Pediatric Annals

Healthy Baby/Healthy Child 

Adolescent Sleep: Challenges and Solutions for Pediatric Primary Care

Sabrina Fernandez, MD

Abstract

As pediatricians, we can all recall an adolescent patient who presents with fatigue. She is groggy in the morning before school, sometimes nods off in class, and then drinks a caffeinated beverage in the afternoon. She sends text messages to friends before going to bed shortly after midnight. After getting a bit of history from her, the parents complain that she has poor sleep habits while the teenage yawns and then rolls her eyes at being outed. For many adolescents, sleep restriction is a conscious choice that is made, as teens are juggling school responsibilities, extracurricular activities, and social interactions. This article is intended to help primary care pediatricians understand the causes of insufficient sleep in teenagers and gives tips on how to address common sleep issues. There is serious morbidity associated with poor sleep in adolescents, including mood disorders such as depression and anxiety, increased obesity risk, and higher rates of drowsy driving. It is my hope that a few tips from this article will help prevent some of these serious sequelae. [Pediatr Ann. 2019;48(8):e292–e295.]

Abstract

As pediatricians, we can all recall an adolescent patient who presents with fatigue. She is groggy in the morning before school, sometimes nods off in class, and then drinks a caffeinated beverage in the afternoon. She sends text messages to friends before going to bed shortly after midnight. After getting a bit of history from her, the parents complain that she has poor sleep habits while the teenage yawns and then rolls her eyes at being outed. For many adolescents, sleep restriction is a conscious choice that is made, as teens are juggling school responsibilities, extracurricular activities, and social interactions. This article is intended to help primary care pediatricians understand the causes of insufficient sleep in teenagers and gives tips on how to address common sleep issues. There is serious morbidity associated with poor sleep in adolescents, including mood disorders such as depression and anxiety, increased obesity risk, and higher rates of drowsy driving. It is my hope that a few tips from this article will help prevent some of these serious sequelae. [Pediatr Ann. 2019;48(8):e292–e295.]

Insufficient sleep in adolescents has been recognized as a serious public health issue with many studies reporting that as adolescents get older, their sleep duration declines. The American Academy of Sleep Medicine, the National Sleep Foundation, and the US Centers for Disease Control and Prevention have suggested that the optimal sleep duration for adolescents is 8 to 10 hours of overnight sleep.1 Some studies estimate that up to 30% of adolescents have sleep disorders, with insomnia being the most prevalent.1 Sleep health is a new topic in the Healthy People goals for 2020, and a specific goal is to “increase the proportion of students in grades 9 through 12 who get sufficient sleep” (defined as ≥8 hours per night).2 The National Sleep Foundation Sleep in America poll found that 16% of sixth graders get fewer than 8 hours of sleep per night, increasing to 75% of 12th graders.2 Furthermore, many studies rely on self-reported or parent-reported sleep duration, which may underestimate the true duration of adolescent sleep, meaning that this public health problem may be even worse than estimated. The pattern of decreased sleep with age has also been demonstrated in international studies of adolescents.2

Racial and Ethnic Disparities in Adolescent Sleep

Adolescents from families with a low income or those from racial or ethnic minorities may be at greater risk for poor sleep quality. In one study of middle school students with low socioeconomic status and in homes where there was overcrowding, high noise levels, and safety concerns, consistency of sleep and getting to bed at an appropriate time proved more difficult compared to students with higher socioeconomic status.2 In a recent review, the studies examined demonstrated that children and adolescents from racial/ethnic minority groups had shorter sleep duration and lesser quality of sleep regarding sleep/wake problems and sleep onset.3 There are also some studies that suggest racial and ethnic differences in sleep-related problems, such as obesity risk and asthma morbidity. Racial and ethnic disparities can sometimes be traced back to differences in socioeconomic status. However, adolescents from homes with higher socioeconomic status also report shorter sleep duration; therefore, having a higher socioeconomic status may not necessarily be protective.2 Furthermore, in a recent review of the literature on racial and ethnic disparities in childhood sleep, socioeconomic status and other covariates did not account for most of the racial/ethnic disparities found.3

Factors Contributing to Poor Sleep in Adolescents

Voluntary Sleep Restriction and Inconsistent Sleep Routines

As adolescents get older, they find that their responsibilities increase, as they try to achieve good grades at school, participate in after-school programs or jobs, and maintain social relationships. These responsibilities play important roles in the decision to forego a good night's sleep. Many families also do not have a set bedtime, leaving the decision to the teenager. Of course, every night will not be perfect, but striving for 8 to 10 hours of consistent, uninterrupted overnight sleep is important. When teenagers voluntarily choose to get fewer than 8 hours of sleep on weeknights, they are often tired during weekdays. Many attempt to make up for their accumulated sleep debt by oversleeping (“sleeping in”) on the weekends or by daytime napping, both of which may contribute to going to sleep later that night, perpetuating weekday daytime sleepiness.2

Caffeine

Caffeinated beverages can further exacerbate the cycles of insufficient sleep outlined above. Caffeine is associated with shorter sleep duration, difficulty falling asleep, waking up after initially falling asleep, and daytime sleepiness. This is true in both adults and adolescents. In one study, high school students who reported a moderate or high intake of caffeine had more difficulty sleeping and morning sleepiness compared to those who reported a low intake of caffeine.4 Adolescents may develop a cycle of increased daytime sleepiness leading to caffeine use, leading to poor sleep overnight, continuing the cycle the next day. Caffeine also alters sleep biology, causing less time spent in slow-wave sleep and rapid eye movement (REM) sleep, both of which play important roles in learning and memory consolidation.2 Therefore, it is no surprise that caffeine consumption and daytime sleepiness are correlated with academic difficulties.2

Technology

The prevalence of electronic devices has contributed to poor sleep in adolescents. Adolescents are using televisions, music players, video game consoles, computers, tablets, and phones in their rooms. Many adolescents have more than one device in their room, and using devices in the evening may disrupt sleep and result in less sleep duration and being more tired during the day. Numerous studies have shown that more screen time is associated with delayed bedtimes and shorter total sleep time among children and adolescents.5 The presence of a television in the bedroom is associated with later bedtime on weeknights, taking longer to fall asleep, sleeping less, and being tired during the day. Similar studies have been shown about computer use before bedtime.2 Computer use seems to be more disruptive to sleep compared with television, perhaps because television watching is more passive than the interactive nature of computers.5 The popularity of smart phones and hand-held devices have also made it easier for adolescents to keep their computer activities going for longer periods of time. One cross-sectional study showed that more than 60% of the adolescents surveyed kept their mobile phones with them when they went to bed.5

Adolescents may also choose to directly displace sleep with electronic device use, particularly on the weekends. With the rise in popularity of social media, social interactions are often ongoing through the day and night, with chats, tweets, emails, and notifications interrupting the calm before sleep. Furthermore, the light produced by electronic devices may disrupt melatonin levels and normal circadian rhythms.2 The light emitted from many smart phones and tablets is in the blue light range, which is generally more effective at suppressing melatonin levels, increasing alertness, and altering sleep.5

School Start Times

Setting an appropriate bedtime and adhering to it consistently are difficult tasks, so a potential systemic solution that some schools have adopted is delaying school start times. Obviously, this presents logistical challenges for a school, such as disruption of after school programs and athletics, as well as transportation issues. The American Academy of Pediatrics policy statement on school start times recommends that middle and high schools start after 8:30 am to combat insufficient sleep in this age group.6 In a recent meta-analysis, each of the 20 studies regarding delayed school start times showed a significantly longer sleep duration for students.7 Studies have found that with delayed school start times, bedtimes did not seem to change, resulting in more sleep for many students and decreased daytime sleepiness.2 There were also improvements in satisfaction with sleep and motivation, and a decrease in self-reported depressive symptoms.7 In a study of middle school students, there were also fewer attention/concentration difficulties and better academic performance compared to schools that started earlier.2 Other studies have not noted significant changes in academic performance. A recent Cochrane review of school start times suggested that there are several potential benefits but noted that the quality of the primary studies was limited, and so could not draw any strong conclusions based on the available literature.8

Secondary Effects of Insufficient Sleep

Mood Disorders

In adults, sleep problems increase the risk of developing depression and may also be a predictor of relapse.2 In the child and adolescent population, similar findings exist, especially between insomnia and depression.2 For patients with severe depression and suicidal ideation, the effects of sleep problems are frightening. Getting less than 8 hours of sleep overnight may be associated with an almost 3-fold increase in risk of suicide attempts.2 There seems to be a correlation between insufficient sleep and suicidal ideation, and this effect is greater in those whose parents also have insufficient sleep. Parental-set bedtimes of after midnight, compared to those before 10 pm, seem to also be correlated with increased depression and suicidal ideation. Therefore, parental-set bedtimes earlier than 10 pm may be protective against mood disorders, specifically depression and suicidal ideation.2

Obesity Risk

In both children and adults, there is an association between short sleep duration and obesity, and by extension, short sleep duration and obesity-related morbidity.2 In adult studies, those that were sleep restricted had alterations in metabolic profiles, resulting in insulin resistance, increased sympathetic nervous activity, increased hunger, and decreased satiety. Sleep restriction resulted in consuming more calories, consuming a greater proportion of calories from fat, and exercising less, as well as consuming a higher portion of daily calories from snacks instead of meals.2 Interestingly, a dose-dependent effect was also seen, with risk of overweight having an inverse relationship to sleep duration. There is also the obvious correlation between overweight and sleep apnea, which may worsen sleep quality and contribute to obesity, resulting in a vicious cycle of insufficient sleep and problems associated with overweight. The studies of obesity and sleep in children and adolescents are not as robust as the studies in adults, and it is important to note that not all studies found a correlation in adolescents; however, the body of evidence from the studies points to some relationship that may have profound public health implications.2

Drowsy Driving and Motor Vehicle Accidents

A recent review of studies on sleep manipulation and cognitive functioning in adolescents showed that adolescents with sleep deprivation have more difficulty in psychomotor vigilance tasks in which the subject must respond as quickly as possible to a simple stimulus.9 It is no surprise, then, that sleep deprivation has an effect on driving in adolescents. In a study reviewing crash reports in North Carolina in which the driver was thought to have fallen asleep at the wheel and was not intoxicated, the majority (55%) occurred in a driver that was age 25 years or younger.2 Young male drivers seem to be more at risk compared to their female counterparts. In one study of college students, 40% reported having sleepiness while driving and 11% reported being in a motor vehicle accident in which sleepiness was the main cause.2

Risk-Taking Behavior

A recent review and meta-analysis of studies on sleep duration and risk-taking behaviors showed that adolescents who have insufficient sleep have 1.43 greater odds of risk-taking behavior.10 The categories of risk-taking behaviors in the studies varied, but included alcohol use, drug use, smoking, violent/delinquent behavior, transport risk-taking/road safety, and sexual risk-taking. Although this review could not claim any causal effects and the quality of the studies were mixed, it seems that there may be an association between sleep difficulties and risk-taking behaviors that can cause great morbidity and even mortality in our adolescent patients.10

How to Address Poor Sleep in Adolescents

Pediatricians can play an important role in helping their patients achieve a good night's rest, reinforcing the importance of adequate sleep and helping families cultivate healthy sleep habits early in life. This includes promoting regular bedtimes (on the weekends and weekdays alike), limiting caffeine use, and removing electronic devices from the room and avoiding them before bedtime. Daytime physical activity also seems to be correlated with earlier bedtimes.11 It is important to stress also that parents should be good role models for their children. If everyone in the household follows the same bedtime rules it may be easier for the child to adhere to them. For screen use, it will be important to also limit passive screens in the background and monitor the content of videos to avoid scary or violent media.12

For patients with more difficulty following these instructions, specific cognitive-behavioral sleep interventions may be helpful. In one review and meta-analysis of nine trials, adolescents who underwent cognitive-behavioral sleep interventions showed improvements in total sleep time, sleep onset latency, and sleep efficiency, as well as sleep quality, daytime sleepiness, and mood disorders such as depression and anxiety.1 Importantly, these effects were generally maintained over time.1 These cognitive-behavioral sleep interventions varied between studies but could include sleep education, sleep hygiene instruction, removing stimuli from the room, relaxation training, and addressing negative thought processes and unhelpful beliefs about sleep. Interestingly, school-based sleep education programs have been shown to be largely ineffective.1 The results of studies on cognitive-behavioral interventions for sleep problems are encouraging, but more studies are needed. Table 1 lists a few take-home points on sleep in adolescents.

Take-Home Points for the Primary Care Pediatrician

Table 1:

Take-Home Points for the Primary Care Pediatrician

References

  1. Blake MJ, Sheeber LB, Youssef GJ, Raniti MB, Allen NB. Systematic review and meta-analysis of adolescent cognitive-behavioral sleep interventions. Clin Child Fam Psychol Rev. 2017;20(3):227–249. https://doi.org/10.1007/s10567-017-0234-5 PMID: doi:10.1007/s10567-017-0234-5 [CrossRef]
  2. 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–e932. https://doi.org/10.1542/peds.2014-1696 PMID: doi:10.1542/peds.2014-1696 [CrossRef]
  3. Guglielmo D, Gazmararian JA, Chung J, Rogers AE, Hale L. Racial/ethnic sleep disparities in US school-aged children and adolescents: a review of the literature. Sleep Health. 2018;4(1):68–80. https://doi.org/10.1016/j.sleh.2017.09.005 PMID: doi:10.1016/j.sleh.2017.09.005 [CrossRef]
  4. Orbeta RL, Overpeck MD, Ramcharran D, Kogan MD, Ledsky R. High caffeine intake in adolescents: associations with difficulty sleeping and feeling tired in the morning. J Adolesc Health. 2006;38(4):451–453. https://doi.org/10.1016/j.jadohealth.2005.05.014 PMID: doi:10.1016/j.jadohealth.2005.05.014 [CrossRef]
  5. LeBourgeois MK, Hale L, Chang AM, Akacem LD, Montgomery-Downs HE, Buxton OM. Digital Media and Sleep in Childhood and Adolescence. Pediatrics. 2017;140(suppl 2):S92–S96. https://doi.org/10.1542/peds.2016-1758J PMID: doi:10.1542/peds.2016-1758J [CrossRef]
  6. Adolescent Sleep Working Group Committee on Adolescence. Council on School Health. School start times for adolescents. Pediatrics. 2014;134(3):642–649. https://doi.org/10.1542/peds.2014-1697 PMID: doi:10.1542/peds.2014-1697 [CrossRef]
  7. Bowers JM, Moyer A. Effects of school start time on students' sleep duration, daytime sleepiness, and attendance: a meta-analysis. Sleep Health. 2017;3(6):423–431. https://doi.org/10.1016/j.sleh.2017.08.004 PMID: doi:10.1016/j.sleh.2017.08.004 [CrossRef]
  8. Marx R, Tanner-Smith EE, Davison CM, et al. Later school start times for supporting the education, health, and well-being of high school students. Cochrane Database Syst Rev. 2017;7:CD009467. https://doi.org/10.1002/14651858.CD009467.pub2 PMID:28670711
  9. de Bruin EJ, van Run C, Staaks J, Meijer AM. Effects of sleep manipulation on cognitive functioning of adolescents: a systematic review. Sleep Med Rev. 2017;32:45–57. https://doi.org/10.1016/j.smrv.2016.02.006 PMID: doi:10.1016/j.smrv.2016.02.006 [CrossRef]
  10. Short MA, Weber N. Sleep duration and risk-taking in adolescents: a systematic review and meta-analysis. Sleep Med Rev. 2018;41:185–196. https://doi.org/10.1016/j.smrv.2018.03.006 PMID: doi:10.1016/j.smrv.2018.03.006 [CrossRef]
  11. Bartel KA, Gradisar M, Williamson P. Protective and risk factors for adolescent sleep: a meta-analytic review. Sleep Med Rev. 2015;21:72–85. https://doi.org/10.1016/j.smrv.2014.08.002 PMID: doi:10.1016/j.smrv.2014.08.002 [CrossRef]
  12. Hale L, Kirschen GW, LeBourgeois MK, et al. Youth screen media habits and sleep: sleep-friendly screen behavior recommendations for clinicians, educators, and parents. Child Adolesc Psychiatr Clin N Am. 2018;27(2):229–245. https://doi.org/10.1016/j.chc.2017.11.014 PMID: doi:10.1016/j.chc.2017.11.014 [CrossRef]

Take-Home Points for the Primary Care Pediatrician

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Many middle school and high school students are getting insufficient sleep (<8 hours per night). The recommended amount for adolescents is 8 to 10 hours every night1

</list-item> <list-item>

Make sleep a priority in your anticipatory guidance with adolescent patients. Regular bedtimes, removing digital devices from the bedroom, and limiting caffeine use are important ways to achieve adequate sleep.

</list-item> <list-item>

Insufficient sleep in adolescence is linked to mood disorders such as depression and anxiety,2 and may be linked to increased obesity risk and drowsy driving9

</list-item> <list-item>

The American Academy of Pediatrics Recommends delayed school start times (after 8:30 am) as a systemic measure to combat insufficient sleep in adolescents6

</list-item> <list-item>

Some patients may benefit from specific cognitive-behavioral interventions to help them address poor sleep1

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Authors
Sabrina Fernandez, MD

Sabrina Fernandez, MD, is a Primary Care Pediatrician, University of California San Francisco, Benioff Children's Hospital; and an Assistant Professor of Pediatrics, Department of Pediatrics, University of California San Francisco.

Address correspondence to Sabrina Fernandez, MD, via email: sabrina.fernandez@ucsf.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20190724-02

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