Transcription
Matt Dwyer: Hi, I’m Matt Dwyer and welcome to Sleep where professor Harriet Hiscock and associate professor Emma Sciberras from the Murdoch Children’s Research Institute tohelp you identify sleeping problems in your children from infancy through to secondary school and give you easy to understand steps to improve their sleep cycles and overall health.
So our children are getting older and we’re going to look at their movement into adolescence. We’ve got things like puberty and big lifestyle changes, gatherings, making new friends, and having more activities to do after school. Harriet, what sleep cycles do we see here and how much sleep do they need?
Professor Harriet Hiscock: We’re moving into the adolescent phase and the high school phase and they need less sleep now but, still, probably more than what we think. Nine hours a night is really what adolescents need and certainly for those early years of high school and even up towards later years when they reach the more adult age and eight hours of sleep.
The really tricky thing here for adolescents is that there’s a natural shift to them wanting to go to sleep later and get up later and that is across all adolescents around the world that we see that. If you had an adolescent child living in Providence, Rhode Island in America, your child would start school at 10:00 AM to accommodate that natural shift in their sleep. We don’t do that here in Australia, as far as I’m aware and so the adolescent brain wants to go to bed late, get up late, but that’s not compatible with school. That’s one of the biggest changes, I think, in adolescence.
Associate Professor Emma Sciberras: Yeah and I think with the amount of sleep that the adolescents end up getting, it’s generally around seven and a half hours on average. So that means that they’re kind of missing out on about two hours of the sleep that they need during this developmental period. The other thing that we see that’s different in adolescent sleep is our drive for sleep. So this is something that also operates for younger kids and adults too. This “drive for sleep” means that the longer it’s been since the last time you’ve been sleepy, the more that drive will increase over time. In adolescence, we see a change in that sleep drive so it actually, because of biological reasons, is the lowest that we see in the whole developmental spectrum.
So the drive for sleep in adolescents is even lower than what we would see in adults, for example. That decrease in drive for sleep, coupled with the changes in our natural circadian rhythm or body cycle or internal clock can create a recipe for the sleep problems in this group.
Matt Dwyer: Are those developmental changes? and why is sleep so important for them in adolescence?
Associate Professor Emma Sciberras: Yeah, so one change that we see is puberty, and there are many hormonal changes that occur with puberty, but we also know that adolescence is a time of peak brain development and maturation, and those things coincide with sleep problems too. There are also huge environmental changes in adolescence. We see the commencement of high school and that requires the management of many different subjects at school, many different teachers, increases in homework that can influence when kids are ready to go to sleep. We can also see an increase in extracurricular activities which can also play an impact.
Also, adolescents may start a part time job too. So that’s another environmental change. So it’s a huge amount of biological and environmental change.
Matt Dwyer: Is that transitional period from being in primary school and moving into high school, is that a really quick change or does that happen over quite some years?
Professor Harriet Hiscock: It will happen over 12 months or so but it’s gradual, you know, 12 to 24 months and like all age groups there’s going to be large variations. It’s that sort of common sense rule of thumb; if your adolescent is waking up by themselves in the morning, if they’re generally in a good mood, at least with their peers-they may not be with you because one of their roles, in adolescence, is to grow apart from you and become an independent person in their own right they gotta be pushing back- but if they’re getting up by themselves, through class time without falling asleep and, getting on with their peers, they’re probably getting enough sleep in that sort of common sense approach.
I certainly have seen adolescents go through major growth spurts in terms of height. I find that they have to get up in the morning to go to school, but come the weekend, they might actually have two or three hour naps and you might think, “Oh God, there’s something wrong. Why are they napping?” but that seems to coincide with major height growth spurts. Then, once that growth spur is over, they go back to not having that daytime nap, but they seem to catch up during that time.
Matt Dwyer: What other things happen when they’re not getting enough sleep?
Professor Harriet Hiscock: Again, I think it’s a bit like the primary school kids, you know, they’ll be grumpy, angry. they’ll find it harder to regulate their emotions so quicker to fly off the handle, moody. Increased moodiness can affect their appetite. They may eat more, they may actually eat less, and, of course, it can impair their learning and their memory as well. So all those things happen when we don’t get enough sleep as they do for adults as well.
Associate Professor Emma Sciberras: I think it’s a developmental period where you can see kind of a vicious cycle occurring with the lack of sleep.
So, for example, if a young person is staying up late doing their homework and they get less sleep that night and then are sleepier during the day, they’re not able to be as efficient at school and learn as well. Then that night they’re doing their homework again, staying up late doing it, but they are actually really tired.
It’s not a productive use of time. Then the vicious cycle continues on and on and you can see this vicious cycle occurring too, with caffeine use, for example. Not getting enough sleep, having caffeine to try to keep you up and alert, and that then contributing to not being able to get off to sleep at night, and so on.
You can start to see more of these kind of patterns of poor sleep and poor sleep-related behaviours feeding into one another.
Professor Harriet Hiscock: Yeah, and I think the other big issue is depression in adolescents. So we might see more anxiety-type symptoms in primary school kids. Adolescence is a risky time for depression and there’s been quite a lot of research looking at the relationship between sleep and depression in adolescents.
There is some evidence that, if you do not have enough sleep or persistently short sleep, that actually leads to depression. So we always thought it was only the other way; that if you were depressed, you didn’t sleep well. But there’s some evidence, nevertheless, that on its own, not getting enough sleep leads to depression.
I think that’s a really hard thing often, to disentangle: is my adolescent depressed? or are they not getting enough sleep? because there’s a big overlap and one of the things I ask about with adolescents is, “are you enjoying things? Are you enjoying your sport or your music or going out with your mates?”
If they’re enjoying that, then it’s probably that not getting enough sleep is the issue. If they’re not enjoying that and they’re not getting enough sleep… I’m thinking about the kids who are awake until 1:00 or 2:00 AM, the parents can’t get them out of bed in the morning, they start to stop going to school and that gets into a vicious cycle because then they miss out on work, they don’t see their peers, they don’t want to go back to school, and we get this school refusal pattern. If they’re not enjoying things and, by definition for two weeks or more, that’s starting to creep into depression.
Matt Dwyer: Yeah, wow. So what are some of the other bigger causes of sleep trouble in adolescents?
Professor Harriet Hiscock: Well, I think screens, screens, screens, screens. Again, it’s not like they’re just the cause independently. Social media becomes incredibly important. Gaming for boys, particularly social media for girls. I think there’s a lot of information showing that the two are related; increased screen time is associated with decreased sleeping time and increased screen time can be associated with poor mental health in some kids.
I think the competitive nature, particularly in social media as it is an issue for girls and teenage girls, “how many likes have I got? who’s responding to my posts? Et cetera. I think getting the screens out of the bedroom is difficult, particularly because they have to do homework on their screens.
There is an opportunity to sit down with your adolescent and really talk about what is healthy screen time use and have some limits. If there are two parents in the household, agree on those rules and stick to them. It might be, for example, that Monday to Friday it’s time for schoolwork so you can use your laptop or your computer for schoolwork. After a certain hour, the phones are out of the bedroom. In the evening and also on the weekends, there might be time for games or whatever it might be, but it’s a limited time and it comes after you’ve done your homework and your sport or whatever else might be happening. It’s really tough though because they push back a lot.
Associate Professor Emma Sciberras: Yeah, it’s really hard. I’m just thinking of an adolescent boy that I saw that a month ago. His parents were really working with him to set some limits around screen time and he was being pretty compliant with it actually and he wasn’t using his phone in the bedroom.
What he was describing was that even though he was doing that and adhering to that, he was just lying in bed, wondering about what was happening on social media. We had to look at some ways to manage his thoughts about that and be able to cope with that. It was just so tricky for him because he felt like he was doing the right thing and, “okay, I’m not going to use screens” and I’m going to work with my parents, but it was still really tricky for him. I think another thing that influences sleep problems in this group is irregular sleep-wake cycles. That becomes even more prominent in adolescence where you’ll see a shorter sleep duration happening on weeknights and then overcompensating and trying to get as much sleep as possible on the weekends.
You’re seeing these biological changes that mean that you’re internal rhythm and need for sleep change but then your environment and the way that you’re managing your sleep-wake cycles also has an impact on that. So I think that’s a key contributing factor alongside the other things we’ve been talking about too.
Professor Harriet Hiscock: Yeah, and I’ll often say on the weekends to the adolescents, “you can sleep in for another hour but not longer than that because then that’s gonna cause problems of going to bed late, getting up late Monday morning, et cetera.” I think school holidays are a particular time when it gets tricky.
Look, they do need to catch up on their sleep. So often I’ll say, “just do what you need to do for school holidays, but the week before you go back to school, get back into your good sleep habits and patterns again.”
Matt Dwyer: What about going to sleep on the weekends, is that similar pushing it just by an hour?
Professor Harriet Hiscock: Yeah, similar, push it by another hour or so because if they go to sleep at midnight, 1:00 AM on Sunday night, Monday morning is not going to be fun.
Matt Dwyer: So, what are some of the other issues that we see in adolescence?
Associate Professor Emma Sciberras: The kind of main sleep difficulties that we see are insomnia and something called “delayed sleep phase”. Insomnia is something we’ve probably all experienced and are familiar with; it’s when we have difficulties getting off to sleep or staying asleep overnight. These are kids that are trying to get off to sleep, they’re lying in bed, but they just can’t switch off and get to sleep. Sometimes that can be related to anxiety and worrying about things that have happened during the day, for example, but there are other adolescents that I see that end up developing a bit of a worry about being able to fall off to sleep. That’s because of repeated patterns of going into bed, not being able to fall asleep, and lying in bed thinking, “why can’t I just fall asleep, please just fall asleep.” It becomes an anxiety-provoking process, going into bed, so you become physiologically aroused because you’ve got your heart beating and you start to experience some of those physiological symptoms of anxiety. That’s something that we see an increase of in adolescence. Another area is the delayed sleep phase: the term we use for our sleep phase shifting to have a preference for a later sleep onset and sleeping later in the morning. If I use the example of me, I like to go to sleep at 10:30 at night and wake up at about 6, so that’s my rhythm. That’s the way that I need my sleep pattern that has to be that way for me to fulfil what I need to do the next day. If I had a delayed sleep phase, it might shift so I’m not actually ready to go to bed until 12:30, so two hours later. Then my preference would be sleeping until 8:30 in the morning.
Professor Harriet Hiscock: What are the other strategies for managing the adolescent who can’t get off to sleep?
Associate Professor Emma Sciberras: Yeah, so let’s take delayed sleep phase first. I think we talked about bedtime fading in our primary school episode but that’s a really key strategy for delayed sleep phase.
If the natural time that you’re falling asleep, isn’t until one o’clock in the morning, for example, but you need to be getting off to sleep by about 10:30, just going to sleep at 10:30 and trying to sleep probably isn’t going to work. Using that gradual approach of taking the pressure off by going to bed at one o’clock temporarily, not even trying to get to sleep earlier, and then slowly bringing your bedtime forward while coupling that with all of the healthy sleep strategies that we’ve been talking about.
So one of the ones that I didn’t mention, actually, was around having a relaxing bedtime routine and wind down periods. So that’s really helpful. You’d start off by going to sleep at 12:45, 12:30 and so on, doing it really gradually until you get to the desired bedtime when you’re implementing that strategy.
Absolutely essential that the wake time is consistent during that period. So if the adolescent needs to be up at 6:30, they have to be woken up at 6:30, because if they oversleep, it’s just going to impact their ability to fall asleep at that time that you’ve set the next night. The other thing that we do with delayed sleep phase is try to get as much light exposure as possible. So, you know, opening up the blinds in the morning, eating breakfast in a light, sunny environment, getting lots of outside time. This relates to just ensuring that our internal body clock is regulated. The other sleep difficulty that is common is insomnia that we talked about before. There, you can use a similar approach. If the sleep is occurring much later than it needs to occur, you can use that bedtime fading approach where you go to bed at the time, you’re naturally falling asleep and bring the bedtime forward. That can be really helpful because when you are trying to go to sleep and you’re not falling asleep, that can increase the anxiety that you might be experiencing. So putting yourself to bed when you’re actually sleepy can really help to offset some of that anxiety, but then you slowly bring the bedtime forward. There are some other strategies that include things such as, even if you go to bed at that later time and you’re lying there and you can’t get to sleep, after about 20 to 30 minutes, getting up out of bed, doing a quiet activity and returning to bed.
So it might be getting up, sitting in the lounge and reading something, and then going back to sleep in bed when you’re tired. That just helps to offset that anxiety related to not being able to fall asleep at night. We can also see some adolescents that develop some negative thoughts about bedtime and that can kind of lead to a spiralling of anxiety. So that, “I’m not going to be able to fall asleep tonight. This is going to be really awful,” and so on. You’re kind of setting yourself up for a bad night. Some other strategies we use are what we’d say is “simple cognitive restructuring” where we work with adolescents to change some of their internal dialogue about sleep. So thinking about, well, last night, you didn’t have a good sleep. You managed to get through the day and it was okay. So even if the sleep isn’t that good tonight, you’ll be okay. Or, even, if I’m not getting off to sleep, even just having a rest in my bed is good for me. Trying to think about how you can change some of that internal dialogue with the adolescent can be really helpful too. Another thing that’s important for adolescents is something called stimulus control. This is basically a fancy name for just doing things in your bed that are conducive to sleep. So, basically, only using your bed for sleep rather than doing homework and being really strict with that. We often see adolescents that just sit in their bedrooms all the time and do everything in bed, but not sleeping. Trying to change that so they do those other activities outside of the room and only use the bed for sleep.
Professor Harriet Hiscock: Yeah, I think that’s another important correlate of this is, when do adolescents learn best? When does their brain learn best? and it’s actually like 10 or 11 in the morning.
I have had some adolescents come to me where all of their really academically challenging subjects are first thing at school and their brains aren’t yet ready. It’s having a conversation with school about scheduling, which is really tricky for schools to do, but saying, can you actually do the maths class or the physics class at 10 or 11 in the morning? not first thing because their brains haven’t actually woken up yet.
Matt Dwyer: You’ve mentioned that some people naturally wake up early. Say someone normally gets up at 5:30, is it bad if they fight that and hit the snooze button?
Professor Harriet Hiscock: Naturally waking up early, you shouldn’t fight it. I tend to find that even if they’ve done that in their early years of life, that such is the change in adolescence, that that tendency temporarily gets overridden and they do sleep in. The parents might be, “hallelujah, at last they’re sleeping in beyond 5:30 in the morning,” but the shift in that adolescent, later morning wake up becomes a challenge. If you’re lucky and you’ve got an adolescent who is getting up and is feeling awake at 5:30, 6 AM let them go for it. That’s fantastic.
Associate Professor Emma Sciberras: I think that’s exactly right.
I think the, the exception to that is if it’s occurring within insomnia. Often, when we think about insomnia we think about the difficulty that we have getting off to sleep at night, but it can also show up in waking up overnight and having an interrupted sleep or also early morning waking. It means that the whole quality of the sleep has been disrupted.
What you’re looking for there is that they wake up not feeling refreshed and ready for the day. So they’re up at 5:00 AM, but they don’t want to be there, they’re really wrecked and tired and would be preferring to sleep, but just can’t get off to sleep. So it’s kind of looking at how you feel when you wake up, “do you feel refreshed and ready for the day?” or “you’re feeling really sluggish and you’re not ready, you want more sleep?”
Professor Harriet Hiscock: That’s a good point, Emma, and certainly that early morning waking can be another symptom of depression. So, again, is your adolescent enjoying stuff? What’s happened to their eating patterns as well as their sleeping patterns? and being aware of all of that.
Matt Dwyer: How do we really identify those problems and then begin taking steps towards managing them?
Associate Professor Emma Sciberras: The first thing to look at with managing these kinds of problems are what we would call “sleep hygiene” or healthy sleep habits and there are a number of different healthy sleep habits that we would consider first to see whether or not some of those can lead to improved sleep. So some of those things might be looking at caffeine intake and making sure that caffeine isn’t being consumed in large quantities and also close to bedtime. We’d say not having any caffeine after three o’clock, for example. It’s better if they can avoid it altogether, but trying to set some limits around when the last caffeinated drink might be.
I guess trying to work towards some consistency in those sleep cycles. Thinking about, okay, “what time do I need to be awake in the morning?” So if it’s 6:30 in the morning, kind of working backwards to say, “okay, in order for me to feel well rested, what time do I need to go to sleep and try to implement a set routine around sleep?
Something else that can be considered a healthy sleep habit: screen time. We’ve touched on screens and media free time, but also having a look at making sure that there are no screens at least an hour before bedtime.
Professor Harriet Hiscock: I think that’s hard with homework. That’s a big issue.
Associate Professor Emma Sciberras: It’s really tricky. It’s also hard because adolescents, they want to be using screens and saying, “I’m not going to use a screen an hour before bedtime,” many adolescents are going to say, “no way I want to use screens.” I think with all of these healthy sleep habits, it’s working in partnership with the adolescent to decide what strategies they want to try related to sleep. It’s not going to be effective to say, “you must do this.”
The adolescent has to be motivated to make the changes. We find that using an approach where we ask the adolescents what things they might feel comfortable tweaking in relation to their sleep routine and starting from there so it’s really in their control.
Professor Harriet Hiscock: That’s absolutely essential.
Unlike toddlers or even primary school aged children, these are adolescents on their way to becoming adults and you can’t make them do things without them also agreeing. One of the best ways for all sleep issues in adolescents, if they’ve got to make quite major changes, is to write up a contract, with them wherein the adolescent has to do something, but in return, the parent has to do something and the adolescent gets to choose that.
It might be for mom and dad to stop nagging me about the state of my bed and the parent has to do that. Then, actually, if they’re with me, I get them to sign a contract and I sign it as well. That’s just a little bit of a way of having that negotiation between the adolescent and the parents so it’s not all the parent’s way and the adolescent does feel some control of the situation and what’s happening.
Associate Professor Emma Sciberras: We recently completed a small pilot study where we tested out some of these strategies with adolescents and asked for their feedback on trying these strategies out at home. I recall a quote from one of the adolescents where we asked them what they found the worst thing about the program was and they said, “my parents nagging me to do the strategies.” I think it just really highlights that balance to have parents being there as a supporter and providing some kind of framework and consistency around it without being too over imposing because it just makes the adolescent pull back.
Matt Dwyer: What sort of approach would you take with a rebellious teenager? They’ve got their social circles now and starting to develop these really strong personalities.
Professor Harriet Hiscock: This is really tricky and you’ve got to make the adolescents see value in making the change. Is there anything about their lack of sleep that is affecting their abilities
the next day in something they care about, sport or something like that? So you have to try and find something that matters to them. I think the parents, this is where the contract can sometimes help, if they see mum and dad are gonna stop nagging me about X, or let me do that, then, if mum and dad are gonna make the change, then I will.
It’s sort of a fair exchange. I think it’s really tricky. I think you also need to look at, is there anything else going on in their life that is making them rebellious? Is there other stuff going on at home or at school that you need to address? Sometimes these kids are acting out because they are falling behind at school, they are getting bullied, or mum and dad are going through a separation or divorce or something like that. There might be context to their situation that you need to understand and try and fix as well.
Matt Dwyer: So you mentioned one of the strategies, previously, muscle relaxation and visual imagery. Can that now be applied here as well?
Professor Harriet Hiscock: Yeah, it’s a great technique for adolescents and I think they often find these things themselves or they’re being taught about these techniques at school, but that, combined with mindfulness, really helps. There are a lot of apps, again this is tricky with phones in the bedroom, but with different white noises on it such as rain falling, leaves rustling, and that can be good as well.
It’s all about just that cognitive restructuring that Emma was talking about of changing your attitude towards not being able to fall asleep, accepting that it is okay. Just saying, “a rest is as good as sleep”, distracting your mind from those thoughts. That’s what the sequential muscle relaxation does do as well.
If you’re on the beach and the sun is shining, the waves are coming up in and out of the shore, the birds are off in the distance, the sun is warm, and there’s a cool breeze coming over your body. You can start to go to sleep. That, I think, can be really helpful.