Amanda currently is going to bed at 8PM, but unable to fall asleep until 11PM. She will repeatedly come out of bed and room and express concerns about not being to fall asleep. She returns to bed without much resistance, but states she is not able to fall asleep. She will frequently check on what her parents are doing. She states she thinks about “everything” during that time.
- On a recent vacation, when bedtime was later, she continued to have difficulties falling asleep although seemed to take her much less time to eventually fall asleep (closer to one hour).
- Spending 3 hours in bed on a nightly basis and failing at achieving the desired goal of sleep onset provides consistent negative reinforcement of failure, worsening levels of hyperarousal and anxiety surrounding sleep.
- Seeing a gap in desired bedtime and physiologic sleep onset time may suggest physiologic circadian shifting which occurs in adolescence, although most with typical delayed sleep phase syndrome do not complain of awakenings once asleep.
When asked, Amanda denies daytime sleepiness at all. She does not nap and does not fall asleep in class or during car rides.
- In many children, particularly pre-pubertal in age, the primary manifestations of excessive daytime sleepiness are not overt sleepiness, but rather impairments in focus, academic performance, worsened mood and emotional lability.
- Providers need to know age appropriate manifestations of daytime sleepiness in order to best ask caregivers, parents, and teachers the questions that will more accurately reflect the impact of insomnia.
Amanda says she is a light sleeper and wakes up to everything. Her mother describes that Amanda can hear somebody close a car door on the street and wake up to it. Amanda also knows what times she wakes up since she looks at her clock a lot overnight, concerned that it may be time to get up without having been able to fall asleep at all.
- Hyperaoursal associated with long standing insomnia includes ability to disrupt sleep maintenance, with low thresholds of arousal to environmental factors such as noise. Hypervigilance to not miss anything while asleep is a common description.
Amanda states that she wakes up almost every night a few times, but cannot recall farther than 1-2 days the timing of these awakenings and how long she is awake. She states that she thinks she is awake for hours. Mom however feels that Amanda is awake only for a few minutes and then falls back asleep quickly.
- Paradoxical insomnia is when more sleep is being achieved than perceived by the patient, who continues to have the same distress and subjective impairment of insufficient sleep as those with true insomnia. There may be secondary gain to the complaints which then continue to reinforce the perceived experiences.
Amanda quickly becomes worried that maybe she does snore. However, her mom does not recall that she snores, and on a recent vacation when they were sharing a hotel room she did not hear Amanda snore. She has never had problems with allergies, asthma, or chronic congestion.
- Many parents are not aware of whether or not their tween or teen snores as they do not frequently sleep in the same room.