Paeds · adolescent-and-young-adult-medicine
Sleep, fatigue and circadian disorders in adolescents
Also known as Adolescent sleep problems · Delayed sleep-wake phase disorder in adolescents · Teenage insomnia · The tired teenager · Adolescent circadian rhythm disorder · Insufficient sleep in adolescents
A fellowship approach to sleep, fatigue and circadian disorders in adolescents: the biologically delayed sleep phase, the two-process model, the differential of the 'tired teenager' (insufficient sleep, insomnia, delayed sleep-wake phase disorder, central disorders of hypersomnolence, obstructive sleep apnoea, depression and medical fatigue), a sleep-history and sleep-diary assessment, and stepped-care management (sleep hygiene, CBT-I, timed light and melatonin) across ANZ, UK, US and Canada.
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Target exams
Red flags
- Cataplexy (sudden loss of muscle tone with emotion) with daytime sleep attacks — suspect narcolepsy type 1
- Loud habitual snoring with witnessed apnoea, especially in an obese adolescent — suspect obstructive sleep apnoea
- Daily irresistible sleep attacks for at least three months despite adequate overnight sleep — suspect a central disorder of hypersomnolence
- Anhedonia, low mood, hopelessness or any self-harm in a 'tired teenager' — depression may be driving the presentation
- New neurological signs, morning headache, or a marked change in personality accompanying hypersomnolence
- Severe functional decline: failing school, withdrawal, drowsy driving or near-miss crashes
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Adolescent and young adult medicine — sleep, fatigue and circadian presentations
- Learning Goal 19 — Adolescent and young adult medicine: assess and manage common sleep and circadian presentations and recognise those requiring referral
- Current 2026 PREP curriculum — apply knowledge of adolescent sleep physiology and the two-process model in clinical assessment
- Renewed curriculum for first-year trainees from 2027 — Learning goal 7: Behavioural and mental health presentations including sleep
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Health promotion and adolescent preventive care
- Adolescent and Young Adult Medicine 4–7
- Growth, Development and Behaviour
- Written Exam: adolescent sleep physiology, the differential of the tired teenager, and stepped-care management
- Short Cases — assessment and management plan for the tired or sleep-disturbed adolescent
- Long Cases — sleep disturbance in the context of chronic disease, obesity or mental illness
- Communication stations — negotiating sleep hygiene, screen boundaries and a consistent schedule with a young person
- Level 2 — Behavioural, emotional and mental health: recognises common adolescent sleep problems
- Level 3 — Adolescent health: manages insomnia and circadian presentations and refers appropriately
- Health promotion and illness prevention — sleep and screen guidance for adolescents
- General Paediatrics: distinguishes sleepiness from fatigue and screens for mood disorder
- Foundation of Practice (FOP) — normal adolescent sleep physiology and common sleep problems
- Applied Knowledge in Practice (AKP) — the differential of the tired teenager and the management of insomnia and DSWPD
- TAS — adolescent development, chronobiology and mental health
- History and Communication — taking a sleep history within the adolescent interview and negotiating behaviour change
- Communication — counselling on screens, caffeine and a consistent schedule
- Clinical — short case on the tired or sleepy adolescent with referral planning
- General Pediatrics Content Outline — Domain 3: Adolescent Care (5%) — sleep and fatigue
- General Pediatrics Content Outline — Domain 1: Growth and Development — adolescent sleep and circadian physiology
- General Pediatrics EPA 3: Providing well-child and adolescent care including sleep guidance
- General Pediatrics Content Outline — Domain 7: Behaviour and Mental Health — sleep and mood
- Patient Care 1: History and Physical Examination — adolescent sleep assessment
- Medical Knowledge 2: Diagnostic Decision Making — differential of the tired teenager
- Medical Knowledge: Adolescent medicine — sleep physiology and circadian disorders
- Systems-Based Practice 4: advocating for school-based sleep health and coordinated referral
- Medical Expert — adolescent sleep physiology, insomnia and circadian disorders
- Development, Behaviour and Mental Health (10–15%) — sleep and fatigue
- Pediatrics: Foundations EPA — Adolescent preventive care including sleep
- Communicator — negotiating sleep hygiene and screen boundaries with adolescents and families
Overview & Definition
A 15-year-old is sent to the clinic because she "can't get up" and is falling asleep in morning classes. Her mother thinks she is depressed or lazy; the school thinks she is disengaged. Ask one question — what time does she actually fall asleep, and what time does she wake on a weekend when left alone — and the picture changes. On weeknights she is in bed by 23:00 but awake until 01:30; she rises at 06:45 for school, getting about five hours. On weekends she sleeps from 02:00 until 11:00, feeling well. The answer is not laziness. It is the single most common adolescent sleep pattern: a biologically delayed clock colliding with a socially fixed morning. [10] [1]
Sleep is the reversible state of reduced consciousness and motor activity the brain needs for memory consolidation, emotional regulation and metabolic recovery. Fatigue is a subjective lack of energy, and it is not the same as sleepiness, the tendency to fall asleep. The tired teenager sitting in front of you may be sleepy (a sleep problem), fatigued (a mood or medical problem), or both, and conflating the two is the commonest diagnostic error on this topic. [11]
The clinical task has three steps. First, name the dominant mechanism: insufficient sleep, insomnia, a circadian timing disorder, a central disorder of hypersomnolence, sleep-disordered breathing, or fatigue from another cause. Second, exclude the can't-miss mimics — narcolepsy, obstructive sleep apnoea, depression with self-harm risk. Third, match the management to the mechanism. The trap is reaching for a "sleeping tablet" before you know which problem you are treating. [10] [16]
[1] [8]References17ShowHide
- [1]Carskadon MA, Wolfson AR, Acebo C, Tzischinsky O, Seifer R Adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep, 1998.PMID 9871949
- [2]Wolfson AR, Carskadon MA Sleep schedules and daytime functioning in adolescents. Child development, 1998.PMID 9768476
- [3]Adolescent Sleep Working Group, Committee on Adolescence, Council on School Health School start times for adolescents. Pediatrics, 2014.PMID 25156998
- [4]Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. Journal of clinical sleep medicine : JCSM, 2016.PMID 27250809
- [5]Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O, DonCarlos L, Hazen N, Herman J, Katz ES, Kheirandish-Gozal L, Neubauer DN, O'Donnell AE, Ohayon M, Peever J, Rawding R, Sachdeva RC, Setters B, Vitiello MV, Ware JC, Adams Hillard PJ National Sleep Foundation's updated sleep duration recommendations: final report. Sleep health, 2015.PMID 29073398
- [6]Owens JA, Belon K, Moss P Impact of delaying school start time on adolescent sleep, mood, and behavior. Archives of pediatrics & adolescent medicine, 2010.PMID 20603459
- [7]Auger RR, Burgess HJ, Emens JS, Deriy LV, Thomas SM, Sharkey KM Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of clinical sleep medicine : JCSM, 2015.PMID 26414986
- [8]Hagenauer MH, Perryman JI, Lee TM, Carskadon MA Adolescent changes in the homeostatic and circadian regulation of sleep. Developmental neuroscience, 2009.PMID 19546564
- [9]Crowley SJ, Acebo C, Carskadon MA Sleep, circadian rhythms, and delayed phase in adolescence. Sleep medicine, 2007.PMID 17383934
- [10]Carskadon MA Sleep in adolescents: the perfect storm. Pediatric clinics of North America, 2011.PMID 21600346
- [11]Beebe DW Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents. Pediatric clinics of North America, 2011.PMID 21600347
- [12]Gradisar M, Gardner G, Dohnt H Recent worldwide sleep patterns and problems during adolescence: a review and meta-analysis of age, region, and sleep. Sleep medicine, 2011.PMID 21257344
- [13]Blake M, Waloszek JM, Schwartz O, et al. The SENSE study: Post intervention effects of a randomized controlled trial of a cognitive-behavioral and mindfulness-based group sleep improvement intervention among at-risk adolescents. Journal of consulting and clinical psychology, 2016.PMID 27775416
- [14]Dewald-Kaufmann JF, Oort FJ, Meijer AM The effects of sleep extension and sleep hygiene advice on sleep and depressive symptoms in adolescents: a randomized controlled trial. Journal of child psychology and psychiatry, and allied disciplines, 2014.PMID 24252173
- [15]Salanitro M, Wrigley T, Ghabra H, et al. Efficacy on sleep parameters and tolerability of melatonin in individuals with sleep or mental disorders: A systematic review and meta-analysis. Neuroscience and biobehavioral reviews, 2022.PMID 35691474
- [16]Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline. Journal of clinical sleep medicine : JCSM, 2021.PMID 34743789
- [17]Carter B, Rees P, Hale L, Bhattacharjee D, Paradkar MS Association Between Portable Screen-Based Media Device Access or Use and Sleep Outcomes: A Systematic Review and Meta-analysis. JAMA pediatrics, 2016.PMID 27802500