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 “Why is he/she so tired all of the time?” I get asked this question a lot by parents.Their child can’t get out of bed in the morning, or is falling asleep in school. Or, alternatively, s/he just doesn’t have a lot of energy for activity or interests. Parents, educators, and kids often wonder why teenagers seem so tired all of the time. Here’s how I evaluate what the problem is, how severe it is, and decide what to do about it. 

Tiredness is unfortunately an imprecise term. My first step is differentiating between fatigue and sleepiness, although they can travel together:

* Fatigue is lack of energy. People with fatigue feel like they just don’t have a lot of energy. There are lots of potential causes of fatigue. Medical causes can include anaemia, low thyroid, other chronic medical issues, or medication side effects. Mental health issues such as excessive stress, depression or dysthymia can also cause significant fatigue. There is also chronic fatigue syndrome which is associated with debilitating fatigue and is poorly understood. If the primary concern is fatigue, a comprehensive evaluation by your child’s pediatrician is a good place to start.

* Sleepiness is an increased propensity to sleep. Sleepy teens can be quite difficult to get up in the morning. They may nap. They commonly fall asleep in class, on the bus, or on short car trips around town. Many teens are a little bit sleepy, as unfortunately less than 10% of teens get enough sleep on school nights. See below to know when to be concerned.

Sleepiness is a common problem in teenagers, and a serious one. The biggest risk to teenagers is from automobile accidents, and drowsy driving is similar to drunk driving in terms of risk. All teenagers seem a bit sleepy compared to their younger selves. This is partially due to a biologic shift in their circadian, or body clock. This means that their natural (physiologic) sleep period is shifting later. That is to say, their bodies want to go to sleep later and get up later. Unfortunately, in most school districts, this coincides with early school start times. Research has shown that later school start times correlate with greater student well-being and academic achievement; in fact, there is a national movement for later school start times, but it is hard to imagine any progress on this in the current political climate.

How do you know if sleepiness is a significant issue in your teen?

* It is very difficult to get him out of bed in the morning, to the point where he is missing his morning class regularly.

* Grades are falling.

* Teachers have complained about her sleeping in class.

* Napping after school is common or prolonged.

* Weekend catch-up sleep is excessive with usual wake times after noon or later.

* Your teen has had a car accident or near-miss car accident. 

This last piece is critically important. There is a strong association between sleepiness and risk for automobile accidents.

Auto accidents are the leading cause of death in teenagers. The only things that make you less tired if you are driving is either taking a nap or having caffeine. Listening to the radio, opening the window, or talking on the phone do not help.


Causes of sleepiness in teenagers

There are essentially four broadly defined causes of sleepiness. Many teenagers who have excessive sleepiness may have more than one.

* Not enough sleep.  This is very, very common, due to the “vicious cycle” of teenaged sleep. Most teenagers need 8 1/2- 9 1/2 hours of sleep per night. So if they need to get up by 6:30 AM on a weekday, he or she should be in bed between 9-10 PM. There is such a rich array of distractions available in the evening– online gaming, television, texting, social media, etc. I encourage families to negotiate a “no phone” policy after bedtime for their teens.  Many adolescents can develop an unhealthy pattern of late nights and difficulty awakening in the morning, described by several authors as the vicious cycle of adolescent sleep. They increase caffeine intake and/or nap in the afternoon, which compounds difficult in awakening in the morning. Late “catch-up” sleep on the weekends further compounds the issue, as they have marked difficulty falling asleep on Sunday night, which starts the whole cycle again. Both napping and sleeping in reduce the need for sleep at bedtime and result in insomnia.   Also, keep an eye on homework loads as excessive homework can also be a factor.

* Disordered sleep.  A medical disorder disrupting sleep such as obstructive sleep apnoea can certainly result in daytime sleepiness, especially in obese teenagers. 

* Body clock disorders. As I discussed earlier, all teenagers have a natural delay in their sleep schedule, called a circadian phase delay. In some teenagers, this can become quite exaggerated, where their natural sleep schedule becomes incompatible with normal functioning, e.g. sleeping on weekends from 4 AM -2 PM and being unable to get up for school. This condition is called delayed sleep phase syndrome.

* Disorders of increased sleep drive. These are disorders which result in increased sleep drive. The most common disorder of increased sleep drive is narcolepsy, and it is still quite rare. Narcolepsy is rare but usually appears during the teenaged years. It is characterized by “sleep attacks”, hypnagogic hallucinations (dreaming while still awake at the onset of sleep), sleep paralysis (waking up but being paralysed for a few minutes), and cataplexy (abrupt onset of muscle weakness after triggers such as laughter or anger).  It is diagnosed with a sleep test called a multiple sleep latency test (MSLT), where the child has an overnight sleep study and five nap opportunities the next day. The amount of time it takes the child to fall asleep is averaged to see if it falls into normal ranges or is suggestive of narcolepsy.

Excessive sleepiness is a serious problem in teenagers and is associated with depression, poor performance in school, and increased risk of car accidents. You can measure your teen’s sleepiness using the Epworth Sleepiness Scale online; although designed for adults, it may still be helpful. If you suspect that your teen is sleepy, please discuss this with his or her paediatrician and review the importance of avoiding drowsy driving.


What can you do if your teen seems excessively sleepy?

* Keep all electronics out of the bedroom and have him or her go on a “light diet” to minimize the effect of electronics on sleep.

* Advocate for healthy school start times in your community and monitor the amount of homework your child receives.

* Monitor your child’s time that he or she is going to sleep and waking up and try to optimize to maximize the sleep opportunity.

* Make sure that your child’s homework load is age appropriate. Here’s an article on what to do when homework is causing sleep deprivation.

* If your child snores, or seems very sleepy in spite of adequate sleep at night, an overnight sleep test and/or evaluation by a sleep doctor may be helpful.

Dr John Pride is a GP at Windsor Village & Oakden Medical Centres

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