sleepiness, excessive

Excessive sleepiness or problems related to inadequate sleep in children are fairly common. Inadequate sleep usually results in some variation of daytime sleepiness or tiredness, but may also curiously result in hyperactivity, school problems, emotional problems, and other daytime behavioral difficulties.

Before considering what might be causing abnormal daytime sleepiness, it is wise to begin by determining whether the child is even getting enough sleep to begin with. When a child goes to sleep at night and when he or she arouses in the morning may well be the explanation for sleepiness and lead to easy resolution of it. The table below will give you an idea of roughly what to expect in terms of total daily sleep depending upon age. For ages 1 ond 3, the total includes naps.

Age	Sleep Requirement
1 year	13-3/4 hours
3 years	12 hours
6 years	10-3/4 hours
9 years	10 hours
12 years	9-1/4 hours
15 years	8-3/4 hours
18 years	8-1/4 hours

Source: Solve Your Child's Sleep Problems, Richard Ferber, Simon&Schuster, 1985

The so-called parasomnias such as bedwetting, sleepwalking, sleeptalking, or night terrors do not ordinarily result in daytime sleepiness or problems related to insufficient sleep.

Medical problems as well as medications can sometimes dramatically affect sleep in children, so this is the first thing to review. Think of the following points for any child with problems of daytime sleepiness or potentially related to sleep problems:

Are there any medical conditions that may influence sleep can lead to daytime sleepiness or sleep-deprivation related problems?

tonsil and/or adenoid enlargement (snoring, sleep apnea)
asthma
epilepsy

Does the child consume any medications or drugs that can influence sleep patterns or lead to daytime sleepiness?

caffeine (colas, Mountain Dew, Dr. Pepper, tea)
chocolate (active ingredient is theobromine, closely related to caffeine with similar effects)
antihistamines
in adolescents, consider drugs of abuse, notably cocaine, marijuana, and alcohol
anti-seizure medications for epileptic children may cause drowsiness, especially phenobarbital

Are there any abnormal sleep behaviors?

snoring or sleep apnea (prolonged cessation of loud breathing noises in sleep)
abnormal sleep positions (for example,the child cannot sleep unless neck is positioned awkwardly)
sleepwalking
night terrors or confusional arousals (screaming or crying while not totally awake)
bedwetting

Are there daytime problems with school performance or behaviror?

hyperactivity, aggressiveness or disruptive behavior
poor grades - is the child functioning well at grade level?
emotional problems, teariness
inattention, mind wandering
sleepiness in class
interference with peer relations

Obstructive sleep apnea occurs in about 3% of children, while snoring is a problem for about 10%. In preadolescent children, sleep apnea seems to cause more problems with aggressiveness or disruptive, hyperactive behavior than complaints of sleepiness.

Sleepiness and disturbed sleep in adolescents

Narcolepsy is a specific neurologic disorder which causes uncontrollable sleepiness during the day. It is rarely diagnosed before 15 years of age, although the majority of narcolepsy patients recall symptoms of excessive sleepiness younger than that age.

Drowsy teenagers often simply do not get enough sleep. During the adolescent growth spurt, more sleep is required than previously because of increased growth (growth essentially goes on only during the hours of sleep). The social pressures of the teen years - staying up late to watch TV, chat on the phone endlessly with friends, or do the homework that should have been done earlier in the evening - when combined with the need to arise early in the morning for school, can easily create a situation in which the adolescent is chronically sleep deprived.

Sleep phase delay syndrome, or delayed sleep phase, is especially troublesome in teenagers. In this situation, the teen's "body clock" has drifted later and later in the day, so that the natural time for night sleep - the natural bedtime - is quite late. Conversely, the normal time to arise drifts correspondingly late in the morning. Since school must be attended, these teens often come home from school and crash for a nap, to then later stay up until all hours of the night in a repetitive cycle.

         Out all night, sleep all day, 
         I know what your're doin'
         If you're gonna act that way, 
         I think there's trouble brewin'...
         
                                           Joe Walsh, "Funk49"

This phenomenon of later sleep phase in the circadian rhythm in adolescents is so common, that there is some suspicion it may be a natural developmental feature of teenagers. In any event, "treatment" is often a prolonged process of counselling progressively earlier bedtimes each night to pull the body clock back in the direction of a more normal (or at least socially acceptable) setting.

Substance abuse among adolescents is unfortunately widespread, and often initially undetected or even unsuspected. Marijuana, alcohol and cocaine all cause disturbances of normal sleep rhythms and can cause daytime sleepiness.

Narcolepsy is, as stated above, unusual before mid-adolescence. It is rare, affecting only about 1 in 2,000 persons. It is a disorder of REM sleep. In addition to daytime sleepiness, one or more of the classic three symptoms are usually present when the diagnosis is made:

cataplexy, a sudden temporary loss of muscle tone - the patient just suddenly sinks to the floor
hypnagogic hallucinations, frightening and recurring visual hallucinations when falling to or arousing from sleep
sleep paralysis, a paralysis of voluntary muscles while falling asleep

Treatment of narcolepsy would be usually supervised by a neurologist or sleep specialist. Dexedrine, a stimulant, is the usual medication used.

Depression should always be considered for any child or adolescent with excessive sleepiness or tiredness. Signs of depression in teenagers can include:

depressed teens often have difficulty falling asleep and difficulty waking up in the morning
depressed mood
loss of interest or enthusiasm for normal activities
unusual weight loss or weight gain
feelings of worthlessness
inability to concentrate
suicidal thoughts
"acting out" behaviors, antisocial troublemaking
substance abuse

So complaints of sleepiness in children and adolescence deserve careful attention by parents and physicians. The explanation for daytime sleepiness may be simple or complex; an understanding of what might be going on, especially as it relates to the age of the child in question, will often help solve what can be a perplexing problem.

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