes in new drivers, and many of these programs include restrictions on night time driving.37
33. Horne JA, Reyner LA. Sleep related vehicle accidents. BMJ 1995;310(6979):565-7.
34. Maycock G. Sleepiness and driving: the experience of heavy goods vehicle drivers in the UK. J Sleep Res 1997;6(4):
35. McCartt AT, Ribner SA, Pack AI, Hammer MC. The scope and nature of the drowsy driving problem in New York State. Accid Anal Prev 1996;28(4):
36. Pack AI, Pack AM, Rodgman E, Cucchiara A, Dinges DF, Schwab CW. Characteristics of crashes attributed to the driver having fallen asleep. Accid Anal Prev 1995;27(6):
37. Chen L-H, Baker SP, Li G. Graduated Driver Licensing Programs and Fatal Crashes of 16-Year-Old Drivers: A National Evaluation. Pediatrics 2006;118(1):56-62.
The peak age for fall-asleep driving accidents is 20 years old
Drivers under 30 account for 2/3 of drowsy-driving crashes.

14. Circadian Rhythm Disorders
Delayed sleep phase syndrome*
Advanced sleep phase syndrome
Irregular sleep-wake disorder
Free running sleep disorder
Shift work disorder
Jet lag disorder
Circadian sleep disorders result from a mismatch between the endogenous rhythm of sleep and alertness, and the desired or expected schedule. The ICSD-221 defines 6 primary circadian rhythm sleep disorders. The general diagnostic criteria include sleep disturbance due to “alterations of the circadian timekeeping system or misalignment between the endogenous circadian rhythm and exogenous factors that affect the timing or duration of sleep.” The criteria also require insomnia, daytime sleepiness or both as well as impairment of daytime functioning. Delayed sleep phase syndrome (DSPS) is the most common disorder in adolescents. The reported prevalence is between 7% and 16%.
21. American Academy of Sleep Medicine. International classification of sleep disorders. 2 ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
* Very common in adolescents

15. Treatment of Delayed Sleep Phase Syndrome with Bright Light Exposure
Goal of treatment is to shift circadian melatonin phase and bedtime to an earlier time
Evening reduced exposure to light
Morning exposure to bright light
Three main therapies for delayed sleep phase have been described: chronotherapy, or progressive delay of sleep onset; bright light therapy, using strategically timed light pulses to phase shift the sleep cycle; and melatonin, used either as a phase shifting agent or as a hypnotic.29 The current literature is limited, with few controlled trials and no head-to-head comparisons of the three treatments. Timing of the treatment, especially bright light and melatonin, may have a significant effect on the results.30
29. Wyatt JK. Delayed sleep phase syndrome: Pathophysiology and treatment options. Sleep 2004;27(6):
30. Mundey K, Benloucif S, Harsanyi K, Dubocovich ML, Zee PC. Phase-dependent treatment of delayed sleep phase syndrome with melatonin. Sleep 2005;28(10):
- Delayed sleep phase syndrome
- Restricted sleep with delayed phase
- Normal sleep

16. Treating Adolescent Delayed Sleep Phase Syndrome
Bright light exposure in the morning
Darkness in the evening
Cognitive Behavioral Therapy
Learning the importance of sleep
Resetting habits and associations
Pharmacologic treatment in the evening
Melatonin
Hypnotics
Adolescents with DSPS affecting daytime function are often treated with light therapy and behavioral – cognitive therapy. A small scale trial of light therapy in seasonal affective disorder reported improvements in depression scales.27 The use of medication in adolescents is more controversial since few hypnotics are currently indicated for use in individuals less than 16 years of age. Melatonin has shown good effectiveness in adolescent DSPS (specifically reductions of onset latency28), however, it is a neuro-hormone with potential side effects that have not been studied in the adolescent population.
27. Swedo SE, Allen AJ, Glod CA, et al. A controlled trial of light therapy for the treatment of pediatric seasonal affective disorder. J Am Acad Child Adolesc Psychiatry 1997;36(6):
28. Weiss MD, Wasdell MB, Bomben MM, Rea KJ, Freeman RD. Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 2006;45(5):512-9.

17. Advocacy Issue: Sleep Curriculum
Educators, parents, and many health care providers receive little training about the physiology and importance of sleep.
Very few schools offer information regarding sleep to their students or include sleep education in the health or science curriculum.
We must teach our adolescents the importance of getting sufficient sleep!
Because sleep is not typically part of any health or education training, most educators, parents, health care professionals such as school nurses as well as teens are not aware of their sleep needs and patterns. Many studies indicate that most people are not aware of daytime sleepiness, nor do they link it to nighttime sleep.
Integrating sleep into existing courses such as biology, health, psychology, math, social studies, geography, or English, providing special sessions on the physiology and association of sleep to health, development and function would encourage teens as well as parents and teachers to practice healthy sleep habits and become aware of the importance of sleep on their lives. A sleep curriculum for high schools is available and more information can be found at the NIH website:

18. Advocacy Issue: School Start Times
High school and middle school start times tend to be early - interrupting adolescents’ sleep patterns - and making it difficult to wake up and be alert.
Symptoms are worst in the morning.
Students are often living with the consequences of sleep deprivation throughout the day.
Schools can play an important role in addressing teenagers’ sleep needs and some of these sleep problems. How aware are school officials and personnel of the effects of early school start times on adolescent sleep and teens’ shift to a later sleep-wake cycle? In recent years, high school start times in many areas have become earlier. And as noted previously, this can cause students to rise with difficulty and before getting sufficient sleep. Teachers report that students walk in like zombies, are not alert in the morning and are not receptive to instruction. Because students are still sleepy, the opportunity to learn and achieve is reduced. The sleep deprivation that most teens experience affects all aspects of their lives in school, at work, during sports and with friends and family.

19. Positive Outcomes from Minnesota Schools – After Change to 8:40 Start Time
Teachers report more alert students.
Students report less sleepiness and better grades.
Fewer students are seeking help from school counselors or nurses.
Parents report more “connect time” and their teens are easier to live with.
Tardiness and sick days declined.
JAMA article on Later HS Start Times, June 2009
A pioneer in this effort was the Edina, Minnesota school district, the first in the nation to change its high school start time from 7:20-8:30 am beginning in the fall of 1996, followed by Minneapolis the following year from 7:15-8:40 am; both were in response to the research, and represented a stable, suburban, high socioeconomic district and an urban, lower economic district, respectively. To assess this change, the Center for Applied Research and Education Improvement (CAREI) at the University of Minnesota gathered data, compiled testimonials and conducted multiple surveys to identify the outcomes.
An executive summary was published in indicating that teachers surveyed reported more alert students in the morning, although not all teachers were pleased with later dismissal times. Fewer students were falling asleep. In Edina, students reported that they were getting more sleep, experiencing less sleepiness and depression and getting better grades. School nurses and counselors also reported that fewer students were seeking help for physical complaints or stress. Parents were also positive, reporting more enjoyable time with teens. And Edina Superintendent Kenneth Dragseth reported that both “attendance and tardiness has improved.”
61. School Start Time Study Final Report Summary (Accessed 09/27/2006, at

20. Helping Schools Become Sleep-Friendly
Many high schools across the country are establishing later start times to get in sync with a teen’s sleep schedule
Several studies cite the positive outcomes of “sleep-friendly” high school start time policies.
Early Bird Gets the Bad Grade - NY Times, 2008
Schools often face the challenge of considering policy changes regarding school start times, which would work more closely with students’ natural sleep schedules and also contribute to the learning process.63 When surveyed, both parents and teachers identified 8:00 am or later as the ideal time to start school. Yet, a significant proportion of American high schools start before 8:00 am. To date, many schools have adopted even later times with positive results.
63. Wahlstrom KL. Accommodating the sleep patterns of adolescents within current educational structures: An uncharted path. In: Carskadon MA, ed. Adolescent sleep patterns: Biological, social and psychological influences. New York, NY: Cambridge University Press; 2002:

21. Dim the Lights and Say No to TV and Computer after 8 pm

22. What’s Next - Innovative Ideas for Better Sleep
Time to digest this information (short time)
Add sleep education to student curriculum and parent curriculum
Change standardized testing from 8 a.m. to 10 a.m. for high schools and middle schools
Set up a task force or committee to evaluate the optimal school start times
Invite Ronnie Youngblood to be on the committee
Decide where this falls on the priority list of funding
Can Leon County be a leader re school start times