In my experience, phase shift is the most common school-age sleep problem. A regular 7 day per week sleep schedule is basically not happening in my patients. Even if bedtime is regular on weekdays, one weekend movie blitz or "(non)sleepover" can reset the biological clock in some children so that they have trouble falling asleep for the rest of the week. Studies have shown that most tolerate a 1-hour and some a 2-hour difference in bedtime on weekends without a problem. The best way to move a late bedtime earlier is by adjusting it by only 15 minutes earlier each night until the ideal time is reached; otherwise the child will lie in bed fretting. To reset the body clock, the child needs to be awakened at the same time 7 days per week, and no naps allowed.
Adolescents in the habit of going to bed at 4 a.m. and waking at 11 a.m. may need to advance their bedtime for this to work. That means a period of going to bed 1 hour later each night, sleeping 8 hours, then staying up until the adjusted bedtime. While they may have to miss some school to carry out this plan, they probably weren’t worth much at school anyway, and this may be the only thing that works. The main problem in these cases is that the teen likely got into this pattern for the benefits of avoiding interacting with parents, or to hang out with peers who keep this schedule. Family counseling may be needed to address these aspects.
Sleep is the "canary in the coal mine" or early detection signal for many other health and mental health problems. Although childhood depression does not involve early morning waking to the same extent as in adults, prolonged periods of being awake at night can be a sign of bipolar disorder or PTSD from sexual abuse. Daytime sleep attacks in spite of enough hours in bed may indicate narcolepsy or sleep apnea. Severe night terrors can be a result of brain tumors. And sleep is easily disrupted by any kind of stress, as we physicians can readily attest.
Learning to crack the code of sleep secrets is a valuable skill that your patients will appreciate.
Dr. Howard is an assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to IMNG Medical Media. E-mail her at pdnews@elsevier.com.