What Do We Know About Sleep In

Adolescence?
1 Mar 2018| SingHealth Medical News, Medical News
The article is contributed/written by SingHealth Duke-NUS Sleep Centre, SingHealth

get insufficient sleep on school nights and attempt to catch up on sleep on weekend nights.

Sleep is important for optimal cognitive

performance and health. However, many
adolescents do not get adequate sleep. This
short review examines factors that contribute to
insufficient sleep during adolescence and
potential consequences of poor sleep on well-
being and metabolic health. Possible solutions
for improving sleep and health outcomes in
adolescents are also discussed.
FACTORS THAT INFLUENCE SLEEP
Sleep duration tends to decrease during
adolescence compared with earlier in
childhood. With increasing age,
adolescents usually go to bed later due
to the convergence of biological and
socio-cultural factors (discussed below) 1,
which can result in reduced time in bed
for sleep on school nights.
Consequently, many adolescents are
exposed to partial sleep deprivation
during the school week and exhibit
‘catch-up’ sleep on weekends (Refer to
Figure 1).

The National Sleep Foundation (NSF) in

the United States recommends that
adolescents get 8 to 10 hours of sleep
per night for optimal health and
cognitive functioning 2.
Based on data collected in Singapore,
about 80% of adolescents report getting
less sleep than what is recommended by
the NSF. This is alarming because
insufficient sleep in adolescents has
been linked with impaired learning and
mood disturbances 3.

Adolescence is associated with biological changes that affect the circadian timing of sleep. There
is a phase delay shift in circadian rhythms during adolescence that results in a preference for
later bedtimes and wake-up times. Hence, adolescents at a more mature Tanner stage have later
bedtimes and a delayed circadian rhythm of the sleep-promoting hormone melatonin 4.
The ability to fall asleep also depends on how long a person has been awake, due to the build-up
of homeostatic sleep pressure. There is evidence that the build-up of sleep pressure during
wakefulness occurs more slowly in adolescents compared with younger children 5, which makes
it easier for post-pubertal children to delay their bedtime.

Therefore, contrary to popular belief, achieving earlier bedtimes on school nights is not simply a
matter of exercising better self-discipline. Rather, adolescents are biologically predisposed to go
to bed later than younger children and adults.
Socio-cultural factors also contribute to changes in sleep patterns. With increased autonomy and
independence, adolescents are more likely to make their own decisions regarding when to go to
bed. For example, many adolescents may be willing to exchange sleep for more study time,
despite evidence that shorter sleep durations are associated with poorer academic performance
6.
The use of electronic devices at night is also more common during adolescence compared with
earlier childhood, and the ability to socialise with friends is facilitated by the proliferation of
smartphones and tablets in this age group. The use of electronic devices near bedtime has been
shown to contribute to later and shorter nocturnal sleep 7, and exposure to light emitted by
these devices may contribute to delayed circadian rhythms and increased sleepiness on the
following morning 8.

EFFECTS OF INSUFFICIENT SLEEP

The most obvious sign of insufficient sleep is daytime sleepiness. Based on data collected in
Singapore, most adolescents extend their sleep duration by more than 2 hours on weekends,
suggesting that they are not getting sufficient sleep on school nights (Dr. Joshua J. Gooley, Duke-
NUS, unpublished).
Adolescents with shorter sleep are also more likely to engage in coping mechanisms for their
tiredness, including taking naps and using caffeine with the explicit purpose of staying awake
during the daytime. We have also found that most adolescents in Singapore rely on a parent or
alarm to wake them up in the morning, indicating that their nocturnal sleep is truncated by
having to get ready for school.

Insufficient sleep impairs cognitive processes that are essential for optimal learning and
academic success. Studies conducted by Duke-NUS researchers have demonstrated that
adolescents who are exposed to a week of sleep restriction (i.e., short sleep each night) exhibit
cumulative negative effects on attention, processing speed, and working memory 9.

The ability to learn and recall facts is also impaired by sleep restriction 10, which raises important
concerns about whether the ability of students to learn is compromised by recurrent exposure
to partial sleep deprivation.
In fact, recent work in Singapore indicates that the catch-up sleep that adolescents get on
weekends may not be sufficient for their attention to recover fully 11.
Sleep restriction also has cumulative negative effects on mood 9, and adolescents with short
sleep on school nights are more likely to report depressive symptoms.

Research findings in Singapore are consistent with those in the United States, in which
adolescents with later bedtimes and shorter sleep durations were more likely to suffer from
depressive symptoms and suicide ideation 12. These studies suggest that sleep is important for
adolescents’ mental health.
Over that past decade, several studies have shown that exposure to short sleep in childhood is
associated with obesity 13. Using self-reported data collected in Singapore, we have found that
the odds of being overweight are about 2-fold higher in adolescents exposed to short sleep (< 7
hours on school nights) compared with those with healthy sleep (8 - 10 hours). Other
researchers have shown that short sleep may contribute to overeating and increased sedentary
activity 14,15.
Hence, the epidemic of short sleep among adolescents should be a cause of concern for
Singapore’s War on Diabetes.
Notably, exposure to short-term sleep restriction has been associated with decreased insulin
sensitivity in healthy adolescents 16, and extending sleep duration has been shown to improve
insulin sensitivity in healthy adults regularly exposed to sleep restriction 17,18. Future studies in
adolescents should therefore examine whether sleep protects against the development of
impaired glucose metabolism.

POSSIBLE SOLUTIONS FOR IMPROVING SLEEP

AND HEALTH OUTCOMES
Because sleep is important for cognitive performance and health, it is important to consider
strategies for improving sleep behaviour in adolescents.

As highlighted above, it can be difficult for adolescents to advance their sleep schedule due to
age-dependent changes in circadian timing and sleep homeostasis. Nonetheless, the tendency
for adolescents to go to bed late can be minimised by improving their sleep hygiene practices.
This includes educating adolescents and their parents about the importance of sleep for well-
being so that they can both make informed decisions that lead to behaviours conducive to
better sleep habits.
For example, adolescents whose bedtime is set by their parents have earlier bedtimes, more
sleep, and less daytime fatigue 19, suggesting that parental involvement can facilitate
improvements in sleep behaviour and cognitive functioning.
It is also important that teachers, policy makers, and healthcare providers are adequately
informed on the benefits of healthy sleep so that they can encourage and reinforce healthy
sleep habits.

An alternative approach for extending nocturnal sleep duration is to make changes that would
allow for later wakeup times. The American Academy of Paediatrics (AAP) issued a policy
statement urging middle/high schools to start no earlier than 8:30am, with the aim of allowing
more students to achieve a healthy amount of sleep each night 20.
Consistent with this recommendation, a large body of evidence collected in the United States has
shown that delaying school start time increases sleep duration on school nights, with many
studies also demonstrating improved mood, less falling asleep in class, and better grades 6,21.
In Singapore, almost all local schools start about an hour earlier than what the AAP considers a
healthy school start time in adolescents.

Recently, Nanyang Girls’ High School delayed their school start time by 45 minutes from 7:30 am
to 8:15 am 22.
After the change in school start time, adolescents reported more time in bed for sleep and fewer
depressive symptoms, assessed up to several months after the intervention (Dr. Michael Chee,
Duke-NUS, unpublished).
These results suggest that adopting later school start times may have sustained benefits for
adolescents’ sleep and well-being.
CONCLUSION
In summary, it can be challenging for adolescents to get sufficient sleep on school nights.
Paediatricians and thought leaders in sleep research can have a positive impact on sleep
behaviour in adolescents by educating the public about the importance of sleep for adolescents’
cognition and health.

It is important to empower parents and their children to make informed, healthy decisions about
the timing and duration of their nocturnal sleep. Late-night activities that are stimulating and
that delay bedtimes should be avoided because they contribute to short nocturnal sleep and can
negatively affect learning and mood during the daytime.
Finally, schools should be encouraged to integrate instructional materials on sleep into multiple
areas of the curriculum, and to consider whether administrative changes can be made (e.g.,
changing school start times, improving transportation options, or reducing evening workload) to
foster better sleep, learning, and health outcomes in adolescents.
For appointments at the SingHealth Duke-NUS Sleep Centre, GPs can call through the GP
Appointment Hotline at 6321 4402 for more information.

By: Associate Professor Joshua J. Gooley, Neuroscience and Behavioural Disorders Programme,
Duke-NUS Medical School; SingHealth Duke-NUS Sleep Centre
Dr. Joshua J. Gooley is an Associate Professor in the Centre for Cognitive Neuroscience, and the
Neuroscience and Behavioural Disorders Programme at Duke-NUS Medical School.
He is Principal Investigator of the Chronobiology and Sleep Laboratory, located in the SingHealth
Investigational Medicine Unit at Singapore General Hospital. Dr. Gooley’s research programme at
Duke-NUS focuses on understanding effects of sleep and circadian rhythms on cognition and
health.

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