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The Real Reason Teens Are Tired, Low Performing, Stressed, Overweight, and Incredibly Hard to Live With

If your child, around the age of 12, 13, or 14, became someone you no longer recognized, you’re not alone. Many children, when they reach adolescence, make a sudden transformation from little darling to big challenge as they become more irritable, more socially conscious, more moody, and more stressed. They may also do less well at school and never have the energy for anything other than closing themselves in their room to listen to music or IM their friends.

Adolescence can certainly be a time of change and frustration— for both the teens going through it and their parents. You, like many parents, may be mourning the loss of that sunny-dispositioned kid who was always ready to go for a bike ride with the family and who thought math was really cool—and may need to learn how to relate to the new incarnation. But teens, too, go through significant changes: Along with the physiological demands of the age—shooting up several inches, growing beards or breasts, developing more muscle—they are changing and growing emotionally, socially, and behaviorally. All of that change—as we know only too well—can make them tired, grumpy, and even a bit irrational. And because we see so many tired and grumpy teens around us, we usually assume that’s the normal state of affairs for this age group.

It’s definitely true that across-the-board change can cause teens to



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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits 2 The Real Reason Teens Are Tired, Low Performing, Stressed, Overweight, and Incredibly Hard to Live With If your child, around the age of 12, 13, or 14, became someone you no longer recognized, you’re not alone. Many children, when they reach adolescence, make a sudden transformation from little darling to big challenge as they become more irritable, more socially conscious, more moody, and more stressed. They may also do less well at school and never have the energy for anything other than closing themselves in their room to listen to music or IM their friends. Adolescence can certainly be a time of change and frustration— for both the teens going through it and their parents. You, like many parents, may be mourning the loss of that sunny-dispositioned kid who was always ready to go for a bike ride with the family and who thought math was really cool—and may need to learn how to relate to the new incarnation. But teens, too, go through significant changes: Along with the physiological demands of the age—shooting up several inches, growing beards or breasts, developing more muscle—they are changing and growing emotionally, socially, and behaviorally. All of that change—as we know only too well—can make them tired, grumpy, and even a bit irrational. And because we see so many tired and grumpy teens around us, we usually assume that’s the normal state of affairs for this age group. It’s definitely true that across-the-board change can cause teens to

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits look and act in less than stellar ways. But recent studies have shown that it’s not only adolescence itself that throws teens—and their families—into a tailspin. Underlying the exhaustion and the irritability, and adding or aggravating a whole slew of other conditions, is sleep deprivation. What would teens be like if they weren’t continually sleep deprived? If they could get a good night’s sleep night after night, would there be happier, healthier, more energetic, and better-performing youngsters sitting across from us at the dinner table? All signs point to yes. (OK, they’d still be wearing those enormous baggy pants and the spaghetti-strap tank tops with their bellies showing—unfortunately getting enough rest doesn’t solve teen fashion issues.) In simple terms, lack of sleep and being sleep phase delayed make a challenging time of life much harder to cope with by robbing teens of what their bodies need to refresh, repair, fight off damaging physical and emotional conditions, and grow. SNOOZE NEWS While you might think that the common cold would be considered one of the greatest afflictions affecting Americans, author Nancy Stedman, in researching her article “Tired of Being Tired?”, found that it is actually drowsiness that bedevils the most people. But problems don’t arise just from sleepiness—there’s another side to the sleep deprivation issue. When you’re sleeping less, you have to sustain wakefulness longer, and this puts extra stress on your body, which leads to additional problems. Think of it this way: If you’re getting only six hours of sleep, your body has to stay awake for 18 hours— which is nearly impossible to do at peak functionality. It’s very difficult for a human being to sustain wakefulness for 18 or more hours at a clip. When does functionality drop off? The critical point of dysfunction appears to be when you hit between 15 and 16 hours of cumulative sleep loss. So if your teen is sleeping only five hours a night, when she should be getting more than nine, after four nights (four hours’ loss per night times four nights) functionality will be at a less than optimal level. And that decreased functionality applies across the board—in school performance, emotional stability, behavior, ability to fight off infection, you name it.

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits SOME IS THE SAME AS NONE In a recent experiment on sleep deprivation, the participants, who were in their early 20s, were divided into four groups. Group 1 volunteers slept for four hours per night over a two-week period, Group 2 volunteers slept for six hours, Group 3 members slept for eight hours, and Group 4 members had no sleep at all for three days straight. At the end of the two weeks, those who had slept for eight hours a night functioned well—no surprise there. But the big surprise was that there was no difference in performance level between those who had slept four or six hours for two weeks and those who had not slept at all for three days. The experiment showed that adolescents cannot perform well without any sleep but also that they can’t perform well with much less than the nine hours they require. The Impact of Sleep Deprivation What exactly is less than optimal performance? Is it really all that bad? As you’ll see in the following sections, statistics show that chronic sleep deprivation puts teens in a blunted, muted “slough state,” severely reducing their ability to learn, behave, and live at their best. Health Issues Lack of sleep impacts teens’ physical health in several different ways. For one, it impairs their immune system, interfering with their white blood cells’ ability to fight off infection in the bloodstream; experiments have shown that once in sleep debt the body’s number of T cells decreases by 30 to 40 percent. That suggests that sleep-deprived teens are much more likely to catch the colds, flus, and other acute and chronic illnesses that seem to be permanent inhabitants of most high schools and teen activity centers. And that of course means they’ll be missing classes and sports events, with all that entails, feeling crummy and worn out, and behaving even more like bears than ever. It could also mean they’re more susceptible to catching potentially serious viruses or developing intercurrent, or coexisting, illnesses. Once tired teens come down with a cold or flu, their compromised immune system may also cause the condition to hang on longer. The National Commission on Sleep Disorders Research warns that sleep

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits THE NIH REPORTS In a National Institutes of Health study, rats were deprived of sleep to see what the effects would be. One group of rats was continually deprived of REM sleep (for information about REM sleep, see Chapter 3). A second group was deprived of all sleep. Rats normally live for two to three years, but those that were allowed no REM sleep lived for only five weeks. The rats denied all sleep lived for only three weeks. The cause of their greatly shortened life spans? Sleep deprivation in animals produces a condition that eventually becomes lethal. Completely sleep-deprived animals develop a syndrome of hypothalamic dysfunction: They overeat, lose weight, lose hair, develop skin lesions, and eventually die of infection. However, researchers have discovered that the syndrome is reversible with sleep—studies suggest that sleep restores the immune system and the antioxidant balance. deprivation can be “a significant barrier to recovery, potentially exacerbating a primary illness.” So a bug that a rested teen could fight off in two or three days might stay around for four or five. And once the virus is finally gone, it’s very likely to come back; sleep deprivation also contributes to recurring and chronic conditions. That cough your teen just never seems to be able to shake could be the result of her ongoing sleep deficit. (It could also be the result of allergies or asthma, which also are associated with sleep deprivation.) In addition to catching more colds and flus, sleep-deprived teens have a higher rate of headaches. Often kids show up at my clinic complaining of headaches and sometimes severe migraines. Because puberty is a peak time for the onset of migraines, many of these kids want medication to relieve the pain. But it often turns out, after consultation and testing, that these teens simply need more sleep, not a drug. When rested, their incidence of migraines may drop dramatically and tension headaches disappear. A 15-year-old patient of mine I’ll call Henry came to me complaining of severe and frequent headaches. The headaches had gotten so bad that Henry, who was an honor student, had been missing a lot of

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits school. He was worried about being able to keep up with classes and the school was concerned about his absenteeism. Finally, a school administrator contacted the family, who contacted their family doctor. But the doctor wasn’t able to find the cause of the headaches and sent Henry to a neurologist. Complicating the already confusing situation was the fact that Henry’s mother suffered from migraines, so everyone he saw had looked for a link. Months went on, with Henry trying four different migraine medications that the neurologist prescribed. But the headaches improved only minimally both in terms of frequency and severity and continued starting up within an hour of Henry’s waking up. He was getting no relief and often missed morning classes. When he did make it to school on time he generally wound up in the nurse’s office, too sick to finish the day. After determining that the migraine medications were not helping to the extent they should have, the astute neurologist thought that lack of sleep might be causing the problem. He referred Henry to my office, and after testing and consultation, it turned out that Henry was severely sleep deprived. On most weeknights he would get into bed sometime around 11:00 but then just lie there until close to 1:00, unable to fall asleep. When he finally nodded off, it was only a little more than five hours until his alarm started blaring at him to get to school on time. And by the time he got out of the shower, another splitting headache had developed. Once I found that Henry had a major sleep phase delay, I started him on a course of treatment. The first step for him, and for all my patients, was education. I sat down with Henry and his parents and talked about sleep: its phases, its requirements, the changes in patterns associated with adolescence, and particularly why Henry was feeling so awful and needed to get more sleep—his brain was running late but his school was starting early. I also told him how my staff and I were going to help him. It all came as a surprise. Like many teens and their parents, Henry and his folks had no idea that teens need at least nine hours of sleep to function at their best and that their sleep-wake cycle is wired to be out of sync with everything around them. But Henry was so medically ill

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits by the time I saw him that the news was welcome—at last he had found some help. Because Henry was so sick, and because adjusting the sleep-wake cycle can take several weeks, I contacted his school to make a change in his schedule immediately. An elective class, on photography, that Henry took started at 7:30, and a reluctant Henry—who loved the class and wanted to do it all—accepted my recommendation to drop the course in order to start school a period later. When his parents contacted the administrators about making the change, they agreed to do so after receiving a letter from me confirming the need. (A note here: Most schools are generally compliant about making these kinds of adjustments when they’re presented with a carefully written letter from the treating physician, but no school will change every teen’s schedule, so schedule changes are best saved for teens who need immediate relief from pain or illness. To learn what you can do to have all middle and high schools in your area start later in the morning, see Chapter 13.) Dropping a favorite subject was a tradeoff for Henry, a compromise, but the headaches were making him sick and miserable and my staff and I finally convinced him that he could take the elective the following semester, after his sleep deficit and headaches were under control. A TEEN’S TAKE “After a long hard week of school, sports, and homework, all I want to do is talk to my friends and have some ‘me’ time. But on the weekends I generally have a very early tennis match, which means I have to get up at 6:00 a.m. to get to a tournament on time. There’s always just so much to do.” How quickly did that control come about? Treating kids with severe sleep deprivation and delayed sleep phase is generally at least a six- to eight-week process requiring continuing reenforcement. But because of the schedule change, Henry was immediately able to start sleeping 45 minutes later in the morning, making a big difference in the severity of his headaches and making him feel a whole lot better. However, the schedule change didn’t address Henry’s underlying delayed sleep phase, so in addition to eliminating his first-period class I recommended that Henry increase the amount of light he got in the

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits LIGHT BOXES AND LIGHT VISORS A successful way to help push your teen’s sleep-wake cycle into a more normal pattern is to have her wear a light visor for 20 minutes in the morning; the visor’s intense light will reinforce a normal wake-up time. A light box will also increase the light cues your youngster receives, but to use a light box your teen will need to get up 20 minutes earlier to sit in front of it— which can be counterproductive during the school week. A light visor can be worn easily while getting dressed and ready for class. (To learn more about treating sleep deprivation with light boxes and light visors, see Chapter 9. For information on where to purchase these products, see Resources at the end of the book.) morning through the use of a light box or light visor (you probably recall from Chapter 1 that teens are not influenced as strongly as adults by light and that they’re able to sleep well into the morning even though the sun is shining). By taking in more light, Henry would reinforce his wake-up time and get his internal clock back on track, so that he could wake up at a reasonable time in the morning and fall asleep more readily by 11:00 at night. Bright light is the most powerful stimulus for shifting the timing of sleep. How did the combined treatment work? As Henry said, his headaches gradually diminished, but he reported after two weeks that he wasn’t falling asleep much earlier. However, he did say that he felt far more awake and energetic in the daytime. And that’s a typical response. Often, before kids notice any greater ease in falling asleep, they realize they’re feeling a little better and have more energy during the day. After several more weeks things usually start improving noticeably; they did for Henry. Within two months his headaches subsided greatly, and by using a light visor and managing his wake-up time his sleep-wake cycle started to shift and he was able to fall asleep earlier. By the following semester he was feeling well enough to go back to a full-time schedule—and take that photography class. During the summer, however, Henry got out of sync again because he let his cycle slip back into a delayed sleep phase—school was out and he stayed up later with his friends. But he had to get to his summer

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits One Patient Says … “Lack of sleep has made keeping up with everything at school much more difficult. I found myself missing school at least once a week—I just couldn’t get out of bed because I had slept so little on previous days. Even more problems ensued when I developed an inflammation in my digestive system [for more on the link between lack of sleep and digestive problems, see below]. I was sick for months and missed school just about every other day—every time I thought I was better I was out of school again, and that hurt my social life as well as my schoolwork. So little sleep made me completely sick and stressed.” job by 8:00 a.m.—and guess what? His headaches returned and he felt exhausted again. But this time Henry knew what to do, and he didn’t wait until the problem was entrenched before he solved it. He got back on a schedule, limited his late nights, and started using his light visor again. Things weren’t perfect—teens do love their late nights, for privacy and for communicating with friends—but the treatment made Henry feel much, much better and enabled him to function a lot more comfortably. (For more on the sleep deprivation–headache link, see Chapter 11.) Incidence of Injury Insufficient sleep can dramatically increase your teen’s risk of injury and death, particularly while driving a car. According to the National Highway Traffic Safety Administration, drowsiness or fatigue is a major cause of at least 100,000 police-reported traffic crashes each year that kill more than 1,500 Americans and injure 71,000. Drivers under the age of 25 are responsible for 55 percent of those accidents. One state, New Jersey, has enacted a law that classifies drowsy driving—defined as operating a motor vehicle after having been awake for 24 hours or longer—in the same category as drunk driving, making those convicted eligible for second-degree homicide charges. The law, called Maggie’s Law, named after Maggie McDonnell, a 20-year-old college student who was killed by a drowsy driver who had been awake for 30 hours, was enacted in 2003. In 2005 the first driver, a New

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits Jersey resident who killed another driver because of sleepiness and inattention, was jailed under the law. Why do young drivers in the United States cause so many crashes? Certainly lack of driving experience plays a role. But it is being sleepy— most teenagers’ chronic state—that contributes significantly to the potentially deadly mistakes they make behind the wheel. And according to sleep researcher Mary Carskadon, similar negative effects on functioning are found in people who live in the rest of North America and in industrialized countries on other continents. The American Academy of Pediatrics tells us that sleeping six to seven hours a night is associated with a 1.8 times higher risk for involvement in a sleep-related crash compared to sleeping eight or more hours. Sleeping less than five hours a night presents a 4.5 times higher risk. Studies analyzing motor vehicle crash data report that 40 percent of drivers who fell asleep at the wheel and crashed had been awake for 15 or more hours and that nearly 20 percent had been awake for 20 or more hours. Being sleepy while driving is also strongly associated with brief mental lapses, which of course can be deadly if you’re speeding down the highway and you blank out for even a few seconds. It also makes it difficult to stick with certain types of behavior, especially routine or boring ones, such as holding the steering wheel in one position while you dazedly watch the road go by. Tiredness also greatly reduces visual reaction time, which might prevent drivers from avoiding an obstacle that suddenly appears in the road, as well as auditory reaction time, which might keep drivers from realizing that the driver of the car they’re about to hit is honking the horn at them. Sleep deprivation also decreases the ability to remember and think clearly, which means that exhausted teen drivers could forget the speed limit or be unable to find the best way home after taking a few wrong turns. (I’ll talk more about the negative effects sleepiness has on these factors in Chapter 4, “The Sleep-Learning Link.”) SNOOZE NEWS About 1 million, or one-sixth of, traffic crashes in the United States are believed to be caused by a lapse in driver attention. Sleep loss and exhaustion increase the chances of such a lapse. If your teen drives drowsy, the evidence shows that the risk of

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits injury or death rises to a great degree. And teens do drive drowsy: More than half the adolescent drivers who participated in the National Sleep Foundation’s 2006 Sleep in America poll say they had driven drowsy during the past year, and 15 percent of participating 10th- to 12th-grade drivers report driving drowsy once a week. But feeling sleepy isn’t the only issue—increased awake time, reduced sleep time, and the phase of your teen’s internal body clock are all independent risk factors for drowsy-driving accidents. That means that teens are at risk of having an accident if they sleep only six hours at night and drive to school when they should still be in their sleep cycle as well as when they’re driving home at night after they’ve been awake for 18 hours. Dr. Christian Guilleminault, an international sleep expert, studied the effects of sleep deprivation in the laboratory and extrapolated his findings to real-life situations on the open road in France. He concluded that road safety campaigns should encourage drivers to avoid driving after sleep deprivation even on relatively short trips, especially if they feel sleepy. Is your child safe because she is a very good driver? Unfortunately it’s not only “bad” kids who drag race or take chances behind the wheel who suffer the consequences. Sleep researcher Mary Carskadon found that high school boys who have the most extracurricular time commitments were the most likely to report falling asleep at the wheel; a hard-working male teen who plays sports after school and then works at a job in the evening may be at the greatest risk of a fatal fatigue-related motor vehicle accident. Crashes can happen to any teen who isn’t getting enough sleep. They are also more likely to happen if a sleep-deprived teen driver drinks alcohol. Banks et al. studied the relationship between age, alcohol, sleep deprivation, and crash risks. After evaluating 20 healthy volunteers with an average age of 23, they found that alcohol, even at legal blood concentrations (under 0.08 in most states), increased sleepiness and impaired both performance and the ability to detect crash risks when the volunteers had been restricted to five hours of sleep. Teens, though, don’t need to drink and drive to have impaired performance. Other studies have shown that sleep deprivation produces psychomotor response (responses that involve both the brain

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits WATCH FOR THESE SIGNS Encourage your teen, and anyone else who drives, to read through this list of danger signs prepared by the National Sleep Foundation to help prevent trouble on the road: Feeling the need to turn up the radio or roll down the window Having difficulty focusing or keeping your eyes open Yawning repeatedly Having wandering, disconnected thoughts Feeling restless or irritable Drifting out of your lane or hitting the shoulder strips Tailgating or missing traffic signs or exits If your teen experiences any of these signs, it’s time for her to get off the road; find a safe, well-lit place for a 20-minute nap; or call someone to pick her up. and movement) impairments—including the ability to stay in your own lane—equivalent to those caused by consuming alcohol at or above the legal limit. After teens are awake for more than 16 hours, they drive as though they had a blood alcohol level of 0.05 to 0.1 percent. To see where your teen stands in her ability to drive safely, encourage her to take one of the interactive video tests—the Reaction Test Challenge, the Interactive Hazard Perception Test, or the Drunk Driving Test— offered online at www.steerclear.org.uk. Click the “Interactive” button on the home page to bring up the choice of tests. SNOOZE NEWS In many jurisdictions, the forms that police officers complete at the scene of a traffic accident have now been updated to include questions about the amount of sleep the driver has had. In the last few years more attention has finally been paid to the link between age, sleep deprivation, and accident rates, which has resulted in uncovering the fact that teenagers are overrepresented in fatigue-related crashes. Using Equipment and Playing Sports Just as sleepiness impairs a person’s ability to drive a car or a truck, it also impairs teens’ use of other mechanical equipment. Tools that require care and thought to operate, like jigsaws in shop class or lawnmowers in after-school or summer

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits A TEEN’S TAKE “Mood swings are probably one of the worst parts of being a teenager. Sometimes you feel yourself just being pissed off for no apparent reason. Then you can be laughing with your friend on the phone and the next minute you hear a song that reminds you of something sad and suddenly you’re in a terrible mood. It sucks, but you just can’t control it.” According to the American Academy of Pediatrics, adolescents who have sleep problems report increased negative moods and/or trouble regulating their moods. And looking at it from the opposite direction, adolescents with clinical mood disorders report high rates of sleep disturbances. While stress may contribute to sleep problems and emotional volatility (see below), there is solid evidence that sleep loss and irregular sleep patterns can make teens irritable and moody. Stress can make teens’ lives very difficult indeed. For example, they might surprise themselves—and everyone around them—by getting angry over a situation that, when they’re well rested, they might shrug off. Or they might become aggressive when they’re driving because they get excessively irritated when another driver cuts in front of them. A sad scene in a movie might make them unhappy and down for hours. And a disagreement with a friend could easily turn into a major blowup. A study using a standard measure of moods, called the Profile of Mood States, showed that restricted sleep time adversely affects all aspects of mood, from anxiety to dejection to anger to vigor to inertia to confusion. Why can sleepy teens feel not only out of sync but also out of sorts? Sleep loss alters the activity of neurotransmitters produced in the brain that regulate emotions. With these changes, we feel emotions more intensely and have greater trouble coping with them. And that can lead to even more difficult and serious conditions. Kids who can’t control their emotions might feel there’s something really wrong with them and become depressed and even suicidal (see Chapter 11 for more on the link between sleep loss and clinical depression). Or they might turn to drugs or alcohol in an attempt to lessen the strong feelings they’re experiencing. They might be too upset or angry and disruptive to do well in school. And any form of emotional upheaval they

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits go through could lead them to get even less rest, which could result in greater and long-term health and behavioral problems. Memory Memory is involved in just about everything we do. We need to remember how to get home, what to pick up at the grocery store, the formula for figuring out how many yards of carpeting we need for the living room, and where in the world we left the car keys this time. For teens, memory is just as important: They have to remember their homework assignments, the plays for the next football game, which day the SAT will be given, and where in the world they left the car keys this time. A highly functioning memory is critical to performing and living at our best. In simple terms, sleep deprivation interferes with memory function. In fact, studies show that it has a dramatically negative effect not only on memory formation but on memory access and retrieval. A sleep-deprived brain keeps neurons from firing quickly enough and working smoothly and efficiently enough to provide you with the information you need in a reasonable time. Memory function fails when a teen, who needs around nine hours of sleep nightly, chronically gets only six to seven. And that failure is pervasive—it affects the teen’s ability not only to remember facts and figures but to sort things out and think clearly. Sleep loss particularly affects episodic memory, that is, your memory time and spatial relationship—what you need to answer the questions on a history quiz. French researchers have found a clear association between restricted REM sleep time (see Chapter 3 for information about REM sleep) and episodic memory deficits when adolescents were given a “what, where, when”–type test. A strongly functioning memory, then, is key to learning and to doing well in school. And because teens spend so much of their life in school and learning all sorts of things, I’ve continued this section on memory in another chapter that’s devoted entirely to learning. See Chapter 4, “The Sleep-Learning Link,” for a comprehensive look at this all-important topic.

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits Energy Level It doesn’t take a rocket scientist—or a neurologist—to tell you that when you’re tired, you have no energy. But being sleep deprived doesn’t just make you feel like crawling to the nearest couch and staying there. Chronic sleep loss produces a global decrease in energy, so you think, move, and react more slowly. Without enough rest, your body doesn’t have the time it needs to repair and restore itself, so everything you do is done at only a percentage of your top speed and effectiveness. When you’re exhausted, do you have the energy you need to put in the hours to finish a big project? Do you feel up to tackling chores or even having a night out with your spouse or friends? Your teen feels the same way. When she is tired, doing anything can seem impossible. That includes exercising—and not exercising, like other negative effects of sleep loss, can have several negative effects of its own. For one, it can lead to weight gain—tired teens are much more likely to ask for a ride to school than walk or bike, and to take the elevator rather than the stairs. They’ll drag their way through gym class and probably choose not to go out for a sport; if they do, their reduced reaction time and unclear thinking will increase their likelihood of injury. If they do gain a lot of weight, they may be more unhappy or depressed, not to mention unhealthy. And because exercise is a good stress reducer, lack of energy can make teens’ stress level shoot up. For teens who tend toward being anxious to begin with, their stress level can skyrocket. A Case History and a Study Anna (I’ve changed all patients’ names to keep them anonymous) was a patient who had been tired and lacking energy for years. In the second semester of her junior year of high school she finally told her parents that she was sick and tired of being sick and tired and asked them to set up an appointment with a doctor to see what was wrong. She had missed a fair amount of school over the years and was starting to worry that her constant exhaustion would keep her from going to the college of her choice the way her older brother had. Anna simply felt too tired to do what she wanted and needed to do. After Anna’s family practitioner considered a diagnosis of chronic

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits fatigue syndrome, he found that the teen was having difficulty falling asleep and getting up in the morning. So he coached her to go to bed earlier, but she simply couldn’t fall asleep at the prescribed time. When he referred her to my sleep center, I took a careful history and then asked Anna to keep a sleep log, which confirmed a severe sleep phase delay and major sleep deprivation. A combination of education, light visor use, regulation of her wake-up time, and taking melatonin—plus Anna’s strong motivation to make a change—reduced her exhaustion and made her feel much better in only two weeks. One more interesting fact to add to your understanding of this problem: In a study of rats designed to measure energy expenditure, those rats that were sleep deprived nearly doubled the normal expenditure, creating a huge drain on the body. In metabolic mapping of brain structures, increased energy consumption in the body has been associated with diminished brain function. Digestion Remember the patient I mentioned earlier in the chapter who said that lack of sleep caused his digestive tract to become inflamed? Unfortunately that teen learned the hard way that, when it comes to sleep deprivation, there is a mind-body connection; loss of sleep is considered to be a source of psychophysiological, or mind-body, stress. I’ve already talked about the fact that sleep loss can contribute not only to emotional, behavioral, and learning issues but to physical problems such as headaches and more frequent infections. Now there is proof that lack of sleep can also cause stomach distress, a problem a number of my patients have suffered with. A study of partial sleep deprivation in rats showed that 30 to 50 percent of the animals developed visible stomach ulcers—which means the lining of their stomachs was actually damaged—within just 7 to 14 days. Researchers concluded that the cause of the ulcers was partial sleep deprivation, which compromised the integrity of the stomach wall by increasing the secretion of gastric acid, reducing blood flow to the stomach and changing blood adrenaline levels. Too much caffeine, as many coffee and tea lovers know, also can lead to stomach upset. And since many teens gulp down a number of

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits caffeinated drinks to help them get through their day, they can actually add to their stomach problems while trying to feel better. Stress and drinking too much alcohol also are known to cause stomachaches, and both can result in severe sleep deprivation. Growth When adolescents sleep, they not only refresh and repair their bodies, they also grow. During the third and fourth stages of sleep, which I’ll talk about more in the next chapter, a growth hormone called somatotropin is secreted. In addition to having several other functions, this growth hormone stimulates the secretion of another hormone called IGF-I, which in turn stimulates both bone and muscle growth. A number of studies have tried to determine whether growing children who are sleep deprived grow less well than those who get adequate rest. One, published in 2000, showed that when normal growth hormone secretion is blunted at night it is compensated for the next day, thereby arguing against the belief that sleep problems can inhibit growth in children. But another study in 2004 revealed that partial sleep deprivation nearly abolished pulses of growth hormone and suppressed concentrations of growth hormone, arguing that sleep deprivation does inhibit growth. Even if greatly reduced secretion of growth hormones is made up for the next day, however, we don’t know if we get the same result from it—if you’re up and around and doing all the things you need to do during the day, is growth hormone secretion able to produce the same results as it does when you’re at rest? Clearly more research is needed, but it might be that sleep deprivation can prevent teens from growing as fully as they should. Acne and Other Skin Problems Ah, pimples: the bane of teenagers’ existence. Nearly every adolescent experiences a breakout at some point, with girls suffering the most eruptions between 14 and 17 and boys between 16 and 19. Dirt, microbes, and several other culprits can be the cause of the apperance of pimples, but severe acne breakouts have also been reported after prolonged sleep deprivation. Ted Grossbart, a psychologist on the faculty of Harvard Medical

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits School and author of the book Skin Deep, studies the mind-body connection in skin diseases. Grossbart points out that emotional issues can trigger outbreaks or make existing outbreaks worse, but he has also found that sleep disturbances sometimes result in higher levels of hormones and adrenaline, which can increase production of the oily substance sebum that clogs pores. Paul Martin, in his book Counting Sheep: The Science and Pleasures of Sleep and Dreams, notes that sleep deprivation weakens the skin’s ability to act as a barrier against dirt. He also points to a study in which animals that were deprived of sleep for long periods developed what he called “unsightly skin disorders.” The National Sleep Foundation states that sleep deprivation makes one more prone to pimples and contributes to acne and other skin problems. While more research is ongoing, it looks as though lack of sleep, especially for adolescents and young adults, can increase and worsen skin problems. Kids who get their “beauty rest,” though, can significantly improve their skin’s appearance. Recently, when I went to greet a patient in my waiting room, I looked and looked and couldn’t find him. But he was sitting there—I just didn’t recognize him. He’d finally been getting the sleep he needed, and his acne had cleared up considerably and his sallow skin had pinked up. Not only that, but being rested had also erased that baggy-eyed, bedraggled look he had sported for so long. And because he wasn’t as irritable and angry as he had been, he looked a lot better—and readily acknowledged he was a lot happier. Pain According to research studies, sleep deprivation, especially the restriction of REM sleep time, may cause increased sensitivity to acute pain. The Arthritis Foundation of New South Wales reports that sleep loss can precipitate muscle pain and that it’s likely that at least some of the pain that accompanies arthritis and other joint disorders is associated with sleep deprivation. Sleep loss interferes with the body’s ability to heal and can aggravate pain and discomfort. Medically healthy kids whose sleep is restricted may also take longer to recover from bumps, bruises, and broken bones.

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits Caffeine and Alcohol It makes perfect sense: Tired teens who need to stay awake through a full day of classes, activities, sports, and socializing are going to do what they need to do to feel more alert and alive. And for many teens, instead of napping, exercising, or eating better for greater energy, that often means turning to caffeinated drinks. Like exhausted adults who need their morning jolt of java to even think about starting the day, more and more sleep-deprived teens are consuming caffeine—the 2006 Sleep in America poll reports that more than three-quarters of adolescents drink caffeinated beverages during the day. A number of my young patients tell me they drink five or six cups of coffee a day on an ongoing basis. Caffeine, like other stimulants, provides users with a brief burst of energy and sense of well-being. But if you keep drinking it throughout the day to keep that feel-awake feeling going, it can wind up keeping you awake and alert well into the night. If you have to get up at the usual time the next day, you sleep even less and wake up feeling more tired—and turn to caffeine again. To make matters worse, consuming caffeine can also decrease the quality of the little sleep you get. In a study published in the journal Pediatrics, 191 seventh- through ninth-graders reported their daily caffeine intake and the amount of sleep they got over a two-week period. Higher caffeine intake—up to 800 milligrams per day, the equivalent of eight cups of coffee—was associated with shorter nighttime sleep, increased wake time after sleep began, and increased daytime sleep. The study also documented increased sleep fragmentation and trouble staying asleep once the kids finally dozed off. Are you rethinking your own four daily cups of coffee? And starting to wonder about banning soft drinks and other caffeine carriers from the fridge? Here’s one other fact to add to your thinking: A recent study correlated caffeine intake with mood deterioration—which means your teen’s mood, and your own, may go downhill even further when you use caffeine to try to pump up your energy after a short or bad night’s sleep. Caffeine is addictive. If you drink it long enough, you become dependent on it for stimulation. And if you finally decide there are

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits COUNT YOUR CAFFEINE The following table identifies the number of milligrams of caffeine found in soda, coffee, tea, ice cream, chocolate, and some over-the-counter medications.     Caffeine Content (mg) Beverages   Aqua Blast—1/2 liter 90   Barq’s Root Beer—12 oz. 22   Coca-Cola Classic, Diet Coke—12 oz. 46   Coffee—8 oz. 100   Dr. Pepper—12 oz. 42   Espresso—2 oz. 100   Hot chocolate—6 oz. 20   Java Water—1/2 liter 125   Juiced—10 oz. 60   Krank—1/2 liter 100   Mountain Dew—12 oz. 55   Pepsi, Diet Pepsi—12 oz. 37   Red Bull—8 oz. 80   7 Up—12 oz. 0   Snapple Iced Tea—16 oz. 55   Sunkist orange soda—12 oz. 42   Tea, black—8 oz. 50   Tea, green—8 oz. 30 Foods   Ben & Jerry’s non-fat coffee yogurt—1 cup 85   Dark chocolate—2 oz. 50   Haagen-Dazs coffee ice cream—I cup 58   Hershey bar—1.5 oz. 10   Milk chocolate—2 oz. 30   Starbucks coffee ice cream—1 cup 40–60 Over-the-Counter Medication   Anacin—2 tablets 64   Excedrin—2 tablets 130   NoDoz Regular Strength—1 tablet 100   NoDoz Maxi Strength—1 tablet 200   Vivarin—1 tablet 200

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits better ways to feel more alert, quitting the stuff can leave you with days of severe headaches and possibly the jitters from withdrawal. (Cutting back slowly, by half a cup a day, can help lessen those effects.) In addition to increased caffeine use, sleep deprivation can also result in increased use of alcohol, nicotine, and other dangerous substances. Teens who are too tired to exercise, stressed from arguments with parents or friends, worried about keeping up in class, or just generally feeling down about how they look or feel may turn to alcohol or other drugs to cope or to ease the pain. On their own, all of these substances are, of course, addictive and bad for your health and safety. But using them when you’re sleepy heightens their effect. Studies show that impairments that result from combining drugs with sleep deprivation are greater than those that result from each alone. SNOOZE NEWS According to the National Sleep Foundation’s 2005 Sleep in America poll, adults who drink four or more caffeinated beverages a day sleep less, have more daytime sleepiness, and take longer to fall asleep. Interpersonal Relationships If you’ve read through most of this chapter, you probably won’t be surprised that a sleep-deprived teen might have some problems with interpersonal relationships. Most likely you’ve seen that effect for yourself, not only in your own relationship with your child but in her relationships with friends and other family members. Just being an adolescent can make developing and sustaining relationships difficult; adolescents’ strong emotions and volatility can cause ruptures with friends and arguments with family. But an exhausted teen has even fewer resources for staying on an even keel with pals and loved ones. Sleep-deprived teens have less patience to see things through. So if they have words with a friend, they might not be able to wait until the blowup simmers down. Being irritable and edgy can provoke them to act immediately and unreasonably—and perhaps cause them to lose a friend. Being constantly tired can also cause teens to miss school and activities. Along with losing class and learning time and perhaps exercise

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Snooze…Or Lose!: 10 “No-War” Ways to Improve Your Teen’s Sleep Habits or honing a skill, that means they also miss out on time with their friends. Particularly during the teen years, friendships can go up and down, and not sharing experiences with friends can loosen the ties that bind. In the home, exhaustion can of course cause strain as well. Sleep-deprived teens are going to be grouchy, quick to take offense, forget or be slow to help with chores, and not have the energy for family outings or other fun. There’s so much potential for clashing, in fact, that parent-child relationships can be stretched until they snap. Stress and the Ability to Cope Sleep deprivation’s effects can make your teenager pretty miserable— less healthy, less happy, and less able to perform well. And all of that can add up to one giant case of stress. Though society is telling them that they need to do it all, teens’ exhausted minds and bodies are simply not up to the job. That can make many teenagers extremely anxious and distressed, to the point where they not only don’t know what to do but shut down completely. A number of kids who have come to my sleep lab are so stressed out that they’re barely capable of functioning. All of those kids are in need of more and better sleep. It’s the ticket not only to reducing stress but to managing the other negative conditions described in this chapter. (Getting enough sleep yourself will help you lower your own stress level and maintain better health as well as set that all-important good example for your teen.) But what is sleep really? And how does it help us live more productive and successful lives? In the next chapter I discuss what happens when we sleep and help you to understand all the forces that are at play. LESS SLEEP CAN EQUAL MORE STRESS In an experiment that monitored students the week they were evaluated for acceptance to a graduate program, those who scored high on the stress scale reported significantly reduced total sleep times.

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