Teenagers and Sleep

Sleep disturbances are common during the teenage years. The two most common sleep problems noted are behaviorally induced insufficient sleep and delayed sleep phase.

Additionally, given the obesity epidemic, obese teenagers are also at risk for development of obstructive sleep apnea, and they may manifest symptoms of this sleep disorder.

Rarely, narcolepsy can appear during teenage years; about 50% of patients with narcolepsy have an onset of symptoms during the first decade of life.

In this article, we will discuss the common sleep problems facing teenagers.

Insufficient Sleep
Given the plethora of activities competing for teenagers’ time and attention, it can be challenging for them to set aside enough time for sleep. Sleep needs are different in teenagers and adults. Research shows that adolescents require at least as much sleep as they did as children, which is generally 8-1/2 to 9-1/4 h each night (Carskadon et al. Sleep. 1980;2[4]:453).

In one study (Noland et al. J Sch Health. 2009;79[5]:224), more than 90% of teenagers reported sleeping less than the recommended 9 h. In fact, about 10% of teenagers slept less than 6 h each night.

Multiple factors are responsible for reducing the amount of sleep during the teenage years. For example, the start of the school day is earlier for high school students. Many high school students have to wake up between 5:30 am and 6:00 am to get to school on time.

Teenagers also engage in many extracurricular activities, such as sports and clubs. In addition, many high school students are taking honors and advanced-placement classes. In the evenings, along with their homework, many teenagers may be working part-time jobs to earn money for college. The Internet, computers, smartphones, video games, and other electronic gadgets compete for their attention.

Also, there is decreased control exercised by parents regarding teenagers’ sleep schedules. Unfortunately, teenagers often give a lower priority to sleep than do adults. Many teenagers try to compensate for this by sleeping in on weekends and during vacations.

There are many consequences of sleep restriction in teenagers. Nine hours of sleep, and sometimes more, is necessary for teenagers to maintain optimal alertness during the daytime. Lack of sufficient sleep affects cognitive function and leads to difficulty concentrating and learning. Teenagers may have difficulty staying awake in class.

Lack of sleep also leads to behavioral problems, such as depressed mood and irritability, which can adversely affect interpersonal relationships and communication skills.

There is literature (Van Cauter and Knutson. Eur J Endocrinol. 2008;159[suppl 1]:S59) showing that sleep deprivation is a risk factor for the development of obesity and other adverse metabolic consequences.

Even more serious is that insufficient sleep increases the risk of drowsy driving and falling asleep at the wheel, leading to major accidents that can be fatal. Significant sleep loss results in cognitive impairment similar to that caused by alcohol ingestion. Insufficient sleep combined with alcohol in an inexperienced young driver is an especially deadly combination.

The only remedy for insufficient sleep by teenagers is getting the recommended amount of sleep. Given the multitude of demands on a teenager’s time, it can be a challenge to set aside 9 h of sleep time. Sleep should be regarded as just as vital to body function as food, water, and oxygen.

Doctors, parents, and teachers should emphasize the importance of getting an adequate amount of sleep. Proper planning and prioritization of activities is a good first step in managing time. This includes avoiding last-minute scrambling and “pulling all-nighters.” Teenagers should prioritize their extracurricular activities and curb late-night social time. If they are working a part-time job, they should try to limit their number of work hours.

Good sleep hygiene practices should be emphasized that encourage adherence to a regular sleep schedule and going to bed and getting up at the same time every day, regardless of whether it is a weekday or weekend.

If teenagers are drowsy during the day, they can consider a short nap of 25 to 30 min after school that can be refreshing and improve their functioning. They should be careful not to take longer naps because that can make it more difficult to fall asleep at night.

Caffeinated beverages may help teenagers stay awake during class, but they should avoid caffeinated beverages after 2:00 pm in the afternoon because caffeine can interfere with sleep onset at night.

Nicotine is a powerful stimulant, and discouraging teens from smoking will also help promote sleep.

Exercise close to bedtime should be avoided. The bedroom environment should be sleep promoting with cool temperature and no bright lights or loud noises.

Stimulating activities such as television, loud music, video games, surfing the Internet, and text messaging should be avoided an hour or two before bedtime. If teenagers have a hard time doing this, turning the television and other electronic gadgets off or removing them from their rooms is an extreme option.

Winding down at night with a warm shower, reading a book, or listening to soft music can help promote sleep.

Delayed Sleep Phase
In the last few decades, there has been a growing awareness of the changes in sleep patterns as children transition to adolescence. There is a normal propensity for small delays of the sleep-wake schedule and circadian phase during adolescence.

The exact mechanism of this circadian phase delay during adolescence is unclear. Carskadon and colleagues (Sleep. 1998;21[8]:871) found that mature adolescents had later circadian rhythm timing based on melatonin secretions in saliva samples.

Melatonin secretion occurs at a later time in adolescents as they mature; thus, it was difficult for them to go to sleep earlier at night. The melatonin secretion also turns off later in the morning, which made it harder for adolescents to wake up early.

The change in the circadian clock delays the time teenagers start feeling sleepy, often until 11:00 pm or later, and it also delays their wake-up time. There are social and behavioral factors that aggravate this delay in adolescents. Social and behavioral factors (eg, evening social activities, staying up late to do homework, watching television, surfing the Internet, playing video games) also favor the delay of the sleep-wake schedule.

Due to early morning classes, most teenagers have to wake up between 5:30 am and 6:00 am. This leads to two problems: (1) insufficient sleep because it is difficult to get 9 h of sleep, and (2) significant difficulty waking up. It is difficult for the teenagers to wake up because they are trying to wake up around the most “sleepy” circadian time. This leads to excessive daytime sleepiness and difficulty paying attention in class.

Some of the strategies to manage the delayed sleep phase in teenagers are to maintain a regular sleep schedule and maintain good sleep hygiene practices as described previously.

Light is the primary synchronizing or entraining agent (zeitgeber) for the circadian clock, so lighting strategies should help with circadian clock alignment to the day-night cycle.

Studies have shown that the circadian timing system can be reset if light exposure is carefully controlled. Hence, dimming the lights as bedtime approaches and turning off the lights during sleep should be considered. Bright light exposure during morning should be encouraged.

Starting school at a later time is a strategy that has been explored in some school districts. Studies from Minnesota and Massachusetts school districts have shown that teenagers who attended schools with later start times were able to sleep about 1 h longer and were more alert during school.

In a Kentucky school district, later school start times increased the sleep time of adolescents and decreased their risk of motor vehicle crashes (Danner and Phillips. J Clin Sleep Med. 2008;4[6]:533).

Changing a school’s start and end time to be later for teenagers is not an easy undertaking. Factors that can be adversely impacted by such a change include school transportation schedules, schedules of younger students, after-school activities, teachers’ free time, and family schedules.

There are multiple stakeholders involved in such a decision—students, teachers, parents, principals, counselors, administrators, school boards, and the community.

Sleep specialists can play an important role by educating school administrators about the potential adverse outcomes of very early school start times.

Hopefully, in the near future, increased awareness of the sleep problems faced by teenagers should motivate schools across the country to synchronize school schedules with students’ circadian clocks. That way, teenagers are in school during their most alert hours to achieve their full academic potential.

In summary, teenagers have a different set of sleep problems that should be promptly recognized and addressed to improve their overall health and well-being.

Dr. Saiprakash B. Venkateshiah, FCCP
Assistant Professor
Emory University School of Medicine
Atlanta, Georgia