Sleep, fatigue and circadian disorders in adolescents — short case and counselling station

Station objectives

1. Take a focused adolescent sleep history, including a two-week sleep diary, weekday–weekend pattern, and a mood and safety screen. [10] [11]
2. Name the dominant mechanism (insufficient sleep, insomnia, delayed phase, hypersomnolence, OSA, or fatigue) and distinguish sleepiness from fatigue. [9]
3. Build and explain a stepped-care management plan matched to the mechanism. [13]
4. Recognise the red flags of narcolepsy and obstructive sleep apnoea and construct an urgent, safe referral. [16]

Candidate brief

You are the paediatric registrar in adolescent clinic. You have 10 minutes for Station A (assessment and counselling of the late-rising girl) and 12 minutes for Station B (assessment, recognition and referral for the sleepy boy with cataplexy). Examiners score history-taking, mechanism recognition, counselling language, safety and referral planning. [10] [16]

Station A — Delayed sleep-wake phase disorder

Setup: A 15-year-old girl and her mother. She "can't get up" and falls asleep in morning classes. On weeknights she is in bed by 23:00 but sleeps only from about 01:30 to 06:45 (five hours). On weekends she sleeps 02:00 to 11:00 and feels well. Her mood and examination are normal. [9] [10]

Expected actions:

• Take a sleep history and obtain (or request) a two-week diary, probing weekday and weekend timing, screens, caffeine, and mood. [10]
• Identify the dominant mechanism as delayed sleep-wake phase disorder: normal, refreshing sleep at a delayed clock time with marked weekend rebound — not insomnia and not laziness. [9]
• Explain the biology to the young person and parent (pubertal phase delay, not a behaviour fault), which itself improves engagement. [9]
• Build a phase-advance plan: consistent rise time seven days a week, 30 to 60 minutes of bright light on waking, low-dose melatonin about three to five hours before habitual sleep onset with the off-label caveat, protection from evening light and screens, and a gradual earlier schedule. [15]
• Safety-net for cataplexy, snoring with apnoea, or mood decline, and arrange review at four to eight weeks with a diary. [11] [15]

Station B — Narcolepsy type 1 (cataplexy)

Setup: A 17-year-old boy sleeps nine sound hours overnight but dozes through afternoon classes. Last week, while laughing at a video, both his legs buckled and he slumped briefly, fully conscious. He is embarrassed and his grades have slipped. [16]

Expected actions:

• Recognise the red flag: cataplexy (emotion-triggered, bilateral loss of muscle tone with preserved consciousness) with daily irresistible sleepiness despite adequate overnight sleep — narcolepsy type 1 until proven otherwise. [16]
• Construct an urgent referral to a sleep specialist for an overnight polysomnogram followed by a multiple sleep latency test, performed after documented adequate preceding sleep and withdrawal of REM-suppressing medication. [16]
• Counsel explicitly and non-judgmentally on drowsy-driving safety and on the functional and educational impact; reassure that this is a recognised, treatable disorder, not laziness. [11] [16]
• Screen mood and safety (chronic hypersomnolence carries depression and driving risk); avoid initiating stimulant or sodium oxybate therapy, which is specialist-led. [16]

Marking anchors

Clear pass: takes a structured sleep history and elicits the weekend pattern; correctly identifies delayed sleep-wake phase disorder by its mechanism and explains it without blame; constructs a coherent phase-advance plan (rise time, light, melatonin, evening-light protection); recognises cataplexy as narcolepsy type 1; plans an urgent MSLT referral; counsels on driving safety and screens mood. [9] [16] Borderline: identifies a sleep problem but misnames the mechanism (e.g. calls DSWPD "insomnia"), or offers melatonin without a rise-time or light plan, or recognises cataplexy but gives a delayed or incomplete referral, or omits the driving and mood discussion. [13] Fail: attributes the presentations to laziness or "just needs an earlier bedtime"; reaches for a hypnotic; misses cataplexy or dismisses it; fails to refer suspected narcolepsy; or neglects to screen mood and safety in a tired teenager. [11] [16]

Debrief pearls

• The discriminating question is what the young person does on a free weekend: normal sleep shifted late is delayed phase, not insomnia. [9]
• CBT-I, not hypnotics, is first-line for adolescent insomnia. [13]
• Cataplexy with sleep attacks is narcolepsy type 1 — refer for MSLT and counsel on driving. [16]
• Always screen for depression, anxiety and self-harm in the tired teenager. [11]