Biological...Sleep onset several hours after sunset & typically awaken before sunrise Temperature a...

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www.woolcock.org.au

Adolescent Sleep in the

Digital Age

A/Prof Delwyn Bartlett PhD MAPS CHP

Health Psychologist

www.woolcock.org.au Page 2

Overview

• Why adolescents are so prone to poor sleep.

• The Impact of Electronic Devices

• Practical Behavioural & Cognitive Interventions


Why Adolescents are Vulnerable to sleep

disturbance



Who Wants the Perfect Storm?

• High school students need 9-9.5 hours of sleep, but mostly achieve only 7.5 hours (National Sleep Foundation 2006, 2012).

• 70% Australian adolescents are sleep deprived. We are in equal bronze medal position (with USA).

• 2011 US Govt formally listed adolescent sleep deprivation as a major public health issue.

• Why? …..‘The Perfect storm’ of biological, emotional, lifestyle factors

• Crowley et al., 2018


Biological

Puberty-linked delay in melatonin causes delayed sleep/wake patterns

Wide awake at night b/c melatonin is lower

Sleepy & irritable in the morning b/c melatonin is still high

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➔ School night sleep restriction

➔ Weekend Catch up

➔ Irregular wake times

➔ Social Jetlag


Emotional

• Anxiety & depression peak onset

during adolescence

• Cycle of sleeplessness and

anxiety/depression.

• Poor sleep is a symptom of anxiety

and depression

• Sleep disturbance can cause

anxiety and depressed mood

• Bidirectional relationship in adults

– Siversten et al., 2012

Sleep

Disturbance

Anxiety &/or

Depression


Tired Brains are more Emotional


The Emotional Brain at Night

Even in those without anx/dep, heightened emotion at night is normal

Limbic (emotional)

system – i.e., ‘the

petrol’

Pre-frontal (rational)

cortex – i.e., ‘the

brakes’

Goes to sleep at

night even if you’re

not.

The brain becomes

“all petrol, no brakes”

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Awake “I can’t sleep”

“I have so much on this week”

Worry, frustration,

distress

Sleep & Stress Cycle

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Sleep time in various animals ? Related to Safety

Animal Av. daily TST in hours)giraffe 1.9

horse 2.9

asiatic elephant 3.1

african elephant 3.3

sheep 3.8

cow 3.9

pilot whale 5.3

human adult 8.0

chimpanzee 9.7

baboon 10.3

bottle nosed dolphin 10.4

dog 10.6

duck 10.8

domestic cat 12.1

lion 13.5

platypus 14.0

tiger 15.8

human infant 16.0

python 18.0

little brown bat 19.9


Sleep in Young Healthy Adolescents & Adults


Sleep = 2 Processes

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Homeostatic Sleep Pressure (S)

Circadian Rhythm ‘body clock’ (C)


Body Clock (SCN) - Melatonin

• Our internal clock is 24:10 -10mins out from the external clock.

• light and dark entrain our body clock to the external clock via the SCN.

• Dark triggers sleep

– Melatonin is released in dim light

– lowers core body temperature and makes you feel sleepy

• Light wakes you up

– Light suppresses melatonin

– Body temperature increases and we feel alert and awake

17 www.woolcock.org.au Page 18

Current Biology, 2017; Gandhi Yetish, Hillard Kaplan, MichaelGurven, Charles

Wilson, Ronald McGregor, Jerome M. Siegel

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Natural Sleep & Seasonal Variations - 3 Pre-industrial Societies

• Highlights

Similar sleep parameters in Tanzania, Namibia & Bolivia

Do not sleep more than ‘‘modern’’ humans, average durations of 5.7–7.1 hr

Sleep onset several hours after sunset & typically awaken before sunrise

Temperature a major regulator of human sleep duration and timing

• In Brief

Hunter-gatherers/ horticulturalists sleep 6.4 hr/day - 1 hr more in winter than in

summer.

Onset 3.3 hr after sunset, & sleep during the nightly falling temperature.

Onset times are irregular, but offset time is very regular.

Little napping is seen. Light exposure maximal in the morning, not at noon.


Lifestyle

Over-

scheduled =

sleep

deprived

Sleep Is A Low

Priority

Increased study

Socialising

Incompatible with delayed

body clock

Extra-curricular

activities


Food - Sleep & Bedtimes

• Assessment of Adolescent sleep

– Weight & Bedtimes N=3342.

– Controlled for demographics

• Fast food consumption - increased

weight

• Later bedtimes – increased weight in

adolescence & into adulthood

• Sleep Restriction over 3 weeks

– students (13-17 years)

– rated sweets/desserts as being more

appealing compared with healthy foodswww.woolcock.org.au Page 22

The Gut & GABA

• Brain-Gut axis can influence

cognition & mood

• Lactobacillus & Bifidobacterium found

in the GUT also secrete GABA &

have a role in Tryptophan

• GABA dysfunction implicated in

anxiety & depression

• Role of Serotonin – mice with higher

intestinal microbiotica had higher

levels of serotonin – insomnia/mood

interaction?

Luna & Foster. Current Opinion in Biotechnology, 2015; 32:35-41


Mood and Sleep


Adolescent Vulnerability to Depression

• 10.5% adolescents have depression

• Balazs et al., 2013. J Child Psychol Psych

• 29% of European youth ‘At risk!’

• Cuijpers et al., 2004. J Affect Dis

• Role of Emotional Awareness & Regulation

• Van Beneren et al., 2018. Europ Child & Adol. Psych

– When decreased is associated with internalising – depression

– Experience more negative affect/emotional reactivity

– Needs balance with developing cognitive systems & life tasks

– Lag in maturation with the prefrontal cortex (executive function) & anterior cingulate cortex (processes awareness of bodily arousal)

• ? At risk – unable to identify, understand & communicate emotions – potentially leading to rumination/aggression & depression

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What to do?

• Role of online Lifestyle Interventions for Adolescents

• Young et al., 2018. ANZJ Psychiatry. Review

• Poor diet, physical inactivity, insufficient sleep, smoking, substance abuse – ALL contribute to poorer physical and mental health.

• 7 studies & targeted: alcohol reduction, improved sleep quality/insomnia, increased physical activity, reduced/cessation of substance abuse, smoking cessation.

• Results: 4/7 studies sig. improvement in targets 3/7 depression

2/4 improvements in insomnia symptom severity

• No improvement in depression without improvement in targeted behaviours


Screen Time & Blue Light


What does Screen Time do?

oActivity is excitatory & therefore wakeful.

oSurges of adrenalin, dopamine & cortisol, which are awake promoting.

oUse on and in bed means the brain gets mixed messages

o “conditioned arousal”

oBrain is conditioned t - bed - a place of wakeful activity, rather than sleep

oEventually the brain automatically releases neurochemicals at bedtime,

even without the electronic triggers.

oLeads to a mistaken loophole – “even when I don’t use devices at night I

can’t get to sleep”


Smart Phone - with & without Blue Light

• What are the immediate effects of phone LED’s

– Heo et al., J Psych Res., 2017; 87:61-70

• Methods: RCT double blind - cross over placebo

– N=22 healthy males

– Smartphone with blue light or Smartphone without

– Serum Melatonin measured (60mins) before during & after use of

Smartphones from 7.30-10pm

• Results: Blue light longer time for DLMO 50% plus non sig. increases in

body temp, in serum melatonin & cortisol

– More errors of commission

• Conclusions: Blue light negatively influences sleep & performance

but ? Does not necessarily change serum melatonin & cortisol

– Small sample size ? potentially an hyperarousal response


It is not just the blue light but……

• Gaming involves

– Interaction

– Aggression

– Additional wiring/alertness


What can I do BUT what will I actually do?

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Set a Regular Wake Time

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• Your wake time is the anchor.

• Wake time determines sleep pressure and melatonin at night


Get Light & Dark Signals at the Right Time

• Dark triggers sleep

• Melatonin is released in dim light

• Dim light ONLY at night – at least 1 hour before bed

• Consider Amber glasses

• Light wakes you up

• Light suppresses melatonin

• Get light in the morning.

• Open bedroom curtains, eat breakfast outside or next to window, go for a walk

• EXCEPT if there is a diagnosis of Delayed Sleep Phase Disorder


Getting the Light Exposure at the Right Time


Winding Down – Valuing Sleep

Give your brain & body a chance – clearly distinguish night and day.

One hour before bed:

1. Stop work and study

2. Turn down the lights

3. Switch off electronic devices

4. Do something soothing - music


Consider Device Use

• Do you sleep with your phone?

• Do you use your phone as your morning alarm?

• Do you use devices in bed at night (watching TV, youtube etc)

• Do you fall asleep watching a device?

• Do you check your phone if you wake up in the night?

• Have you already conditioned your bed as a place of wakefulness (even

when I don’t use devices I still don’t sleep).

• Are you motivated to put boundaries around device use at night?

• What would you gain vs lose by changing?

• What sort of change could you live with long term?


Too Wired to Sleep?

• Remember the emotional brain at night

• Its normal to feel more intense emotions at night

• If you feel too “wired” to sleep there are some things you can try…

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The “What IFS!”


Use that time for…….…?


Mindfulness

• Keep your attention in the present moment rather than worrying about the future or ruminating about the past

• Focus attention on your breath

• Describe what you can see hear, touch, taste and smell


Changing the effect of the bed & bedroom


Stimulus Control Therapy - or Quarter Hour

Rule (QHR)

STEP 1• Go to bed ONLY when you are comfortable, sleepy- tired

STEP 2• Use bed ONLY for sleep and sex

STEP 3

• Get our of bed if unable to sleep within around 1/4 hour - Options -

STEP 4

• Return to bed ONLY when you are feeling comfortable, sleepy-tired or more relaxed/or bored – may be 10 mins but do not stay up for hours!

STEP 5• Repeat Steps 3 and 4 as needed


Options – Victim vs “setting boundaries”

Stand on the cold bathroom

floor

OR

Dig your toes into the carpet

Go into another room until you feel

less tense

Sit on the edge of your

bed/floor and take a few

gentle slow deep breaths

https://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0CAcQjRw&url=https://www.pinterest.com/Angelaohara92/sleep-memes/&ei=FZV2VcW0AuTAmwWw6oDQCg&bvm=bv.95039771,d.dGY&psig=AFQjCNEp9n5UJv1tpAtgppV5BJe-2Caf_Q&ust=1433921159524660

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What to do when up

Good Strategies

• Keep the lights dim• Listen to a pod-cast on an old fashioned ipod• Flip through a magazine• Read a few pages from a favourite book you’ve read

before• Mindfulness, breathing, any slowing down techniques

Not Good Strategies• Looking at your phone, start studying, read something

for school, exercise


Bed Restriction/Sleep Consolidation

• Time in Bed now – 9 hours

• Estimated sleep time - 5 hours

• Staying in bed awake trains the individual to be more alert in bed

– 5/9 x 100/1 = 55%

– Healthy sleep efficiency is 85%


Working out Bed Restriction Regimes

• ?more of a morning person or an evening person – what would work better?

• Bed times

• Getting up times

• Time in Bed – sleep deprived during the week 4-5.5 hours

• Weekend 10 -12 hours – need reduce long sleep ins.

• Sunday a mid point between sleeping in Saturday and Time up on Monday


Paradoxical Intention

• The paradox is to put the effort into staying awake instead of

– “trying so hard to go to sleep!”

• Morin Sleep 2006:29

– Update of the Recent Evidence

• Sit in a chair in the dark

– Keep your eyes wide open

– Stay still

– Stay there for 5-15 mins

– Repeat 2-3 times as needed

– OR - Sit up all night in the kitchen

– Write down ALL your sleep worries

• Role of “Mary Poppins” – Stay awake!

.


The Mind

• Repeating sleep stories perpetuate the fear of not sleeping – A thought is just a thought

it is not a fact!

• A friend – Looking forward to bed &

“letting go” of the day

• An enemy– Sabotaging sleep on a

nightly basis!


There is no “Off Switch” for the Brain at Night!

• It is all about letting stuff play in the background?– attentional bias

• Issue of responsibility

• Inadvertent training to think when awake - rumination and “holding onto stuff”

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Letting go of “Things” & Thoughts

Bedtime might be the first opportunity to be alone, think and process.

Worries, sadness and anger can flood in.

In the hour before bed, or earlier you can try the following

• Write about whatever is on your mind.

• Stream of consciousness – no editing, spelling unimportant

• Can destroy (shred, scrunch etc) to symbolically let go or get rid of the concerns

• Can keep and re-examine the next day

• Based on Pennebaker expressive writing research.

• https://www.youtube.com/watch?v=XsHIV9PxAV4

• https://www.youtube.com/watch?v=PGsQwAu3PzU


Switch & Savour (Allison Harvey Sleeping Tigers program)

Identify toxic headspace and switch the

channel to a better one OR GET OUT OF BED

Link helpful/okay thoughts with bed.

Use “safe” topics to visualise or “let go” of the day

Changing the Channel


Exercise & Insomnia

• Meta-analysis & review of RCT’s exploring the effect of exercise on sleep quality

– Rubio-Arias et al., Mauritas, 2017; 100:49-56

• Five publications – 12-16 weeks;

• Conclusions: Exercise improves sleep quality but not necessarily insomnia severity.

• Morning vs Evening Exercise

• Small non-randomised cross over study - 2 week wash out

– Morita et al., Sleep Med., 2017;34:200-208

• Conclusions: Acute morning exercise improves sleep quality and

reduces wakes in 2nd half of night – reduces sleep stage shifts


Polyphenols for more Energy & Better Health


Effects of Diet

• Flavonoids, Cognition & Dementia

– Williams & Spencer. Free Radical Biology & Medicine 2012;52:35-45

• Impact of Fruit Flavonoids on Memory & Cognition

– Spencer. Brit J of Nutrition. 2010;104:S40-S47

• Aronia Berry Polyphenol Consumption Reduces Cholesterol in former Smokers

– Xie et al., Nutrition Res. 2017;37:67-77


Parental Input – management strategies

• Establish screen media habits & adequate time in bed

• Bed & media boundaries increase sleep confidence

• Encourage Reading time/music time instead

• Prioritise your sleep as an encouragement to set those important boundaries

• Have discussions around the importance of healthy sleep habits

• Long term this is all about developing self regulation

NOT HELPFUL

https://www.youtube.com/watch?v=XsHIV9PxAV4

https://www.youtube.com/watch?v=PGsQwAu3PzU

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Future Directions

Research indicates that screen-based media represents a threat to the sleep

quality of youth, many of whom already have insufficient sleep.

Few studies demonstrate easy-to-implement and effective interventions.

Future research should develop, implement, and evaluate sustainable

interventions that minimize the adverse effects of evening screen use on sleep.

? Reducing fear of missing out from social media and other screen-based

activities may significantly improve the sleep of adolescents.(109,110)

Need basic, translational, and clinical research into the effects of screen-based

media on sleep and related health consequences among children and

adolescents, to educate and motivate parents, clinicians, teachers, and youth to

foster healthy sleep habits.

Hale et al., 2018. Child Adolesc Psychiatric Clin N Am;27:229-245.


Amalgamation of Treatments

• Brain & Body Care

• Understanding of sleep & Mood for Clinicians & Parents & Adolescents

– Timing of Light

– Diet & Gut Bacteria

– Exercise

– CBT & addressing Rumination

– Insomnia, Depression & Circadian Rhythm Disorders

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