Sleep issues in young people and strategies to support them

Key learning points

Sleep patterns change in adolescence and may lead to delayed sleep phase disorder
Sleep issues impact on emotional, physical and mental wellbeing
A cognitive and behavioural approach to sleep issues can be very effective

In 2014, the Children’s Sleep Charity developed a pilot project to explore more about the kind of support that young people need for sleep issues.

Despite the fact that young people should spend almost a third of their lives asleep, it was immediately apparent that there is very little support available to them when they face difficulties. Research suggests that up to 40% of children will suffer with sleep issues at some point.¹ Insomnia is a huge public health problem affecting mental, physical and emotional wellbeing. Sleep deprivation also has a negative impact on learning and concentration levels, affecting attainment.

Teenage sleep patterns typically change during adolescence, with many young people finding their circadian rhythm is disrupted. They fall asleep in the early hours of the morning and then need to sleep in the next day. The increased use of technology has also had a significantly negative effect on sleep patterns.² One common theme that emerged during our project was that young people were finding it difficult to wake early to begin school on time. These early wake-up times work against the natural teenage circadian rhythm, leading them to feel lethargic.³ Delayed sleep phase disorder occurs when an individual’s bedtime moves later and later, resulting in their circadian rhythm being out of sync.

BOX 1: Key findings from the sleep council teen sleep survey
83% of teens admit their sleep is affected by stress and worry
82% use their bed to revise in
56% admit to regularly cramming all their revision for an exam into one night
26% use energy drinks or caffeinated drinks to stay awake

A common situation was that young people were sent to bed at around 9.30pm by parents who were concerned about their sleep patterns. They were, however, unable to get to sleep until 2 or 3am but then needed to get up for school at 7am and were exhausted. This then led to them sleeping in during weekends in an attempt to catch up.

Delayed sleep phase disorder is thought to affect up to 16% of young people. Light therapy used alongside sleep hygiene can be effective. In some cases, melatonin may need to be prescribed as the young person follows a programme of chronotherapy to reset the body clock.

Staying in bed at weekends and holidays was found to be a common pattern and produced a jet-lag effect. Young people frequently admitted to staying up later on Friday and Saturday nights by up to five hours. Studies suggested that if sleep routines were kept consistent throughout the week, school attainment was improved.^4,5

Stress and anxiety were also another factor that led to young people having sleep issues. In 2015, we worked alongside The Sleep Council to provide tips on how to improve sleep patterns following a survey of 1,000 youngsters that demonstrated the impact of exam season on sleep. The results can be seen in Box 1 (see above). It became apparent that there was a significant need to develop quality sleep information to educate and empower young people to improve their own sleep patterns.

The last decade has seen a sharp increase in the use of electronic equipment such as games consoles, tablets and mobile phones. Electronic gadgets now play a central role in the lives of most adolescents.

The blue light from screens has been proven to suppress production of melatonin, the sleep hormone. Melatonin is often referred to as ‘the hormone of darkness’. Exposure to light will suppress it and make it more difficult for individuals to fall asleep. Electronic gadgets are also highly stimulating. Being woken throughout the night by the sound of text messages and social media alerts was common.

Over 80% of the young people we worked with admitted to leaving their phone on overnight so they could keep up to date with their friends. Many slept with it under their pillow so they could be woken by it more easily.

It is vitally important that primary care professionals access training on the benefits of sleep and strategies to support a good night’s sleep. A cognitive and behavioural approach can be extremely effective and also cost saving.

Doncaster Clinical Commissioning Group commissions the charity to provide a sleep service in the town. This currently runs at over a 90% success rate and reduces costs in other areas such as melatonin prescriptions and paediatrician appointments.

Promoting healthy living to young people is incredibly important. They are taught about the importance of a healthy diet, exercise and the consequences of substance misuse. But sleep is almost never discussed.

The young people we worked with were very receptive to learning about sleep. They showed a genuine interest in the basic physiology of sleep.

Once they were made aware that sleep issues could be improved and why they were occurring, they became more motivated to make changes. Providing sleep hygiene information proved to be important, but the key was to explain the science behind the advice. Tips included:

Go outside and have 30 minutes natural daylight each morning to help to reset the circadian rhythm.
Avoid screen activities for at least an hour in the run-up to bedtime to support the production of melatonin to aid drowsiness.
Carry out homework or revision in a designated space, but not in your bed.
Avoid sugary snacks and caffeine drinks after 4pm.
Get up at the same time each day, even at weekends, to support your circadian rhythm.
Spend some time away from your bedroom in the hour before sleep. Consider what activities you can engage in that are relaxing, such as reading a book, playing a musical instrument or a craft type of activity.
If listening to music, choose more calming tunes in the hour before bed.
Having a bath 30 minutes before sleep time can help.
Mindfulness can be helpful.

James Wilson, a sleep practitioner, led much of the work with young people. He was able to empathise with their situation, having struggled with sleep issues himself as a teenager. As well as being a sleep practitioner, James is also a bedroom environment expert and was able to offer specific advice to make the space more conducive to sleep.

Key points include:

Consistency in terms of lighting. Many young people were falling asleep with televisions on and then waking when they emerged through the sleep cycles and parents had switched them off. Lighting should be consistent in the room throughout the night to minimise the chance of night wakings. A dark bedroom can be helpful to promote melatonin and to block out the sunlight during the summer months. Some youngsters with visual and hearing impairments may find total darkness disorientating and may benefit from a softly glowing night light consistently throughout the night.
Assessing the temperature. Bedrooms ideally should be around 16 to 18 degrees.
Dimming lights in the run-up to bedtime can encourage the production of melatonin.
Consider the comfort of the bed and how supportive the mattress is.
Recognise that pets can disturb night-time sleep and it is better if they do not share rooms.
Sunlight alarm clocks can be helpful to aid a gradual wake-up in the morning.

Changes can only take place if young people are willing to engage in a new routine. Our project demonstrated that young people find peer support particularly favourable as a way of gaining information. Attending sleep clinics with a sleep practitioner was also cited as being useful, allowing them to access tailored support for their individual needs. Surprisingly, online support was not popular, with many sharing that they had already explored that avenue with little success.

In order to make the project sustainable, resources have been developed to train those working in schools such as school nurses, counsellors and support staff to become ‘sleep champions’. The one-day training course includes materials for the sleep champion to share with pupils, colleagues and parents to embed quality sleep information in the heart of school communities. Sleep should also be embedded in all primary care training and featured as part of routine assessments. Reducing levels of sleep deprivation must be a key priority for young people as they move into their adult lives.

References

1 Quach J, Gold L, Hiscock H et al. Primary healthcare costs associated with sleep problems up to age 7 years: Australian population-based study. BMJ Open 2013;3. Available from bmjopen.bmj.com/content/3/5/e002419 (acessed May 2017).
2 Hysing M, Pallesen S, Stormark KM et al. Sleep and use of electronic devices in adolescence: results from a large population-based study. BMJ Open 2015.
3 Edward B, O’Malley M. Sleep and Psychiatric Disorders in Children and Adolescents CRC Press, 2008.
4 Gruber R, Somervile G, Bergmame L et al. School-based sleep education program improves sleep and academic performance of school-age children. Sleep Medicine 2016;21:93-100.
5 Gruber R1, Laviolette R, Deluca P et al. Short sleep duration is associated with poor performance on IQ measures in healthy school-age children. Sleep Med 2010;11:289-94.
6 The Sleep Council. How the Exam Season Is Affecting Teens’ Sleep. 2015 sleepcouncil.org.uk/how-the-exam-season-is-affecting-teens-sleep/.