Sleep and its restorative actions are crucial for proper cognitive, emotional, and physical performance. Adolescents commonly report insufficient sleep duration and poor sleep quality.1–3 The National Sleep Foundation found that only 35% of 6th to 8th graders get an optimal (≥9 hours per night) amount of sleep. This dropped to 9% in 9th to 12th graders. The most common direct consequence of insufficient and/or poor sleep quality is excessive daytime sleepiness.4,5 More than one-half of adolescents report they feel sleepy during the day at least once a week.1 Daytime sleepiness may lead to decreased alertness and cognitive functioning, which can affect judgment, attention, decision-making, and affective regulation.5,6 The consequences of inadequate sleep duration and quality are numerous and include poor academic performance, mental health symptoms, substance use, and drowsy driving.
Causes of Adolescent Sleepiness
The onset of puberty is associated with changes in the processes regulating sleep timing and homeostasis. Hormonal factors lead to the development of a physiologic phase delay, which translates to later sleep-onset and wake times.7 This phase delay is approximately 2 to 3 hours and is progressive throughout adolescence, with later sleep times at more mature Tanner stages.8 Exposure to evening light during adolescence has a more profound effect on suppression of melatonin release in the pineal gland than found in younger children.7 The homeostatic sleep system, which regulates sleep-wake pressure, also goes through a maturation process during adolescence. Specifically, the accumulation of sleep propensity or pressure occurs at a slower rate among adolescents, resulting in a greater ability to delay sleep-onset when compared with younger children.7
Delayed sleep-wake phase disorder (DSWPD) is a common sleep disorder, occurring in up to 5% to 15% of teens.9 DSWPD is characterized by a persistent delay in the circadian sleep-wake cycle of at least 2 hours after the desired bedtime, which may present as daytime sleepiness, insomnia, and academic or behavior problems. Successful management requires a highly motivated patient, as maintaining a consistent bed and wake time throughout the entire week is crucial. Treatment involves gradually advancing the sleep-wake cycle, increasing natural light exposure in the morning, and limiting napping. In addition, melatonin has been used to treat DSWPD; however, currently there are no consensus guidelines regarding the most appropriate timing and dosage.10
Insomnia may be the primary reason for insufficient sleep or it can present as a comorbid condition. Insomnia results from a combination of predisposing factors (genetics, medical, or psychiatric disorders), precipitating factors (stress, illness, trauma), and perpetuating factors (poor sleep practices, maladaptive cognition and worries regarding sleep). Up to 10% of adolescents meet the criteria for an insomnia disorder, presenting with difficulty falling asleep, frequent night-time and early morning awakenings, and daytime dysfunction.11 Risk factors include female gender and lower socioeconomic status.9 Management includes evaluation of contributing factors, identification of medical or psychiatric comorbidities, and maintenance of healthy sleep practices (Table 1). Referral to a sleep or behavioral specialist for cognitive-behavioral therapy for insomnia may also be warranted.
Healthy Sleep Practices for Adolescents
Obstructive sleep apnea (OSA) is present in about 1% to 5% of adolescents.12 OSA involves repeated episodes of upper airway obstruction often presenting with snoring, witnessed apneas, and hypersomnolence. Although adenotonsillar hypertrophy remains the most common cause of pediatric OSA, obesity has emerged as a significant risk factor among adolescents.9 Overnight polysomnography is required for a definitive diagnosis. Treatment options vary based on apnea-hypopnea index, duration and severity of symptoms, and presence of comorbidities, and include both surgical and nonsurgical options such as pharmacotherapy, weight loss, and continuous positive airway pressure.
Restless legs syndrome (RLS) is a disorder characterized by an irresistible urge to move the legs, accompanied by uncomfortable sensations in the lower extremities. Symptoms are alleviated by movement and worsened by inactivity or prolonged rest. Although RLS only has a prevalence of approximately 2% in adolescents, it is likely underdiagnosed as 38% of adults report symptoms prior to age 20 years.13 Aggravating factors for RLS include sleep deprivation, nicotine, alcohol, and medications (selective serotonin reuptake inhibitors, metoclopramide, diphenhydramine, dopamine antagonists). Iron deficiency and low iron stores are involved in the pathophysiology of RLS, and research has shown that symptoms may improve with iron therapy.13 Treatment outcomes with dopaminergic agents have also been promising, although research supporting their use in adolescents is lacking.14
Attention-deficit/hyperactivity disorder (ADHD) is a neurobehavioral disorder affecting approximately 7% of adolescents.15 There is significant overlap between the symptoms of insufficient sleep and the behavioral symptoms associated with ADHD. ADHD may also coexist as a separate disorder with primary sleep disorders such as RLS and OSA.9 Standard treatment for ADHD includes stimulant medications, which may further exacerbate insufficient sleep by increasing sleep-onset latency and decreasing total sleep duration.16
The bidirectional relationship between mental health disorders and sleep is well established. Most adolescents with major depressive disorder have sleep disturbances such as insomnia.17 Adolescents with higher depressive mood scores (indicating feeling down/low) more commonly reported insufficient sleep, poor sleep quality, inconsistent sleep/wake schedules, and feeling too tired or sleepy during the day.1 Adolescents with generalized anxiety, fear and phobias, and severe stress reactions also commonly report sleep difficulties. Effective treatment of anxiety and social phobia has been shown to reduce sleep-related complaints.18 In fact, patients who underwent cognitive-behavioral therapy with or without medication for anxiety reported significantly less sleep-related problems.18
Rigorous academic loads, employment, and extracurricular activities such as athletics, music/arts, gaming, and socializing with peers serve as competing interests to adolescents achieving adequate sleep. In fact, evening activities were the most commonly listed challenge to getting a good night sleep.
Adolescents have fewer parental enforced sleep-related rules (bedtime, caffeine use, electronics in the bedroom) and therefore more bedtime autonomy than younger children.1 More than 90% of parents reported that sleep is either “very important” or “extremely important” for their child's mood, health, performance, and behavior, yet survey results indicate that parental modeling of healthy sleep practices was less than ideal.1 Specifically, 68% of parents and 51% of adolescents have two or more electronic devices, including mobile phones, in their bedroom at night.1 This has consistently been associated with inadequate sleep duration. Older adolescents are more likely to wake during the night and read or send electronic communication in households with less-strict parents.1
Similarly, adolescents who engage in excessive use of interactive electronic devices are at higher risk for inadequate sleep. A recent study indicated that higher video-game usage resulted in less total sleep with data suggesting that gaming time simply delayed bedtime, with no significant effect on sleep-onset latency.19 Another study showed that 150 minutes of gaming a day as compared to 50 minutes led to a decrease in objective sleep efficiency, subjective sleep quality, total sleep time, and rapid eye movement sleep.20
Family dynamics and socioeconomic status can also influence the sleep environment. Family disorganization and chaotic sleep/wake schedules are associated with poor sleep hygiene, decreased sleep duration, increased sleep-onset latency, and daytime sleepiness.21 Low socioeconomic status and neighborhood variables, such as overcrowding and safety, are inversely associated with consistent sleep schedules.22
Beverages containing caffeine such as coffee, tea, soda, and energy drinks serve as central nervous system stimulants that decrease sleepiness and increase alertness.9 Consumption of caffeine-containing products leads to shortened sleep duration, increased sleep-onset latency, increased wake fragmentation, and earlier rise times, ultimately leading to excessive daytime sleepiness. Later bedtimes and irregular weekday/weekend sleep schedules have also been associated with caffeine use.9,23
Biological changes during adolescence result in a preference for later wakes times; therefore, early school start times contribute to inadequate sleep.7 The American Academy of Pediatrics has put forth a policy statement supporting later school start times.22 In response, several school districts have delayed middle school and high school start times, improving both attendance and school enrollment.9 Delaying high school start times has been shown to increase total sleep time on weeknights by 45 minutes. As a result, the percentage of students getting less than 7 hours of sleep decreased by 80%, whereas those reporting 8 hours of sleep increased 3-fold. Decreased daytime sleepiness, increased satisfaction with sleep, and decreased report of depressed mood was also linked with delayed school start times.24
Consequences of Adolescent Sleepiness
Insufficient sleep and the resultant daytime sleepiness affect school attendance and academic performance. Among adolescents in the United States, 28% of high school students fall asleep at school at least once a week, and 14% report missing school or being late due to oversleeping.1 Furthermore, 80% of students reporting optimal (≥9 hours per night) sleep achieved As or Bs, whereas those who obtain insufficient sleep reported lower grades.1 Adolescents with struggling or failing grades have a greater than 2-hour weekend bedtime delay, a shorter sleep duration, and later weekday bedtime than those who have a more consistent sleep/wake schedule.25 Poor sleep quality has also been found to negatively affect adolescents' school performance.25 A recent meta-analysis of studies including children age 8 to 18 years supported the theory that daytime sleepiness, sleep quality, and sleep duration are significant moderators of school performance.26
College students who report poor sleep quality are more likely to describe falling asleep in class and skipping class more than 2 times per month than those who report optimal sleep.3 Grade point averages (GPAs) among college students are significantly lower if they have decreased sleep on school nights, poor sleep quality, or inconsistent sleep/wake schedules.27 Students reporting symptoms suggestive of OSA, insomnia, or circadian rhythm disorders were overrepresented among students with GPAs less than 2.0.
The presence of sleep disorders increases rates of depressive symptoms, the risk of developing depression, and may be a predictor of relapse.28 Shorter total sleep duration and chronic sleep deprivation among adolescents' have been associated with depressive symptoms and daytime sleepiness.25,29 Moreover, an association between insomnia and clinically diagnosed depression has been observed.30 College students with poor sleep quality are more likely to have significantly higher levels of stress and self-reported negative moods than those with optimal sleep quality.3 Recent studies have focused on sleep and its possible effect on suicidal ideation. Short sleep duration (<8 hour per night) was found to be associated with an almost 3-fold increased risk of suicide attempts.31 Teens with parents that allow a midnight or later bedtime are more likely to suffer from depression and have suicidal ideation.22 The causal association between sleep disturbances and anxiety is less well documented; however, at least one study stated that adolescents who self-reported having insomnia also described symptoms of anxiety.32 Sleep complaints are directly related to the severity of anxiety and often exacerbate anxiety symptoms.17
A recent survey of US 9th to 12th graders revealed that sleeping less than 8 hours per night was associated with higher odds of current smoking, alcohol, and marijuana use.33 Excessive daytime sleepiness, later weekend bedtimes, and sleep disruption are also related to increased tobacco, alcohol, and marijuana use.34,35 Among college students, poor quality sleepers who use alcohol to induce sleep reported drinking significantly more alcohol per week compared to students who do not use alcohol to induce sleep.3 In addition, poor sleep quality was linked to increased over-the-counter (OTC) and prescription sleep aids as well as OTC stimulant use.3
One of the most troubling consequences of sleepiness in adolescents is drowsy driving, which can lead to reduced attention and impaired response time. In fact, 51% of adolescents who drive reported they have driven drowsy at least once in the past year, with 15% doing so at least once per week.1 More startling is that 5% of these teens reported nodding off or falling asleep while driving.1 In an important paper reviewing “fall asleep” crashes in which intoxication was not a factor, drivers younger than age 25 years were found to be responsible for more than one-half of the crashes.36 A study assessing the effects of delaying school start times found that teens with later start times obtained more sleep, and drivers had a lower crash rate than those with earlier start times.37 This highlights the fact that countermeasures aimed at decreasing insufficient sleep in adolescents may potentially improve general public safety.
Evaluation of Adolescent Sleepiness
An adolescent sleep history includes eliciting information about sleep patterns, sleep environment, psychosocial issues, as well as daytime functioning (Table 2). Sleep diaries can provide information regarding sleep schedule consistency, sleep onset latency, number of night awakenings, and the time, duration, and frequency of naps. More objective data of sleep/wake patterns can be obtained with actigraphy. Actigraphy data are collected with a watch-like device that continuously measures the wearer's movements and light exposure for up to 2 weeks. Overnight polysomnography, if clinically indicated, is the gold standard for the diagnosis of OSA and sleep movement disorders.
Clinical Evaluation of Adolescents with Sleep Complaints and Daytime Sleepiness
Insufficient and poor-quality sleep result from the interaction of biological, environmental, and lifestyle factors. The resultant daytime sleepiness and dysfunction pose a serious risk to the emotional and physical health, academic success, and safety of adolescents. A thorough clinical history and sleep diary is adequate to diagnose insufficient sleep in most cases. Treatment involves education on healthy sleep practices, maintaining a consistent sleep/wake schedule, and addressing any medical or psychiatric disorders. Several factors that contribute to insufficient sleep and poor sleep quality, such as electronics use, stimulant consumption, and early school start times are modifiable, highlighting the pediatrician's vital role in screening, education, and health promotion efforts.
- National Sleep Foundation. Sleep in the Modern Family. https://sleepfoundation.org/sleep-polls-data/sleep-in-america-poll/2014-sleep-and-family. Accessed August 16, 2017.
- Pallesen S, Saxvig IW, Molde H, et al. Brief report: behaviorally induced insufficient sleep syndrome in older adolescents: prevalence and correlates. J Adolesc. 2011;34(2):391–395. doi: . doi:10.1016/j.adolescence.2010.02.005 [CrossRef]
- Lund HG, Reider BD, Whiting AB, Prichard JR. Sleep patterns and predictors of disturbed sleep in a large population of college students. J Adolesc Health. 2010;46(2):124–132. doi: . doi:10.1016/j.jadohealth.2009.06.016 [CrossRef]
- Moore M, Meltzer LJ. The sleepy adolescent: causes and consequences of sleepiness in teens. Paediatr Respir Rev. 2008;9(2):114–120. doi: . doi:10.1016/j.prrv.2008.01.001 [CrossRef]
- Fallone G, Owens JA, Deane J. Sleepiness in children and adolescents: clinical implications. Sleep Med Rev. 2002;6(4):287–306. doi:10.1053/smrv.2001.0192 [CrossRef]
- Beebe DW. Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents. Pediatr Clin N Am. 2011;58(3):649–665. doi: . doi:10.1016/j.pcl.2011.03.002 [CrossRef]
- Carskadon MA. Sleep in adolescents: the perfect storm. Pediatr Clin North Am. 2011;58(3):637–647. doi: . doi:10.1016/j.pcl.2011.03.003 [CrossRef]
- Andrade MMM, Beneditosilva AA, Domenice S, Arnhold IJP, Mennabarreto L. Sleep characteristics of adolescents: a longitudinal study. J Adolesc Health. 1993;14(5):401–406. doi:10.1016/S1054-139X(08)80016-X [CrossRef]
- Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.
- Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. Sleep. 2007;30(11):1445–1459. doi:10.1093/sleep/30.11.1445 [CrossRef]
- Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006;117:e247–e256. doi: . doi:10.1542/peds.2004-2629 [CrossRef]
- Marcus CL, Lee JB, Ward SD, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:e714–755. doi: . doi:10.1542/peds.2012-1672 [CrossRef]
- Picchietti D, Allen RP, Walters AS, et al. Restless legs syndrome: prevalence and impact in children and adolescents--the Peds REST study. Pediatrics. 2007;120(2):253–266. doi: . doi:10.1542/peds.2006-2767 [CrossRef]
- Simakajornboon N, Dye TJ, Walters AS. Restless legs syndrome/willis-ekbom disease and growing pains in children and adolescents. Sleep Med Clin. 2015;10(3):311–322, xiv. doi: . doi:10.1016/j.jsmc.2015.05.014 [CrossRef]
- Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9:490–499. doi: . doi:10.1007/s13311-012-0135-8 [CrossRef]
- Kidwell KM, Van Dyk TR, Lundahl A, Nelson TD. Stimulant medications and sleep for youth with ADHD: a meta-analysis. Pediatrics. 2015;136(6):1144–1153. doi:. doi:10.1542/peds.2015-1708 [CrossRef]
- Meltzer LJ, Mindell JA. Sleep and sleep disorders in children and adolescents. Psychiatr Clin N Am. 2006;29(4):1059–1076. doi:. doi:10.1016/j.psc.2006.08.004 [CrossRef]
- Caporino NE, Read KL, Shiffrin N, et al. Sleep-related problems and the effects of anxiety treatment in children and adolescents. J Clin Child Adolesc Psychol. 2015;1–11.
- Wolfe J, Kar K, Perry A, Reynolds C, Gradisar M, Short MA. Single night video-game use leads to sleep loss and attention deficits in older adolescents. J Adolescence. 2014;37(7):1003–1009. doi: . doi:10.1016/j.adolescence.2014.07.013 [CrossRef]
- King DL, Gradisar M, Drummond A, et al. The impact of prolonged violent video-gaming on adolescent sleep: an experimental study. J Sleep Res. 2013;22(2):137–143. doi: . doi:10.1111/j.1365-2869.2012.01060.x [CrossRef]
- Billows M, Gradisar M, Dohnt H, Johnston A, McCappin S, Hudson J. Family disorganization, sleep hygiene, and adolescent sleep disturbance. J Clin Child Adolesc Psychol. 2009;38(5):745–752. doi: . doi:10.1080/15374410903103635 [CrossRef]
- Owens JAdolescent Sleep Working GroupCommittee on Adolescence. Insufficient sleep in adolescents and young adults: an update on causes and consequences. Pediatrics. 2014;134(3):e921–932. doi: . doi:10.1542/peds.2014-1696 [CrossRef]
- James JE, Kristjansson AL, Sigfusdottir ID. Adolescent substance use, sleep, and academic achievement: evidence of harm due to caffeine. J Adolesc. 2011;34(4):665–673. doi: . doi:10.1016/j.adolescence.2010.09.006 [CrossRef]
- Owens JA, Belon K, Moss P. Impact of delaying school start time on adolescent sleep, mood, and behavior. Arch Pediat Adolesc Med. 2010;164(7):608–614. doi: . doi:10.1001/archpediatrics.2010.96 [CrossRef]
- Wolfson AR, Carskadon MA. Understanding adolescents' sleep patterns and school performance: a critical appraisal. Sleep Med Rev. 2003;7(6):491–506. doi:10.1016/S1087-0792(03)90003-7 [CrossRef]
- Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bogels SM. The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: a meta-analytic review. Sleep Med Rev. 2010;14(3):179–189. doi: . doi:10.1016/j.smrv.2009.10.004 [CrossRef]
- Gaultney JF. The prevalence of sleep disorders in college students: impact on academic performance. J Am Coll Health. 2010;59(2):91–97. doi: . doi:10.1080/07448481.2010.483708 [CrossRef]
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- Regestein Q, Natarajan V, Pavlova M, et al. Sleep debt and depression in female college students. Psychiatr Res. 2010;176(1):34–39. doi: . doi:10.1016/j.psychres.2008.11.006 [CrossRef]
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Healthy Sleep Practices for Adolescents
Maintain consistent sleep/wake times, with school day and weekend/holiday schedule within 2 hours of each other
Sleep until it is time to wake, avoid hitting the “snooze” button
Create a consistent bedtime routine that involves calm, quiet activities
Ensure the bedroom is quiet, cool, and dark
Use the bed for sleep only, avoid doing activities such as homework or electronics in bed
Limit use of electronics to 60 minutes before bedtime (remove television from bedroom)
Try not to nap during the day (if it occurs, limit to 30 minutes)
Avoid caffeine in the late afternoon and evening
Avoid exercise in the evening
Clinical Evaluation of Adolescents with Sleep Complaints and Daytime Sleepiness
|Obtain a detailed sleep history
Assess daytime behaviors and functioning
Sleep/wake times during the week, weekend, holidays
Sleep environment (electronics, temperature, noise)
Sleep onset latency
Nocturnal events (night awakenings, sleepwalking, nightmares, snoring)
Difficulty waking in the morning
Attention and concentration
School and work performance
Mood and stressors
Caffeine or energy drink consumption
Substance use (alcohol, nicotine, illicit drugs)