Non-24-Hour Sleep-Wake Disorder in Children and Adolescents: A Case Series

PURPOSE: To describe clinical characteristics, comorbidities, diagnostic approaches, and treatment outcomes in six pediatric cases of non‑24‑hour sleep‑wake disorder (N24SWD). METHODS: We conducted a single‑center retrospective case series of children and adolescents diagnosed with N24SWD clinically evaluated by histories, sleep diaries, actigraphy, and available treatment outcomes. RESULTS: Six sighted children with N24SWD were identified; five had autism spectrum disorder, three had attention-deficit/hyperactivity disorder, and two had anxiety disorders. All demonstrated free‑running sleep cycles (24-29 hours) with progressive delays in sleep and periodic daynight reversal. Behavioral and functional impairments were exacerbated during circadian misalignment. Entrainment strategies utilizing melatonin, bright light therapy, and behavioral interventions showed variable success; long‑term entrainment was rarely achievable due to adverse effects, inconsistent adherence, and family burden. Several families opted to maintain flexible, free‑running schedules, reporting improved mood and function when natural sleep patterns were accommodated. CONCLUSION: Pediatric N24SWD in sighted individuals is frequently associated with neurodevelopmental comorbidities. In all of our reported cases, children with N24SWD were sighted and had neurodevelopmental disorders. Standard circadian‑based treatments may be difficult to sustain. Management should be individualized, family‑centered, and supported by improved diagnostic tools and research into long‑term therapeutic strategies.