Sleep disorders in teenagers

13-year-old Lars has had problems falling asleep for years: He lies awake for one or two hours in the evening before he can finally sleep. He is often preoccupied with worries and fears - on the one hand about school, but increasingly also the fear of not being able to sleep. His parents are worried that his lack of sleep could have a negative impact on his school performance.

Sleep disorders are not uncommon among adolescents - and have increased in recent years: According to a report in the Deutsches Ärzteblatt, the proportion of 15 to 19-year-olds suffering from a non-organic sleep disorder more than doubled between 2006 and 2016.

Overall, around 20 per cent of children and adolescents suffer from a sleep disorder at some point in their development. This can have a significant impact on their everyday lives: Teenagers are tired and unfocussed during the day, are in a bad mood and perform less well at school.

It is typical for a sleep disorder that sleep is impaired in some way, which often leads to tiredness or sleepiness during the day. However, in individual cases it is not so easy to recognise which sleep disorder is present and what the exact causes are. The severity of the sleep disorder and the extent to which it affects everyday life can also vary greatly.

«If the child or adolescent is very tired during the day or tends to fall asleep, or if the sleep problems lead to mood swings, concentration problems or a significant deterioration in school performance, this should be investigated by a doctor,» says Martina Hug, senior physician at the Department of Developmental Paediatrics at the University Children's Hospital Zurich. «The same applies if abnormal behaviour occurs during sleep, such as breathing stops or unusual, rhythmic movements. But even if parents are unable to categorise an observation and are worried about it, they should not be afraid to seek professional support.»

Sleep disorders: First to the paediatrician

In most cases, the first point of contact is the paediatrician. «They can check whether there is a physical cause behind the sleep problems, such as frequent coughing due to asthma or pain,» explains Alexandre Datta, Senior Physician and Deputy Head of the Department of Neuro- and Developmental Paediatrics and Co-Head of the Centre for Sleep Medicine at Basel University Hospitals. «Tiredness during the day can also have a variety of causes that are not necessarily related to sleep, such as iron deficiency or psychological causes such as depression.» The paediatrician will therefore investigate the causes carefully.

It is important to differentiate between tiredness and sleepiness, i.e. the tendency to fall asleep. «Based on the symptoms, he can assess what type of sleep disorder is present,» says Datta. «Accordingly, they can advise the parents and initiate initial treatment measures themselves - or, if necessary, refer the child to a specialist or a sleep outpatient clinic.»

Awake in the evening and tired during the day

A total of six categories of sleep disorders can be distinguished. By far the most common sleep problems in children and adolescents are difficulties falling asleep and staying asleep and tiredness during the day. This is also referred to as insomnia. «In addition to small children, adolescents aged 11 to 12 are particularly frequently affected,» reports Datta.

«On the one hand, sleep pressure decreases at this age, making it harder to fall asleep in the evening. Secondly, the sleep rhythm shifts backwards for hormonal reasons: Teenagers go to bed later and sleep longer in the morning - and if they have to get up early for school, for example, this often leads to a chronic sleep deficit.»

Using smartphones or tablets shortly before going to bed has an unfavourable effect on sleep.

Just like 16-year-old Marco: he likes to party late into the night with his friends, where there are energy drinks as well as alcohol. During the week, he plays computer games until late in the evening. He often can't fall asleep until the early hours of the morning, is very tired during the day and sometimes doesn't even get out of bed in the morning. The idea of finishing school without any qualifications worries him greatly.

Psychological stress often plays a role in problems falling asleep and staying asleep, which are related to problems at school, conflicts with parents or peers: for example, anxiety, pressure to perform, sadness or anger. Sometimes sleep problems are also linked to depression. «According to studies, up to 90 per cent of children and adolescents with depression have disturbed sleep,» reports Hug. «They find it difficult to fall asleep in the evening, are awake more often at night and often wake up too early in the morning.» Conversely, a lack of sleep can also contribute to depressive symptoms such as low mood, listlessness or mood swings.

Finally, using smartphones or tablets shortly before going to bed can have an unfavourable effect on sleep. «The blue light from screens, as well as the increased arousal caused by social media use, inhibit the release of the sleep hormone melatonin, which is important for a regular sleep-wake cycle,» explains Datta. It is therefore important to first find out the causes of sleep problems. «In our sleep consultation, we ask carefully about the factors that can lead to sleep problems,» says Hug. «In addition, the adolescents should keep a sleep diary for 14 days, with which we can record their actual sleep requirements and sleep characteristics.»

The parents and the child or adolescent are then given advice on what they can do to get a grip on their sleep problems. «They first receive important information about sleep, such as how much sleep a child needs at what age and what is important for a good night's sleep,» reports Hug.

With self-confidence against sleep disorders

On the one hand, sleep hygiene measures are important. They should help to improve sleep behaviour and sleep. «The cooperation of the child or adolescent is fundamental to successful treatment,» says Hug. «We therefore emphasise in particular with adolescents that they can have a direct influence on their own lives and that they can feel fitter again during the day and perform better at school as a result of the changes.»

If the sleep problems are related to psychological stress, it is important to strengthen the child's self-confidence and allay their fears. «In the case of more severe psychological problems or a mental illness, such as depression, it is essential to be accompanied and treated by a child and adolescent psychiatrist in addition to sleep hygiene measures,» says Hug.

If parents notice that their child snores frequently even without an infection or stops breathing briefly during sleep, they should discuss this with their paediatrician.

If the sleep-wake rhythm is disturbed, in addition to sleep hygiene measures, the sleep hormone melatonin or light therapy can be used to favourably influence the internal clock. In some cases, however, there is also a physical cause behind daytime sleepiness. «These include breathing disorders and movement disorders during sleep, which can occur at any age,» explains Datta. «They should always be clarified by a specialist and, if necessary, by an examination in a sleep laboratory.»

If parents notice that their child snores frequently or stops breathing briefly during sleep, even without an infection, they should discuss this with their paediatrician as soon as possible. This is because breathing problems, also known as sleep apnoea, cause a short-term drop in the oxygen content in the blood. It also leads to repeated brief awakenings. As a result, children are tired and less productive during the day.

Unpleasant tingling in the legs

«The most common cause in children is enlarged tonsils or other anatomical features,» says Datta. «This should be carefully investigated by an ENT specialist and, if necessary, in a sleep laboratory.» In certain cases, surgery is necessary at a very young age. «This often leads to significant improvements,» explains the sleep physician. «The children can breathe better, sleep better, are fitter during the day and often have a better appetite.»

Periodic leg movements during sleep and restless legs syndrome, in which sufferers feel an unpleasant tingling sensation in their legs at rest, can also significantly disrupt sleep and lead to tiredness or hyperactivity during the day. «A common cause in children is iron deficiency, which can be treated well,» says Datta.

Sleepy during the day: narcolepsy

After all, it can happen that a child or adolescent is not only tired during the day, but also feels sleepy and falls asleep again and again - even though there is no lack of sleep. This is known as hypersomnia. «You have to look for the exact causes, which is usually done in a sleep laboratory,» says Datta.

The best-known form of hypersomnia - which only affects around 40 in 100,000 people - is narcolepsy. Those affected suddenly fall asleep during everyday activities, such as eating or speaking. Strong emotions, such as laughing or excitement, lead to so-called cataplexies - a temporary slackening of the muscles. When falling asleep and waking up, visual hallucinations and sleep paralysis can also occur - in other words, those affected are unable to move at that moment. «The symptoms usually only become fully pronounced in adolescence,» explains Datta. «In children, on the other hand, they are often still atypical: they are often not sleepy, but rather restless and hyperactive. As a result, the disorder is often not recognised at this age.»

If narcolepsy has been diagnosed, stimulant medication and sleep hygiene measures can help to reduce the symptoms. «In addition, those affected can incorporate regular, short naps into their daily routine to reduce their sleepiness,» says Datta. «They also learn coping strategies, for example to avoid situations that trigger cataplexies.»

In some cases, the solution to sleep problems - once the cause has been recognised - is quite simple. This is the case with 7-year-old Marlene: she becomes a little «tyrant» in the evening, constantly asking for something else and simply doesn't want to fall asleep. During sleep counselling, it turns out that Marlene doesn't need much sleep for her age. After she regularly goes to bed later in the evening, the situation quickly improves. And the parents are happy to know that less sleep does not harm their daughter.