Snooze... or Lose!: 10 "No-War" Ways to Improve Your Teen's Sleep Habits (2006)

For many sleepy teens, taking the steps detailed in Chapter 8 will go a long way toward paying down their sleep debt and getting onto a track that will bring them a better quality and a greater amount of sleep. By taking control of their surroundings, their schedule, and how they treat their body, they can reap the benefits of a complete night of energizing sleep.

For teens whose sleep-wake cycles are greatly out of whack, though, some additional steps may be necessary. When adolescent night owls come to see me, I discuss with them the 10 sleep strategies and encourage them to put them in place right away. But we also talk about how the timing of their sleep is delayed and about what it will take to shift that timing to allow them eight and a half to nine and a half hours of nighttime sleep.

Education, then, is an important part of resetting a teen’s clock to a more normal, manageable sleep-wake cycle. To make the needed changes, teens have to understand both why they’re out of sync and the process for getting back in. But they also have to want to make the changes. If they don’t think they have a problem or they’re happy with the way things are, it will be next to impossible to successfully shift their cycle.

Some kids, particularly younger teens, can be adamant about not

wanting to change; then both education and guidance are critical (and a little psychology doesn’t hurt). One of my patients, 13-year-old Eric, told me that his mother was “stupid” for bringing him to a doctor and that although his teachers said he was exhausted and falling asleep in class, he was only falling asleep because he was completely bored. Hostility oozed out of every pore, and I knew that laying down a lot of rules on him wasn’t going to work. Instead, I asked him if he was able to fall asleep at 9:00 a.m. His answer was a snarly “Sure.” Well, I said, most people are well rested at 9:00 in the morning, and if you can fall asleep then, something is wrong—you’re not getting enough rest. If you think nothing’s wrong, though, why don’t you show me? Do a daytime sleep study for me, and after we do it tell me what you think happened and I’ll tell you what your brain waves told me happened. If you’re not falling asleep quicker than what’s normal during the day, then I’ll get everyone off your case and you can keep on going just the way you’re going.

There was a lot of fast talking on my part, to be sure. But I chose my words carefully to allow Eric to see for himself that something was wrong—and he did. When his sleep study showed that he was falling asleep immediately after being given the opportunity to nap during the day, he began to see that there was a problem—and, after putting up a bit longer with my spiel, that something could be done to make him less drowsy and irritable.

In addition to using a light box and taking melatonin—part of the treatment I typically prescribe and that I’ll detail below—I recommended that this patient, who was a little pudgy, start working out with weights and paying attention to his body (I also recommended that he check in with his pediatrician or family doctor, which I always do before having an adolescent patient embark on an exercise program, especially one that involves weights). This encouraged him even more, because the idea of getting buff appealed to him. I wouldn’t say he was the most compliant patient I’ve ever had, but education, evidence, and a little bit of stroking helped him agree to begin treatment— and put effort into adjusting his sleep phase delay.

There are four parts to my program for shifting teens’ late-to-bed, late-to-rise cycle. Three of the components are therapies—light therapy, melatonin, and chronotherapy; and one is behavioral—having a mature, responsible attitude. While each can provide a great deal of improvement on its own, studies have shown that it takes therapy plus positive behavior to maximize results. You need to apply the complete package.

One point before I begin. You may be wondering why I don’t recommend simply taking a sleeping pill to adjust patients’ sleep and wake-up times. The answer is: If a teen’s circadian clock is programmed to send her to sleep at 2:00 a.m. and wake her up at 10:00 a.m., taking a sleeping pill, or hypnotic, at 10:00 p.m. isn’t going to make her fall asleep then and sleep for the next eight hours. Sleep-promoting medication works only when taken during the appropriate “circadian window” for sleep, in sync with where the clock is set for sleep. Hypnotics won’t move the clock. Only by shifting a teen’s sleep phase will she be able to fall asleep and wake up at more normal hours.

While much of my discussion so far has been aimed at getting teens to fall asleep earlier at night, it’s also critical for them to be able to get up earlier in the morning—both to get to school on time and to start the process that will make them sleepy again at a reasonable hour that night. Many teens set alarm clocks all over their rooms or ask their parents or siblings to drag them out of bed each morning—I even had a patient who asked his mother to throw ice water on him—but there’s something more useful, and less jolting, that they can do to help entrain themselves to a more successful pattern.

Light therapy, or bright-light therapy, as it often is called, uses artificial light to help restore the natural circadian rhythm; it’s one of the most powerful components of my program. Bright-light therapy provides much brighter light than standard indoor lighting and even more than the outdoor light of a clear spring morning. The reason it’s used? The intense light augments and amplifies the natural ambient light that signals the brain that it’s morning and time to rise and shine. When the artificial light enters the eye, it travels to the brain and, just as bright outdoor light would do, cues the suprachiasmatic nucleus (if you need a refresher on this process, see page 15) to stimulate the body to wake up.

The ability of bright-light therapy to wake the body up and adjust the sleep-wake cycle depends on several things: the duration of its use, the intensity of the light, the timing of its use, the number of exposures to the light, and the consistency of its use. The spectrum of the wavelengths may also make a difference, and studies are now being done to measure their effects. Blue light appears to have stronger circadian effects than red light.

When I recommend that patients begin bright-light therapy, I usually ask them to do it first thing in the morning for 20 to 30 minutes, or as long as they can before leaving for school; even 15 minutes is better

than nothing. Exposure as soon as they wake up reinforces their wake-up time, and bathing themselves in the bright light morning after morning helps to set a pattern. If teens routinely treat themselves with light in this way, they should start seeing clear effects in about six to eight weeks. However, bright-light therapy has immediate alerting effects. Studies show that the light suppresses melatonin and increases activity in attention pathways in the brain. It also has a mild antidepressant effect, especially for seasonal affective disorder, in which sufferers experience a mood disorder during the winter, when there are fewer hours of sunlight.

Currently there are several different products that provide the intense light needed to reset a stubborn clock: light boxes, light visors, and light books. None require a prescription, and all are readily available. (For catalogs or ordering information, contact one of the companies listed in Resources.)

For quite some time, light boxes were the only source of bright-light therapy, and they are still a very effective way to receive cycle-reinforcing light. A light box, as the name implies, is a fixture that houses a set of lightbulbs. The bulbs are usually white fluorescent or full-color-spectrum bulbs or a tube that’s hidden behind a diffuser and tilted forward so the light angles down. The positioning reduces glare while letting more light into the eyes; the diffuser spreads the light out more evenly and absorbs and filters out potentially harmful ultraviolet (UV) rays. Light boxes, which deliver 10,000 lux of light, should be positioned so the light is level with the user’s eyes, but it’s not necessary to look directly into it. A light box can be placed 14 to 36 inches away from the user; consult the manufacturer’s product information to determine optimal placement.

Light boxes can be purchased in several different sizes and intensities. Larger models are available on floor stands so that you can stand in front of them to receive light, for example, while you’re walking on a treadmill. Other boxes, some of which look like desk lamps, are smaller and can be placed on a table while you’re eating or reading.

Light treatment should be used in the morning as soon after wake-up as possible. The same beneficial effect may be achieved with the use of a light box (left) or a light visor (right).

Still other models are so compact that they can be carried with you when you travel.

Available only recently, lights visors are a practical alternative to light boxes, especially for the rushed adolescent. Worn on the head like a sports visor, light visors are powered by rechargeable batteries

and project blue-spectrum light down very close to the eyes. While earlier versions of wearable light, which were actually glasses with lights attached, were fairly cumbersome to wear, today’s visors are smaller and much more lightweight. A popular visor delivers 8,000 or 12,000 lux (there are two settings) and should be used for 20 to 30 minutes each morning, just like a light box.

The size of a small DVD player, approximately 8 × 8 × 1 1/2, the light book is the latest light-therapy product. It employs a blue light diode and provides the same amount of lux as a light box but at a lower and, for some, more comfortable intensity. Because of their small size and the fact that you can flip them open and shut, they’re easy to use, convenient for travel, and hard to damage.

So how do you choose which product your teen should use? It all depends on her schedule and style. Many of my adolescent patients prefer to wear the visor because they’re used to wearing hats or caps and because it frees them from having to sit still in front of a light box or a light book. I ask patients who use a visor to put it on as soon as they dry off from the shower in the morning and to keep it on while they dress, eat breakfast, and get themselves ready for school. Because the visor is mobile, the kids can still rush around as much as they need to while using all the available time to soak up as much light as possible. If you can get them to do it, they could even wear the light visor in the car as they’re driven to school (I haven’t yet met a teen who was willing to wear a visor on the bus, but I have thought about suggesting that school buses have bright lights inside!).

The light box and the light book, though, are also good alternatives. Although teens need to sit in front of them to receive the light being emitted, and perhaps get up a bit earlier to use either one of them, they could get their light quota while eating breakfast or while going over study notes for an exam. They could also share a large light box treatment with a sibling and have someone to talk to while getting their daily dose.

Will there be any side effects from treatment? Light therapy is thought of as safe and effective, with very few side effects, if any. Headache, nausea, jitteryness, and eye irritation are rare transient side effects that often improve or disappear by the end of the first week of treatment. If they persist, decreasing the intensity of the light by changing the setting, moving the light farther away, shortening exposure time,

or avoiding reading during treatment may be helpful. However, individuals with a history of bipolar disease or mania should be especially cautious when using light therapy and have their condition under good control before using it. Anyone taking a drug associated with a photosensitive skin reaction, such as tetracycline, should check with their doctor or pharmacist before starting light therapy, as should patients with eye disease or any chronic condition that might affect the eyes.

In Chapters 1 and 3 I talked about how melatonin, when secreted from the pineal gland, plays an important role in setting our circadian clocks. Taken orally in synthetic pill form—it comes in a range of doses and can be purchased in a drugstore without a prescription— melatonin also helps to reset out-of-sync clocks.

How does it work? Let’s say your daughter needs to wake up at 6:30 at the latest to make it to school on time. To get the eight hours of sleep she needs (nine would be wonderful, but we’ll take eight), she would need to fall asleep at 10:30 p.m. But her sleep phase delay keeps her from feeling sleepy until midnight. (Remember that melatonin secretion begins approximately 10 hours after wakeup and six hours before sleep.) To help her feel sleepy closer to 10:30, she would take a small amount of melatonin six hours earlier, at around 4:30 or 5:00 in the afternoon, after she gets home from school. By doing this for approximately six to eight weeks, the melatonin would help entrain your daughter to a more comfortable and healthful sleep-wake cycle.

A large dose of the drug isn’t needed. When I first started prescribing melatonin 15 years ago, I had patients take it later in the evening and in 3-milligram doses; it was thought to have a hypnotic effect and the recommendation was to take it at bedtime. But it was not particularly effective; studies have now shown that melatonin is

much more of a clock setter than a sleeping pill. So now I prescribe 200 to 500 micrograms (1,000 micrograms = 1 milligram) to be taken about six hours before a bedtime that will provide eight straight hours of sleep.

I don’t always prescribe melatonin, though. I only do so if parents are comfortable having their son or daughter take it. But it’s not a drug—the Food and Drug Administration classifies it as an herbal preparation that is safe to use. Doses as high as 60 milligrams have produced no major side effects, and only rare and minor side effects of vivid dreams or slight tiredness during the day have been seen. Melatonin won’t put an insomniac to sleep, but there is strong evidence of its effectiveness in pushing back the sleep clock. In combination with light therapy in the morning it can help keep your teen’s sleep onset from slipping later into the night.

Chronotherapy isn’t a treatment that I prescribe every day. Though it’s drug free and device free, I use it only for the most severe cases and when the patient has several straight days that can be given over completely to the therapy. A holiday period or the summer is a good time to use this treatment, particularly the end of summer when your teen may need to move—quickly—from routinely staying up very late to a schedule that will get her up on time for school.

Chronotherapy actually takes a very different approach from light therapy or taking melatonin. Both of those treatments work to pull the sleep-wake cycle back earlier, say, from falling asleep at 2:00 in the

morning to feeling sleepy at 11:00 at night. Chronotherapy works with the teen body clock’s comfort zone, pushing the sleep-wake cycle later—until it moves around the clock to a more normal time. This is physiologically easier than trying to phase advance to an earlier bedtime.

It works like this. Say your daughter’s typical sleep time is 2:00 a.m.—she just doesn’t feel tired any earlier. So let her stay up even later—give her a gift she’ll love and tell her she should follow her physiological direction and stay up until 6:00 a.m. Every night after that, move her bed-time later by four hours and allow an eight-hour block for sleep. By the fifth night she should be going to bed at a more normal and healthful 10:00 p.m. (I usually use a five-day treatment period, but if more time is available, the process can move forward in two- or three-hour rather than four-hour blocks).

While your teen may feel a bit strange through this process, being awake and asleep at unusual times, there shouldn’t be any ill effects and the adjustment takes place very quickly. She will have to stick with the schedule to really entrain it, but falling asleep as soon as she gets in bed should help with its adoption. Taking melatonin to simulate the dim light melatonin onset of the desired schedule,

in this case 4:00 p.m., will also keep the schedule from slipping back out in time, as will the critical ingredient of bright light at the 6:00 a.m. wake-up time.

If your teen agrees to try this phase-shifting process, you might want to suggest that she do it with a friend. While the friend may not be on as late a schedule as your teen, she can be a great support and make the time more enjoyable. It’s also a good idea for your teen to have scheduled activities during awake times, to get lots of exercise, and to turn off her cell or bedroom phone during the daytime hours devoted to sleep. A plus for this therapy is that it can be a time for your teen to do things she normally can’t, like go to a special spot to watch the sunrise or star gaze very late at night.

Whether you and your teen choose to use light therapy and/or melatonin or chronotherapy, an additional key ingredient for success must be added: mature and responsible behavior. A proper attitude is necessary for successfully adjusting a debilitating delayed sleep phase.

That means your teen needs to be mature enough to recognize that sleep deprivation is having a negative effect on her health and well-being. She needs to understand that being exhausted just isn’t cool, and be able to say, “I don’t like the way I feel. I don’t like what’s happening to me.” Then she needs to agree to the best treatment. She also needs to follow through with recommendations: get more exercise, avoid caffeine, use the light box or light visor and take melatonin if prescribed, wear sunglasses in the evening, maintain a weekend wake-up time that’s no more than two hours later than the weekday time, turn off the cell phone or tell friends not to call in the middle of the night, eliminate naps or at least keep them to a minimum—all the things I’ve talked about that can enable eight to nine hours of sleep within an appropriately timed sleep-wake cycle. Your teen needs to take responsibility for getting the sleep she needs.

That, of course, is going to take education as well as discussion. But without your teen’s cooperation, the problem won’t get solved. Encourage your teen to take charge of her health, and make it known that you’re going to help all you can.

If your teen just won’t engage in coming up with a solution, and is chronically sleep deprived and feeling awful, you may need to look for an alternative school that starts later; a school that’s more amenable to her phase-delayed life can give your teen the extra sleep time needed to live more successfully. Changing schools may seem extreme, and your teen may object strenuously, but if it’s the only way to carve out more sleep time, it’s a step you should consider seriously. Discussing a school change with your teen can alert her to the seriousness of the situation and motivate her to engage consciously in the treatment program, send a clear message to her that you care and that you’re willing to help—that you’re a supporter, not an adversary—and give your teen hope that she can feel better. You can also work to get your teen’s current school to start later in the morning. (See Chapter 13 for more on this topic.)

If your teen’s circadian clock is in need of normalizing, you may be ready to put into practice one or more of the treatments I’ve just described. So I’m going to take you through my typical treatment process—which includes using a light box, taking melatonin, and regulating the weekend wake-up time—so that you can see for yourself how it works. (Chronotherapy is pretty straightforward, but it takes several consecutive days to complete and is used only when time and motivation permit.) By addressing your teen’s sleep problems early, with the kind of treatment I recommend, you can avoid getting into an extreme situation that may cause a lot of harm.

Carson came to see me during the summer before his junior year in high school. On the small side for his age, he had a history of attention deficit hyperactivity disorder (ADHD), for which he was taking Ritalin, and depression, which had improved since he had transferred a few months earlier to a new school that he enjoyed much more. His pediatrician had referred him to my office because he was having great difficulty falling asleep and greater difficulty waking up in the morning. He often awoke with a headache and also coughed a lot when he

first woke up. The headache, like the depression, had abated some since his transfer to the new school.

As I talked with Carson, I learned more about both his sleep issues and his life. He told me that he usually got into bed between 11:00 and midnight on weekdays and between midnight and 1:00 a.m. on weekends and that it generally took him several hours to fall asleep. His new school started at 9:00 a.m., which was great, but because it took him so long to fall asleep he was only getting about five and a half hours of sleep a night. He was very sleepy during the day and napped both on the way to school and on the way home. He was not involved in sports or an exercise program though he did walk a bit during the day.

After talking with Carson, who was eager to understand his problem, and getting his history, I did both a physical exam and a neurological exam. I noted Carson’s airway dimensions, the size of his tonsils, his chin and jaw structure, the length of his neck, and the overall appearance of his body, looking for any signs that might suggest underlying sleep apnea (see Chapter 10 for more on this disorder). I also looked for overt signs of depression, which I didn’t find. Physically, Carson was in good health.

But with a sleep-wake cycle of 3:00 a.m. to 8:30 a.m., Carson was quite sleep deprived and phase delayed, which resulted in the headaches and exhaustion. His problem was significant and was about to become even worse because he was set to start a summer job that required him to be up at 8:00 a.m.

Before prescribing treatment, I had a long discussion with Carson about sleep phase delay and the impact it was having on his ability to function. We went over the mechanisms that govern the timing of sleep, the concepts of Process C and Process S, and the role Carson’s sleep-wake behavior played in his problem. I also told him that his being sleep deprived wasn’t his fault. Then I told him, and his mother, who was there for the appointment, that there were behavioral as well as pharmacological treatments that would help.

The regimen I recommended was to aim for a bedtime of 11:45 p.m. and a strictly enforced wake-up time of 7:45 a.m. I asked Carson to get a light visor and to wear it for at least 20 minutes as soon as he woke up to signal his suprachiasmatic nucleus that it was time he

should be awake. I also asked him to run the steps in his house first thing in the morning to get his adrenaline flowing, to avoid napping in the afternoon, and to take 500 micrograms of melatonin at about 5:30 or 6:00 p.m. to reprogram his body’s dim-light melatonin onset. As part of his evening routine I asked him to wear sunglasses for the last two hours before bedtime and to shower and lay out his clothes for the next day to minimize the time he needed to get out the door in the morning.

I also asked him to spend the last hour before bedtime winding down—not watching television, not talking on his cell phone or IMing on the computer—and writing in a journal to release some thoughts and feelings. I suggested that if he still had trouble falling asleep that he listen to soft music in bed, preferably using a headset, or read using a low-intensity book light. I emphasized the need for him to make every effort to stick to the program, including on weekends. I also told him that if he did well on the regimen, eventually he could have a slightly later wake-up time on weekends, but not more than two hours later than during the week. Finally, I gave him a sleep log form (see page 131) to keep a detailed record of what he did and how it went.

When I saw Carson for his follow-up appointment three weeks later, he had already seen some improvement, though it generally takes six to eight weeks to see significant light therapy and melatonin effects. He had stopped taking naps, aided by the fact that he worked all day, and was falling asleep a little more easily at night. And that, of course, gave him more rest, which was already making him feel better. It had been difficult, he said, not to sleep later on the weekends, but he was trying to keep his weekend wake-up time to around 10:00 a.m. He continued to take his antidepressant medication and felt that it was helping his mood, which was a plus for helping his phase delay. All in all he was making good progress, although he still seemed a bit sluggish. So I recommended that he have a thyroid function study done, a vitamin B12 level taken, a blood count taken, and liver function studies done to make sure that there were no additional complicating metabolic or physical factors. I also coached him again to stay with his program to reentrain his sleep-wake cycle. At his next appointment, I expect to hear great results.

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