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ORIGINAL ARTICLE

The tired teen: A review of the assessment


and management of the adolescent with
sleepiness and fatigue

Sheri M Findlay MD FRCPC

SM Findlay. The tired teen: A review of the assessment and L’adolescent fatigué : Une analyse de l’évaluation
management of the adolescent with sleepiness and fatigue.
Paediatr Child Health 2008;13(1):37-42.
et de la prise en charge de l’adolescent somnolent
et las
The symptoms of sleepiness and fatigue are frequently encountered
when caring for adolescents. Up to 40% of healthy teens experience Les adolescents présentent souvent des symptômes de somnolence et de
regular sleepiness, defined as an increased tendency to fall asleep. lassitude. Jusqu’à 40 % des adolescents en santé ressentent une somnolence
Fatigue is the perception of low energy following normal activity and régulière, définie comme une augmentation de la tendance à s’endormir.
La lassitude est la perception de manque d’énergie après des activités
is reported by up to 30% of well teens. Chronic fatigue syndrome is an
normales, dont jusqu’à 30 % des adolescents en santé font état. Le
unusual syndrome with severe fatigue accompanied by other physical
syndrome de fatigue chronique est un syndrome inhabituel qui
and neurological symptoms. A thorough assessment is required for all
s’accompagne d’intense lassitude et d’autres symptômes physiques et
teens with sleepiness and fatigue; however, a treatable underlying neurologiques. Tous les adolescents qui ressentent de la somnolence et de
medical condition is rarely found. Most fatigue and sleepiness in teens la lassitude doivent subir une évaluation approfondie, mais le médecin
is attributable to lifestyle issues, notably too little time spent sleeping. trouve rarement un trouble médical sous-jacent et traitable. Dans la
Physicians are in a position to screen for, assess and manage these plupart des cas, la lassitude et la somnolence chez les adolescents sont
common conditions in teens. attribuables au mode de vie et, notamment, au manque de temps consacré
au sommeil. Les médecins sont bien placés pour dépister, évaluer et
Key words: Adolescent; Chronic fatigue syndrome; Fatigue; prendre en charge ces problèmes courants chez les adolescents.
Sleepiness

eens complaining of being tired are frequently encoun- often has an overlap of these common symptoms, yet it is
T tered in primary, secondary and tertiary paediatric care.
The vagueness of the symptoms expressed a variety of dif-
important for the teen to be clear about what he or she is
experiencing because it aids the clinician in the manage-
ferent subjective experiences of the teen from fatigue to ment of the condition. Therefore, although somewhat arti-
sleepiness to low mood and feelings of loss of motivation. ficial, for the purposes of defining and discussing a
The range of possible physical and mental health condi- differential diagnosis, a separation of sleepiness and fatigue
tions that may initially be present in an adolescent report- may be useful.
ing tiredness is enormous.
The goals of the present paper are to review the available Sleepiness
literature on the complaint of ‘being tired’, particularly Sleepiness is defined as “an increased tendency to fall
focusing on the common symptoms of sleepiness and asleep” and is generally considered the opposite of alertness
fatigue, and to suggest an approach to assessing and manag- (1,2). Subjectively, the rates of daytime sleepiness among
ing this troublesome and sometimes disabling symptom. teens vary between 10% and 40%, (3-5), and tend to
increase from early to later adolescence (4,5). Objectively,
DEFINITIONS AND ETIOLOGY sleepiness is measured using the multiple sleep latency test,
The tired teen may report fatigue or sleepiness, or often in which the patient attempts to nap under fixed ideal con-
both. For example, a 14-year-old boy may report that he ditions, and sleep latency (time to the onset of sleep) is
feels too tired to go to school every day (fatigue), but that measured. In support of the descriptions by teens, objective
he is no more likely to fall asleep during the day than his measures using the multiple sleep latency test confirm that
peers (not sleepy). Alternatively, a 16-year-old girl may many teens do, in fact, have a higher than expected (and
report that she repeatedly falls asleep in class (sleepiness), healthy) tendency to fall asleep during the day (2,6,7).
yet she has the energy to do a wide array of school, sport and Not surprisingly, the usual cause of excess sleepiness is
social activities (not fatigued). In reality, the tired teen insufficient or inadequate sleep – both very common during
Adolescent Medicine, Department of Pediatrics, McMaster University, Hamilton, Ontario
Correspondence: Dr Sheri M Findlay, Adolescent Medicine, Department of Pediatrics, McMaster University, 1200 Main Street West,
Room 3G48, Hamilton, Ontario L8N 3Z5. Telephone 905-521-2100 ext 75644, fax 905-308-7548, e-mail findls@mcmaster.ca
Accepted for publication November 14, 2007

Paediatr Child Health Vol 13 No 1 January 2008 ©2008 Pulsus Group Inc. All rights reserved 37
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the teen years. A recent publication of the American illness has the potential to affect one’s energy level and
Academy of Pediatrics’ Working Group on Sleepiness in sleep patterns; therefore, listing possible causes of fatigue
Adolescents/Young Adults (1) summarized that teens need would be encyclopedic. For this reason, the discussion of
9 h to 10 h of sleep per night for optimal functioning, but fatigue requires the caveat that the symptom is not readily
for a variety of reasons, many do not get this. Lifestyle fac- explainable by a diagnosed physical or psychiatric illness
tors contributing to this problem include early start times (especially anxiety and depression). In some adolescents,
for most high schools, and an increasing amount of fatigue is one of several medically unexplained symptoms
extracurricular and employment demands on many adoles- that should prompt the physician to consider a somatization
cents. The availability of highly entertaining computer and disorder (21).
video games, as well as late night socializing via the CFS is often used to describe a constellation of symp-
Internet also contribute to the unwillingness to get to bed toms of which the predominant symptom is severe fatigue.
at a decent time to get the recommended 9 h to 10 h of The syndrome often appears to be triggered by an illness,
sleep. Such teens may find napping in the afternoon but evolves into a chronic state of poor functioning that is
unavoidable, giving them an ill-timed sense of energy late related to poor physical conditioning, sleep disturbance and
in the day, further contributing to the late nights. Teenagers is often perpetuated by psychological factors. Although
with insufficient sleep typically catch up on sleep on week- numerous causes have been suggested, the etiology of CFS
ends, with very late rise times on weekend mornings. remains unknown. Infectious, immune and neurological
Although unusual, sleep disorders must be ruled out in causes have been studied, yet a clear etiology remains lack-
the sleepy teen. Delayed sleep phase syndrome (DSPS) is ing. Observations that some patients with CFS also experi-
the most common sleep disorder in adolescents, with an ence postural tachycardia and orthostatic intolerance (22)
incidence as high as 7% in some studies (1). Teens with have led to questions about whether autonomic nervous
DSPS have difficulty falling asleep when they go to bed as a system dysfunctions may be etiologically related to CFS;
result of a circadian rhythm disorder, in which their inter- however, this hypothesis remains controversial (23). The
nal sleep-wake cycle is not synchronous with the world most commonly encountered physical symptoms are
around them. They complain of an inability to fall asleep malaise, headache, sore throat, sleep disturbance, memory
when they go to bed, as opposed to teens who choose to stay and concentration impairment, nausea, joint and abdomi-
up late but fall asleep very quickly once they are in bed. nal pain (13,16,19,24). Significant functional impairment
Sleep-disordered breathing (obstructive sleep apnea) can is part of the presentation, as are worsening symptoms with
also result in daytime sleepiness in teens, and is often physical or mental exertion. Diagnostic criteria for children
related to enlarged tonsils and adenoids or obesity. Typically and teens with CFS remain controversial, and many physi-
there is a history of snoring. Uncommon sleep disorders, cians feel that the CFS label should be avoided for children
such as narcolepsy, periodic leg movement during sleep and and teens because it may erroneously imply an unremitting
restless leg syndrome can be considered when daytime condition with a lifetime of functional impairment (16,17).
sleepiness is severe and chronic. There are often specific
complaints to suggest these disorders, such as a history of HISTORY
sudden sleep attacks or a restless uncomfortable feeling in Taking a medical history from the tired teen is the most
the legs only resolved by movement. important diagnostic intervention. At least part of the
Regardless of the cause, the consequences of excessive history must be taken with the teen alone to ensure that
sleepiness in teens can be serious; clear associations have accurate information is obtained about topics such as
been made with many adverse outcomes, including poor substance use, school attendance and mental health. A
school performance, mood disturbance and increased risk of detailed history provides reassurance that a thorough
accidents, particularly motor vehicle crashes (1,2,8). approach has discovered or ruled out any pernicious condi-
tions. Integrating holistic questioning from the beginning of
Fatigue the interview gives the teen and the family the idea that
Fatigue is generally defined as “abnormal exhaustion after investigation of psychosocial stressors is just as important as
normal activities” (9,10), and is an extremely common questions about their physical health. To delay this line of
subjective symptom of many physical and mental health questioning until after the physical examination and labora-
conditions. By definition, chronic fatigue lasts for more tory investigations delivers the message that psychosocial
than six months; chronic fatigue syndrome (CFS) is the inquiries are only relevant in the absence of physical causes.
presence of severe chronic fatigue, which is associated with Open-ended questions are extremely helpful in under-
other somatic symptoms (11-13). Studies (14,15) evaluat- standing the onset and course of the symptoms, and the
ing the presence of fatigue in the general population have teen should be encouraged to tell the story of their illness.
indicated that 15% to 30% of teens report frequent fatigue; This often reveals a specific trigger for the onset of sleep
however, only between 0.5% and 2% meet criteria for CFS disturbance or fatigue – such as a concomitant illness,
(1,11,13,16-20). notably a viral illness, or a significant life event, such as a
The differential diagnosis of fatigue is extensive, and death in the family, travel over time zones or a change in
multiple causes frequently coexist. Almost every known daily routine. The duration and stability of the complaint

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The tired teen

may give clues to psychosocial or environmental contribu- TABLE 1


Screening questions for sleep difficulties in adolescents
tors, such as persistence of symptoms during weekends and
holidays, and in different seasons. Many teens have tried BEARS screening instrument (adolescent questions)

prescription and nonprescription remedies for their symp- Bedtime problems Do you have any problems falling asleep
toms, and inquiries should be made about the use of herbal at bedtime?

and alternative therapies. Excessive daytime sleepiness Do you feel sleepy a lot during the day?

To determine whether the teen has predominately fatigue In school? While driving?

or sleepiness, a detailed sleep history is essential. A recently Awakenings during the night Do you wake up a lot at night?

published screening tool, referred to by the acronym BEARS Regularity and duration of sleep What time do you usually go to bed on
school nights? Weekends? How much
(25), can help to structure the history (Table 1).
sleep do you usually get?
A detailed review of symptoms is needed to facilitate
Sleep-disordered breathing Does your teenager snore loudly at
which investigations are needed and also to ascertain
night? (ask parents)
whether other somatic symptoms are present. Inquiry
Additional questions to ask
should be made into constitutional symptoms such as fever,
appetite and weight changes. The review should be system- How often do you nap after school, and for how long?

atic and specific, because many teens do not volunteer what How much exercise do you get, and what is the time of day?

may seem to them to be an unrelated symptom. For exam- How much coffee, tea and cola do you drink each day?

ple, a 13-year-old girl may be experiencing heavy menstrual How often do you drink alcohol?

bleeding, but she may not think to share this with the doc- Adapted from reference 25
tor unless specifically prompted. Many teens with com-
plaints of chronic tired feelings also report frequent pain
symptoms (head, back and abdomen) in addition to vague PHYSICAL EXAMINATION
complaints such as dizziness, weakness, and poor concentra- Unless the history provides a specific organ system to focus
tion and memory (13,16,19,23). on, the physical examination in the tired teen needs to be
When assessing the psychosocial well-being of the teen, thorough and general, with attention paid to ruling out any
the commonly used HEADSS interview remains useful. chronic or infectious illnesses (9,16). Before the examina-
Please refer to the commentary by Grant (pages 15-18) tion, the physician should already have a good sense of the
published in this Journal and the Sacks and Westwood arti- patient’s level of functioning, communication and affect.
cle (26) outlining the use of this interview. The clinician Observing the teen’s personal hygiene, their choice of
can focus on the symptom’s impact on the teen’s ability to clothing and their ability to make eye contact with the doc-
meet age-appropriate expectations, particularly looking at tor is helpful. Does the teen look tired during the interview,
missed school or shifts at work, and changes in social activ- with persistent yawning and a sense of indifference to the
ities. It is very helpful to ask the teen to give examples of questions? What is the interaction between the teen and
the symptom from the past week, such as ‘How has being the parent when they are together? Is the teen able to speak
tired affected you this week? Was there anything you could when the parent is present, or is he or she silenced?
not do?’ When teens have missed out on their usual activi- Vital signs should include temperature and orthostatic
ties, what is filling their time? If they are not going to measurements. A height and weight measurement should be
school, are they watching television or spending time on taken. Growth parameters should be plotted and compared
the Internet? Finding out who is at home during the day if with prior measurements when available. The head and neck
the teen is missing school can give some clues to family examination should include palpation over the sinuses, and
dynamics. A detailed screening for mood and anxiety disor- assessment of cranial nerves and fundoscopy. The chest
ders is one of the most important parts of the interview of should be examined for evidence of heart or respiratory ill-
the tired teen. The HEADSS interview also allows the cli- ness, and the abdomen should be evaluated for the presence of
nician to understand the competing demands in the teen’s hepatosplenomegaly or pelvic masses. Unless the history
life in terms of overscheduling. suggests possible pregnancy or pelvic pathology, an internal
Finally, the teen’s prior illnesses and medical history may examination is not usually necessary. Lymphadenopathy
direct the physical examination and investigations toward a should be looked for. The skin should be examined for rashes,
specific diagnosis, but may also reveal a pattern of pallor or hyperpigmentation, and the extremities for any
prolonged illnesses and somatic complaints. Many teens evidence of arthritis. The neurological examination needs to
with persistent symptoms report significant impairment include an assessment of muscular strength and gait.
with illnesses or events that are not typically associated
with prolonged absenteeism, such as the teen who missed LABORATORY INVESTIGATIONS
three weeks of school following their wisdom teeth extrac- Laboratory testing should be directed by findings on the
tion or the teen who is routinely home for a week with cold history and physical examinations; certain tests are
symptoms. The family history may reveal similar patterns of indicated for most teens complaining of being tired, and to
illness behaviour, with a parent themselves experiencing eliminate those conditions that are vague and do not
persistent fatigue or chronic pain. always present with specific symptoms (9,16). Suggested

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TABLE 2 TABLE 3
Guidance for teens getting too little sleep Suggested feedback to teens and families regarding
• Have a relaxing bedtime routine. Always fall asleep in your bed, not in
chronic fatigue
front of the television. • The history and physical have ruled out serious medical and psychiatric
• Try to be in your bed at least 8 h per day. Many teens need 9 h or 10 h conditions that can present as fatigue (if there are specific illnesses that
to not feel sleepy during the day. the teen or family was concerned about, these can be highlighted).

• Try to go to bed at approximately the same time every night. • Unexplained fatigue in teens is common and is probably related to the
combination of rapid physical and psychological change, which can leave
• Open the curtains or turn on the lights as soon as you get up in the
some teens feeling exhausted.
morning.
• Although there are no tests to confirm the fatigue, we know the symptoms
• Be active every day, but avoid vigorous exercise in the evening.
are real.
• Avoid all products with caffeine after mid-day.
• For some teens, the fatigue is triggered by something, eg, an illness, or a
• Avoid napping during the day. If you do, keep it short (less than 30 min).
time when competing demands have left the teen physically and
• On weekends, no matter how late you go to bed, try to get up within 2 h of
emotionally overwhelmed with too many obligations.
your usual wake time.
• For some teens with chronic fatigue, the symptom has become a vicious
• Have a light snack (such as a glass of milk) before bed.
cycle – fatigue limits what the teen is able to do, then inactivity and
• Use your bed for sleeping only, do not do homework, watch television or
isolation lead to deconditioning and mood changes, which results in
spend time talking on the telephone while in your bed.
further fatigue.
• Avoid using any products to help you sleep (including alcohol, herbal
• Fatigue is manageable and most teens recover, although sometimes this
products or over-the-counter sleep aids).
takes months or even years.
Data from references 10 and 16 • Despite the fact that we do not know the cause, we do know which
interventions are helpful for most teens with fatigue.

baseline testing includes a complete blood count with


differential and platelet counts, erythrocyte sedimentation
rate, fasting glucose, electrolyte, urea, creatinine, liver For the teen with sleepiness of which the obvious cause is
function tests, albumin, creatine kinase, mononucleosis insufficient sleep, the clinician can assist the teen by
screen, thyroid stimulating hormone, thyroxin, pregnancy discussing what is known about good sleeping habits. Table 2
test and urinalysis. The results of the history, physical lists common advice given to the overtired teen.
examination and the baseline tests may suggest other Parents should be aware of the guidance that teens are
investigations, such as rheumatologic tests (eg, antinuclear receiving about sleep hygiene, although they should not be
antigen, rheumatoid factor, complement or immunoglobu- in charge of it. Many sleep-deficient teens have sleep-
lin tests), a search for an occult infection (eg, sinusitis, deficient parents who may themselves benefit from hearing
HIV or Lyme disease) or an endocrinological illness (eg, the sleep counselling information provided to the teen.
Addison’s disease). In circumstances in which the cause of Parents can be reminded that a teen’s late night habits may
the sleepiness is clear (eg, not sleeping enough), laboratory represent a need for increased privacy and time alone –
investigations can be deferred pending response to initial something that is hard to achieve in a busy household.
interventions. The variety of accompanying somatic symp- Parents can be asked to consider whether their teen is over-
toms, and the duration of the fatigue and sleepiness can scheduled, thus not leaving enough time for homework,
lead to overinvestigation and repeating previously normal socializing, fun and ‘downtime’ during normal waking
blood work. It is important to limit this as much as possible hours.
because it can delay the teen and their family’s ability to For most teens with poor sleep hygiene and those with
move toward getting better. mild DSPS, the above advice to teens and families may be
adequate to resolve the daytime tiredness. For those with
MANAGEMENT more severe and prolonged DSPS, a more intensive pro-
Following completion of the history, physical examination gram of sleep rehabilitation may be needed. Review articles
and laboratory investigations, the clinician’s primary focus (27,28) detailing the management of paediatric sleep disor-
becomes providing feedback to the patient and family, and ders have been published, and if available, referral to a sleep
proceeding with treating underlying causes and managing specialist may be helpful.
the symptoms, with a focus on having the teen return to Management of the teen with unexplained fatigued can
normal functioning as soon as possible. Treatment of any be very challenging (9,16,29). Whether the teen has
conditions identified on testing is necessary, but it is impor- isolated chronic fatigue or the more encompassing CFS,
tant to not use the discovery of a minor condition as the starting with providing very clear feedback to the teen and
sole explanation of the teen’s symptoms. For example, an their family is critical. Even for teens with mild fatigue of a
adolescent girl with mild iron deficiency anemia will likely short duration, this approach can be used early, perhaps
benefit from iron therapy; however, the clinician should avoiding deterioration into a more pervasive condition
still council about the importance of sleep hygiene and reg- (Table 3).
ular exercise to maintain normal energy levels throughout Before discussing specific interventions, the physician
the day. should ensure that the teen and their family are ‘on board’

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The tired teen

with proceeding to the management phase. The importance TABLE 4


An approach to managing the fatigued teen
of this step in managing fatigued teens cannot be
overstated because the recommendations that the doctor • Summary of approach: The teen requires rehabilitation to slowly return to
an age-appropriate level of functioning. During the rehabilitation, the
makes are unlikely to be followed unless the family and the
physician follows progress closely, monitoring for emerging symptoms and
teen are prepared to move on (16). Lingering doubts about
managing concurrent conditions.
the completeness of the testing may not allow the parent
• The first goal is to improve function through increased activity and fitness,
and the teen to push through the rehabilitation, which in spite of the symptoms, which often are slower to resolve.
may be challenging. Helping the family to understand pos- • Care must be taken to not overwhelm the teen with too many expectations,
sible psychological contributors is important, but it needs because this may make the fatigue worse.
to be handled cautiously. An explanation that some chil- • Priority should be given to school and socialization before employment,
dren with chronic symptoms have a tendency to ‘internal- chores and extracurricular activities. Returning to one class at school per day
ize’ their feelings may help the family understand the and one evening out with friends per week may be a good place to start.
reasons for further psychological evaluation, even though • The teen should be provided with advice about sleep hygiene (Table 2)
the child may not express any worry or unhappiness. There and regular, balanced eating.
is evidence that teens with parents who do not endorse • Graded exercise therapy, coordinated by a physical therapist, can be very
psychological contributors to chronic fatigue have a poorer helpful.
prognosis than other fatigued teens (30). It is also impor- • Counselling, specifically cognitive behavioural therapy, has been studied
tant to warn teens and families ahead of time that the in randomized trials and appears to be effective (27).
management may seem ‘backwards’ to them. Families may • Medications for pain (acetaminophen or ibuprofen) can be prescribed at
be expecting physicians to help with the symptoms and appropriate doses. Some physicians prescribe tricyclic antidepressants for

then function can return, whereas physicians propose a chronic pain and sleep disturbance; however, there is no evidence on
efficacy.
return to function followed (hopefully) by a reduction of
• In the absence of a major depressive episode, there is no evidence that
symptoms (Table 4).
antidepressants improve the symptoms or the global functioning in teens
Most outcome studies (11,23,29,31-33) suggest that at
with chronic fatigue.
least 50% of teens with chronic fatigue and CFS have
• There are no complementary treatments that have been shown to be
significant improvement in symptoms and daily effective for chronic fatigue. Many patients and parents, however, are
functioning, although recovery is often delayed several interested in trying these options and should not be discouraged unless
years. More severe illnesses with more functional impair- there is evidence of potential harm.
ment suggest a poorer long-term prognosis (11).
Data from references 1, 16 and 34

SUMMARY
The tired teen is commonly encountered by clinicians who changes to established routines. Most teens with these con-
work with adolescents and their families. Our approach to ditions are expected to recover, although there is a subset of
helping patients must begin with ruling out physical and teens with CFS in whom prognosis is guarded and long-term
psychiatric conditions, then moving to assist the teen with management may be necessary.
lifestyle and rehabilitation to return to a normal level of
functioning. Throughout this process, a therapeutic relation- ACKNOWLEDGEMENTS: The author would like to thank the
ship should be established and maintained with the teens and members of the Adolescent Health Committee for their assistance
with editing the present paper.
their families if they are to follow recommendations for

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