Sleeping through the night is a hot topic in pediatrics, so it was no surprise that there was a standing-room-only crowd for a lecture on it at the national conference of the American Academy of Pediatrics in New Orleans over the weekend.
The speaker, Dr. Adiaha I.A. Spinks-Franklin, a developmental behavioral pediatrician, did her training at Children’s Hospital, Boston, where her teachers included the pediatric sleep expert, Dr. Richard Ferber, whose name has become a verb: “we Ferberized our baby.”
But Dr. Spinks-Franklin, an associate professor of pediatrics at Baylor College of Medicine, wasn’t talking about the burning question of whether to let babies cry. In her presentation, “Strategies to Help Sleepless Teens,” she started by reviewing the factors that can contribute to inadequate sleep in adolescents: social media and electronic devices in the bedroom. Intensely caffeinated drinks. The pressures of heavily overloaded schedules, including academic demands, extracurricular activities, travel sports teams, jobs and social lives.
The biology of adolescent sleep reflects a natural and normal delay in melatonin secretion that leads to a later sleep onset time, which unfortunately coincides with early high school start times, creating a high-stress set up. Pediatricians often see adolescents with insomnia, who have trouble falling asleep or staying asleep, waking up too early or finding sleep not restful or refreshing.
Evaluating insomnia in an adolescents means looking at the predisposing factors, she said, including how that adolescent responds to stress, and possible genetic influences, and the precipitating factors — the specific triggers for insomnia — and finally, the perpetuating factors, which can keep the pattern going.
All these adolescents should be screened for depression and anxiety, Dr. Spinks-Franklin said; both can affect sleep onset or sleep maintenance. And both are alarmingly common in adolescents.
Chronic sleep deprivation can be caused by depression or anxiety, but it can also put kids at risk for depression and anxiety, as well as for obesity and diabetes.
And more immediately, it can mean that teenagers are not performing at their best, whether academically, in sports or behind the wheel of a car.
“I talk about sleep as being every bit as important as making sure they stay hydrated,” Dr. Spinks-Franklin said. “I say, something has to give, your academic performance and your athletic performance are being damaged, your brain can’t even store what it has learned if you’re not getting enough sleep.”
Her presentation was crowded because so many pediatricians are seeing these kids. In a study presented as an abstract at this meeting, researchers looked at national survey data about the sleep habits of 49,050 children from 6 to 17, to see how many were getting enough sleep. They used the A.A.P. guidelines for sufficient sleep: a minimum of nine hours a night for younger children and eight for adolescents.
Dr. Hoi See Tsao, a pediatric emergency medicine fellow at Hasbro Children’s Hospital and the Warren Alpert Medical School of Brown University, who was the lead author on the study, got interested in the subject when she worked as a teacher and noticed that many of her students were tired in class. The researchers found that 31.9 percent of the 13- to 17-year-olds did not get sufficient sleep.
The study looked at the association between how much sleep kids were getting and whether they appeared to be “flourishing” according to several measures. When parents and caretakers were asked about how their children were doing, the adolescents who were not getting eight hours of sleep a night had a 34 percent increase in the odds of not showing interest or curiosity about learning new things, a 34 percent increase in the odds of not staying calm when faced with a challenge, and a 36 percent increase in the odds of not doing all their required homework.
Younger children who were not getting sufficient sleep (that is, an average of nine hours on weeknights for those 6 to 12) also had higher chances of not showing these flourishing markers — in fact, their parents were 61 percent more likely to report that they did not show interest in learning new things.
This is a cross-sectional study, which shows association, not causation, but “it reinforces the importance of having children get enough sleep, the importance of setting good bedtime routines, a good sleep environment,” Dr. Tsao said. This may mean changes in the home, she said, but also advocacy on a community level, changes in the school system — school start times, homework loads — and a rethinking of how fully scheduled the days of children and adolescents ought to be.
[In California, a new law will shift school start times to help teens get more sleep.]
The consequences of sleep deprivation in adolescence include daytime fatigue, which can look like low energy and be marked by falling asleep in school, or like poor concentration and inattention. “The parent may be thinking the teen has A.D.H.D.,” Dr. Spinks-Franklin said, but in fact, attention deficit hyperactivity disorder is not something that develops suddenly in adolescence. And in addition to poor concentration, sleep deprivation may contribute to poor executive function, and an increased tendency toward bad judgment.
For some adolescents, this results in a more extreme picture, delayed sleep phase syndrome, in which they stay up later and later, trying to catch up by sleeping in on weekends, but shifting their circadian rhythms further away from being asleep at night and awake during the day. Treatment involves behavioral interventions, consistent wake-ups, scheduling changes and melatonin, but there is a high recurrence rate.
The strategies for helping adolescents sleep in healthy patterns are similar to the resolutions we make for ourselves as adults. Stay away from caffeine for at least four hours before bedtime, and practice consistent bedtimes and wake-up times.
Avoid all screens for an hour before bedtime, Dr. Spinks-Franklin said, since light suppresses the secretion of melatonin by the pineal gland, and it takes an hour to recover.
When there is conflict between parents and teenagers over sleep issues, often connected to phones and screens, she asks about other areas where power and control may be contested — curfews, mealtimes, homework — and sometimes recommends family therapy.
She suggested a cellphone jail to lock up devices at night, and urged parents to exercise their authority around getting screens — including phones — out of adolescent bedrooms. “Parents are in charge,” she said. “Parents are responsible for limits and boundaries and guidance around media use and the balance between media use and appropriate sleep.”
But Dr. Spinks-Franklin knows how hard it can be for her patients to change their sleep habits: She has done it.
“When I graduated from fellowship and I moved to Texas, I called Dr. Ferber and I said, ‘I need you to Ferberize me,’ and he did,” she said.
They discussed her evening schedule, the lighting in her apartment, the temperature, doing calming things before sleep, moving the TV out of the bedroom, turning off devices. She started reading paper books again, rather than reading on a device.
“If something is important to us, we figure out a way to do it — if sleep is a priority, you’ll figure it out.”
