Bedtime reboot 

By Jeff Garafano, PhD, Johns Hopkins Medicine 

A 15-year-old boy, Mason, was referred for evaluation due to increasing irritability and low mood. He also reported difficulty falling asleep (30+ minutes in bed before sleep onset) and not feeling rested in the morning. Mason spent several hours every night playing video games in his bedroom, often late into the evening and had to wake up at six in the morning for school.  

Recognizing a possible connection after consultation with his pediatrician, the family implemented a 10 p.m. cutoff for video games and a 10:30 p.m. bedtime on school nights. Mason complied, but sleep worsened, and irritability and low mood persisted. It started taking Mason 60+ minutes to fall asleep, resulting in only six to seven hours of sleep on school nights. On weekends, he continued to play games late into the night and would wake around 10 a.m. Despite wanting to fall asleep, his mind remained active, and his efforts to force sleep prolonged sleep onset. With sleep and mood concerns persisting, his parents became worried about emerging depression, recognizing that adolescence is a peak period for the onset of mood disorders. 

When they met with a psychologist for consultation, standardized screening measures indicated mild depressive symptoms, but moderate sleep disturbance and severe sleep-related impairment, including near-daily difficulty falling asleep. After following up on the screening tools through clinical interview, the psychologist suggested that playing video games in bed may have resulted in Mason’s mind and body associating his bed with wakefulness and stimulation rather than sleep, contributing to delayed sleep onset, reduced sleep duration, and downstream effects on mood. Similar patterns are seen across medical settings, where sleep disturbance can shape symptoms such as pain, attention, fatigue, and treatment adherence.  

Start with targeted sleep screening 

Brief standardized measures such as PROMIS Sleep Disturbance and Sleep-Related Impairment can efficiently assess nighttime sleep quality and daytime impact. If concerns are identified, a targeted clinical interview can further clarify sleep patterns and modifiable contributors (e.g., behavioral, circadian, or sleep-disordered breathing). The BEARS (Bedtime Issues, Excessive Daytime Sleepiness, Awakenings, Regularity and Duration, Snoring) framework provides a practical clinical interview model for characterizing these domains. In this way, PROMIS helps identify and quantify sleep disturbance and related impairment, while BEARS helps define the underlying contributors that guide intervention. 

When sleep disturbance is clinically meaningful, clinicians should provide education on the relationship between sleep and the patient’s presenting concerns, emphasizing that sleep is a modifiable factor that may explain or influence symptoms. Initial management should focus on behavioral strategies. When concerns persist or require additional support, consider referral for behavioral sleep intervention, CBT-I, or, when indicated (e.g., concern for sleep-disordered breathing), a formal sleep study. 

Counseling families: behavior and environment matter 

Mason’s behavioral sleep intervention focused on stimulus control and a consistent sleep schedule to improve sleep initiation and duration. The bed was reserved for sleep only, and gaming was moved out of the bedroom. If unable to fall asleep after about 20 minutes, Mason got out of bed, engaged in a relaxing activity, and returned only when sleepy. A consistent schedule was established across weekdays and weekends. 

Environmental cues were added to support circadian rhythm, including a warm shower to start his bedtime routine, a dark and slightly cooler room, and 30-60 minutes of calming/relaxing activities before bed. 

Over several weeks, sleep initiation and duration improved, along with mood. What initially appeared to be a mood problem was, in part, driven by learned associations between his bed and wakefulness, which improved with targeted behavioral and environmental changes. 

Practical tips for clinicians: 

1. Consider sleep as a factor in presenting concerns.

2. Use standardized sleep screening tools.

3. Through clinical interview, ask about sleep behaviors and routines.

4. Assess bed-behavior associations.

5. Compare weekday-weekend sleep patterns.

6. Start with behavioral and environmental strategies to support sleep.

7. Refer for behavioral sleep treatment or CBT-I, or when indicated, additional sleep evaluation (e.g., polysomnography, actigraphy).

Across medical specialties, sleep should be considered a modifiable factor that may underlie or shape clinical presentations and influence response to treatments.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.