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To sleep, perchance to recover

November 17, 2011
by Thomas Wright, MD
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Rosecrance alters adolescent treatment schedule in response to sleep data

Ask parents of teenagers about the peculiar sleep habits of their children, and chances are they will launch into some version of the same story:

Their kids stay up half the night—in fact, many teens seem incapable of going to sleep at a “normal” time. On the flip side of the clock, they are difficult to wake for school/church/chores/family time. Forced to get up, they have the disposition of ticked-off grizzly bears.

The truth is: They can't help it.

Research indicates that the natural circadian rhythm of teens makes them mentally unready for sleep when the rest of the family is yawning. By the time a typical teen drifts off, other people in the household are halfway through their time of rest. The problem is complicated in an age when cell phones, computers and video games give young people myriad forms of stimulation and the temptation to stay awake.

While teens leave their gadgets at home when they come to treatment at Rosecrance, patients can't turn off their biological clocks. In October 2010, our staff began systematically studying this issue and looking at how the night-owl pattern of adolescent patients might be affecting their treatment and recovery. Further, we asked ourselves: Is there a way to bend to circadian rhythm reality and improve treatment at the same time?

Our eventual decision to revise the treatment schedule to allow Rosecrance's teen patients to sleep longer had a top-to-bottom impact on the treatment program at the campus, which is the largest adolescent inpatient program in Illinois.

The four-month process we used to get there, which involved leadership, clinical and support staff, and patients, presented an opportunity for everyone on campus to step back and review what we were doing and what we might change to offer teens the best opportunity for lasting recovery.

What is sleep?

We know that sleep is a universal biologic need in nearly all species that is characterized by a general state of immobility and reduced responsiveness that is rapidly reversible.1 Alongside food, shelter and water, sleep is one of the most basic human needs for survival.

Thomas Wright, MD
Thomas Wright, MD

Science is not exactly sure of the purpose of sleep, but what we do know is we can literally die of lack of sleep. It takes only a couple of days of sleep deprivation to begin to see severe symptoms such as hallucinations and delusions. Even mild sleep deprivation has been associated with cognitive and psychological problems. Some animal studies have shown that sleep deprivation can result in death faster than food deprivation. 2

Our brains simply cannot function without adequate sleep. Some studies have shown that sleep is necessary for proper energy conservation, neuronal recuperation, synaptic homeostasis, and brain plasticity, among other things.1 Substances of abuse also have a substantial impact on the quality and quantity of sleep. Most addiction treatment centers struggle with how to best manage this in addition to the rest of the patient's recovery needs. At Rosecrance, we believe it is important to address this aspect of recovery in a holistic way.

Sleep and adolescence

Behavioral science generally accepts the developmental period of adolescence as marked by significant change. Dramatic changes occur in physical, social, psychological and biologic functions. It is a time of great physiologic activity.

The structure of adolescent sleep also changes at this time because of these physiologic pressures. One of the most significant changes observed is a gradual shift in the timing of sleep. Beginning around the age of 13 in youths, a shift occurs toward a general wakefulness during evening activities. Adolescents become “owls” rather than “larks.”3 This change has been observed across cultures and countries. Young people seem to reach their greatest tendency towards “eveningness” at about age 20, with women reaching it slightly sooner than men.

Adolescents' need for sleep peaks around age 12 or 13, with the amount decreasing about 14 minutes per year up to about age 20. Many studies have shown that school start time might be an important factor adding to potential sleep deprivation with adolescents, especially during the school week.4

The result of this overall sleep deprivation has been shown to be a contributing factor toward poor school performance and other serious behavioral problems, including substance abuse. Studies have shown increased risk for nicotine, cannabis and alcohol use among this population, as well as increased incidence of feeling sad or hopeless and having suicidal or self-harm thoughts.5 Intervention studies have shown that shifting the start time of school for these teens fits better with their natural sleep rhythm and can improve academic performance and behavior.

For these reasons, and in order to give our patients at Rosecrance the best chance for recovery, we thought it important to review our own schedules and modify and improve them to reflect the sleep needs of our teens.

Change process

The process started for us when a staff member read an article that spoke to the circadian rhythm of adolescents and how it is naturally a part of their “clocks” to stay up later at night and want to sleep in. The leadership team discussed the issue and managers took the matter back to their respective teams.

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