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Abstract
Sleep is important for our survival. Research suggests that getting ‘good’ sleep is a problem for a proportion of adolescents. The paper advocates for holistic treatment of sleep disorders incorporating expertise from a multidisciplinary team. Much of the assessment and treatment of sleep disorders in adolescents comes from research within adult populations, therefore, there is a need for further research to be completed within the adolescent population to ensure there is a robust evidence base for assessment and treatment of sleep disorders.
- Sleep
- Adolescent Health
- Neurology
- Psychology
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Key messages
Sleep is extremely important for our day-to-day functioning, physical health, mental health and overall well-being.
Sleep in adolescents is affected by a range of interacting biopsychosocial factors.
Thorough assessment, diagnostics, formulation and intervention by a multidisciplinary team lead to improved outcomes in a teenage population experiencing sleep difficulties.
The evidence base of interventions for sleep disorders in the paediatric population is lacking.
Introduction
"I cannot remember the last time I got a full night’s sleep. I feel exhausted, it sucks the life out of you."
Good sleep is essential for us to maintain our day-to-day functioning. It is a vital biological requirement.1 2 The adolescent period is often defined as the age of 10 years old to 19 years old and is sometimes considered to be up to age 24.3 This paper uses the term adolescence to reflect the structure of how children’s services are designed in the UK, which supports children and adolescents up to the age of 19. This period encompasses many changes for a young person including physiological changes, personal exploration and growth, in addition to facing obstacles such as exams and social pressures.3 Without sufficient sleep, adolescents may experience irritability, behaviour changes, difficulties with tasks that require sustained attention,4 poorer academic achievement,2 weight gain5 and mood problems.6 Evidence suggests that adolescents, on average, benefit from at least eight to ten hours of sleep each night.4 A proportion of adolescents are not achieving this and may develop chronic sleep debt.2 There are various biopsychosocial factors which may affect adolescent sleep which may act in combination. A young person may be affected by developmental changes, physical health, mental health and social factors, all of which may contribute to the development of sleep disturbance. These factors may interact and exacerbate one another, and they are explored in more detail below.
Biology
Biologically, there is a well-reported phase shift that occurs in the sleep circadian rhythm of adolescents. Evidence suggests that sleep pressure builds more slowly in adolescents, making it easier for them to stay awake later at night.7
At a molecular level, key neurotransmitters (dopamine, glutamate and gamma-aminobutryic acid (GABA)) are expressed in approximately a 24-hour rhythm which is modulated by the 'sleep hormone' melatonin. Disruption of these neurotransmitter processes is thought to be linked to a range of affective disorders. These neurotransmitters also have an important role in modulating behaviour (such as risk taking and emotional responses) during adolescence,8 9 therefore, disruption to these processes might provide some explanation for associated behaviour changes (see online supplemental material A and online supplemental figures 1–3 for further information about the science of sleep).
Supplemental material
Psychology
Sleep deprivation has been linked to an increase in symptoms of mental health difficulties, such as increased levels of anxiety and heightened threat perception in adolescents.10 Evidence suggests that the relationship between sleep and mental health is bidirectional.11 When there are pre-existing physical or mental health conditions, the impact of sleep difficulties can be more detrimental.12
Social factors
Most adolescents access education full time, and this may require them to be awake earlier than their natural body rhythm preference,13 which can mean that adolescents experience a decline in total sleep time.7 Lack of sleep affects a range of behavioural and cognitive processes and can impact on school attendance and academic attainment.2 14
The adolescent years can be a time of changes in role and identity, which can include a desire for increasing independence, for example characterised by setting their own bedtimes.7 Additionally, there is increasing importance placed on maintaining social relationships with peers15 and using social media to do this.16 The use of technology, particularly late at night, impacts sleep latency and quality.7 In the context of wanting to engage with social networks or using technology for other reasons such as gaming, it is understandable that sleep may be affected and not always prioritised in our adolescent years. The use of stimulants should also be considered in a sleep history with adolescents and is associated with poorer sleep outcomes.17
Various biopsychosocial factors may lead a young person to present with one of several sleep disorders. These include insomnia and delayed sleep phase disorder (DSPD; see online supplemental material B for description of sleep disorders). Reported rates of insomnia in adolescents vary from 4% to 23.8%.18 19 DSPD has a prevalence between 7% and 16%.20 21 Rarer hypersomnolence disorders seen in adolescents such as narcolepsy and Kleine-Levin syndrome (KLS) also occur but will not be discussed in detail in this paper.
We conducted a survey of professionals working in Child and Adolescent Mental Health Services (CAMHS) and Paediatric Services in London, to assess knowledge of assessment and intervention of sleep difficulties in adolescents, to inform this paper. Experience and confidence in managing sleep disorders in children and young people varied according to the place of work and local referral pathways. We surveyed a total of 154 professionals (psychologists 45%, CAMHS practitioners 28%, psychiatrists 9% and paediatricians 5%) working in CAMHS (86%) and paediatric services (general and specialty; 12%) to scope the understanding of adolescent sleep in local health and mental health services. The majority of respondents (66%) reported that they frequently see adolescents with sleep problems in their clinical practice with less than 1% reporting never seeing adolescents with sleep problems. One in three were not confident in managing sleep disorders in adolescents and 74% did not know of a local referral pathway available for their client group. In the subsample of 114 respondents from CAMHS, although 89% felt confident in offering advice on routine sleep issues, 64% did not feel confident in offering an intervention. This paper presents three case studies illustrating a range of sleep presentations commonly seen in adolescents and describes evidence-based approaches to support these illustrating useful approaches to management.
Clinical cases
Case A: an adolescent who cannot sleep
Presenting complaint
'A' is a 15-year-old girl who was referred by her paediatric team with several years history of having difficulty falling asleep at night, connected to anxiety and worry at night-time. Her bedtime was 20:00 hours. She would reportedly take 3–4 hours to fall asleep. There was a medical history of generalised anxiety and obsessive–compulsive disorder diagnosed at 11 years old. She took dihydrocodeine for migraines, which lasted up to a week at a time, and which had led her to attend her local accident and emergency (A&E) department. She had diagnoses of dyslexia and dyspraxia. She described feeling that on some nights she had ‘not slept at all’. She had tried blackout blinds, eye masks, aromatherapy, electronic curfews, yoga and accessed counselling and reported that none of these had helped. There was a degree of social jetlag at weekends with her staying in bed 3–4 hours longer in the morning beyond her normal wake time (through to 10:00 hours).
History of presenting complaint
'A' was assessed by a clinical psychologist. She was found to sleep for less than 8 hours (less than the recommended of up to 10 hours sleep for teenagers). She reported frequent night waking and extreme fatigue during the day. There was no history of sleep apnoea, parasomnias, restless leg symptoms, rhythmic body movements or daytime naps. The local paediatrician trialled melatonin but this was stopped as the family did not perceive any benefit from it.
Psychological formulation
'A' had a difficult transition to secondary school which coincided with an unexpected appendectomy involving general anaesthetic which 'A' described as traumatic. Her sleep deteriorated at this time. She reported a subsequent fear of dying with catastrophic thoughts focused on ‘I will die if I fall asleep’ which led to heightened anxiety before bedtime. She engaged in safety behaviours such as avoiding going to bed and distracting herself with other activities. There was also a vicious cycle identified where her poor sleep and migraines exacerbated one other. After her multi-professional assessment, she was given a diagnosis of insomnia secondary to anxiety.
Intervention
The psychologist created a treatment plan for 'A' (see box 1) based on her sleep history and actigraphy. Strategies were outlined to manage insomnia (see online supplemental material C) and barriers to change were identified. A’s anxiety was a significant perpetuating factor in her sleep staying the same. She was worried that reducing her time in bed would mean that she was more tired at school, and therefore, unable to perform academically. This meant that initially she did not engage with the intervention. Building a relationship with 'A' helped the psychologist to formulate this with A and create a plan to overcome this worry. Part of this included referring 'A' to a sleep and anxiety workshop, which included psychoeducation and practical activities.
Case A’s sleep intervention / management plan -modified sleep restriction for insomnia
A’s sleep plan initially involved calculating average total sleep time and time in bed (TIB) then calculating sleep efficiency (SE; see table 1). Ideally SE should be above 85%. Her initial sleep efficiency fell below this at 78%. The first part of the plan involved restricting time in bed, with the aim to increase sleep efficiency to above 85%. This part of the treatment plan was aided by explaining sleep stimulus control to the family, see figure 5 for sleep stimulus control image.
Once 'A' achieved a sleep efficiency of above 85% for at least a week, she was advised to add 15 min onto her TIB (ie, bring bedtime earlier by 15 min), until her sleep efficiency was between 85% and 90% and she did not feel fatigued in the day.
Sleep intervtion for Case A - insomnia written plan
Image to demonstrate sleep stimulus control. The red bed depicts how unhelpful associations can develop between bed and a range of activities, as opposed to bed being associated simply with sleep as shown in the green bed.
Outcome
'A' engaged in various psychological interventions during the 4-year timeframe that she was seen by the sleep service. She found the sleep and anxiety group helpful and said ‘even hearing about other people who were going through similar things was helpful’. She acknowledged that she found it hard to implement sleep restriction because she was anxious about being sleep deprived at school. Using motivational interviewing strategies (see online supplemental material D),22 23 'A' acknowledged that she already felt sleep deprived at school as a result of insomnia, and that a trial of sleep restriction might lead to long-term gains. She set treatment goals and identified strategies to improve sleep and physical well-being.
Case B: teenager sleeping at the wrong time
Presenting complaint
'B' was initially referred aged 13 years old with a 4-year history of an erratic sleep pattern. He had a history of chronic pain, following orthopaedic surgery on his knee 4 years prior. The pain was more troublesome after exercise and at night when it precipitated night wakings. The family’s impression was that he only slept for 4–6 hours a night. His bed time was 21:00 hours and he would reportedly not fall asleep until 01:00–02:00 hours. During weekends and in the holidays, he would sleep in till midday.
History of presenting complaint
'B' reported that he was able to fall asleep independently, however, he felt he slept fewer than 7 hours per night. There was no history of sleep terrors, nightmares, apnoea, seizure activity or restless legs. There was no history of daytime naps. There was a family history of sleep apnoea (paternal). There were questions about possible autistic traits. The initial working diagnosis was possinble insomnia.
Sleep investigations (actigraphy and polysomnography: see box 2 for descriptions) revealed that 'B' took over an hour to fall asleep, had a mean total sleep time of 7 hours and 42 min and had a low sleep efficiency of 76%. There was a degree of delayed sleep phase. 'B' met with a sleep psychologist on four occasions. His psychoeducation plan included information on routine, morning bright light and reducing overnight screen time. He was also prescribed melatonin in line with guidance.24 25
Summary of sleep investigations
Various diagnostic tools exist to help determine the triggers and nature of sleep disorders:
Actigraphy uses a wrist-worn device that quantifies the wearer’s movement levels as well as light exposure, usually over a few weeks, to track their sleep schedule and pattern. This may be useful in assessing insomnia and circadian rhythm disorders. It is recommended as part of the assessment in support of narcolepsy, prior to multiple sleep latency tests (MSLT) (see below).
Common terms used in actigraphy reports include:
TST—total sleep time (actual time asleep measured in hours).
SE—sleep efficiency=TST/TIB×100%; (normal value >85%).
TIB—time in bed (time spent in bed measured in hours).
Cardiorespiratory sleep studies (CRSS) and oximetry are used to assess or screen for various respiratory issues during sleep, including sleep disordered breathing such as obstructive or central sleep apnoea, to evaluate gas exchange and to help decide non-invasive ventilation requirements.
Polysomnography studies (PSG) combine Electroencephalogram (EEG) traces with CRSS to enable holistic assessment of sleep: from sleep architecture to any triggers of sleep disturbance or sleep-related movements.
Multiple Sleep Latency Test (MSLT) is the gold-standard diagnostic test used to help assess hypersomnolence, scheduled following a nocturnal PSG (including cardiorespiratory monitoring), where the patient is allowed to take short 4–5 naps during the day. The presence of dream sleep and the time taken to fall asleep over the naps (sleep latency) is calculated to rule out conditions such as narcolepsy.
Human leucocyte antigen typing is a blood test used to clarify narcolepsy (type 1) diagnosis but is not diagnostic.
Orexin/hypocretin (which is a neurotransmitter produced by cells in the hypothalamus) measurement from Cerebrospinal fluid may be used to diagnose type 1 narcolepsy. A value of <110 pg/mL is diagnostic for narcolepsy. 110–200 pg/mL is an intermediate/borderline result and values above 200 pg/mL are considered normal (this may not be required in all cases).50 51
Reassessment
'B' was reassessed by the sleep psychology team when he was 17 years old as his sleep had become markedly delayed. He estimated that he was falling asleep between 12:00 and 03:00 hours when taking melatonin and between 01:00 and 05:00 hours without melatonin. B stated that he felt he had no control over his sleep. Rather than describing insomnia, his presentation was more in keeping with a circadian rhythm disorder (delayed sleep phase disorder or DSPD).
Psychological formulation
'B' was thought at a later stage, to have significant delayed sleep onset, and this made it difficult for him to attend school full-time and engage in daytime activities. Note his inital presentation was described as possible insomnia. Predisposing factors included autistic traits, issues in peer relationships and anxiety. We wondered whether a perception that he was different to others maintained these difficulties. Precipitating factors included circadian rhythm adjustments related to adolescence and increased social and academic demands. We wondered about whether his current sleep pattern served a perpetuating function, as being unable to attend school meant that he avoided the challenges he experienced there. 'B' had several protective factors including his mum who understood him well.
Intervention
Motivational interviewing, was arranged, to help 'B' commit to change by exploring ambivalence and his own arguments for change22 23 (see online supplemental material D for further information).
Further psychoeducation and joint formulation of difficulties was outlined.
A chronotherapy plan which is the standard approach for DSPD was created with the family and young person (see below and figure 1 for further information).
'B' was referred to a sleep and anxiety workshop.
A trouble shooting plan was put in place (see online supplemental material E).
Example chronotherapy schedule. This is an example schedule and would be tailored to a young person’s routine and preferences.
The chronotherapy plan entailed pushing sleep progressively later in 3-hour increments (see figure 1 for visual example) until ''B reached the desired sleep and wake time.26
Once sleep reached the desired sleep and wake times, a number of strategies were implemented to help keep B’s sleep stabilised. These were:
Consistent bedtime routine.
Maintaining consistent waking and rising time every day (including weekends).
Bright light exposure in the early morning.
Exercising at least once a day in the early afternoon.
Three healthy meals at set times.
Range of meaningful activities scheduled in the day.
Melatonin 30 min before desired sleep time (not always required).
Outcome
B was sleeping in a consistent pattern by his final psychology session. His psychological input spanned 4 years. He reflected that during A-level exams, he was extremely stressed and anxious and his sleep pattern reverted. However, he was able to recognise this and followed the chronotherapy plan again. He reported being more energetic, more alert and his mood was improved. He subsequently enrolled at university and was discharged from the service.
Case C: young person presenting with daytime sleepiness
Presenting complaint
'C' was 15 years old and had a background of severe headaches, thought to be migraines. He was seen by a paediatric neurologist; his Magnetic Resonance Imaging (MRI) brain scan was normal and fundi examination unremarkable. He was noted to fall asleep up to 10 times a day and an onward referral to a tertiary sleep service was made.
The clinical question at referral was whether he had a primary sleep disorder. The secondary question was whether his disturbed sleep cycle was contributing to his headache symptoms or if his migraines were significant enough that they were contributing to night-time sleep fragmentation and secondary excessive daytime sleepiness.
History of presenting complaint
'C' reported sleep latency of 5 min. He experienced nightly visual hypnogogic hallucinations (dreams occurring while still awake before the transition to sleep). He had occasional sleep paralysis (weakness in skeletal muscles while awake which normally occurs first thing in the morning and can be associated with hallucinations). The family did not give a history of circadian disturbance or shift. There were no reported symptoms of KLS. C was highly motivated and supported by his family however his attendance at school was 50% due to his symptoms and he missed several lessons and mock exams in preparation for his school-leaving exams taken at 16 years old (GCSEs; General Certificate of Secondary Education). The provisional working diagnosis was possible narcolepsy.
Management plan
The sleep clinic arranged weekly telephone appointments and an urgent second opinion from paediatric neurology was arranged. Prophylaxis for migraine-related medication and analgesia were ineffective.
Sleep investigations
Polysomnography (see online supplemental figure 4) covered a total recording time of under 11 hours. Sleep latency was 7 min with REM latency at 50 min. Total sleep time was just over 3 hours and sleep efficiency was 30%. There was no sleep disordered breathing.
MSLT was not conducted the next day due to the results of polysomnography and actigraphy.
Actigraphy (see online supplemental figure 5) showed widely variable bedtimes which ranged from 17:30 to 09:30 hours (average bedtime of midnight). Wake times varied from 06:30 to 18:00 hours (average waketime of midday). Average total sleep time was under 6 hours with prolonged sleep latency of over 3 hours. Sleep efficiency was low at 45%.
Bloods: Full blood count (FBC), ferritin, thyroid function tests, vitamin D—all normal
HLA typing—HLA-DQB1*06:02—negative.
Outcome
C’s actigraphy showed a circadian rhythm disturbance with catch up sleep. The sleep investigations showed that he did not have narcolepsy. The day after his polysomnography, a chronotherapy plan was put in place by the sleep psychology team. Motivational interviewing was not required in this case as 'C' and the family were highly motivated. C’s sleep pattern was corrected (see sleep diary—figure 2) and was anchored with low-dose melatonin 30 min before bed in the evening and use of a light box (10 000 lux) for 30 min in the morning.
Demonstration of good sleep scheduling and resolution of circadian sleep disturbance on sleep diary.
C’s school played a key part in organising pastoral care and liaised with his exam board to ask for reasonable adjustments to be made. He had his GCSEs grades adjusted to consider time lost and missed exams. He successfully enrolled in college and his headaches and sleep problems resolved. 'C' is now at university.
Discussion
Adolescence is a complex period in the developmental trajectory.27 28 The necessity of sleep is becoming more fully understood, but management of sleep disorders in clinical practice can be suboptimal due to a lack of sleep expertise, experience or resources within local services,29 and a lack of medical education in sleep and sleep disorders internationally.30
These case studies demonstrate the necessity of a multidisciplinary team approach to sleep, as sleep difficulties in teens can be multifaceted. Case 'A' was complex and both Cases 'B' and 'C' presented with a probable working diagnosis that was later confirmed as an alternative, based on objective sleep investigations and multiprofessional assessment. A sleep problem or disorder may form part of a far more complex and wide-ranging constellation of concerns. This could include physical and mental health concerns, as well as neurodevelopmental issues. There may be additional factors such as historic traumatic events,31 which may require specialist intervention. A medical and psychological perspective is likely to improve the chances of an accurate assessment and successful formulation and intervention for a teenager’s sleep difficulties. This should be supported by robust diagnostic services. Sharing a clear formulation of the young person’s difficulties, in language that they and their family can understand, conveys the rationale for any intervention offered and hopefully facilitates their engagement.
When faced with stressful events, it is human nature to have a tendency towards ‘experiential avoidance’.32 This can take the form of trying to avoid thinking about something, use of substances to avoid feeling a certain way or literally avoiding anxiety-provoking situations, perhaps by refusing to attend school, or staying up at night when there are fewer social demands and pressures. While these behaviours might feel anxiety-relieving in the short term, they often compound anxiety in the longer term and are often not conducive to sleep.32 Experiential avoidance may add to the complexity of how we see teenagers presenting with sleep difficulties.
There are wide-ranging factors that can influence the chances of an intervention succeeding. Assessment should include factors which potentially influence sleep holistically and biopsychosocially, including family, culture, attachment, wider systems, medical concerns, socioeconomics and geography. It might be helpful to use a framework such as the ‘social GGRRAAACCEEESSS’33 or the ‘HEEADSSS assessment’,34 to guide these conversations. A young person’s attachment to their parent or caregiver can influence their proneness to sleep difficulties.35 Co-sleeping which may occur in children and young people with a disability,36 may serve a function for one or both members of the dyad, making it reinforcing and potentially presenting barriers to separation.
Formulations of how sleep problems have developed and are maintained can take various forms. One such approach is by using a vicious flower formulation,37 which focuses on maintenance cycles and can help identify opportunities for intervention. Sleep problems might be at the centre of a vicious flower or form one of the petals, resulting from and perpetuating a condition such as anxiety or low mood. Figure 3 shows an example of a vicious flower formulation for sleep. Figure 4 shows a virtuous flower, which suggests ways to optimise sleep in teenagers. Physical and emotional pain can impact on sleep. Families, schools and society can give teens a sense of pressure to academically achieve, which may feel especially unfeasible for those who are sleep deprived, excessively sleepy or with erratic sleep, potentially perpetuating their sleep difficulties. Pain, for example, might be a precipitant of sleep issues, and there is evidence to show that poor sleep can increase the perception of pain,38 increasing the chance of its then becoming a perpetuating factor. A vicious flower for case A would include A's experiences of anxiety, migraines, learning difficulties, a difficult transition to secondary school, worry about sleep and behaviours such as avoiding bedtime. A virtuous flower in case A might include, migraines being managed effectively, changes to beliefs about sleep, management of school workload pressures, an effective sleep plan and peer support.
Vicious flower formulation for poor sleep in teenagers.
Virtuous flower formulation for good sleep in teenagers.
Beliefs about sleep, both in the individual (eg, ‘if I don’t sleep tonight, I am going to have a rubbish week’) and in family scripts (eg, ‘we are all poor sleepers’) can contribute to sleep difficulties. It is important to tailor interventions to the individual: there is no one approach that can work for everyone.39 For example, sleep hygiene alone cannot address insomnia, excessive, or erratic sleep, but it provides a solid foundation for the more active components of the intervention, such as sleep restriction and stimulus control. Engagement is key in work with young people, and motivational interviewing22 could facilitate this process, as well as the recruitment of supporters from a young person’s network.
The effects of social media and smart device use on sleep are nuanced. Czeisler and Shanahan40 found that two-thirds of parents of 15–17 years had a smart device active while they were sleeping, and that 43% engaged in messaging after their initial sleep onset. Ofcom41 found that nearly three quarters of 16–24 years said they had missed sleep due to their online habits. A systematic review42 of data from over 125 000 persons (6-19 years of age) found that even those who had access to but did not actually use their devices overnight, still lost on average an hour of sleep per night, had reduced quality sleep and experienced more daytime sleepiness. On the other hand, the NSPCC reported that ‘restricting a young person’s access to the internet could inhibit the development of the skills needed to handle online risk’,43 so removing access to devices is not an ideal solution, but being mindful of the timing of access to devices, both for young people and the adults around them who set examples to them is important.
Critique of evidence base
In general, treatments for sleep in adolescents are largely adapted from adult approaches. For example, the evidence base for treatment for chronic insomnia, such as group cognitive–behavioural therapy for insomnia, is better established in adult populations,44 which means that clinicians must extrapolate from adult literature. Research shows positive effects of stimulus control, psychoeducation and thought management though there is also evidence to support the efficacy of interventions such as hypnotherapy,45 which is not routinely offered in paediatric sleep services. For those who have erratic sleep or a circadian rhythm disturbance, it is still unclear which components of the chronotherapy intervention lead to change: motivational interviewing and engagement, timetabling, support, addressing the function of the behavioural aspects of the delayed sleep, melatonin or blue light.46 Further research is necessary to improve the evidence base for sleep interventions for insomnia in younger people. See online supplemental material F for details of organisations and resources with a focus on sleep in young people.
Conclusion
Sleep issues and the diagnosis of disorders are of paramount importance in adolescent medicine. Further research is necessary to determine the most effective ways to treat adolescent sleep issues. Engagement is a key component of this, as well as determining the possible protective effects that a given sleep problem might have on an adolescent. Exploration of interventions that address sleep disorders in adolescence and ways to mitigate these impacts are areas for potential future research. Sleep is important at all life stages, but adolescents are often under immense pressure to perform socially, physically and academically, and these are all areas where being well slept can make a positive difference.47–49 We, therefore, need to establish the most effective intervention strategies, as well as the factors that are likely to maximise their success. This begins with thorough assessment and accurate formulation of presenting difficulties and effective multidisciplinary intervention.
Ethics statements
Patient consent for publication
Ethics approval
This paper did not receive ethical approval as it was a review of literature and description of case studies. All patients used for case studies gave their informed consent.
Acknowledgments
We would like to thank all the young people who contributed to this paper. We would also like to thank Corin Whitfield (Trainee Clinical Psychologist) who reviewed published literature on teenage sleep and the impact of the COVID-19 pandemic, and Dr Deborah Woodman (Consultant Neuropsychologist) and Dr Shreena Unadkat (Highly Specialised Clinical Psychologist) for completing a detailed review of the paper. And we thank the Evelina paediatric sleep multidisciplinary team (MDT) for their continued support, including Dr Michael Farquhar who has led on work in adolescent sleep nationally and internationally, as well as Prof Paul Gringras.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors DJ conceived the idea for a review paper on adolescent sleep, contributed to writing and reviewed the content, as well as held overall responsibility for the paper content. M-KD compiled the cases and was lead contributor to the writing of the manuscript. CT and SK also collaborated, contributed to case studies and and wrote the manuscript as well as edited and reviewed.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
Author note The paper was written jointly by M-KD, CT, DJ and SK. With detailed input regarding psychological theory and interventions by M-KD and CT and specialist expertise regarding medical management by DJ. SK contributed details related to diagnostic intervention and the science of sleep physiology. We used the CARE checklist when writing our report.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.