Question

A 14-year-old boy is brought to the physician by his mother because she has had difficulty awakening him in the morning since the start of the school year 3 months ago. She reports that last year he would always get up on his own. She now has to rouse him several times every morning. She says that he has the same group of friends as he did last year. When interviewed alone, the patient says that during the summer he discovered a talk show at 10 PM that he enjoys watching. He states that he is not tired at 10 PM , which was his bedtime last year. Physical examination shows no abnormalities.

Which of the following is the most appropriate next step?

A) Urine toxicology screening

B) Use of an over-the-counter sleeping medication as needed

C) Modafinil use in the morning

D) Zolpidem use at bedtime

E) No further treatment is indicated

 Answer: No further treatment is indicated (Option E)

This patient's difficulty waking up is due to a delayed sleep phase, a common occurrence during adolescence as the sleep-wake cycle shifts. His late-night viewing habits and natural change in sleep patterns explain the difficulty awakening. Here’s a pathophysiological flowchart that outlines the reasoning, covering incorrect options and confirming the correct answer.

Clinical Scenario:

14-year-old boy (Adolescence 🧠)with difficulty awakening in the morning 🧠

Began watching a late talk show, delaying sleep onset

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Puberty leads to a natural delay in the circadian rhythm

Tendency to stay up later and wake up later 🧠 ( Adolescence and Sleep-Wake Shift)

⬇️

Late-night activity (watching TV) reinforces the delay (Environmental Reinforcement)

Reduced motivation to sleep early

⬇️

Outcome

Difficulty waking up in the morning due to misaligned sleep schedule

Feels awake later at night but struggles with morning fatigue

⬇️

Management Recommendation

No pharmacological treatment needed; educate on good sleep hygiene

Gradually adjust bedtime and limit late-night stimulation

Correct Option: E

Explanation of Other Answers

Urine Toxicology Screening

• Unnecessary in the absence of signs of substance abuse.

• The behavior aligns with normal circadian changes, not substance use.

Use of an Over-the-Counter Sleeping Medication

• Not recommended for a developmental sleep phase shift.

• Medications would not address underlying circadian delay.

Modafinil Use in the Morning

• Used for narcolepsy or severe sleep disorders, not for circadian misalignment.

• Could mask underlying need for better sleep habits.

Zolpidem Use at Bedtime

• Not suitable for adolescents and could risk dependency.

• Sleep hygiene is a safer approach.

Flashcards

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Dr. Shoaib Ahmad