Insomnia Insomnia

58 Garcia
the reality that the tendency toward delayed sleep-phase syndrome seen in teens is
biologically driven by the circadian system.
The treatment of circadian rhythm disorders in children and adolescents can be
discussed in three groups: chronotherapy, phototherapy, and pharmacotherapy. A
review of the sleep log helps to set the context for discussion of chronotherapy or
sleep–wake scheduling. A common method of chronotherapy is known as sleepphase
advancement (32–34). Taking into account the youth’s social expectations
and requirements, a reasonable wake time is agreed upon. The agreed upon earlier
wake time drives the sleep-onset time earlier. There is often a 3- to 5-day delay as
the sleep phase advances. The teen may be advised that during this time, he or she
may feel tired. It is emphasized that over the next 2 to 3 months, strict wake and
bedtimes must be adhered to 7 days a week. Once a more appropriate sleep phase
has been established, relaxing the schedule once or twice a week may be allowed if
it does not throw the teen back into a delayed sleep phase. Alternatively, some
physicians prefer to delay the sleep onset and wake time by several hours each day
until the sleep-onset and wake times have been delayed to a phase consistent with
the teen’s social expectations. This form of chronotherapy is known as sleep-phase
delay. For example, the teen falling asleep at 3 AM and waking at noon is asked to
delay sleep onset until 6 AM. The wake time is proportionately delayed until 3 PM.
On the second day, sleep onset is at 9 AM and wake time is at 6 PM. The sleep-onset
time is delayed 3 hours each day until sleep onset is at 9 PM and wake time is at 6
AM. Thereafter, the sleep phase is fixed again for several months. One may choose
to emphasize the nature of the relationship at this point. The physician is often seen
as a coach. This places responsibility and control in the hands of adolescent.
Phototherapy is the second fundamental treatment in children with circadian
rhythm disorders (35–37). The goal is to decrease the evening light and increase
exposure to waking bright light. It is important that the teen’s exposure to bright
light, including television and computer monitors is eliminated after 9 PM. In the
morning, early morning bright light exposure with a light box or ambient light is
effective in resetting the biological clock. Generally, 10,000 lux is necessary. Precautions
should be taken to avoid exposure to ultraviolet spectrum (38) light. Use
of light therapy should be avoided in patients with a history of bipolar disease as it
can trigger mania. It should be emphasized that the patient need not look directly at
thea light box; the direction of gaze may deviate 15°. It is recognized that children
often have difficulty using a light box and integrating the light box into their morning
routine is often a challenge. Some children choose to put the light box on the
breakfast table or where they do their homework in the morning.
Medication therapy is mentioned last because it is rarely effective without
simultaneously using sleep–wake scheduling and/or phototherapy. Two groups of
medication have been described. The first is the sleep-inducing medications including
the benzodiazepines and zolpidem. These medications are most effective when
there is a pre-existing sleep debt. The second is melatonin. Melatonin has been shown
to advance the sleep phase in some patients with delayed sleep-phase syndrome (39–