Apple is a bright, happy, 11 year old white female. The nurse at her school referred her to the local health clinic because Apple frequently falls asleep in class, especially the last three months. She comes to the clinic with her maternal grandmother for an evaluation.
Apple says that both her math class and her history class are “boring” and she cannot pay attention to the teacher. Sometimes she nods off during those classes. History class starts at 10 AM and math begins at 1 PM. Apple’s grandmother says she goes to bed at 10 PM most nights and occasionally a little later on the weekend. Apple gets up in the morning at 6:00 AM in order to be at school by 7:30AM. Her grandmother says the parents have been getting Apple to school on time this school year, because they did not want the “school to call again”.
Apple lives with her mom and her older sister who is 17 years old. Her grandmother lives a few miles away and is very involved in Apple’s life. Apple’s parents divorced when she was a toddler, and Apple spends equal amounts of time at the home of each parent. Apple’s parents met while living in a what Apple’s grandmother calls “that free spirit hippie commune place,” but they left that community after the oldest child was born. The grandmother states that because Apple’s parents chose not to have her receive vaccines, the family has been fired from several pediatric practices, and Apple mostly gets her care at a “doc in the box” when she is sick.
When interviewed, Apple reports she spends most evenings alone. Her dad works from 7PM to 7AM, 4 nights a week, on a road maintenance crew. Apple states her dad fixes her supper, then heads to work. Her dad does not permit her to leave the house while he is at work. She does her homework, watches TV, and gets in bed at 10:00PM. She actively Tweets, Snapchats, and posts on Instagram. She keeps her phone in bed with her all night. When asked about how she spends her time while at her mom’s house, Apple replies “My mom says we’re all equal and that I can make my own decisions about what to do, just like my sister did at my age.” Apple does not have a routine at her mom’s house; sometimes she hangs out with a 14 year old neighbor and sometimes she stays home. Her mom does not have a tv, but Apple spends a lot of time on her laptop. Looking over Apple’s dietary intake, Apple drinks several energy drinks in the evenings. She remarks that the 14 year old neighbor has encouraged evening energy drinks so she will seem more outgoing and will be more popular with other kids.
Teenagers and adolescents require approximately 9 hours of sleep at night.
During the teenage years, patients often have a delay in sleep onset leading to later bedtimes and late wake times.
The most common cause of teenage/adolescent sleepiness is insufficient sleep syndrome. Insufficient sleep syndrome is the result of inadequate time asleep that is usually caused by a lack of time to sleep. This is exacerbated by the presence of smartphones and tablets in children’s sleep environment.
Staying up at night to be connected on social media is called “Vamping,” in reference to both vampires and “virtual camping.”
BEARS Screening for Hypersomnolence
As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Apple and her grandmother.
Apple takes a long time to fall asleep. She gets in bed around 10PM, but doesn’t fall asleep until 1 or 2AM. She is texting, watching Netflix, and Snapchatting with her friends.
Apple has some insomnia that is worsened by her use of technology in the bedroom.
Excessive Daytime Sleepiness
Apple falls asleep frequently in her history class at 10:00 AM and during her math class at 1:00 PM. She does not feel more rested after a short 20 minute nap. She often takes a nap after getting home from school. She does not feel as sleepy on the weekend.
Falling asleep during the day is the hallmark of hypersomnolence disorders.
Patients with other causes of daytime sleepiness do not improve as rapidly from a short nap.
Apple occasionally wakes up in the middle of the night. This usually happens when her alerts on her phone wake her. She does not have any trouble falling back asleep.
Patients with inadequate sleep due to poor sleep hygiene frequently have sleep that is disrupted by their phones and social media alerts. They typically use their phones and computers in the bed.
Regularity & Duration
During the school week, Apple gets in bed around 10:00 PM. She typically is in her bed from 10 until she falls asleep at 1 or 2 AM. She wakes up between 6 and 6:30 AM in order to be at school by 7:30 AM.
On Friday and Saturday nights, she gets in bed between midnight and 2AM. She typically falls asleep around 2:00 AM. She then sleeps until 12:30 PM or later on Saturday and Sunday afternoons.
Apple falls asleep in school and often takes a nap at home after class.
Apple is not obtaining the 9 hours of sleep that is suggested as a baseline for her. This suggests a diagnosis of insufficient sleep syndrome is more likely. Her story can be further confirmed with the use of actigraphy or a sleep diary.
Apple’s sleepiness does not compromise her ability to socialize. With insufficient sleep syndrome, patients rarely give up social events or extracurriculars.
Sleep-Disordered Breathing / Snoring
No. Apple’s grandmother does not report that she snores.
Patients with daytime sleepiness may be sleepy due to a lack of restorative, non-fragmented sleep during the prior night. One of the more common causes of this dysfunctional sleep is sleep disordered breathing.
Apple's Evaluation & Diagnosis
What evaluation & diagnostic protocol should be used to diagnose Apple’s excessive daytime sleepiness?
Consider her triage vitals:
Height: 146.5cm (57.6 in)
Weight: 43.2kg (95 lbs)
BMI: 20.1kg/m2 (74th percentile)
BP 98/62 HR 84
RR 18 Oxygen saturation of 100%
What are the next steps in the evaluation that should be used to diagnose Apple’s excessive daytime sleepiness? Check all that apply:
The evaluation protocol strategies we recommend for Apple's case are:
Determine the child’s sleep history
Obtain an Epworth Sleepiness Scale score
Perform physical examination
Order labs or other diagnostic tests
Complete a sleep diary
The history of a patient’s sleep problem is always of critical importance. This information obtained helps to guide the physical exam and the ordering of further testing. The history here may guide toward poor sleep hygiene, insufficient sleep syndrome, sleep disordered breathing, or medication induced insomnia.
Determine Apple's sleep history
Case Specific Information
Apple's Evaluation Results
What the child does at night
What does Apple do prior to going to bed?
At Dad’s house. she does her homework, watches TV, and gets in bed at 10:00PM but she stays up posting on Instagram, Snapchat, and Twitter. She also keeps her phone in bed with her all night. At Mom’s house her routine is not much different and she has unrestricted access to her phone and computer.
Review timing of events at night (bedtime/wake time)
Tell me about your routine to get ready for bed.
At Dad’s, Apple gets in her bed around 10 and ‘chats with her friends until she falls asleep. That usually occurs between 1 and 3AM. She wakes between 6 and 6:45Am to get to school. At mom’s house, she gets in bed later but still falls asleep with her phone around 2AM.
Screen for other sleep issues (OSA, restless leg syndrome)
Has anyone ever noticed that Apple snores during the night? Do your legs ever hurt before bedtime?
Mental health concerns
Do you ever feel anxious or depressed?
Apple says she feels happy when she is with her friends. She denies feeling depressed.
Review of medications (antidepressants, seizure medications, and antihistamines all have impacts on sleep)
Does Apple take in medications or herbal supplements?
Apple took some diphenhydramine in the spring for her allergies and this made her more sleepy during the day. She does not take any other medications.
Assess for family history of sleep disorders
Does anyone in the family have trouble staying awake or going to sleep?
Grandmother notes that the older sister stays up very late as well, but she does not seem to have the trouble staying awake during the day.
Obtain an Epworth Sleepiness Scale score
The Epworth Sleepiness Scale was given to Apple to better understand her level of daytime sleepiness.
Sitting and Reading
Sitting, inactive in a public place (i.e. a theatre or a meeting)
As a passenger in a car for an hour without a break
Laying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Perform physical exam
Information to obtain includes:
Case Evaluation Results
Assess the patient’s nutritional status.
Assess the HEENT system to evaluate for tonsillar hypertrophy or narrow upper airway. Neurologic examination should be performed to rule out evidence of central nervous system process that might result in hypersomnolence.
Apple has a BMI at the 74th percentile. Her throat examination reveals 1+ tonsils and Mallampati scale of 1. Her neck is supple. Cardiac examination reveals normal pulses 2+ and no murmurs with a normal S1 and S2. Chest examination reveals bilaterally clear lung fields with no increased work of breathing. No wheezes. GI: Abdomen is soft, non-tender, non-distended with normal bowel sounds. Neuro examination: No focal deficits noted with 5/5 bilateral upper and lower extremity strength. Normal mentation and normal cranial nerve examination.
Order Labs/Other Diagnostic Tests
Information to obtain includes:
Case Evaluation Results
Urine drug screen
Apple provided a urine sample that was assessed for drugs of abuse. Her urine drug screen was negative with no illicit drugs found.
Complete a Sleep Diary
Information to obtain includes:
Case Evaluation Results
A sleep diary was given to Apple to complete for 10 days. This includes time in bed and sleep times.
Apple returned the sleep diary after completing it for 10 days. It is shown below.
Options that are Not Recommended
Order a Sleep Study
Ordering a sleep study would not be recommended in this situation.
Refer to a Specialist
Referral to a sleep specialist is not indicated for Apple.
Daytime sleepiness with neurologic abnormalities should prompt further evaluation.
Daytime sleepiness that is unexplained by lack of sufficient sleep or another sleep disorder.
When evaluating a child for daytime sleepiness, consider how other health care providers may also need to be involved.
Expert Insights: Triggers for Hypersomnolence
Expert Insights: Triggers for Daytime Sleepiness
Late bedtimes coupled with early school start times restrict the amount of time that adolescent have available to sleep.
Delayed sleep phase, a shift of the normal peak of sleepiness and wakefulness to later hours of the day, occurs during adolescence. This phase shift increases the risk of having increased periods of sleepiness in the early morning times. When teenagers are starting the school day, their internal clock feels as if it is still time to be asleep.
Electronic devices, such as smartphones, tablets, and televisions, disrupt normal sleep patterns and increased daytime sleepiness.
Evaluation & Diagnosis
What diagnosis is consistent with Apple's daytime sleepiness? Check all that apply:
Apple’s signs and symptoms are consistent with the diagnosis of:
Insufficient sleep syndrome
In this case, Narcolepsy, Obstructive sleep apnea, and Restless legs syndrome are not consistent with Apple's sympotoms.
Apple reports a very fragmented sleep schedule and poor sleep hygiene, with frequent screen use prior to bed. Her sleep diary demonstrates that she is getting 5:45 of sleep on average per day. This is consistent with a diagnosis of insufficient sleep syndrome.
Insufficient sleep syndrome is very common in adolescents due to a combination of poor sleep hygiene, increased social demands on their time, and a physiological shift in the sleep-onset time of adolescents. Most teenagers experience a shift in their sleep and wake times with a shift to 11:00PM for bedtime and a corresponding wake time of 8:30-9:00AM. Most teenagers get far less than the 9 hours of recommended sleep time.
Apple's Treatment & Referrals
Now it’s time to recommend treatment options for Apple. Check all that apply:
Treatment Strategies for Narcolepsy
The following treatment strategies are recommended for Apple:
Increase her time asleep in bed.
Remove electronic devices from her sleep area.
Establish better sleep hygiene.
Treatment Strategies for inadequate sleep hygiene
Beneficial sleep habits include maintaining a consistent sleep-wake schedule (even on the weekends), a regular bedtime, a consistent bedtime routine, eliminating caffeine from the diet, and avoiding the use of electronics (particularly with LED, or blue-light producing, screens) in the 60-120 minutes prior to bedtime.
Beds should only be used for sleeping. Other stressful activities such as studying, doing homework, arguing on the phone, or paying bills should not be performed in the bed, or ideally, the bedroom.
A sleep promoting environment includes a cool, dark, quiet environment. Eliminate screens from children’s bedrooms.
When to consult a sleep specialist or refer to another discipline:
If the patient continues to experience bouts of daytime sleepiness after making changes to their sleep hygiene and sleep time.
If the patient has other symptoms of sleep disturbances, such as snoring or early morning headaches.
If the patient experiences episodes of cataplexy.
Interdisciplinary Treatment Components
Good news! Apple and her grandmother have implemented a few of the changes that were suggested. Apple’s parents have been receptive to counseling, with a focus on limit-setting and consistency across households. After a few months, Apple’s parents are permitted to have some weekend visits to see how if the changes stand up over time. Apple’s dad is giving serious consideration to a job change so he can be home at night but worries about money.
Treatment strategies and results for Apple’s daytime sleepiness:
Remove electronic items from the sleep area
At her grandmother’s house, they have created a family charging station in the kitchen. All devices for the family must be charged there. If the devices are not charged in this location, then they will not have a charge for the next day. Apple reports that she plugs her phone in the station between 11:30 and midnight each night. Her mother agrees to this, too. So far Apple has only visited her dad’s house on nights the dad does not have to work.
Increase time asleep in the bed
After plugging her phone into the family charging station, Apple gets in bed and falls asleep within 20 minutes most nights. Apple is not getting into her bed prior to plugging in her cellphone in the charging station. This has resulted in Apple spending less overall time in bed, but the percentage of time that she is bed sleeping has increased. Based on the second sleep diary that Apple brought with her to clinic, her sleep efficiency (time in bed asleep compared to total time in bed) increased from 55% to 93.2% while at her grandmother’s home. Despite not making all of the recommended changes, her change in behavior also improved her sleep efficiency at her father’s home to 70%, and 80% at her mother’s home. Great progress but still room for improvement!
Establish beter sleep hygiene
Apple’s mother still voices some resistance to a “formal schedule”, but grandmother and Apple have recognized that she feels better with a routine. In addition, Apple has stopped consuming energy drinks in the evening and has had an easier time falling asleep at bedtime. Apple still does not have a set wake time, particularly on the weekend.
Apple and her grandmother should work together to continue to improve her sleep hygiene and to maintain a consistent sleep schedule at all the homes in which she lives. Apple and her grandmother should share the sleep tips that they are using with Apple’s mother and father.
A family preservation worker assigned to the family helps with making sure everyone knows the goal is a healthy, happy, well-rested child.
The medical team should be involved in the decision regarding when Apple can safely go back to her parents’ custody.