Insufficient Sleep in Adolescents and Young Adults

FROM THE AMERICAN ACADEMY OF PEDIATRICS

TECHNICAL REPORT Insufﬁcient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences

Judith Owens, MD, MPH, FAAP, ADOLESCENT SLEEP WORKING GROUP, and COMMITTEE ON ADOLESCENCE abstract KEY WORDS Chronic sleep loss and associated sleepiness and daytime impair- adolescents, caffeine, car crashes, media use, obesity, sleep loss, ments in adolescence are a serious threat to the academic success, sleepiness health, and safety of our nation’s youth and an important public health ABBREVIATIONS REM—rapid eye movement issue. Understanding the extent and potential short- and long-term This document is copyrighted and is property of the American repercussions of sleep restriction, as well as the unhealthy sleep Academy of Pediatrics and its Board of Directors. All authors practices and environmental factors that contribute to sleep loss in have filed conflict of interest statements with the American adolescents, is key in setting public policies to mitigate these effects Academy of Pediatrics. Any conflicts have been resolved through and in counseling patients and families in the clinical setting. This a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any report reviews the current literature on sleep patterns in adoles- commercial involvement in the development of the content of cents, factors contributing to chronic sleep loss (ie, electronic media this publication. use, caffeine consumption), and health-related consequences, such as The guidance in this report does not indicate an exclusive depression, increased obesity risk, and higher rates of drowsy driving course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be accidents. The report also discusses the potential role of later school appropriate. start times as a means of reducing adolescent sleepiness. Pediatrics All technical reports from the American Academy of Pediatrics 2014;134:e921–e932 automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. INTRODUCTION Since the publication of the American Academy of Pediatrics technical report on excessive sleepiness in adolescents in 2005,1 there have been a considerable number of articles published pertaining to sleep. These articles expand on many of the topics raised in the original report and add a number of new important health issues not pre- viously or minimally discussed (ie, short sleep and its association with obesity, caffeine/stimulant use). The previous technical report – www.pediatrics.org/cgi/doi/10.1542/peds.2014-1696 provided an overview of the profound changes in sleep wake regu- doi:10.1542/peds.2014-1696 lation and circadian biology occurring during adolescence, outlined factors (ie, parental influence, school start times) contributing to PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). insufficient sleep in adolescents, and summarized consequences such Copyright © 2014 by the American Academy of Pediatrics as negative impacts on mood, attention, and school performance. It also focused in particular on clinical sleep disorders such as insomnia, narcolepsy, and restless legs syndrome contributing to daytime sleepiness in adolescents. The new material in the present report adds to what is known about the extent of sleep restriction in the adolescent population and reinforces the importance of recog- nizing insufficient sleep both as a key public health issue and one that is immediately relevant to pediatric practice. The focus of this updated technical report is on insufficient sleep, specifically as a consequence of voluntary sleep restriction. It should

PEDIATRICS Volume 134, Number 3, September 2014 e921 Downloaded from www.aappublications.org/news by guest on September 28, 2021 be noted that such terms as insufficient note that studies comparing self- study were not presented, the average sleep, inadequate sleep, short sleep reported sleep duration with objectively reported wake times on school days duration, sleep loss, and sleep re- measured sleep amounts (ie, with was 7:00 AM or later, suggesting that the striction are used interchangeably and actigraphy) suggest that self-reports of schools these students attended did not as generic descriptive terms only and sleep often overestimate actual sleep start before 8:00 AM. do not imply specific amounts but duration, signifying that the problem of A number of studies have indicated that rather “less sleep than needed.” chronic sleep loss in adolescents may sleep health disparities exist and that Insufficient sleep in adolescents was be even greater than the data indicate.12 adults,19 children, and adolescents20–22 recognized as a serious health risk in US-based4,13 and international studies5,6,14 from families with low income or of 2010 in a jointly sponsored American revealed that as students get older, sleep racial or ethnic minorities may be at Medical Association/American Academy durations decline. The National Sleep even greater risk of poor-quality and of Sleep Medicine resolution acknowl- Foundation Sleep in America Poll4 found insufficient sleep. For example, in a re- edging the problem.2 Furthermore, that by the 12th grade, 75% of students cent study of middle school students, objectives for Sleep Health, a new topic self-reported sleep durations of less than appropriate timing and consistency of in Healthy People 2020,3 specifically 8 hours of sleep per night compared with both weeknight and weekend sleep includes reducing adolescent sleep loss: 16% of sixth graders. Furthermore, al- schedules were inversely correlated “SH-3: Increase the proportion of stu- though 30% to 41% of sixth through with low socioeconomic status and dents in grades 9 through 12 who get eighth graders were getting 9 or more specific household/neighborhood varia- sufficient sleep” (defined as ≥8hours). hoursofsleep,only3%of12thgraders bles (eg, overcrowding, noise levels, A second focus of the present report is reported doing so. Adolescents often safety concerns).23 This relationship may on unhealthy sleep behaviors (ie, poor attempt to address the accumulated have important health implications. For “sleep hygiene”) in teenagers, including weekday sleep debt during the week- example, a recent study suggested that irregular sleep–wake patterns, elec- end, when oversleep (the difference be- less sleep was a predictor of obesity risk tronic media use in the bedroom, and tween weekday and weekend sleep in African-American adolescents but not excessive caffeine use. A third focus durations) of up to 2 or more hours is in white adolescents.24 “Missed” sleep is on the myriad of potential conse- commonly reported.4,7,8,15,16 was also reported to be an important quences of inadequate sleep in ado- Comparisons with other countries show factor in asthma morbidity, especially in 25 lescents, including depression/suicidal similar patterns of decreased sleep Latino children. However, higher socio- ideation, obesity, car crashes attribut- durations with increasing age among economic status is not necessarily pro- able to drowsiness, and poor academic adolescents. For example, in Northern tective because studies have also shown performance. Taiwan,5 Germany,14 and India,17 average that youth from households with higher sleep duration dropped to below 8 socioeconomic status have shorter sleep 16,26 EPIDEMIOLOGIC STUDIES OF hours for high school–aged students. durations. SLEEPING ADOLESCENTS The most precipitous drop was reported For older adolescents, additional environ- Epidemiologic studies of sleep typically in 2005 for more than 1400 South mental factors, such as after-school em- 16 5,6,12 rely on self- or parent-reported ques- Korean adolescents, for whom the av- ployment, striving for good grades, 27,28 tionnaire data to document adolescent erage duration of sleep was 4.9 hours.6 socializing, participation in sports sleep patterns and the factors affecting In general, studies have demonstrated and other extracurricular activities, and them. The key advantage of this method similar weekend sleep durations across lack of parental monitoring or rules is the ease of assessment of large countries, but weekday sleep durations about bedtimes, can further interfere sample sizes. As a result, epidemiologic tend to vary greatly.5,9 In contrast, Aus- with sleep durations.6,29,30 School start studies can determine sleep patterns tralian adolescents seem to do com- times are reviewed later in the present across the full adolescent age range paratively well, with students 17 years report. with less potential sampling bias than and older reporting average sleep In summary, short sleep durations, cou- smaller case-control studies. Consistent durations between 8.5 and 9.1 hours.18 pled with evidence of daytime sleepiness with other methodologic approaches, The difference between weeknight and (eg, increased self-reported sleepiness the consensus finding across epidemi- weekend sleep durations also was not ratings,5,6,11,31 daytime napping,5,14,26 ologic studies is that both younger4–6 large, with weekend durations reported weekend oversleeping,6,10,14,32 need for and older4,7–11 adolescents are not get- at 9.3 hours. Interestingly, although data assistance in waking6), as well as in- ting enough sleep. It is important to on school start times in the Australian creased use of fatigue countermeasures

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(eg, excessive caffeine consumption4,5,15), more mature adolescents accumulate in an average of 4 electronic activities all indicate that adolescents are sleeping this sleep pressure at a slower rate.38,39 after 9:00 PM. fewer hours than they need. The clear and Maturational changes to these 2 bio- It is not surprising that several studies consistent message is that middle and regulatory processes begin in adoles- in adolescents have demonstrated that high school students are not getting cents as young as middle school and electronic exposure in the evening enough sleep and that this issue is present a major challenge for young potentially disrupts sleep. The use of a chronic problem worldwide. In addi- people to fall asleep in the early evening multiple electronic devices at the same tion, the health and behavioral outcomes and to wake refreshed/restored in the time has been associated with less linked to restricted sleep, as further early morning to attend school. The sleep at night and a greater degree of detailed in the following sections, are most prominent factors in this regard sleepiness during the daytime.4,15,31,42,43 alarming. These outcomes include in- are evening and nighttime screen use Having a television in the bedroom 4,33 creased risk of car crashes, de- and social networking, both of which (or even out of the bedroom) has 27 8,10,34 linquent behaviors, depression, have increased markedly in the 21st been associated with later bedtimes 35 and psychological stress. century.40 Going to bed later and wak- on weekdays, longer sleep latencies, ing later on weekends than on week- shorter total sleep times, later FACTORS CONTRIBUTING TO days reflects the biology of circadian wakeup times on the weekends, and INSUFFICIENT SLEEP IN rhythm and is also a response to in- more daytime sleepiness in adoles- ADOLESCENTS sufficient weekday sleep. Later sleep cents.44–46 In the Children in the Influence of Biological Processes timing and catch-up sleep on the Community Study in 1976,47 adoles- on Adolescent Sleep weekends further delay the signal for cents who were watching 3 or more the biological night (ie, melatonin The association of early adolescent hours of television not only experi- production) and dissipate residual fi development/pubertal onset and a more enced dif culty falling asleep and sleep pressure.41 In summary, the evening-type circadian phase preference frequent awakenings but also had combination of biologically driven fi (ie, preferred timing of sleep and wake as a risk of having dif culties with their processes with modern lifestyles and well as daytime activities) has been sleep later in adolescence and young social obligations minimize the oppor- documented since the 1990s.36 The be- adulthood. The use of computers be- tunities for adolescents to obtain havioral result of this biological process fore bedtime has also been shown to adequate sleep. is most clear in the timing of sleep, have the same effect, and this finding particularly for weekends. For example, has been demonstrated in a wide range Electronic Media and Sleep – Roenneberg et al37 measured the mid- of countries and cultures.45,46,48 51 point of weekend sleep in European Today’s adolescents and young adults Engaging in a greater number and schoolchildren and revealed a marked have grown up in an electronic age. range of sleep-interfering activities linear delay of 2 (girls) to 3 (boys) hours According to the National Sleep Foun- before going to bed has also been across the second decade, roughly 12 to dation’s 2006 Sleep in America Poll, associated with less nocturnal sleep 18 minutes later with each year of age. almost all adolescents had at least 1 and more daytime sleepiness in ado- The reversal of this delayed weekend media electronic device in their bed- lescents.45 Several mechanisms have sleep pattern may be a “biological room.4 Among the devices reported been postulated about how media marker for the end of adolescence.” were televisions (57%), music players disrupts sleep.40 One is that the use of Recent data have indicated that another (90%), video game consoles (43%), media directly displaces sleep; an process involved in regulating sleep computers (28%), and phones (64%). A adolescent or young adult may simply timing seems to be altered to favor late more rigorous study of subjects stay up later enjoying whatever media nights across adolescent development. recruited from a pediatric office in he or she is using. In addition, elec- This process, called sleep–wake ho- a Philadelphia suburb showed that of tronic media allow for greater in- meostasis, can be thought of as the the 100 adolescents ranging in age teraction between friends. Early data system that accounts for greater pres- from 12 to 18 years, two-thirds had suggested that peer-to-peer in- sure to sleep as one stays awake longer. a television in their bedroom, almost teraction did not have a major in- Data collected with 2 different para- one-third had a computer, almost 80% fluence on school-night bedtime but digms to estimate the rate of buildup of had a digital music player, and 90% rather had a more significant in- sleep pressure in prepubertal versus had a cellular phone in their bedroom.42 fluence on a teenager’s sleep on postpubertal adolescents indicate that The teenagers engaged simultaneously weekends.52 These findings may no

PEDIATRICS Volume 134, Number 3, September 2014 e923 Downloaded from www.aappublications.org/news by guest on September 28, 2021 longer hold now that there are en- countermeasure. There are clearly and decreased daytime sleepiness hanced ways for adolescents to com- a number of practical implications associated with delayed school start municate electronically. Calamaro et al42 and/or challenges that schools might times,61 as well as increased satis- found that after 9:00 PM, 34% of adoles- face when considering altering school faction with sleep and motivation and cents in the study sample were text start times, such as changes in athletic significant declines in self-reported messaging, 44% were talking on the schedules, effects on after-school ac- depressed mood, health center visits phone, 55% were online, and 24% were tivities, and transportation issues.57 for fatigue-related complaints, and playing computer games. In another Despite these hurdles, a small yet in- first-period tardiness.62 study of Belgian teenagers, 62% of the creasing number of school districts Research on the effects of early versus subjects used their phones after the over the last 15 years have responded delayed school start times for young lights were turned off, and phone use at to research reports regarding the adolescents has resulted in strikingly this time was associated with increased prevalence of inadequate sleep among similar findings. Students at later- 53 daytime tiredness the next day. middle and high school students by starting middle schools report later Another possible mechanism for the delaying school start times. Research rise times, more total sleep on school detrimental effect of electronics use on on the effects of delaying the start nights, less daytime sleepiness, less sleep is that the light produced by times of middle and high schools for tardiness, fewer attention/concentration electronic devices may disrupt circa- adolescents’ sleep and daytime func- difficulties, and better academic perfor- dian rhythms by suppressing melato- tioning is discussed in this section, mance compared with middle school nin, resulting in the inability to fall and a more detailed discussion is students at earlier-starting schools.63,64 In asleep at a reasonable time.40 Recent available in the American Academy of addition, middle school students with studies have demonstrated that expo- Pediatrics policy statement on school a delayed start time of 1 hour for just 1 sure to relatively low-intensity light can start times.58 week performed better than the earlier- 54,55 alter circadian rhythms and sup- In one of the first studies to assess the starting comparison group on tests re- 56 press nocturnal melatonin secretion. effect of school start times on ado- quiring attention.65 Undoubtedly, delaying Finally, media use may cause increased lescents,59 a 65-minute earlier school the start of middle school allows early sleep-disrupting mental, emotional, and start time in the transition from grade adolescents, similar to their older high physiologic arousal.40 One study found 9 to grade 10 resulted in fewer than school–aged peers, to obtain sufficient that subjective sleepiness was lower, one-half of 10th graders obtaining an sleep and to perform better in school. sleep latency was longer, and rapid eye average of 7 hours or more of sleep Danner and Phillips33 demonstrated movement (REM) sleep was shorter in on school nights and physiologic lev- that delaying school start times in 1 subjects after playing video shooting els of daytime sleepiness ordinarily community in Kentucky decreased the games, independent of the brightness seen in patients with narcolepsy. A average crash rate for teenaged of the screen used.56 Another study that large prospective longitudinal study of drivers by 16.5%, while the state as compared playing an interactive com- delays in school start times in both an a whole increased by 7.8% in the puter game with watching a movie on urban and a suburban school district same time period. In another recent 51 television in the evening found a de- found improvements in attendance study conducted in 2 adjacent, decline in verbal memory performance, rates and an increase in the percent- mographically similar cities, there prolonged sleep latency, and an in- age of high school students continu- were significantly increased teenaged crease in light sleep in the computer ously enrolled in the district or the (16- to 18-year-olds) crash rates over game cohort. same school, although grades did not a 2-year period in the city with earlier show a statistically significant im- high school start times.66 School Start Times provement.60 Similar to what has been Taken together, it is clear that when As has been described elsewhere in reported in subsequent studies,55 middle and high schools (schools the present report, a multitude of bedtimes did not change with the designed for adolescents) institute the changes occur over the course of delay in start times, but morning countermeasure of delaying the start adolescence that can affect the quality wake times were significantly later, time of school, students obtain more and quantity of sleep in adolescents resulting in the students obtaining sleep and there are associated and young adults. One of the most nearly 1 hour more of sleep on school improvements in behaviors pertinent salient and arguably most malleable is nights. Other studies have also to academic success (attendance and that of school start times, a systemic reported increases in sleep duration school performance) and safety.

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Caffeine than either the high-soda or low-caffeine was found to be attributable to caffeine Use of caffeine has been understudied use groups. A higher percentage of use.82 The authors further postulated in adolescents and children; however, mixed users compared with high-soda that daytime sleepiness might be an current research has raised important users reported that the reasons for important mediator of the negative im- questions regarding the complex in- their caffeine use were related to get- pact of not only caffeine but also alco- terrelationship between caffeine use ting through the day, experimentation, hol use and cigarette smoking on and sleep patterns during this de- and recreation.68 academic success. Caffeine use may velopmental period.67–70 Regardless of the reasons adolescents also serve as an affect modulator, particularly when it comes to adolescents Similar to studies of adult caffeine use, use caffeinated substances, there are with excessive daytime sleepiness or higher caffeine intake as early as 12 clear consequences. Adolescents ex- insufficient sleep. For example, studies years of age is associated with shorter perience tolerance and withdrawal have suggested that adolescents may sleep duration, increased sleep onset symptoms; however, in general, caf- use caffeine as a means of regulating latency, increased wake time after sleep feine dependence in adolescents is 75,76 mood and/or helping to alleviate de- onset, and increased daytime sleepi- poorly understood. Female high pression.75,83 ness.68,69,71 High school students who school students were more likely to report a moderate to high intake of report withdrawal/dependence caf- Undoubtedly, there is growing evi- caffeine versus very low intake were feine expectancies as well as appetite dence that caffeine use is increasing nearly 2 times more likely to have diffi- suppression expectancies compared among adolescents, with negative culty sleeping and to report morning with their male peers.68 Although implications for sleep and other sleepiness.71 High and regular caffeine adolescents may consume excessive behaviors. Significant questions, how- users seem to develop a cycle in which caffeine in an attempt to mitigate ever, remain regarding the direction of disrupted sleep attributable to caffeine daytime sleepiness, this action not this complex relationship. Are adoles- use leads to sleepiness, which then only further compromises the quality cents turning to caffeine because of leads them to increase their caffeine and quantity of sleep, but high caf- insufficient and inconsistent sleep consumption.72 Moreover, caffeine re- feine users may also be at risk for patterns, or does increased caffeine use duces the percentage of time spent in other substance use and/or abuse exacerbate sleep problems for de- slow-wave or “deep” sleep in a dose- as well as other risk-taking behav- veloping adolescents? These findings related manner and alters the temporal iors.68,75,77–79 Consumption of caffeine document the need for more extensive organization of REM/non-REM sleep.70,72,73 is linked to nicotine use in adoles- health education about caffeine use This outcome is particularly important cents,80 which in turn may further during adolescence. Furthermore, with because of the critical role that both disrupt sleep81 and perpetuate the the dramatic and potentially dangerous slow-wave sleep and REM sleep play in cycle of sleep fragmentation/daytime rise in the consumption of energy drinks learning and memory consolidation. sleepiness coupled with stimulant in combination with alcohol (particularly Researchers are beginning to examine use. Not surprisingly, increased caf- on college campuses), researchers and adolescents’ expectancies regarding caffeine use frequently coexists with physicians need to carefully investigate feine use. Reported expectancies for other behaviors that negatively affect the implications for adolescents across ’ 84 caffeine users were for energy and sleep, such as adolescents late-night, the developmental spectrum. mood enhancement and to counteract multifaceted technology use. For exam- the effects of sleep disturbances. Other ple, a recent study42 found that high Other Factors Affecting Sleep in – studies have found that adolescents re- school aged adolescents who reported Adolescents port using energy drinks for the energy the highest levels of multitasking with A number of other factors have been boost or “buzz” and that these bev- media-related electronic products also related to reduced sleep durations erages make them “feel more ener- consumed the most caffeine. across the adolescent age range, such getic.”74 In comparing different types of The correlation between caffeine con- as chronic medical illnesses, mental users, “mixed” caffeine product users sumption and daytime sleepiness is, in health issues (ie, anxiety/stress), and (ie, soda, coffee, energy drinks) reported turn, inversely correlated with academic prescribed psychotropic medications.10,15 higher levels of withdrawal and/or achievement. For example, 1 study of Chronic respiratory illnesses, such as dependence, energy and mood en- over 7000 adolescents reported that asthma, and pain conditions, such as hancement, appetite suppression, and asignificant proportion of the variance migraines, may contribute to truncated performance enhancement expectancies that occurs in academic achievement and disrupted sleep. Although obesity

PEDIATRICS Volume 134, Number 3, September 2014 e925 Downloaded from www.aappublications.org/news by guest on September 28, 2021 does not necessarily lead to poor sleep sleep on weekdays, but it also leads to a higher risk of reporting depressive per se, it is an increasingly important disrupted sleep–wake cycles, exacer- symptoms.96 Similarly, in high school risk factor for obstructive sleep apnea bation of the normal adolescent circa- students, shorter school-night total inadolescents,whichinturnresultsin dian phase delay, and perpetuation of sleep time has been associated with poor-quality sleep and daytime con- compromised weekday alertness. More- both daytime sleepiness and depres- sequences. Moreover, although the evi- over, consequences such as poor judg- sive symptoms,97 whereas increased dence is still largely anecdotal, the use ment, lack of motivation, and inattention risk-taking behaviors were associated of stimulants (particularly those typi- and affective dysregulation resulting with irregular sleep patterns and self- cally prescribed for the treatment of from sleep loss, as well as the effect of reported sleep problems rather than attention-deficit/hyperactivity disorder) insufficient sleep on decision-making sleep loss. These outcomes are simi- as a “countermeasure” to sleepiness skills,88 further compound the potential lar to the findings of a large longi- and/or as academic “performance negative effects in adolescents. In par- tudinal adolescent health study in enhancers” seems to be an increasingly ticular, higher level cognitive “executive which symptoms of possible insomnia common phenomenon across college functions,” for which adolescence is (ie, trouble sleeping, morning tired- campuses.85,86 Future investigations a critical period of evolution, are selec- ness) predicted risk behaviors (eg, need to assess the extent and context of tively affected by sleep loss.89 drinking and driving, smoking, delin- “diversion” of legitimately prescribed quency) after controlling for depres- stimulant medications as well as the 97,98 Sleep Loss and Depression, Mood sion symptoms. use and abuse of increasingly diverse Disturbances, and Suicidal There is evidence that other sleep- alternative sources of caffeine (eg, caf- Ideation related parameters may also have feinated alcoholic beverages, candy, a significant effect on mood; for ex- foodstuffs). Finally, it should also be It has long been recognized that mood ample, adolescent self-reported sleep noted that both over-the-counter (ie, di- disorders (especially major depressive variables (including trouble sleeping, phenhydramine) and prescription (ie, disorder) in clinical samples of adults tiredness, nightmares, and being a zolpidem) medications taken by adoles- exhibit a bidirectional relationship with long sleeper) have been found to be cents to induce sleep may result in re- sleep disturbances, and the presence of significantly associated with psycho- sidual daytime sleepiness and that sleep problems has been shown to both logical symptoms, including anxiety/ commonly used medications (eg, decon- increase the relative risk of developing 90 depression, and withdrawal.99 Circa- gestants) and prescription drugs (eg, depression and to be a predictor of 91,92 dian factors may also play a role in activating antidepressants [eg, fluoxe- relapse. Similar findings have mood regulation; increased self- tine], stimulant medication for attention- emerged in the child and adolescent reported “eveningness,” a marker of deficit/hyperactivity disorder) may also population, particularly with regard to circadian phase delay, has also been result in disrupted sleep and consequent an association between insomnia (diffi- associated with depression and lower daytime sleepiness in adolescents. culty initiating and/or maintaining sleep) and clinically diagnosed depression.93 behavior activation/positive affect.100 CONSEQUENCES OF INSUFFICIENT Recent studies have shown that ad- A number of recent studies have fo- SLEEP dressing insomnia will greatly im- cused on the possible relationship It is important to recognize that the prove treatment of depression. Although between sleep and suicidal ideation.101,102 causes and consequences of chronic studies examining sleep architecture in Sleeping less than 8 hours at night sleep loss in adolescents are often depressed adolescents94 have not con- seems to be associated with an al- closely intertwined in complex ways, sistently replicated differences in poly- most threefold increased risk of sui- further exacerbating the situation. For somnographic findings in depressed cide attempts after controlling for a example, alcohol consumption can lead adults (ie, increased REM sleep, de- number of confounding variables.101 to insufficient and poor-quality sleep and creased REM onset latency), there may Not only do adolescents with insufficient subsequent daytime sleepiness.10,32,87 In be other sleep electroencephalographic sleep have an increased risk of sui- turn, chronic sleep loss has been linked markers, such as sleep spindle activity cidal ideation, but the risk may be to an increased risk of alcohol and and cyclic alternating patterns,95 that similarly increased in adolescents drug use.14,28,34 Similarly, compensatory have more relevance for the adolescent whose parents also have insufficient oversleep behavior on weekends pro- population. sleep, raising some interesting ques- vides some temporary relief from Sleep debt in college students has tions about multigenerational envi- sleepiness generated by insufficient been shown to be associated with ronmental and/or genetic factors.103 A

e926 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 FROM THE AMERICAN ACADEMY OF PEDIATRICS similar relationship has been found in metabolic profiles (eg, insulin, ghrelin, likely to play an important role. In middle and high school students; leptin, cortisol) associated with sleep particular, perturbations in the levels of adolescents with parental-set bed- loss, which result in insulin resistance, neurohormones known to be associ- times of midnight or later are signifi- increased sympathetic nervous system ated with hunger and satiety (eg, adi- cantly more likely to suffer from activity, and increased hunger and ponectin, ghrelin) as well as increased depression and to have suicidal idea- decreased satiety.105 As a result, sleep- insulin resistance (as measured by tion compared with adolescents with restricted subjects consume more calo- the homeostatic model assessment parental-set bedtimes of 10:00 PM or ries, exercise less, and consume a higher [HOMA]) have been demonstrated in earlier. Earlier parental-set bedtimes, percentage of calories from fat.106–109 adolescents sleeping <5 hours per therefore, could potentially be pro- In 1 earlier study, it was estimated that day.115 These “short sleepers” were tective against adolescent depression for each hour sleep lost, the odds of also found to have a higher percentage and suicidal ideation. Finally, both being obese increased in adolescents by of carbohydrate intake according to ≤ decreased ( 5 hours) or increased 80%.110 Furthermore, there is evidence of a dietary questionnaire.116 Similarly, ≥ ( 10 hours) total sleep times may put a “dose–response” inverse relationship older adolescents sleeping less than 8 fi adolescents at a signi cantly higher between sleep and weight,111 with odds hours have been shown to consume risk of suicidality compared with a to- ratios of overweight increasing with de- a higher proportion of calories from 104 tal sleep time of 8 hours. However, creasing sleep duration (<5hours,5–6 fats, and shorter sleep duration is also increased risk of the most severe hours, 6–7hours,and7–8 hours com- associated with increased odds of con- forms of suicidality (attempt requiring pared with students sleeping >8hours). suming a higher percentage of daily treatment) seems to be associated The increased risk of obesity associ- caloric intake from snacks.117 Impor- fi with signi cantly shorter sleep dura- ated with insufficient sleep seems to tantly, these metabolic perturbations ≤ tion (total sleep time 4 hours). be equivalent to or higher than the also increase the risk of development In summary, sleep has an important risk associated with other factors of type 2 diabetes in these obese influence on mood and the develop- strongly correlated with weight, such adolescents.118,119 Finally, it should be ment of depressive symptoms in ado- as parental obesity and television noted that the relationship between lescents. Although insufficient sleep viewing.112 short sleep duration and obesity may and daytime sleepiness seem to have Early sleep patterns may influence BMI be further complicated by the pres- the most robust relationship with in adolescents and young adults as ence of obstructive sleep apnea. Not mood dysregulation, poor-quality sleep well. Longitudinal data suggest that only is obesity emerging as an in- and irregular sleep patterns are also children who sleep less, have later creasingly important risk factor for associated with depressed mood. Im- bedtimes, or get up earlier sub- sleep-disordered breathing in children,120 portantly, from a clinical standpoint, sequently have higher BMIs and are but obstructive sleep apnea may fur- improvements in sleep may lead to more likely to be overweight, even ther exacerbate the inflammatory and improvements in mental health func- after controlling for baseline BMI.113 metabolic consequences of both obe- tioning (and vice versa). The associa- – This association may be established sity and chronic sleep loss.7,121 123 tion between sleep loss and increased early in life; for example, an increased Some evidence also suggests there suicidality in adolescents is particu- BMI and high prevalence of obesity in may be gender differences in the larly troubling and is clearly important young adults was found in individuals strength of the association between for pediatricians to recognize. whose mothers had reported sleeping obesity and sleep duration, with ado- problems (“irregular” or “troubled” lescent boys seeming to be at higher Insufficient Sleep and Obesity Risk sleeping) at ages 2 to 4 years (al- risk compared with girls in both A considerable body of evidence now though sleep duration was not speci- cross-sectional and longitudinal stud- 124 links short sleep duration in both fied) compared with those who had ies using large data sets. However, 114 fi adults and children with an increased not had sleeping problems. not all studies have identi ed gender risk of obesity, an association that Although the underlying potential differences; in 1 study of junior high obviously has long-range health im- mechanisms for the relationship be- school students, short sleep duration plications. With regard to mechanisms, tween sleep and weight in adolescents was significantly associated with over- experimental studies of sleep restric- have yet to be elucidated, metabolic weight in girls only.125 tion in healthy adult volunteers have alterations associated with sleep loss Finally, it should be noted that not shown that there are alterations in similar to those observed in adults are all studies have found an inverse

PEDIATRICS Volume 134, Number 3, September 2014 e927 Downloaded from www.aappublications.org/news by guest on September 28, 2021 relationship between sleep duration reports from the state of North Car- be further magnified in high-risk and obesity in adolescents.126 It has olina between 1990 and 1992 in which adolescents. Pediatricians have the been postulated that some of these the driver was judged to have fallen opportunity to make significant in- discrepancies may be attributable asleep behind the wheel. In the 85% of roads into addressing the health to measurement issues; in a nation- crashes in which intoxication was not risk that sleep loss presents ally representative sample of ado- thought to be a contributing factor, through screening and health edu- lescents that included 2 different the majority (55%) occurred in indi- cation efforts. Many of the factors measures of sleep duration (24-hour viduals 25 years or younger. Crashes that have been shown to contribute time diaries and self-reported “usual” in this younger age range generally significantly to the current “epi- sleep hours), self-reported sleep du- occur at night, unlike crashes with demic” of insufficient sleep in teen- ration and time-diary sleep were only older adults, which typically occur agers, such as electronic media use, weakly correlated with each other, during the mid-afternoon,133,134 and caffeine consumption, and early and only self-reported sleep hours tend to occur predominantly when the school start times, are potentially were inversely associated with over- drowsy driver is alone.135–137 In addi- modifiable and, as such, are impor- weight.127 tion, young male drivers are more tant intervention points in anticipa- In summary, despite a number of likely to be involved in sleep-related tory guidance in the clinical setting. methodologic limitations, the body of crashes than are young female driv- On the local and national levels, evidence from studies assessing the ers.132,134,136 pediatricians need to advocate for relationship between short sleep and Sleepiness while driving is a common educational, administrative, and health increased overweight/obesity risk in complaint among adolescents136 and policies that promote healthy sleep adolescents is both compelling and college students.137 In a study of high and reduce the risk factors for sleep potentially far-reaching in its public school students with driver’s licenses, loss in adolescents. health implications. More research is one-fifth reported poor-quality sleep, urgently needed to identify specific almost two-thirds complained of day- LEAD AUTHOR metabolic, inflammatory, and hor- time sleepiness, 40% reported having Judith A. Owens, MD, FAAP monal mechanisms as well as the sleepiness while driving, and 11% interactions among sleepiness and reported having had an automobile ADOLESCENT SLEEP WORKING GROUP activity levels, mood, cognition, and crash in which sleepiness was the Rhoda Au, PhD behavioral responses in this complex main cause. Being sleepy behind the Mary Carskadon, PhD Richard Millman, MD equation. Moving forward, both wheel and poor-quality sleep at night Amy Wolfson, PhD community-based obesity prevention also seem to increase the risk of programs, such as “Let’sMove” having an automobile crash in college COMMITTEE ON ADOLESCENCE (http://www.letsmove.gov), and clin- students. 2012–2013 ical treatment programs for over- Countermeasures may potentially help Paula K. Braverman, MD, FAAP, Chairperson weight and obese teenagers should fi William P. Adelman, MD, FAAP prevent traf c accidents in this age Cora C. Breuner, MD, MPH, FAAP include consideration of sleep as an range. Avoidance of driving when sleep David A. Levine, MD, FAAP important variable in the relative deprived and not drinking alcohol Arik V. Marcell, MD, MPH, FAAP success or failure of these inter- before getting behind the wheel are Pamela J. Murray, MD, MPH, FAAP ’ ventions. obvious solutions. Other counter- Rebecca F. O Brien, MD, FAAP measures that have some empiric LIAISONS Drowsy Driving in Adolescents support in adults and may be effective Loretta E. Gavin, PhD, MPH – Centers for Disease in adolescents include planned nap- It is now well recognized that daytime Control and Prevention ping.138,139 Rachel J. Miller, MD – American College of sleepiness and fatigue are associated Obstetricians and Gynecologists with an increased rate of motor vehicle Margo Lane, MD, FAAP – Canadian Pediatric CONCLUSIONS crashes.128–131 The fact that sleepiness Society – could be a major factor in individuals Adolescent sleep loss poses a serious Benjamin Shain, MD, PhD American Academy of Child and Adolescent Psychiatry without known sleep disorders was risk to the physical and emotional not universally accepted until the health, academic success, and safety STAFF 132 landmark paper by Pack et al in of our nation’s youth. The prevalence Karen Smith 1995. This group reviewed crash and effects of insufficient sleep may James Baumberger, MPP

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e932 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from www.aappublications.org/news by guest on September 28, 2021 Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences Judith Owens, ADOLESCENT SLEEP WORKING GROUP and COMMITTEE ON ADOLESCENCE Pediatrics 2014;134;e921 DOI: 10.1542/peds.2014-1696 originally published online August 25, 2014;

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Insufficient Sleep in Adolescents and Young Adults: An Update on Causes and Consequences Judith Owens, ADOLESCENT SLEEP WORKING GROUP and COMMITTEE ON ADOLESCENCE Pediatrics 2014;134;e921 DOI: 10.1542/peds.2014-1696 originally published online August 25, 2014;

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