Hello, everybody. Thanks so much for joining us. My name is Argelinda Baroni. I'm a clinical assistant professor in the Department of Child and Adolescent Psychiatry at NYU Grossman School of Medicine. And I'm also a sleep specialist. I did one extra year of fellowship at the end of my psychiatry fellowship. And I'm going to talk to you about a condition which may present similarly and that we psychiatrists often encounter and may have trouble diagnosed. So the objective is going to be to differentiate delayed sleep phase disorder from insomnia and idiopathic hypersomnia. We'll talk about psychological and environmental factors that affect delayed sleep phase disorder. I will talk about treatment and then we'll talk briefly toward the end about how to detect excessive pathological sleepiness or hypersomnia or idiopathic hypersomnia in children and adolescents. This is actually a topic which is dear to me because by chance I ended up seeing many of these kids and I realized they are often missed. And so I said, well, I'm going to add a little part about idiopathic hypersomnia. Because I think that sometimes learning is easier, starting by cases, I'm going to present two cases which are going to guide us through the presentation. So we'll start with Maggie, obviously not a real name or picture. This is actually actress Coleman. But for our purpose, this is Maggie. She's a 16 year old female. She has trouble falling asleep and waking up in the morning. Her sleepiness scale, we're going to show you in a few minutes. It's eight over 24, which is, you know, borderline, not terrible. And it's the sleepiness is mostly in the morning. Her sleepiness has caused her to have school problems with multiple school absences and tardiness. However, she's a good student and she is very upset about the situation. Nuclear precipitants started about two or three years ago. It's progressively getting worse. That's why she came to see me. And she was stable, sertraline, 50 milligrams for anxiety, currently in remission. My other case, similar age. Again, not real name, not real picture, Sarah. For this purpose, a 17 year old female. She has trouble waking up on time in the morning. She feels tired. At the same time, she said she sleeps too much and her sleepiness scale is shows pathological excessive daytime sleepiness, 16 over 24. I'll show the scale in a second. She has a lot of multiple school absences and tardiness. To the point that when I meet her, she was enrolled in a private one to one setting school, so she was one student with one tutor through the day to finish high school. The symptoms started when she was around 15, possibly after a viral infection. She was on fluoxetine 80 when I met her, Ospiron 10 TAD, and she said that the breast mood fatigue were her prominent symptoms. Again, in this case, I was consulted as a sleep physician, and then CL actually took over the case as a full psychiatrist and sleep physician. So what is our thoughts about these cases? The excessive daytime sleepiness is actually what brought them to me. Neither of them was able to function and go to school. How would you define excessive daytime sleepiness? Is the propensity to fall asleep during normal daytime activities? It is not fatigue. Is it not being tired? Is really propensity to sleep is when people fall asleep when they shouldn't. So both my patients tend to fall asleep in class. And we'll see there are some differences. But sleepiness, what brought her brought both of them to me. Excessive daytime sleepiness is always pathological for children above five. So while, you know, the three or four year old, the toddlers are cute and fall asleep everywhere, should not have anybody above age of five to fall asleep on public transportation, on in class, while watching TV, et cetera. If they do, there is something to investigate more. You can use a scale, which is free. The Airport to Airport Sleepiness Scale for children to assess excessive daytime sleepiness. This is actually the scale that I was talking about. It's very simple. The patient can fill it out in, you know, less than a minute and goes from the option goes from zero to three zero. Never have a chance to doze off sleep or three. In this situation, I have a high chance of dozing off or sleeping. And then there is a list of eight situation. And that gives you the score. So you can imagine that my patient who scored 16 had a lot of threes and again, can be sitting and reading, watching TV, studying, doing home, actually doing homework, sitting and talking to someone, et cetera. So you can use it, it's free and is a very simple way to assess excessive daytime sleepiness. I think there is some disagreement in the field about what is a score. I would say the rule of thumb, anything eight or more always indicates excessive daytime sleepiness in children. And then, you know, we can question whether they should have even less sleepiness. And then obviously depends on what are the scores. What are the excessive daytime sleepiness causes? Classically, we have primary hypersomnia, narcolepsy, neurological disorder due to lack of orexin, ibuprofen or idiopathic hypersomnia. And then we have obviously secondary cases, which you see a lot of them, for example, volitional sleep deprivation, kids that play video game all night. They'd be very sleepy in the morning, but they don't have idiopathic hypersomnia or narcolepsy. They have volitional sleep deprivation and obviously have psychiatric disorder presents with excessive sleepiness. We have sleep disorder, might disrupt sleep and give as a consequence excessive daytime sleepiness. Classically, obstructive sleep apnea, medication and neurological condition. Today, though, we're going to focus mainly on delayed sleep phase disorder and we're going to touch upon idiopathic hypersomnia. Just a quick reminder, this is a list in our own manual, the DSM-5 TR of sleep-wake disorder. We have a big chapter. Some of the fellows sometimes I teach get surprised that we have, you know, OSA and hypersomnolence disorder, et cetera. They're actually all there. As probably all of you know, but again, we're going to focus mainly on delayed sleep phase disorder under the circadian rhythm, sleep-wake disorder and hypersomnolence. So delayed sleep phase disorder. Again, we'll focus on Maggie. Just a quick reminder, she's somebody who has trouble falling asleep, trouble waking up, the difficulty waking up have really caused a lot of impairment in her academic and school functioning. She's upset, nuclear precipitant, very stable psychiatrically. This is actually her sleep log. I'm sure some of my co-panelists have discussed this. This is a very simple form. You can download it for free. The American, if you can just Google Sleep Diary, American Academy of Sleep Medicine. This PDF, these things will pop out, and this is actually what Maggie compiled for me. As you can see, this is a very interesting sleep log. This kid was sleeping very little and was actually having sort of huge sleep marathons or, you know, day off or days that she was not going to school. And otherwise she was really sleeping at times three or four times, you know, falling asleep at three or four or later. This sleep log is a classical sleep log for individuals who suffer from delayed sleep phase disorder. What is this disorder? It's a sleep disruption due to misalignment between our endogenous circadian rhythm and the sleep wake schedule required. So if you have more than two hours of delay or falling asleep later than you wish and having trouble waking you up when expected. These might be a sign that the person suffers from a circadian rhythm disorder, specifically the delayed phase of the sort of the schedule, if you want, for those of you on Eastern Eastern time is like you live in New York, but you are on California time. And looks like insomnia, I'm saying this because the treatment, you know, has definitely some components, stimulus control, et cetera, but it does have its own peculiarity. So normal sleep, like where I'm now that I'm middle aged. I sleep from roughly 11. I wake up at seven. But actually, when I was in medical school, my preferred time would have been, you know, three or four. And I naturally I would wish to sleep till noon or one. But as when I was in medical school, my I have to I try to go to bed earlier and I would have increased sleep onset latency. So I thought at the time to have insomnia and I would be very sleepy in the morning because actually my sleep period would have been truncated. I'm saying this because a lot of people think that kids have insomnia for me, unless it's otherwise proved. Somebody can't tell me that they don't sleep. I assume they have the delayed phase disorder. Not always the case. Some have rumination and have concern about their sleep and sleep anxiety and all the symptoms classical for chronic insomnia. And they should receive CBTI. But they're not as many as sometimes we assumed. What is the pathogenesis of delayed sleep phase disorder? We know that circadian misalignments are probably due to genetic factors and there are mutation in circadian clock genes that lead to longer circadian periods. So for this individual, the day, the internal day, instead of lasting 24 hours, last maybe 24 hours and enough, which means that if not exposed correctly to light, they'll tend to stay up later and later and go to bed and then wake up later and later. And obviously, I'm going to talk quite a bit about this. There are environmental influences. So excessive light exposure in the evening, classically from screens, does delay our own internal rhythm. And in other words, morning light might also reduce our ability to reset our clock in a correct way. And then there are social factors, school, work schedule, late night activities, you know, convenience for a teenager to be up. How prevalent is delayed sleep phase disorder? That really depends on how the criteria that are used. So you have a very wide range from one percent to 16 percent. In some data in general population, in clinical sampling, general population can go from, you know, less than one percent to eight percent, depending on the criteria. Unfortunately, these usually they're adolescents or young adults have higher proportion of school refusal, academic failure, disciplinary action compared to peers without delayed sleep phase, exactly as it happened to my patient, Maggie, that was risking to fail because of all their absences and tardiness in school. They have threefold greater risk of lower GPA compared to peers. And even later, they're often out of school and unemployed. Seventy percent of patients with delayed sleep phase disorder have mood and anxiety symptoms, ADHD and substance use disorder. And also the reverse is true, especially true for ADHD. A lot of individuals with ADHD have delayed sleep phase disorder or at least a very clear preference for a delayed schedule. How do you assess it? Obviously, I highly recommend everybody. And I do it myself when when I can't sleep, I'll definitely do a. I'll definitely do a sleep diary on myself, so I recommend it to everybody. But how do we assess for delayed sleep phase disorder and how do we differentiate, given that they both presents with difficulty falling asleep? How do you differentiate from insomnia? Bedtime and sleep onset are very important to us. Clarify the schedule and understand if there are any variation in weekdays, weekends and vacation. So individual with delayed sleep phase disorder typically fall asleep more than two hours later than expected. But if. They are on vacation and they can fall asleep at 2 a.m., they would not travel, they would have no trouble falling asleep, they will not ruminate about their sleep and they would be very happy. Same. They usually have difficulties waking up in the morning. Often they need multiple alarms, they need help from parents and they might have sort of sleep marathons over the weekend or on scheduled day and they might wake up very late. So if you see here in the lower part of my screen, I would have a mega sleep log. You see that there is, you know, this very long dark periods than when she was, you know, sleeping till here, even 2 p.m. They're typically very alert in the evening. These are kids that will tell you that they have a lot of their thoughts in the evening, they study the best, they write poetry, they do, they have their best creative moments between 9 and 11 p.m. or even later. And you can assess both the schedule and the alertness through both interview questionnaires and sleep diary. You can also look at consumer wearables. I put it here just to remember to mention it. I find that sometimes the output of the consumer wearable, things like Fitbit, et cetera, is not as easy for me to interpret as it is sleep diary. But definitely if they want to use it, it's something can be considered when you're looking for the irregularity of the schedule, when there is just this very long sort of sleep marathon. And. As I said, the schedule is irregular, especially when there are morning demands at school, but we're not required to wake up as early, the schedule can stabilize, but remain delayed. So 3 a.m. to 11 a.m., for example, would have been one of my preferred schedule when I was, you know, in high school or med school. Presence of naps, the naps are often presence because these these individuals, for a number of reasons, end up being very sleep deprived because they have their morning sleep curtailed. So you've seen the sleep log earlier. You have very multiple short periods of sleep and then you have influences of activities. You should really understand what do they do during the day and what to do at night, because obviously there might be a lot of issues. And so, again, I present this again now that I described to you the characteristic, the vertical lines is when Maggie was trying to fall asleep. So you see that this girl is a young woman or, you know, adolescent girl was awake in bed for hours before falling asleep. So here are two hours, two hours and a half, you know, an hour and a half, an hour and a half. And it was so she definitely presented the difficulty falling asleep. But you also have this very long sleep time, especially on the weekend here. She slept, for example, till 2 p.m. with, you know, regular napping, you know, up to three hours here and there. She did have a lot of alertness in the evening, by the way. Mom said that she would have a lot of interesting questions. So what are key differences between insomnia and delayed sleep phase? Timing of sleep and sleep quality. For people with insomnia, you have difficulty initiating or maintaining sleep independently from the schedule. So you might have a lot of night awakenings. Actually, for people with delayed sleep phase disorder, the onset is delayed, so it takes them longer to fall asleep. But when they're asleep and if let them sleep according to their schedule, they might feel they might feel that their sleep is actually normal and they might wake up refreshed. People with insomnia tend not to have a lot of sleep marathons, not even weekend. They might spend a long time in bed awake, as one of the other speaker mentioned, but they don't have this pattern of, you know, 14 hours of sleep or long, long sleep marathon. What about daytime functioning and sleep anxiety? People with insomnia have a lot of daytime impairment, like fatigue, mood disturbances, cognitive deficits, and they have a lot of sleep rumination. Patient insomnia does tell you that they start thinking about their sleep at night. The moment they wake up, they have a lot of anxiety and they have a lot of alertness toward sleep threats. So sleep rumination and anxiety are very common for individuals with delayed sleep phase disorder. Daytime impairments are mainly due to sleep deprivation due to truncated sleep. So the fact they have to have to wake up earlier than expected. But again, as I said, they feel fine when allowed to sleep on their natural schedule, for example, on vacation. And they have increased alertness and creativity in the evening. So what do you want to ask as a question to differentiate delayed sleep phase disorder from insomnia? How do you sleep on vacation? What's your natural schedule on vacation and many hours? And when you fell asleep and when you wake up, does it take longer if you have several days in which you can have your natural schedule? I always ask at what time do you wake up if you can sleep undisturbed over the weekend? And so that's very important to know whether they wake up naturally at noon or one, because it should make you think that maybe their daily schedule is really moved toward later time during the day. When do you feel most alert and creative? When do you feel the least alert and creative? And do your difficulties falling asleep depend on the time you go to bed? So you try to differentiate whether they have trouble falling asleep because their body and brain is not ready or because they have a lot of anxiety and rumination. And what do you do when you can't sleep at night? This is very important for teenagers because availability of unsupervised time may be very tempting and might actually create a vicious cycle in this realm. Sleep and development. Why do why I keep saying kids and I could say adolescents because actually there are several things that happen in the sleep realm around puberty and just after puberty during adolescence. This is very important to be aware. So as other speakers have mentioned, we can imagine sleep as the product of two processes that sort of work in parallel to create, you know, variation in our alertness level. So we have the homostatic drive, the process S that sort of increases as time goes by, and then we have our clock-dependent alerting system, which gives us sort of our alertness, our second kick in the second part of the day. Obviously, this sort of second kick, which is here in my nice drawing, is around, you know, eight or nine. But if you are, if you have delayed sleep phase disorder, this might happen at 10 and 11 at midnight. And so you have that second kick. And unless you address some of the factor that creates this delay, it's going to be very hard to treat this disorder. Why adolescent is so important. And Dr. Cascado, which is really a giant of pediatric sleep, had written and discussed this and had talked about this as adolescents can sleep the perfect storm, because several things happen in the sort of regulatory system, in the psychosocial sort of environment that adolescents are in, and finally in social pressure, and we'll go one by one. So in terms of sleep timing, the circadian phase delays, so teenagers naturally produce melatonin, the hormone that regulates our sleepiness and circadian rhythm later. So they naturally are more prone to go to bed later. And they are more tolerant to sleep deprivation. So slowed rise of sleep pressure. So if you have a child and you keep them awake for a substantial amount of hours, they're going to feel very sleepy. In the end, adolescents become much more tolerant to sleep deprivation. And as such, you have all of a sudden more tolerance to be sleep deprived and you have this natural delay, you might end up having somebody who has a biological preference to go to bed later. At the same time, there are a lot of psychosocial pressure to delay, with bedtime autonomy, you know, parents sort of stop enforcing or enforce less bedtime, there's academic pressure, so good students or high school students end up staying late to study, and there is obviously screen time, social networking, etc. All of these elements tend to delay. And at the same time, there is now a movement toward delaying school time. But there is definitely many states, or has been for a long time, a lot of societal pressure to have early wake up time. And so when you have all these things combined, you might have kids who have to wake up much earlier than biological would do. And that's actually what I was mentioning, when I mentioned that the homeostatic, both the sleep drive and circadian alertic signal change. So if you have a 10 year old, you know, the homeostatic signal sort of goes down very steeply, steepling, and so that creates a lot of sleep pressure. At the same time, the circadian alertic signal happens much earlier. So by, you know, eight, nine, our 10 year old is really ready to sleep. But what happens during adolescence is that circadian alertic signals happens much later, so maybe peaks around midnight. And at the same time, the sleep drive is much less steep. So they do tolerate sort of the pressure to sleep is much less strong. And that goes that they tend to go to bed much later. What are some of the regulator? As I said, circadian rhythms are our daily rhythm, and they are regulated by the suprachiasmatic nucleus, which is a very small nucleus of neurons, as the name says, very close to the optic chiasm, which has an intrinsic 24 hour cycle. So sort of metabolically is able to keep time roughly of 24 hours. Again, I said there are variations given by individuals. But in order to be entrained, so to be sort of regulated in the 24 hours, we need to reset our clock basically daily. And these reset, of course, via light. So with our light exposure, we influence our retina, our retinal hypothalamic tract goes to suprachiasmatic nucleus, and these sort of regulates or reset our clock from the suprachiasmatic nucleus, we might have, we have several outputs, some of which are arousal, some of which are autonomic system, and some of which are actually signaling to the pineal gland, which then will release melatonin, and will affect both our brain and body, and reaffect themselves. So melatonin in dim light condition, so again, the suprachiasmatic nucleus is affected by light, which also means though in dim light condition, if there is no light, or there is very little light, you'll be able to observe the natural period that every individual has. So and again, it's roughly 24 hours, and as a consequence, you will have a fluctuation of the melatonin. So our melatonin naturally raise at the beginning of the night, and then decreases, you know, at the end of the night, and then goes on, restarts naturally during dim light. Incidentally, so we have many rhythms, we always talk about melatonin, you know, again, raise in the middle during the sleep period, or, you know, start raising before the sleep period, peaks during the middle of sleep period roughly, and then decreases after we wake up. But we have many other rhythms going concurrently. And we're going to just going to mention that core body temperatures also fluctuates, and we have our lowest core body temperature just before we wake up, couple of hours actually prior our natural wake up time. And I'm just mentioning this, because actually is important for treatment. So remember that we have many other kinds of rhythms, one of those is core body temperature, and core body temperature goes at the lowest point, approximately as a rule of thumb, a couple of hours prior natural wake up time. So if I naturally wake up time at noon, my lowest core body temperature time is going to be around 10. And while I'm doing all this preamble, I said that light is our main entrainment, Zeitgeber sort of element, and light suppress melatonin, which if you imagine we live in the nature makes a lot of sense, because it's still day, I need to tell my body, hey, this there is still sun up, you better stay up longer tomorrow. So don't feel sleepy now, and actually try to feel sleepy later the day after. And this is really a seminar article by Sizler in New England Journal of Medicine in 1995. And he was showing that in individual, blind individual, even without perception of light, where actually if the retinotolamic tract, retinotolamic tract was intact, we're able to have melatonin suppression. And actually, I'm showing this for a normal subject, but it also happens on the blind subject. But just for the normal subject to stay a little bit simpler, we have melatonin goes, this is dim light condition, melatonin goes up, goes down during the day and goes up again. And here the subjects are sort of flashed with bright light, and you see melatonin going down. And this has been followed by many, many other studies. But just for our case, we're going to talk about a following study, same group, Sizler's last name, done by Chang's first author, appeared in 2015. This actually will enter interest, any of you that treats adolescents and because they did a study of iPad versus books. So they took few subjects, I remember for eight or 10 or something like that, and they keep them in the lab for roughly two weeks. And they have two condition, these young adults, actually, there were probably many of them are college students could use either an iPad or they could use after a day of wash up or wash out, they could use a book, and then each of them would switch condition. So each subject what is on control. And with these designs, really very elegant, they showed that when people were reading in print book, the black dots, the melatonin would rise sooner and would decline earlier. So people would feel naturally also sleepier earlier and would wake up naturally probably earlier when compared with the light emitting ebook, which is where iPads are very high brightness. And again, now I'm going to go through all the graph, but same, there was on average 30% of melatonin suppression when each of the individual was in one condition versus the other. So you see the melatonin, there was less suppression of melatonin with the books, and there was significant suppression when they were using iPad. And so this is one of the study that then led all these things about blue light blocking glasses and other devices to reduce bright light. How do you assess for delayed sleep phase disorder? You want to do an evaluation of sleep and wake pattern, eveningness, daily activities, assessment of circadian phase timing. So how do they feel at different time of the day? You want to establish realistic sleep schedule. Sometimes parents are a little bit appalled by my sleep prescriptions. Okay, you can go to bed at 1am, and the parents at 1am, I'm here. So well, it goes to bed at 6am. So 1am, just making a joke is a big improvement. Secondary gains or psychological factors and establish expectation, again, realistic versus unrealistic. Treatment plan, I put here, the devil is in the detail, because it's really a lot of things to take into consideration. But obviously, psychoeducation and sleep hygiene should be provided. Then you have to decide what direction of phase you want to do. Meaning, if somebody's falling asleep at 2am, it might make sense just to try to send them to bed a little bit earlier. And we'll talk about this. This is called phase advance, and it's based on bright light, melatonin, blue light, blocking glasses. If somebody goes to bed at 6am and wakes up at 2am or later, it might be a little bit harder to do phase advance. Some people may do. So there are other strategies specifically, but behavioral strategy called chronotherapy, in which you send them to bed later. We're not going to discuss that tonight, but I just want you to be aware that that will be the case. In terms of psychoeducation, patients should be educated about the dual process model, so process S, process C, circadian rhythm, and light effect, some of the things that I mentioned. Goals need to be reasonable and, ideally, incremental. And obviously, you should discuss a possible wind-down routine accepted by the patient. Motivation, negotiation, and leverage are key elements of this treatment. So you have to find what this kid cares about and try to negotiate between them and the parent, depending on what is attainable. I also want to mention that this treatment is based in many ways. It's based on a third wave of cognitive behavioral therapy plus a specific element for sleep medicine. But if you're interested, there is the Transdiagnostic Model for Sleep Disorder, which is an excellent book by Colib Stanford, which now I'm blanking on the name. But it's a very good book and goes point by point about how to establish a wind-down routine that is really helpful for delayed sleep phase disorder. In terms of a sleep-wake schedule, maintenance of regular sleep-wake schedule with no more than two hours duration from weekdays to weekend. Sometimes I say to teenagers, you know, you have five hours different every weekend because you wake up at seven during the week and you wake up at noon during the weekend. It's the same as going to London every weekend and coming back to New York. And sometimes it's very helpful to see it this way, sort of, that's what's happening, giving them a practical example. Naps should always be limited to 30 minutes and never later than 4 p.m. in order to have good maintenance of sleep pressure. And patient engagement is key and parental or, you know, caregiver's engagement is key. Bright light treatment, actually I have it here just for the joy of people and my joy. So this is actually a bright light machine. I'll show it just for moment of show and tell. Bright light machine are relatively inexpensive. The usual prescription is 10,000 lux, which is actually just shining in my eyes, should be used for 30 to 60 minutes after the core body temperature lowest point, calculated as two hours prior to natural wake up time. So these kids that do bright light at 7 a.m. but then sleep till noon, that's actually not ideal. All rule of thumb, they should really expose themselves after natural wake up time. The light can be progressively administered earlier, 15 to 30 minutes, until target wake up time is achieved. As a very simple way to achieve some of that, walking to school or to work for 20, 30 minutes can be a good alternative if timing is appropriate. Sometimes for kids to live in metropolitan cities, you know, get off the subway one stop earlier. So at least you do this 10, 15 minutes of walking that might be helpful for your problem. Requires day to sleep because changing the schedule progressively earlier, both for the light, for going to bed, and for wake up when they can, unless they're already in school, might require days. Sometimes I do a five hour accommodation to receive light treatment in nursing office. I might write a letter to the school to justify tardiness while the treatment is established. So I try to help with some of this situation. Obviously bright light treatment should be used cautiously in bipolar patients, but I would say in most cases it's easy to titrate, meaning you can decrease it or you can stop it and symptoms disappear. Dim light exposure, avoidance of intense light before the lowest point of core body temperature, no electronic devices, one or two hours prior to scheduled sleep time, blue light blocking glasses or simply sunglasses. You want to try something for a couple of hours in the evening actually makes wonders. And there are now a lot of tricks that kids can use to decrease light on their devices, decrease white point, I don't know if you've ever used it, it's under accessibility of your phone, makes the screen really dark, use black and white screen in the evening, so invert the colors, might be helpful. In general for teenagers and adolescents, I do recommend that electronic devices should be locked away or put away during the night because sometimes temptation is just too high and we all know that willpower is limited. Melatonin, that's one of the things I often receive the most questions about, is when to give it what dose, my preferred way to treat the late sleep phase, I give a low dose of melatonin, half a milligram to one milligram four hours prior to target bed time. So if I see somebody go to bed at 2 a.m. and I think well midnight might be a sweet spot in terms of not too late, not too early for this person, I might try half a milligram of melatonin at 8 p.m. If nothing happens after a week, I might go up to one milligram. Liquid dissolvable forms can be easier to use at lower doses. If the person forgets, you know, sometimes it's hard, you know, you have to think about your melatonin several hours prior going to bed, I just give a larger dose at bedtime. So acceptable, it's not ideal sort of physiologically, but it is acceptable and sometimes it will help anyway to reset the system. So for example, three milligram at 11.30 for target bedtime of midnight. A lot of negotiation, as I said, with the teenagers and I mentioned leverage. For example, I negotiated with Maggie's mother so that she could visit the boyfriend because one of the things she was doing late at night was to do this very long video call with the boyfriend and so I said okay let's not do that but let's have maybe unsupervised call during the day so we don't have to have unsupervised call in the middle of the night. Sometimes parents have to agree to allow video game time during the day rather than after homework um and sometimes it's very helpful to work with the teenager about exactly what they're gonna do in the evening because they sort of expect to okay I finished to do all my activity at 11 and then at 1101 I should be ready to sleep and obviously we all know that for a number of reasons that's not how it works um and so it might be very helpful to help them to come up with a good plan and having written down what they're gonna do almost um you know minute by minute from the time they finish their schedule activities whatever they are to when they're going to bed and this is actually same patient uh Maggie before and after six weeks of treatment um she was once she understood the logic of not sleeping on the weekend etc and she understood the physiology honestly she did very well even with minimum bright light she told me after it was too complicated for her to just took the melatonin stick to the schedule and solve the problem but as I mentioned I wanted to talk about another disorder that might cause or might present with difficulty going to school in the morning falling asleep in class and a lot of sleep excessive daytime sleep this is my patient Sarah 17 at the time I met her four years ago uh she had trouble waking up in the morning she felt tired again her upward sleepiness scale was 16 so definitely um pathological daytime sleepiness it was um so severe morning sleepiness that she was enrolled in a private one-to-one setting school and these symptoms started a year and a half ago possibly due to viral infection she was on um fluoxetine and uh buspirone and she was still sort of depressed and had a lot of severe fatigue that was um Sarah's sleep diary so if you see it's very different and these diaries are actually a real diary I built them um as you see this um adolescent girl was sleeping 11 to 14 hours per night most nights yes a little things here but most nights she was living and she was napping between two or three out two and three hours per day every day somebody might ask about all this exercise actually I shared with um her that I was presenting her case she was very excited the idea that more psychiatrists would be aware of this condition because before she met me she was misdiagnosed and all of this was just considered depression and she said you know you have to tell them that all this exercise were not like four hours of exercise I was so deconditioned that I was doing one sit-up and then have to rest for half an hour so actually to put in 10 or 15 minutes of workout I was doing it for three or four hours just to give you an idea of her tiredness what are the features of um idiopathic hypersomnia idiopathic we don't know exactly what it causes pathogenesis remaining unclear we'll talk in a second about that but we have excessive daytime sleepiness really the hallmark symptom with prolonged non-restorative naps that do not improve alertness actually there is a lot of grogginess after these um naps um sleep um inertia which is really this intense grogginess difficulties waking up I think you um heard dr shank talking about um parasomnia so it's really like confusion and arousal these people can be groggy for you know half an hour 30 minutes um unrefreshing sleep so despite long sleep duration 10 12 hours they feel unrefreshed feel sleepy and tired cognitive impairment decrease attention concentration and memories and as I said pathogenesis remain unclear can be post-infectious actually I've seen several post-infectious cases for by chance I guess and when long COVID came up and everybody was surprised about long COVID I said you know it's very similar to idiopathic hypersomnia in many ways what are the criteria you have daily excessive daytime sleepiness for at least three months so these people despite appropriate sleep length for children more than 10 12 hours really present with excessive daytime sleeping and they fall asleep in places like my patient Sarah which has an effort sleeping a scale of 16 they don't have cataplexy so they don't have sudden lack muscle tone with strong emotions which is a public mnemonic symptoms actually of another sleep disorder which is narcolepsy so in idiopathic hypersomnia you don't have um cataplexy um when you do a sleep study when you do polysomnography there is no evidence of significant nocturnal sleep disturbances so you should not have sleep apnea or anything else and then you can do a test which the multiple sleep latency test in which you should really measure or there should be evidence of a brief sort of the patient falling asleep very quickly so as a mean latency eight minutes and having no sleep onset in REM because that would be indicative of narcolepsy so this is actually Sarah polysomnography and multiple sleep latency test is actually a real testing the polysomnography was a remarkable the multiple sleep latency test showed really um sleep on four out of five naps and sleep latency was um nine minutes so meaning she fell asleep on all the um on four out of five of nap opportunities and she fall asleep within nine minutes was not technically but the agnostic but for teenagers and children the criteria are a little bit more relaxed so i i did the agnosia with um idiopathic hypersomnia and i'm just mentioning this because often this patient gets sort of missed and instead they are eminently treatable and they do much better as i'm gonna show you in a few minutes um management of idiopathic hypersomnia includes behavioral intervention so sleep hygiene that um you guys have discussed earlier i'm not going to talk more about sleep hygiene naps should be brief to avoid sleep inertia and then pharmacological treatment weakness promoting agents so modafinil and armadafinil are often prescribed to reduce sleep excessive sleepiness stimulants uh methylphenidate or amphetamine can be used they're off label as a child psychiatrist i'll admit that i use them often because i'm very familiar with them and they work um often they work well and you can consider sodium oxybate which actually nobody's not as the physician can prescribe so but it is part of the approved treatment and monitoring regular follow-up the other things that sometimes is helpful is really a physical should have mentioned here but is a really physical reconditioning so low-grade exercise so what happened to my patient um four years later i did try modafinil she did not tolerate um so eventually i decided to start very low dose of methylphenidate very low when i say very low it's very low it was 2.5 milligram bid i was uh sure it was slowly titrated um to higher dose of methylphenidate immediate release and to get to concerto 27 and methylphenidate 5 bid as needed for exam or long day of study she started practice moderate exercise regularly and improve their sleep hygiene all of this helped extensively and uh you know reconditioning is really important for some of this patient so not to be um neglected she's currently enrolled in college is about to successfully complete a b.a in fine arts she's happy she has a boyfriend she goes out she does all the things uh and medically i was actually i also given her symptoms i always wonder whether she had another medical condition underlining she was diagnosed with POTS um post-traumatic static hypotension other things and eventually um she was diagnosed with chronic Lyme and another tick-related infection and treated and she did a little bit better with treatment so with this i'm finished uh my um talk about a bodily sleep phase and ever sonia but i just want to remember everybody for children adolescent when to refer to a sleep specialist and so there are and specifically when to refer to a sleep study so there are respiratory indication uh remember if a child snores chronically definitely should see ent or sleep doctors if you have children with some neurodevelopmental disorders would be also very helpful to know whether they had um they have had a sleep study or if they have neuromuscular disorder um would be helpful a pre and post on select me might be uh indicated in selected cases especially if the obstructive sleep apnea was severe because 50 percent of children with severe sleep apnea unfortunately still have some degree of sleep apnea even post on select me and then remember that um for suspicion of periodically movement disorder for evaluation as in my case of hypersomnia narcolepsy um might be helpful to do a polysomnography with multiple sleep latency test for you know severe or frequent parasomnia and obviously the case is very unclear and um nothing works and uh with this i think just in time i thank you for listening and i wonder if you have any question maybe there is another way to do it um people often ask me about um hypersomnia how many i see them and i would say as a psychiatrist um with an interest in sleep maybe it's a selective referral but i ended up seeing several patients with hypersomnia so it's something that i just want uh people to be aware and um consider uh because i think they are a little bit uh more common than people think um what are the brands of melatonin to recommend i don't have a specific brand i recommend everybody to use um pharmaceutical grade if you can have access to it um unfortunately all the studies on melatonin have shown that melatonin which is not pharmaceutical grade have significant really huge range um between 50% less to 200% more than what um written so um i generally ask patient to look for pharmaceutical grade and the other things i mean one of the brand is the most used in study is um natural um is commonly mentioned and has worked um well but again i think the main things is um to be to be sure that the product the patient are taking is the correct one and again it depends also in um dosing because i do use low doses for the delayed sleep phase disorder any other question about the differences between insomnia and a delusive phase that sometimes might be um tricky because um patient comes in and said they have insomnia and you gather all the information about the time they go to bed and it really seems like insomnia and sometimes they might have um overlap syndrome meaning if you spent a lot of time in bed unable to sleep even if originally was the phase disorder disorder you might end up um developing a lot of rumination concern and anxiety around your sleep and that might cause um difficulties would you call a normal bedtime for high schooler is 11 to 1 at what time do we call it pathology i think it really depends if the high schooler um is able to sleep enough so if they are able to be alert enough and healthy enough which honestly for a sleep doctor they should sleep at least eight hours um i think that's that would be okay so if they go to bed at midnight and they can wake up at eight because maybe they are the lucky um adolescents in which the school starts late it's fine if it's seven hours and they still are okay it depends a little bit case by case um if they have no trouble but they're sleeping four or five hours well that wouldn't i would consider that that is not um great but you have to see when they wake up even more than when when they fall asleep they should to see whether they have delayed sleep phases when when they're waking up when left by themselves on their own devices um do you see much utility for delayed release melatonin for kids with sleep continuity disturbances um first of all i always wonder why a child might have maintenance insomnia so the first things i want to make sure in children is they don't have sleep apnea and if they don't have sleep apnea so they never snore they have small tonsils they have a good airway um and i also tend to exclude their restless leg and periodically movement then yes i can start considering maybe they have natural if you want awakenings or you know awakenings related to insomnia and yes i have used delayed release melatonin with all these caveats of excluding there are other causes for the night arousal no there is not known any bad outcomes with long-term use melatonin um that we are aware of so i would say it's relatively it's considered for what we know at this time relatively safe um personally unless there are obviously a lot of situations which might be indicated children with severe psychopathology um or children with you know extreme psychosocial factor etc i think when possible it would be ideal to have um to teach the children that sleep is natural and is usually it's pretty reliable unless you do something to affect it negatively you're able to sleep without medication that said there are no bad outcomes that we know it's a large uh worldwide experiment with melatonin because it's over the counter basically in most countries in the world and there is no known bad outcome even in people that took it for a long time this might change anytime we do know the melatonin can affect the immune system we do know the melatonin negatively the immune system we can know the melatonin might affect to some extent insulin resistance and glucose balance so there are a lot of definitely it is medication and so i think benefits and cost should be assessed it does not change effectiveness with time in most studies there are studies that showed even up to six months um perfect so i'll stop sharing my screen oh sorry now i see the question um when i close the question when i close my screen i saw the question i'll use my extra two minutes to answer the question okay is there any option of using melatonin twice prior to bedtime and early awakenings yeah it can be done um i would use low doses i don't know if you guys have noticed in the slide that i projected but physiological melatonin dose melatonin levels are in the pico uh pico moles which means a tiny tiny tiny so when we start taking i don't know milligrams of melatonin we really might risk to go um hundreds of times above our physiological level so i think it's um people can consider it to use it more to those but again thinking about what is the tiny the dose they're taking that should be time in that case uh any use for melatonin receptor agonist in children adolescent um i haven't used it much i've colleagues that swear by um by it so i think if um other agent are failed and it's something that it seems appropriate for the case um yes i would say in general i wouldn't use them personally for delayed sleep phase disorder but for insomnia they can be considered um uh do you find that you need to increase the stimulant dose over time for my patient i think she stabilized eventually after you know we probably do a very slow titration for the um idiopathic hypersomnia which stabilized on a dose that i felt it was very reasonable because it was 27 um plus 10 of immediate release um which he used basically for the afternoon uh when she was really really tired but maybe she still had long assignment so there was not really a need to um increase the dose and i think now now sorry guys i didn't see the the question answer at the opening another panel um i'm now happy to join So I think this time we can open the. I have a question about are this patient able to get off meds over time, the patient with adiabatic, if the question is about the patient with adiabatic hypersomnia, I would say. Usually not. It is tends to be a chronic condition. One can try or one can decrease a patient that decide to be a little bit sleepier, maybe their life condition change and they can tolerate it better or they have other reason, a lot of children. But now they tend to stay on for a long time. And for delayed sleep phase disorder, I would say they can get off melatonin eventually when getting older makes all of us a little bit more larks rather than night owls. So at this point, I think we can start our joint panel. So I would like to invite, if possible, in screen Dr. Benka and Dr. Dograjamy. And I thought Dr. Shatkin maybe was also joining us and Dr. Winkelmann, but maybe not. And so I think we can open the question for the panelists we have here. If there are questions, because we understand for our audience that it was a long day and you heard a lot of things, well, I think if there are no other questions, I would say this concludes our virtual immersive program, clinical updates on sleep disorders. Thank you for joining us today. Your participation has been invaluable and we hope it was useful for you. Your participation has been invaluable and we hope you found the program both enriching and informative. All of today's session we're recording will be available on the APA Learning Center starting next week. You'll receive an email notification once recordings are accessible. You can now claim credit for the session you attended. And if you have any questions or need any assistance, feel free to contact the APA Learning Center at learningcenter.psych.org. Please be sure to register for our next virtual immersive on innovation in digital psychiatry scheduled for Tuesday, November 5th. On behalf of the APA, thank you again and we look forward to staying connected.

delayed sleep phase disorder

insomnia

idiopathic hypersomnia

children and adolescents

sleep patterns

Epworth Sleepiness Scale

behavioral interventions

bright light therapy

melatonin

sleep schedule