Doctors probe why it's hard for many kids to get up
March 21, 2006
Associated Press

Staying up late and sleeping until noon usually seems like normal teenage behavior.

But there's increasing concern among doctors that many teens may actually be suffering from a little-known sleep disorder. The problem, called delayed sleep phase syndrome, isn't well known and is often underdiagnosed, but it may afflict anywhere from 360,000 to several million teens and young adults, according to a 2004 review article in the medical journal Sleep. One of the gravest concerns, researchers say, is that it is often misdiagnosed as attention deficit disorder, depression or a behavioral problem that is treated with prescription drugs. The sleep disorder, however, can usually be treated without drugs.

DSPS is believed to be the result of the body's internal clock - called the circadian system - getting stuck in the wrong place, causing kids to stay up late. As kids enter puberty, circadian rhythms that affect sleep begin to change, which is why most kids' bedtimes shift about an hour later as they get older. But for reasons no one understands, some kids experience more dramatic changes as their internal clocks shift forward too far. Those kids can't fall asleep until the early hours of the morning, but still have to get up early for school, so they have to get by on just a few hours of sleep each night.

It isn't clear why this happens. It may be hereditary. External factors may also play a role. As kids get older, schools start earlier, and homework loads and extracurricular activities increase, often forcing kids to stay up later than normal. Every adolescent has to deal with these pressures, but in some kids, the changes may upset the circadian system, causing it to essentially get stuck in a place where sleep is consistently delayed.

"The parents get stigmatized as not having control over their kids when they can't get them to school in time," says James Wyatt, co-director of the sleep-disorders center at Rush University Medical Center in Chicago who is conducting research looking for ways to better diagnose the disorder. "Children themselves get stigmatized as avoiding school or lazy. There's a lot of baggage associated with it."

One of the biggest challenges of delayed sleep phase syndrome is getting the right diagnosis. Sleep problems aren't usually on the radar screen of pediatricians, school counselors or parents. "If teachers were more aware and if parents more aware that they should go to a sleep specialist, then it's usually pretty easy to fix," says Lawrence MacDonald, medical director for the Sinai-Grace Hospital Sleep Disorders Center in Detroit.

One of Dr. MacDonald's patients is a 17-year-old Grosse Pointe, Mich., boy whose grades started falling two years ago. After making straight A's in junior high, the teen started bringing home low C's from high school. He was often unable to pay attention in class, and complained of constant fatigue and feeling overwhelmed. After visits with the school counselors, the pediatrician and a psychiatrist, he was diagnosed with depression and started therapy. But the psychiatrist eventually said he didn't seem depressed and suggested his problems at school might be due to ADD. He was given the drug Strattera.

His mother, a nurse, heard about Dr. MacDonald after talking with a colleague who had recently attended a medical seminar with the doctor. After hearing about the teen's sleep troubles, Dr. MacDonald suspected the boy might be suffering from DSPS.

When the teen tried to go to bed at a normal time, he would lay awake for hours, or get up and play on the computer or watch TV. He would finally fall asleep around 4 a.m., only to be awakened at 7 a.m. for school. The cycle lasted about two years before he was correctly diagnosed.

Short-term use of melatonin, a hormone that influences sleep patterns, may help, but the problem can return when the treatment is stopped. Prescription sleeping aids also can offer short-term relief, but they typically aren't recommended for adolescents.

A nondrug treatment called chronotherapy can be used to "re-set" the body clock. Chronotherapy essentially "winds" the body clock forward three hours at a time, moving the child's bedtime around the clock until he or she ends up with a "normal" bedtime.

For instance, for a child who can't fall asleep until 4 a.m., the bedtime is first delayed until 7 a.m., and the child is allowed to sleep until about 3 p.m. The next day bedtime is delayed another three hours, this time until 10 a.m., and the child is awakened at 6 p.m. The process continues, with bedtime moving around the clock to 1 p.m., 4 p.m., 7 p.m. and 10 p.m. until the desired bedtime is reached. Windows are taped up and phones turned off so midday sleep stretches won't be interrupted.

Parents typically have to sacrifice sleep themselves and take turns staying up late and helping kids pass the time in the middle of the night. The treatment typically takes about a week, so a parent can choose to do it during a school vacation.

But it is well worth the effort. In the case of Dr. MacDonald's patient, the teen now consistently falls asleep at 11 p.m. and wakes at 7 a.m. His grades are mostly A's and B's.

Most kids and young adults eventually outgrow the problem, but they remain at risk for relapsing.

Once the treatment is finished, teens are advised not to stay up late on weekends and avoid late-night cramming for tests for fear of throwing off the schedule. Because the circadian system is sensitive to light, television and computer use are discouraged within an hour before bedtime. Light boxes are sometimes advised for 15 minutes or so in the morning after waking, to keep the circadian system on track and help reinforce the new wake-up time.