Clinical reviewFunctional consequences of inadequate sleep in adolescents: A systematic review
Introduction
In the past decade, there has been an increasing interest in the investigation of sleep in adolescence.*1, 2, 3, 4 Growing evidence suggests that sleep plays a crucial role in healthy adolescent development, particularly in the regulation of important daily functions such as behavior, emotion and attention.*1, 5, 6, 7, 8, 9, 10 The main lines of evidence are obtained from sleep restriction protocols as well as descriptive studies and survey data, in which associations between sleep loss and various functional and behavioral outcomes are explored.
Investigations examining the effects of experimentally induced sleep restriction in adolescents have demonstrated declines in some neurocognitive functions.*1, 6, 7, 11, 12 In a review of the evidence, sleepiness was consistently demonstrated in most case-control sleep restriction protocols. However, evidence for cognitive deficits as a function of sleep restriction, was found in tasks of complex cognitive functions such as verbal fluency and creativity, computational speed and abstract problem solving, but not in low complexity tasks such as verbal memory, auditory attention, visual sustained attention, psychomotor speed and computational accuracy.7 Furthermore, it has been hypothesized that whereas single tasks may be resistant to the effects of sleep deprivation, the performance of two different tasks simultaneously, such as cognitive and emotional tasks, may be particularly sensitive to the effects of sleep loss.1 Dahl and Lewin have suggested that such dual or multi-tasking may well represent the challenges typically encountered in adolescents' daily lives.1
This hypothesis may explain why more consistent relationships have been reported between sleep loss and more global measures of functioning and behavior. Experimental studies have demonstrated increased academic difficulties and attention problems following sleep restriction, based on teacher ratings blind to experimental condition,13 as well as greater problems with behavioral regulation such as impulse control, emotional regulation and behavioral flexibility.5
Despite the potentially serious implications of inadequate sleep on the development and well being of young individuals, to date, the consequences of sleep patterns and disturbances on daytime functioning and health issues in the adolescent population remains a relatively understudied and unappreciated area of investigation.4 Few descriptive reviews, based primarily on experimental findings (i.e., sleep restriction protocols), have previously been published.7, 10, 14 However, a systematic review of descriptive studies based in naturalistic settings on sleep, health and functioning in the healthy adolescent population is lacking. The aim of this study was to systematically review the associations between inadequate sleep (i.e., sleep loss, disturbed sleep patterns and insomnia), and impairments in various measures of health (i.e., somatic and psychosocial) and daytime functioning (i.e., school performance and risk behaviors), in the normative healthy adolescent population in a naturalistic setting.
Section snippets
Study selection
A literature search was conducted using PubMed and PsycNET (which is inclusive of PsycARTICLES and PsycINFO) electronic databases, covering all publications up to December 2012. These databases were chosen as they are considered comprehensive for the areas of health/medicine and psychology, respectively. Search terms for sleep measures were ‘sleep’ (covering all aspects of interest regarding sleep, e.g.,: short sleep duration, sleep loss, sleep disturbances) and ‘insomnia’. Search terms for
General health outcomes
Few prospective studies have followed adolescent sleep disturbances and consequent general health outcomes based on self-report.*20, *21 In a 12 mo study on the functional impact of insomnia in over 4000 11–17 y old adolescents based on DSM-IV (Diagnostic and statistical manual mental disorders, fourth edition). symptom criteria,20 insomnia at baseline significantly increased risks for all subsequent somatic dysfunctions at follow up, which were operationally defined as self reports of
Discussion
Developmental changes in sleep patterns during adolescence are well characterized. Based on accumulated scientific investigation, it has been established that bio-regulatory systems controlling sleep, as well as environmental and psychosocial factors are involved in these observed changes.97, 98, 99 Delays in both circadian and homeostatic sleep mechanisms have been shown to underlie one of the hallmarks of adolescent development, i.e., a shift to a later sleep phase,9, 99, 100 characterized by
Study limitations
This review aimed to encompass major areas of health and functioning in adolescents which have been investigated in association to sleep. Areas not reviewed here include environmental, cultural and lifestyle factors such as socioeconomic status, parental styles, electronic media exposure and school start times, all of which have been associated with sleep disparities in this population (e.g.,*1, 4, 105). These areas were not considered for the systematic review as they are more often implicated
Future directions
Given the paucity of longitudinal investigations, additional prospective and outcomes research is needed in order to better understand underlying mechanisms, direction of causality and mediating factors, as well as inform the development of targeted interventions that can be widely implemented. As evidence regarding the serious outcomes associated with inadequate sleep is mounting, targeted intervention studies with long term follow up should examine whether early sleep-related interventions
Conclusion
This systematic review provides ample evidence to demonstrate that inadequate sleep has significant consequences on various key aspects of adolescent health and functioning, including somatic and psychosocial health, academic performance and risk taking behavior. The evidence collectively supports the premise that sleep plays an important role in this crucial period of development, and indicates that the pervasive effects of chronic sleep debt have become a serious worldwide public health issue.
Conflict of interest
The authors report no conflicts of interest
References∗ (106)
- et al.
Pathways to adolescent health sleep regulation and behavior
J Adolesc Health
(2002) - et al.
The relationships between sex, age, geography and time in bed in adolescents: a meta-analysis of data from 23 countries
Sleep Med Rev
(2010) - et al.
Recent worldwide sleep patterns and problems during adolescence: a review and meta-analysis of age, region, and sleep
Sleep Med
(2011) - et al.
Attention, learning, and arousal of experimentally sleep-restricted adolescents in a simulated classroom
J Adolesc Health
(2010) - et al.
Sleepiness in children and adolescents: clinical implications
Sleep Med Rev
(2002) Cognitive, behavioral, and functional consequences of inadequate sleep in children and adolescents
Pediatr Clin North Am
(2011)- et al.
Sleep problems in childhood: a longitudinal study of developmental change and association with behavioral problems
J Am Acad Child Adolesc Psychiatr
(2002) - et al.
Holiday and school-term sleep patterns of Australian adolescents
J Adolesc
(2008) - et al.
Impact of insomnia on future functioning of adolescents
J Psychosom Res
(2002) - et al.
Sleepless in adolescence: prospective data on sleep deprivation, health and functioning
J Adolesc
(2009)
Correlates of adolescent sleep time and variability in sleep time: the role of individual and health related characteristics
Sleep Med
Sex differences in the association between sleep and body mass index in adolescents
J Pediatr
Sleep duration and emerging cardiometabolic risk markers in adolescents. The AFINOS Study
Sleep Med
Association of short and long sleep durations with insulin sensitivity in adolescents
J Pediatr
Associations between sleep disturbance and mental health status: a longitudinal study of Japanese junior high school students
Sleep Med
The association of insomnia with anxiety disorders and depression: exploration of the direction of risk
J Psychiatr Res
Sleep problems in adolescence
J Am Acad Child Adolesc Psychiatr
Differences in reported sleep need among adolescents
J Adolesc Health
Sleep duration, insomnia and behavioral problems among Chinese adolescents
Psychiatry Res
The influence of sleep quality, sleep duration and sleepiness on school performance in children and adolescents: a meta-analytic review
Sleep Med Rev
The joint contribution of sleep, intelligence and motivation to school performance
Pers Individ Dif
Chronic insomnia and its negative consequences for health and functioning of adolescents: a 12-month prospective study
J Adolesc Health
Relationships between hours of sleep and health-risk behaviors in US adolescent students
Prev Med
The association between short and long nocturnal sleep durations and risky behaviours and the moderating factors in Taiwanese adolescents
Psychiatry Res
Sleep patterns and risk of injury among adolescent farm residents
Am J Prev Med
Epidemiologic study of sleep quality and troubles in French secondary school adolescents
J Adolesc Health
Smoking and sleep disorders in Chinese adolescents
Sleep Med
Sleep problems and substance use in adolescence
Drug Alcohol Depend
Sleep, circadian rhythms, and delayed phase in adolescence
Sleep Med
Normative data on the sleep habits of Australian children and adolescents
Sleep
Feasibility and behavioral effects of an at-home multi-night sleep restriction protocol for adolescents
J Child Psychol Psychiatr
Sleep schedules and daytime functioning in adolescents
Child Dev
Regulation of adolescent sleep: implications for behavior
Ann N Y Acad Sci
Sleep and its importance in adolescence and in common adolescent somatic and psychiatric conditions
Int J Gen Med
The effects of sleep restriction and extension on school-age children: what a difference an hour makes
Child Dev
Delaying school starting time by one hour: some effects on attention levels in adolescents
J Clin Sleep Med
Experimental restriction of sleep opportunity in children: effects on teacher ratings
Sleep
Shorter sleep duration is associated with increased risk for being overweight at ages 9 to 12 years
Pediatrics
Sleep and the body mass index and overweight status of children and adolescents
Child Dev
Sleep duration or bedtime? Exploring the relationship between sleep habits and weight status and activity patterns
Sleep
Adequate sleep among adolescents is positively associated with health status and health-related behaviors
BMC Public Health
Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference
Pediatrics
Role of sleep and sleep loss in hormonal release and metabolism
Endocr Dev
Shortened sleep duration does not predict obesity in adolescents
J Sleep Res
Examining the longitudinal relationship between change in sleep and obesity risk in adolescents
Health Educ Behav
Sleep patterns, electronic media exposure and daytime sleep-related behaviours among Israeli adolescents
Acta Pædiatrica
Eveningness, sleep patterns, daytime functioning, and quality of life in Israeli adolescents
Chronobiol Int
Relationships among sleepiness, sleep time, and psychological functioning in adolescents
J Pediatr Psychol
Association between short sleeping hours and overweight in adolescents: results from a US Suburban High School survey
Sleep Breath
Obesity among adolescents: sedentary leisure time and sleeping as determinants
J Adv Nurs
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The most important references are denoted by an asterisk.