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Disturbed circadian core body temperature rhythm and sleep disturbance in school refusal children and adolescents
Disturbed Circadian Core Body Temperature Rhythm and Sleep Disturbance in School Refusal Children and Adolescents Akemi Tomoda, Teruhisa Miike, Kazuko Yonamine, Kei Adachi, and Seiji Shiraishi
We examined the circadian rhythm of core body temperature (CBT) in 22 school refusal patients, ages between 12 and 18 years, who did not have any physical or psychiatric disorders, but had indefinite complaints, and were suspected to have a circadian rhythm disturbance. To obtain normal data for analysis, CBT in 9 healthy age-matched school attendants who did not have any sleep, psychiatric, or medical disturbance were monitored. Circadian variation of CBT in school refusal patients did not present a clear rhythm, and appearance time of their lowest CBT was markedly delayed compared to healthy subjects. Amplitude of circadian CBT changes, fitted to a cosinor curve by the least square method, was significantly smaller in school refusals than in healthy subjects. These findings suggest that in school refusal patients who do not have physical and psychiatric disorders, clinical psychosomatic symptoms (e.g., fatigue and memory disturbance) and school refusal could be closely related to the desynchronization of their biorhythms, particularly the circadian rhythm of body temperature and sleep-wake rhythm. © 1997 Socie~ of Biological Psychiatr)' Key Words: School refusal, circadian rhythm, core body temperature, sleep-awake disorder, delayed sleep phase syndrome, non-24-hour sleep-wake syndrome BIOL PSYCHIATRY 1997;41:810-813
Introduction Psychosocial factors have been considered to be a main reason of school refusal in children and adolescents (Last and Strauss 1990; Gittelman-Klein et al 1971). We have examined many school refusal cases and found that
From the Department of Child Development. Kumamoto University School of Medicine, Kumamoto, Japan. Address reprint requests to Akemi Tomoda, MD, Dept. of Child Development, Kumamoto Univ. School of Medicine. 1-1-1, Honjo, Kumamoto 860. Japan. Received June 27. 1995; revised March 6. 1996.
© 1997 Society of Biological Psychiatry
definite causative psychosocial factors can be distinguished only in a small portion of these patients. The majority of them do not have specific psychosocial factors nor physical abnormalities or diseases. They usually have definite or indefinite complaints, such as general fatigue, headache (not migraine), gastrointestinal discomfort, and ruminative thinking (Ohta et al 1992; Tomoda et al 1994; Tamura et al 1987), and they cannot explain why they are unable to attend a school. In our clinical practices, we recognized that the majority of our patients have a circadian rhythm disorder even though they usually do not mention or recognize this problem at the first interview. 0006-3223/97/$17.00 PII S0006-3223(96)00179-5
School Refusal, CBT. and Sleep Disorder
BIOLPSYCHIATRY
811
1997;41:810-813
We hypothesized that there could be a certain relationship between biological rhythm disorders in these patients and their indefinite symptoms as well as their school refusal. This study examined sleep patterns and circadian rhythm of core body temperature (CBT) in school refusal children and adolescents.
Methods
Patients Among 55 children and adolescents with school refusal who were referred to our Department between 1992 and 1993, we selected 22 subjects (10 boys and 12 girls), ages between 12 and 18 years (mean: 15.7 years), who were absent from their schools at least for 2 months and the longest, 87 months (mean: 22.8 months), and who satisfied the following criteria: i) major complaint was headache, generalized fatigue, and/or memory disturbance; ii) they had certain depressive symptoms (including the abovementioned three symptoms) that interfered with normal school functioning, but did not have psychological disorders, and did not meet major depression criteria, as described in the DSM-III-R (this state was evaluated by a psychiatrist); iii) no organic pathology accounting for the symptoms was detected in appropriate investigations [including brain magnetic resonance imaging (MRI) in some patients], as well as in consideration of medical history, by a pediatrician; and iv) they were suspected to have sleep disturbance because of their sleep--wake pattern. The ages when school refusal started ranged from 11 to 16 years (mean: 13.5 years). Prophylactic drug(s) administration (e.g., tranquilizers) was stopped at least 1 month prior to the assessment for study inclusion. Excluded from the study were the school refusal children who had just recently started treatment of antidepressants or antianxiety drugs, or who were diagnosed as having neurological illness, migraine, mental retardation, or serious psychopathology. Mental retardation was defined as IQ < 100, and serious psychopathology was evaluated by referring to at least one psychiatrist if the patie~lt presented some indicative symptoms. All of the patients had no history of drug abuse. Before starting the study, the purpose and meaning of this study were fully explained to the patients and their family, and their agreement was obtained either verbally or in a written form of informed consent. To obtain data in normal age-matched persons, we recruited 9 healthy school children as volunteers. They were 6 boys and 3 girls, aged 10-21 years (mean age, 17.3 years), who had no mental retardation, physical problems, or psychiatric psychopathology.
Recording of Sleep-Wake Rhythm Each subject kept daily recordings (logs) of their time of sleeping and awaking for 4 weeks or longer. These logs were used to analyze their sleep pattern during a 24-hour period. According to the International Classification of Sleep Disorders (ICSD) revised by the Association of Sleep Disorders Center in North America in 1990 (Diagnostic Classification Committee 1990), our school refusal patients were diagnosed as either delayed sleep phase syndrome (DSPS), non-24-hour sleep--wake syndrome (non-24), irregular sleep, or long sleeper. DSPS is characterized by difficulty in falling asleep at night and an inability to be easily aroused in the morning, and this diagnosis corresponds to DSM-III-R: Sleep-Wake Schedule Disorder. Non-24 presents sleep-wake cycles longer than 24 hours, and this corresponds also to DSM-III-R: 307.45. Irregular sleep is characterized with no recognizable circadian patterns of sleep onset or waking time, and this does not correspond to a sleep disorder diagnosis in DSM-III-R. Long sleepers have sleep times longer than 9 hours, although they do not have any organic abnormalities, and this corresponds to DSM-III-R: 780.54.
Circadian Rhythm of Core Body Temperature Continuous monitoring of CBT for 3 days, at every 1 minute, was carded out by using a deep body temperature monitor (Terumo Corp., Tokyo, Japan). Mean values of the three measurements at each time point during the 3 consecutive days were used in the examination. A chronograph was used to determine the circadian rhythm, and the single cosinor method, to analyze the CBT circadian variation for both groups (Halberg 1977). A cosine curve with a period of 24 hours was fitted to the data by using the least squares method, and the following parameters were obtained: mesor (°C, rhythm-adjusted average), amplitude (difference between the highest and lowest temperature), and acrophase (time of the highest point in the rhythm defined by a fitted cosine curve). In statistical analysis, analysis of variance (ANOVA) was used, and when the p value was less than .05, the group difference was considered to be statistically significant.
Results
Sleep Disturbance in School Refusal Patients Based on the self-recorded sleep-wake logs, all 22 school refusal patients were diagnosed as having one of the four sleep disturbances, i.e., 5 were DSPS, 6 non-24, 6 irregular, and 5 long sleeper. Among patients in these four
812
BIOLPSYCHIATRY
A. Tomoda et al
1997;41:810-813
Table 1. Circadian Rhythm of Core Body Temperature: Results of a Cosinor Analysis
Mesor (°C) Double amplitude (°C) Acrophase (clock time) In advanced patients (n = 6) In delayed patients (n = 16)
Patients (n = 22)
Controls (n = 9)
p value
36.71 ___0.17 0.85 --- 0.36
36.61 _+ 0.18 1.51 +- 0.37
p > .1 p < .005
15.10 ___ 1.02
17.44 _+ 1.34
p < .005
20.02 ~ 1.18
17.44 _+ 1.34
p < .005
p value: significant difference in ANOVA.
disease categories, there were no significant differences in the duration of school refusal, ages when school refusal first started, and their current age.
CBT Circadian Rhythms Results are summarized in Table 1. In school refusal patients, the amplitude of circadian CBT rhythm was significantly lower (0.85 -2-_ 0.36°C) than the normal subjects (1.51 + 0.37°C) (p < .005). Acrophase in the control subjects was recorded on 5:44 +_ 1:34 PM, whereas it was advanced in 6 patients to 3:10 _+ 1:02 PM (p <5 . 0 0 5 ) , and delayed in 16 patients to 8:02 _ 1:18 eM (p < .005). Advance or delay was determined in comparison to the time defined in the control subjects. In 4 school refusal subjects (3 non-24 and 1 long sleeper), there were no rhythmical changes in their CBT.
Discussion Among school refusal children or adolescents, some have clear physical, psychiatric, or social reasons, which caused their school refusal syndrome, but the majority of patients do not have definite causes that explain why they cannot attend a school. In this study, we selected school refusal children or adolescents who were evaluated as not having physical abnormalities, psychiatric disorders, or specific social problems, but they were suspected to have sleep disturbance because of their daily life pattern. They were healthy in terms of physical and psychiatric examinations, but unable to attend school because their overall conditions did not allow. Those patients who satisfied our inclusion criteria to this study accounted for 40% of the total school refusal cases whom we examined in a 2-year period. This portion is quite large, and indicates the difficulty to prescribe appropriate therapy for these patients.
In human biological rhythm, two types of circadian rhythms are noted (Aschoff and Heise 1972; Aschoff and Wever 1981). One is the sleep--wake rhythm, and the other is the circadian rhythm of core body temperature. Sleep disturbance was for the first time described in adults. Even though this disorder is considered to begin in childhood, there have been no in-depth reports on this problem in children (Thorpy et al 1988). Regarding the body temperature rhythm in children, there is only the study of Tamura et al (1987), who reported that dissociation in temperatures on the forehead and the sole was useful to understand blood circulation condition in school refusal children. In our study, all 22 school refusal subjects were diagnosed as having sleep-wake rhythm disturbance based on their sleep log evaluation and CBT monitoring. As shown in Table 1, their body temperature rhythm was disturbed in the manner typically shown in adult sleep disorder patients. Among our 6 school refusal patients diagnosed as having non-24, 3 did not show clear rhythm of CBT. Because non-24 is considered most difficult to treat among the four categories of sleep disorder, this therapeutic difficulty could be attributable to the severely disturbed CBT rhythm. Even though school refusal is usually considered as a psychogenic response to various factors (Last and Strauss 1990; Gittelman-Klein et al 1971), our findings suggest that a large portion of school refusal could be caused by a circadian rhythm disorder. The two biological rhythms (sleep and CBT) are sometimes desynchronized with each other, e.g., when a person is completely isolated from time cues. Once the desynchronization occurs, psychosomatic symptoms, such as headache, gastrointestinal discomfort, general fatigue, or ruminative thinking develop. These symptoms could make the affected person unable to perform ordinary daily activities. In case of sleep disturbance patients, their need to sleep longer or at socially unacceptable times may prevent the adjustment of body temperature rhythm, and could result in conditions mimic to depression, and, in some cases, school refusal. We previously examined cerebral blood flow in school refusal children by using single-photon emission computed tomography (SPECT), and demonstrated that blood flow, expressed as corticocerebellar ratio (CCR), in the frontal, temporal, and occipital lobes was markedly lower in those subjects (Tomoda et al 1995). Results of our previous study indicated the usefulness of interventions that could normalize this cerebral blood flow, in treatment of school refusal patients whose major complaints were indefinite symptoms, such as general fatigue and headache. On the other hand, the present study indicated a large portion of school refusal patients have a biological rhythm disorder. Therefore, treatment for sleep disturbance could be another possible effective therapy for school refusal
School Refusal, CBT, and Sleep Disorder
BIOLPSYCHIATRY
813
1997;41:810-813
children or adolescents who do not have clear physical, psychiatric, or social problems, but have sleep disturbance. These biological rhythm disturbances could be related to changes in cerebral blood flow or metabolism.
We wish to thank Dr. Keiko Uezono and Prof. Terukazu Kawasaki, Institute of Health Science, Kyushu University,for the cosinor analysis, and Dr. Motonori Deshimaru, Department of Psychiatry, Kikuchi Hospital, for the cooperation in this project and evaluatingthe patients.
References Aschoff J, Heise A (1972): Thermal conductance in man: Its dependence on time of day and ambient temperature. In Itoh S (ed), Advances in Climatic Physiology. New York: Springer-Verlag, pp 334-348. Aschoff J, Wever RA (1981): Biological rhythms. In Aschoff J (ed), Handbook of Behavioral Neurobiology. New York: Plenum Press, pp 311-331. Diagnostic Classification Committee ( 1990): International Classification of Sleep Disorders: Diagnostic and Coding Manual. Rochester, MN: American Sleep Disorders Association. Gittelman-Klein R, Klein D, Oaks G (1971): Controlled imipramine treatment of school phobia. Arch Gen Psychiatry 25:204-207. Halberg F (1977): Implications of biologic rhythms for clinical practice. Hosp Pract (Off Ed) 112:139-150. Last CG, Strauss CC (1990): School refusal in anxiety-disordered children and adolescents. Adolesc Psychiat O, 29:31-35.
Ohta T, Iwata T, Kayukawa Y, Okada T (1992): Daily activity and persistent sleep-wake schedule disorders. Prog Neuropsychopharmacol Biol Psychiatry 16:529-537. Tamura M, Murata M, Kusakawa S (1987): Monitoring the deep body temperature at night time in school refusal cases (in Japanese). In Kusakawa S (ed), The 1986 Annual Report of the Research Committee on the Biorhythms in School Refusal. Tokyo: The Ministry of Education, pp 21-26. Thorpy MJ, Korman E, Spielman AJ, Glovinsky PB (1988): Delayed sleep phase syndrome in adolescents. J Adolesc Health 9:22-27. Tomoda A, Miike T, Uezono K, Kawasaki T (1994): A school refusal case with biological rhythm disturbance and melatonin therapy. Brain Dev 16:71-76. Tomoda A, Miike T, Honda T, et al (1995): Single-photon emission computed tomography for cerebral blood flow in school phobias. Curr Ther Res 56:1088-1093.
We examined the circadian rhythm of core body temperature (CBT) in 22 school refusal patients, ages between 12 and 18 years, who did not have any physical or psychiatric disorders, but had indefinite complaints, and were suspected to have a circadian rhythm disturbance. To obtain normal data for analysis, CBT in 9 healthy age-matched school attendants who did not have any sleep, psychiatric, or medical disturbance were monitored. Circadian variation of CBT in school refusal patients did not present a clear rhythm, and appearance time of their lowest CBT was markedly delayed compared to healthy subjects. Amplitude of circadian CBT changes, fitted to a cosinor curve by the least square method, was significantly smaller in school refusals than in healthy subjects. These findings suggest that in school refusal patients who do not have physical and psychiatric disorders, clinical psychosomatic symptoms (e.g., fatigue and memory disturbance) and school refusal could be closely related to the desynchronization of their biorhythms, particularly the circadian rhythm of body temperature and sleep-wake rhythm. © 1997 Socie~ of Biological Psychiatr)' Key Words: School refusal, circadian rhythm, core body temperature, sleep-awake disorder, delayed sleep phase syndrome, non-24-hour sleep-wake syndrome BIOL PSYCHIATRY 1997;41:810-813
Introduction Psychosocial factors have been considered to be a main reason of school refusal in children and adolescents (Last and Strauss 1990; Gittelman-Klein et al 1971). We have examined many school refusal cases and found that
From the Department of Child Development. Kumamoto University School of Medicine, Kumamoto, Japan. Address reprint requests to Akemi Tomoda, MD, Dept. of Child Development, Kumamoto Univ. School of Medicine. 1-1-1, Honjo, Kumamoto 860. Japan. Received June 27. 1995; revised March 6. 1996.
© 1997 Society of Biological Psychiatry
definite causative psychosocial factors can be distinguished only in a small portion of these patients. The majority of them do not have specific psychosocial factors nor physical abnormalities or diseases. They usually have definite or indefinite complaints, such as general fatigue, headache (not migraine), gastrointestinal discomfort, and ruminative thinking (Ohta et al 1992; Tomoda et al 1994; Tamura et al 1987), and they cannot explain why they are unable to attend a school. In our clinical practices, we recognized that the majority of our patients have a circadian rhythm disorder even though they usually do not mention or recognize this problem at the first interview. 0006-3223/97/$17.00 PII S0006-3223(96)00179-5
School Refusal, CBT. and Sleep Disorder
BIOLPSYCHIATRY
811
1997;41:810-813
We hypothesized that there could be a certain relationship between biological rhythm disorders in these patients and their indefinite symptoms as well as their school refusal. This study examined sleep patterns and circadian rhythm of core body temperature (CBT) in school refusal children and adolescents.
Methods
Patients Among 55 children and adolescents with school refusal who were referred to our Department between 1992 and 1993, we selected 22 subjects (10 boys and 12 girls), ages between 12 and 18 years (mean: 15.7 years), who were absent from their schools at least for 2 months and the longest, 87 months (mean: 22.8 months), and who satisfied the following criteria: i) major complaint was headache, generalized fatigue, and/or memory disturbance; ii) they had certain depressive symptoms (including the abovementioned three symptoms) that interfered with normal school functioning, but did not have psychological disorders, and did not meet major depression criteria, as described in the DSM-III-R (this state was evaluated by a psychiatrist); iii) no organic pathology accounting for the symptoms was detected in appropriate investigations [including brain magnetic resonance imaging (MRI) in some patients], as well as in consideration of medical history, by a pediatrician; and iv) they were suspected to have sleep disturbance because of their sleep--wake pattern. The ages when school refusal started ranged from 11 to 16 years (mean: 13.5 years). Prophylactic drug(s) administration (e.g., tranquilizers) was stopped at least 1 month prior to the assessment for study inclusion. Excluded from the study were the school refusal children who had just recently started treatment of antidepressants or antianxiety drugs, or who were diagnosed as having neurological illness, migraine, mental retardation, or serious psychopathology. Mental retardation was defined as IQ < 100, and serious psychopathology was evaluated by referring to at least one psychiatrist if the patie~lt presented some indicative symptoms. All of the patients had no history of drug abuse. Before starting the study, the purpose and meaning of this study were fully explained to the patients and their family, and their agreement was obtained either verbally or in a written form of informed consent. To obtain data in normal age-matched persons, we recruited 9 healthy school children as volunteers. They were 6 boys and 3 girls, aged 10-21 years (mean age, 17.3 years), who had no mental retardation, physical problems, or psychiatric psychopathology.
Recording of Sleep-Wake Rhythm Each subject kept daily recordings (logs) of their time of sleeping and awaking for 4 weeks or longer. These logs were used to analyze their sleep pattern during a 24-hour period. According to the International Classification of Sleep Disorders (ICSD) revised by the Association of Sleep Disorders Center in North America in 1990 (Diagnostic Classification Committee 1990), our school refusal patients were diagnosed as either delayed sleep phase syndrome (DSPS), non-24-hour sleep--wake syndrome (non-24), irregular sleep, or long sleeper. DSPS is characterized by difficulty in falling asleep at night and an inability to be easily aroused in the morning, and this diagnosis corresponds to DSM-III-R: Sleep-Wake Schedule Disorder. Non-24 presents sleep-wake cycles longer than 24 hours, and this corresponds also to DSM-III-R: 307.45. Irregular sleep is characterized with no recognizable circadian patterns of sleep onset or waking time, and this does not correspond to a sleep disorder diagnosis in DSM-III-R. Long sleepers have sleep times longer than 9 hours, although they do not have any organic abnormalities, and this corresponds to DSM-III-R: 780.54.
Circadian Rhythm of Core Body Temperature Continuous monitoring of CBT for 3 days, at every 1 minute, was carded out by using a deep body temperature monitor (Terumo Corp., Tokyo, Japan). Mean values of the three measurements at each time point during the 3 consecutive days were used in the examination. A chronograph was used to determine the circadian rhythm, and the single cosinor method, to analyze the CBT circadian variation for both groups (Halberg 1977). A cosine curve with a period of 24 hours was fitted to the data by using the least squares method, and the following parameters were obtained: mesor (°C, rhythm-adjusted average), amplitude (difference between the highest and lowest temperature), and acrophase (time of the highest point in the rhythm defined by a fitted cosine curve). In statistical analysis, analysis of variance (ANOVA) was used, and when the p value was less than .05, the group difference was considered to be statistically significant.
Results
Sleep Disturbance in School Refusal Patients Based on the self-recorded sleep-wake logs, all 22 school refusal patients were diagnosed as having one of the four sleep disturbances, i.e., 5 were DSPS, 6 non-24, 6 irregular, and 5 long sleeper. Among patients in these four
812
BIOLPSYCHIATRY
A. Tomoda et al
1997;41:810-813
Table 1. Circadian Rhythm of Core Body Temperature: Results of a Cosinor Analysis
Mesor (°C) Double amplitude (°C) Acrophase (clock time) In advanced patients (n = 6) In delayed patients (n = 16)
Patients (n = 22)
Controls (n = 9)
p value
36.71 ___0.17 0.85 --- 0.36
36.61 _+ 0.18 1.51 +- 0.37
p > .1 p < .005
15.10 ___ 1.02
17.44 _+ 1.34
p < .005
20.02 ~ 1.18
17.44 _+ 1.34
p < .005
p value: significant difference in ANOVA.
disease categories, there were no significant differences in the duration of school refusal, ages when school refusal first started, and their current age.
CBT Circadian Rhythms Results are summarized in Table 1. In school refusal patients, the amplitude of circadian CBT rhythm was significantly lower (0.85 -2-_ 0.36°C) than the normal subjects (1.51 + 0.37°C) (p < .005). Acrophase in the control subjects was recorded on 5:44 +_ 1:34 PM, whereas it was advanced in 6 patients to 3:10 _+ 1:02 PM (p <5 . 0 0 5 ) , and delayed in 16 patients to 8:02 _ 1:18 eM (p < .005). Advance or delay was determined in comparison to the time defined in the control subjects. In 4 school refusal subjects (3 non-24 and 1 long sleeper), there were no rhythmical changes in their CBT.
Discussion Among school refusal children or adolescents, some have clear physical, psychiatric, or social reasons, which caused their school refusal syndrome, but the majority of patients do not have definite causes that explain why they cannot attend a school. In this study, we selected school refusal children or adolescents who were evaluated as not having physical abnormalities, psychiatric disorders, or specific social problems, but they were suspected to have sleep disturbance because of their daily life pattern. They were healthy in terms of physical and psychiatric examinations, but unable to attend school because their overall conditions did not allow. Those patients who satisfied our inclusion criteria to this study accounted for 40% of the total school refusal cases whom we examined in a 2-year period. This portion is quite large, and indicates the difficulty to prescribe appropriate therapy for these patients.
In human biological rhythm, two types of circadian rhythms are noted (Aschoff and Heise 1972; Aschoff and Wever 1981). One is the sleep--wake rhythm, and the other is the circadian rhythm of core body temperature. Sleep disturbance was for the first time described in adults. Even though this disorder is considered to begin in childhood, there have been no in-depth reports on this problem in children (Thorpy et al 1988). Regarding the body temperature rhythm in children, there is only the study of Tamura et al (1987), who reported that dissociation in temperatures on the forehead and the sole was useful to understand blood circulation condition in school refusal children. In our study, all 22 school refusal subjects were diagnosed as having sleep-wake rhythm disturbance based on their sleep log evaluation and CBT monitoring. As shown in Table 1, their body temperature rhythm was disturbed in the manner typically shown in adult sleep disorder patients. Among our 6 school refusal patients diagnosed as having non-24, 3 did not show clear rhythm of CBT. Because non-24 is considered most difficult to treat among the four categories of sleep disorder, this therapeutic difficulty could be attributable to the severely disturbed CBT rhythm. Even though school refusal is usually considered as a psychogenic response to various factors (Last and Strauss 1990; Gittelman-Klein et al 1971), our findings suggest that a large portion of school refusal could be caused by a circadian rhythm disorder. The two biological rhythms (sleep and CBT) are sometimes desynchronized with each other, e.g., when a person is completely isolated from time cues. Once the desynchronization occurs, psychosomatic symptoms, such as headache, gastrointestinal discomfort, general fatigue, or ruminative thinking develop. These symptoms could make the affected person unable to perform ordinary daily activities. In case of sleep disturbance patients, their need to sleep longer or at socially unacceptable times may prevent the adjustment of body temperature rhythm, and could result in conditions mimic to depression, and, in some cases, school refusal. We previously examined cerebral blood flow in school refusal children by using single-photon emission computed tomography (SPECT), and demonstrated that blood flow, expressed as corticocerebellar ratio (CCR), in the frontal, temporal, and occipital lobes was markedly lower in those subjects (Tomoda et al 1995). Results of our previous study indicated the usefulness of interventions that could normalize this cerebral blood flow, in treatment of school refusal patients whose major complaints were indefinite symptoms, such as general fatigue and headache. On the other hand, the present study indicated a large portion of school refusal patients have a biological rhythm disorder. Therefore, treatment for sleep disturbance could be another possible effective therapy for school refusal
School Refusal, CBT, and Sleep Disorder
BIOLPSYCHIATRY
813
1997;41:810-813
children or adolescents who do not have clear physical, psychiatric, or social problems, but have sleep disturbance. These biological rhythm disturbances could be related to changes in cerebral blood flow or metabolism.
We wish to thank Dr. Keiko Uezono and Prof. Terukazu Kawasaki, Institute of Health Science, Kyushu University,for the cosinor analysis, and Dr. Motonori Deshimaru, Department of Psychiatry, Kikuchi Hospital, for the cooperation in this project and evaluatingthe patients.
References Aschoff J, Heise A (1972): Thermal conductance in man: Its dependence on time of day and ambient temperature. In Itoh S (ed), Advances in Climatic Physiology. New York: Springer-Verlag, pp 334-348. Aschoff J, Wever RA (1981): Biological rhythms. In Aschoff J (ed), Handbook of Behavioral Neurobiology. New York: Plenum Press, pp 311-331. Diagnostic Classification Committee ( 1990): International Classification of Sleep Disorders: Diagnostic and Coding Manual. Rochester, MN: American Sleep Disorders Association. Gittelman-Klein R, Klein D, Oaks G (1971): Controlled imipramine treatment of school phobia. Arch Gen Psychiatry 25:204-207. Halberg F (1977): Implications of biologic rhythms for clinical practice. Hosp Pract (Off Ed) 112:139-150. Last CG, Strauss CC (1990): School refusal in anxiety-disordered children and adolescents. Adolesc Psychiat O, 29:31-35.
Ohta T, Iwata T, Kayukawa Y, Okada T (1992): Daily activity and persistent sleep-wake schedule disorders. Prog Neuropsychopharmacol Biol Psychiatry 16:529-537. Tamura M, Murata M, Kusakawa S (1987): Monitoring the deep body temperature at night time in school refusal cases (in Japanese). In Kusakawa S (ed), The 1986 Annual Report of the Research Committee on the Biorhythms in School Refusal. Tokyo: The Ministry of Education, pp 21-26. Thorpy MJ, Korman E, Spielman AJ, Glovinsky PB (1988): Delayed sleep phase syndrome in adolescents. J Adolesc Health 9:22-27. Tomoda A, Miike T, Uezono K, Kawasaki T (1994): A school refusal case with biological rhythm disturbance and melatonin therapy. Brain Dev 16:71-76. Tomoda A, Miike T, Honda T, et al (1995): Single-photon emission computed tomography for cerebral blood flow in school phobias. Curr Ther Res 56:1088-1093.