Sleep Needs, Patterns, and Diffculties of Adolescents

INTRODUCTION

Sleep is not only a biological necessity but also a physiological drive. In today's fast-paced world, though, a good night's sleep is often the first thing to go. The effects of inadequate sleep are more than mere annoyances: they affect our mood and how we perform at school, work, and home and behind the wheel. Lost sleep also accumulates over time; the more “sleep debt ” an individual incurs, the greater the negative consequences, according to researchers in the field (Carskadon and Dement, 1981; Wolfson and Carskadon, 1998).

Research on adolescents and sleep has been under way for more than two decades, and there is growing evidence that adolescents are developmentally vulnerable to sleep difficulties. To discuss current research in this area and its implications in the policy, public, health, and educational arenas, the Forum on Adolescence of the Board on Children, Youth, and Families held a workshop, entitled Sleep Needs, Patterns, and Difficulties of Adolescents, on September 22, 1999. Both the board and the forum are initiatives of the Institute of Medicine and the National Research Council of the National Academies.

The workshop brought together researchers, educators, health care providers, and policy makers to review current findings on adolescent sleep. More than 100 individuals attended the workshop, including medical researchers, teachers, parents, and young people themselves. David A. Ham-



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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP Sleep Needs, Patterns, and Diffculties of Adolescents INTRODUCTION Sleep is not only a biological necessity but also a physiological drive. In today's fast-paced world, though, a good night's sleep is often the first thing to go. The effects of inadequate sleep are more than mere annoyances: they affect our mood and how we perform at school, work, and home and behind the wheel. Lost sleep also accumulates over time; the more “sleep debt ” an individual incurs, the greater the negative consequences, according to researchers in the field (Carskadon and Dement, 1981; Wolfson and Carskadon, 1998). Research on adolescents and sleep has been under way for more than two decades, and there is growing evidence that adolescents are developmentally vulnerable to sleep difficulties. To discuss current research in this area and its implications in the policy, public, health, and educational arenas, the Forum on Adolescence of the Board on Children, Youth, and Families held a workshop, entitled Sleep Needs, Patterns, and Difficulties of Adolescents, on September 22, 1999. Both the board and the forum are initiatives of the Institute of Medicine and the National Research Council of the National Academies. The workshop brought together researchers, educators, health care providers, and policy makers to review current findings on adolescent sleep. More than 100 individuals attended the workshop, including medical researchers, teachers, parents, and young people themselves. David A. Ham-

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP burg, chair of the Forum on Adolescence, and William C. Dement, director of the Sleep Disorders Center at Stanford University, cochaired the meeting. As Hamburg noted in his opening remarks, the workshop offered an “opportunity to call attention to a very important and, until recently, neglected problem area.” “Adolescence is the time of greatest vulnerability from the standpoint of sleep,” Dement, a pioneer in the field of sleep research, told workshop participants. Counterproductive adolescent sleep patterns tend to be viewed as part of the culture of the teenage years. But according to Dement and other researchers, the need for sleep does not decrease as individuals go through adolescence (Carskadon, 1982). The amount of sleep that adolescents get drops precipitously, however, making it very difficult for them to avoid chronic sleep loss. Dement asked the workshop participants to consider several questions: How much sleep do adolescents require? What factors contribute to sleep loss in adolescence? What are the consequences of chronic sleep loss in young people? What can be done about it? Through presentations and panel discussions, workshop participants addressed these questions. They summarized results from research over the past two decades on issues such as how much sleep teenagers need and how much they typically get, the sleep patterns of adolescents, and the factors—biological, behavioral, and environmental—that influence them. They discussed recent efforts to facilitate meeting the sleep needs of adolescents, including consideration of later starting times for high schools and efforts to educate the public, including parents and youth, on the importance of adequate sleep. Workshop participants acknowledged the complexity of the issue and observed that additional research on the causes and consequences of adolescent sleep problems is appropriate. Assessing the impact and effects of changes in policy and practices by educators, parents, and youth themselves, as well as increased public understanding of the dimensions of the problem, also could advance the search for remedies. Drawing on workshop participants' presentations and subsequent question and answer sessions, this report summarizes key themes that emerged from the day's discussions. It is intended as an overview of the issues discussed for an audience of educators, parents, youth, health care providers, and other interested readers. It is not intended to provide a comprehensive review of findings from the entire field of research on adolescent sleep. Of necessity, the report reflects the content and emphases of the presentations and discussions. It therefore does not provide full details on research meth-

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP ods and samples or a critical analysis of the strengths and weaknesses of the studies discussed. It is important to note that workshop participants agreed that adolescent sleep needs and difficulties are complex issues for which there is no single solution. Because the factors that influence adolescent sleep patterns are both biological and behavioral, solutions need to address those processes as well as the constraints on sleep imposed by the practicalities and habits of young people's daily lives. Additional research is appropriate on a number of topics, as outlined later in this report. Research can also further understanding of the links between sleep difficulties and such outcomes as poor school performance, as well as the extent to which biological rhythms affect sleep patterns in teenagers. Viewing adolescent sleep problems from a public health perspective suggests that public education programs and social marketing campaigns related to other health concerns may provide models appropriate in this area as well. ADOLESCENT DEVELOPMENT AND SLEEP To provide a background for examining the sleep problems of young people, Robert Blum, professor and director of General Pediatrics and Adolescent Health at the University of Minnesota, reviewed recent research on adolescent development, highlighting new ways of looking at developmental stages. He noted that, historically, adolescent development has been looked at as a discrete phenomenon. Today, that has changed and adolescent development is understood to be heavily influenced by the contexts within which young people live. In short, young people adapt to their environment as the environment adapts to them. Puberty is a transitional period between childhood and adulthood. During this time of growth and change, young people begin to develop adult reproductive capabilities and their organ systems undergo dramatic changes. The timing of puberty is extremely variable. For boys the age of onset is between 9 and 15, whereas girls may experience puberty at 8 to 16 years of age (National Research Council and Institute of Medicine, 1999). The age of pubertal onset shifted downward in the 20th century in North America and Europe, due in part to public health factors such as improved sanitation and better nutrition. Accompanying these dramatic physical changes are shifts in cognitive development. During this period, adolescents move from a child's trial-and-error approach to problem solving to more abstract reasoning and skills.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP Completing a puzzle, for example, is likely to be done first by arranging pieces mentally before moving them on the board. Adolescents grow in language sophistication as well, as they begin to grasp multiple meanings of words—for example, puns and double entendres. During puberty, young people also begin to understand and engage the world differently, shifting gradually from egocentrism to mutuality. With the development of mature social cognition comes the capacity to read social cues, to infer what people are thinking based on not only language but also nonverbal signals. This is seen very dramatically at about seventh grade, when young people start becoming socially savvy. For those who fail to develop this capability, the consequence can mean social isolation. All these changes take place in particular environments—family, community, social—some of which may promote healthy development and others may predispose adolescents to risk. Research on resilience and protective factors, for example, shows that parental connectedness enhances and promotes healthy development in adolescents. Findings also indicate that having fewer children and spacing births two or more years apart provides greater opportunity for family interaction, Blum said. Parental mental health is a significant influence, particularly if there is a history of substance abuse or psychiatric hospitalization. Conflict within the family undermines the security of the home as a place for positive development. “Children need a safe and secure base,” Blum said. “There are two places where they can get this: at home or at school. If neither provides safety and security, the potential for trouble exists.” Blum noted that policies also have an influence—policies related to youth employment, for example. Research indicates that working more than 20 hours a week during the school year is associated with a variety of unhealthy and problem behaviors in youth, including substance abuse, insufficient sleep, and limited time spent with families (National Research Council and Institute of Medicine, 1999). Understanding the influence of various policies, including school starting times, is important to the discussion of adolescent sleep issues as well. ADOLESCENT SLEEP PATTERNS AND DAYTIME SLEEPINESS Workshop participants heard from a panel of researchers who reviewed findings from the United States and abroad on sleep patterns and problems

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP in adolescents. They discussed findings indicating that the factors contributing to teenagers' sleep loss lie in both the biological and the social realms. Mary A. Carskadon, director of the E. P. Bradley Hospital Sleep Research Laboratory and professor in the Department of Psychiatry and Human Behavior, Brown University School of Medicine, noted several major trends in adolescent sleep patterns. Data from cross-sectional surveys of students show that, from ages 10 to 17, students' self-reported bedtimes become later and later, on both weekdays and weekends (Carskadon, 1990; Wolfson and Carskadon, 1998). In middle adolescence, rising times become earlier during the week, due largely to school starting times. High school starting times, which typically are earlier than those of middle and elementary schools, have moved to even earlier hours in recent years. Many begin at or before 7:30 a.m., largely due to the timing and availability of school buses. Thus, while sleep needs remain unchanged, Carskadon said, adolescents are spending less time sleeping, and alterations in sleep schedules during the week compared with those on the weekend are becoming more pronounced. This is in sharp contrast to the stable pattern of sleep found in younger children, who get the same amount of sleep during the week as on weekends—an average of 10 hours a night, Carskadon noted. The effects of restricted sleep on sleep structure, mood, and performance in children and young people have been evaluated under different conditions (Carskadon and Dement, 1981). In a longitudinal study of sleep and sleepiness in young people, researchers assessed children in a summer “sleep camp” laboratory at Stanford University (Carskadon, 1982). Researchers began studying the children when they were 10 to 12 years of age and followed them every summer for 4 to 6 years. Researchers measured their sleep according to the Multiple Sleep Latency Test (MSLT), a standard measure of sleepiness; the test is administered at designated periods throughout the day to determine the time it takes subjects to fall asleep (Carskadon et al., 1986). In the laboratory the young study subjects wore electrodes that gauged their physiological reactions in sleep and while they were awake. Each night they had the same 10-hour window of time available for sleep, with sleep latency—the time it takes to fall asleep—tested throughout the day at 2-hour intervals. Starting with the hypothesis that the amount of sleep needed would decrease with age to a typical adult 7.5 hours a night, the study assessed the youngsters at various stages of pubertal development to shed light on the issue of sleep needs. The results showed that the younger children slept 9 hours and 20

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP minutes on average and awoke spontaneously. As they progressed through adolescence, they continued to get the same amount of sleep, but they no longer woke spontaneously before the end of the sleep window. At midpuberty, adolescents also became sleepier during the day. According to the MSLT, prepubertal and early adolescents were unable to fall asleep in the daytime, but at midpuberty, even with 9 hours and 20 minutes of sleep, daytime drowsiness appeared and worsened. These older adolescents struggled to stay awake throughout the day, whereas the younger adolescents had no problem at all. A sleep habits survey administered to more than 3,000 Rhode Island 9th to 12th graders revealed that the median amount of reported sleep in this group was 7.5 hours (Wolfson and Carskadon, 1998). A quarter of these students reported sleeping 6.5 hours or less. For two-thirds of the students, bedtime was after 11 p.m. on school nights; 91 percent rose at 6:30 a.m. or earlier. Seventy percent of the teenagers delayed both bedtime and wake-up time by an hour or more on weekends to try to catch up on their sleep. Sleeping late on Saturday and Sunday, however, usually fosters a later sleep onset on Sunday night. Despite this, sleeping in on weekends allows adolescents to pay back some of their weeknight sleep debt, some workshop participants observed. Influences on Adolescent Sleep Patterns The various factors that influence how much adolescents sleep cluster into two major areas. One is intrinsic—the biological processes going on internally in adolescents; the other is the external factors— social, academic, and environmental—that play a significant role in their sleep habits. Intrinsic Factors Internal processes themselves fall into two types. One is the biological timing system—the circadian rhythms of approximately 24-hour intervals that influence when and how much we sleep. The second is the internal system that tallies the balance of sleeping and waking—the sleep/wake homeostasis system: when sleep is deprived, more sleep is needed. Thus, as discussed at the workshop, “sufficient” sleep can be defined as the amount that satisfies the homeostatic process and is not associated with daytime sleepiness. This is analogous to the daily caloric requirement to maintain a stable weight.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP Research findings suggest that changes occur in the “biological clock” during adolescence. As a result, teenagers have a natural tendency to fall asleep later and to wake up later. This is referred to as sleep phase delay. Carskadon described research on college students that restricted their sleep to 5 hours a night for several nights. This study found that daytime sleepiness increased with each night of restricted sleep, indicating the cumulative effect of sleep loss. The research also showed that even with restricted sleep students felt more alert in the evening, encouraging the tendency to stay up late again (Carskadon and Dement, 1981). If additional tests of sleep latency are carried out at 8 and 10 p.m., a student who struggled and dozed through the early afternoon becomes energetic and internally stimulated in the evening, often past midnight. Another study that looked at the effects of the biological clock did so by examining melatonin secretion. As night falls, melatonin is “turned on,” preparing the body for sleep. Toward dawn, it shuts off, as cortisol secretion increases. Carskadon discussed research on 10 adolescents (five boys and five girls; mean age of 13.7) who were put on a fixed sleeping schedule for 10 days at home. Their schedules were checked by sleep logs, telephone calls, and wrist actigraphy (a device worn to measure daily activity levels). They then were assessed in a laboratory setting on a 28-hour schedule that controlled for all environmental and psychosocial influences on sleep (e.g., lights, television, radio). A correlation was found between subjects ' melatonin secretion and their stage of development. The results indicated that melatonin onset occurs later in adolescents, making it difficult for them to go to sleep earlier at night. At the same time, the hormone “turns off” later in the morning, making it harder for them to wake up early (Carskadon et al., 1998, 1999). At the workshop, Carskadon said that more research is needed to determine whether the apparent changes in melatonin secretion found in this study are a primary intrinsic phenomenon. Comparisons with adults and adolescents under the same conditions are required for more definitive examination. “While it may not be an immutable biological process, ” Carskadon told workshop participants, “it sets the stage for other psychosocial and environmental conditions that make it easier for these adolescents to stay awake.” Adolescent development in general, she added, is “a handshake” between biology and behavior, not just one or the other. The circadian system is governed by the 24-hour alteration of light and darkness. These findings in a laboratory setting in which light and darkness are controlled suggest that the circadian system can be reset with

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP controlled light exposure. At the same time, Carskadon noted that it may take less light to affect this system. An interesting question is whether teenagers' sensitivity to the ambient light they are exposed to in the evening—including from television, computers, and video games—might contribute to this evening arousal (Minors et al., 1991). Other participants noted that it is not just sleep loss that is troublesome in adolescents but also the enormous variation in their weekday/weekend sleep patterns. While some argued strongly that allowing students to sleep in on weekends was essential for reducing their sleep debt, others pointed out problems: a youngster who gets up at 6 a.m. on weekdays and then sleeps until noon or later on weekends is experiencing “a Washington to Hawaii time zone change twice a week,” said Richard Ferber, a workshop discussant. In effect, the body is in a physiologically wrong time zone. Other studies have examined teens under the conditions in which they normally function. A field study of adolescents with an early school starting time (7:20 a.m.) showed that many had an elevated rate of REM sleep1 and fell asleep within 5 minutes during morning MSLT tests (Carskadon et al., 1998). “For these kids,” Carskadon said, “biological night is 8:30 a.m., when they are in second-period class.” The challenges of engaging such youngsters intellectually when they are in the trough of their circadian rhythms was vividly explored by Catherine Colglazier, a teacher in Virginia (see Box 1). In addition to the obstacles to learning, for those who drive to school the increased risk of accidents because of drowsiness is a serious concern. External Influences While an inherent phase delay may make it difficult for teenagers to go to bed early at night, other factors clearly play a significant role in the amount of sleep they get. During adolescence, social obligations and opportunities increase, academic requirements become more demanding, and opportunities for work expand. Young people themselves often point to homework as a contributing factor; however, many adolescents actually spend little time on academic pursuits, Carskadon said. Those on the academic fast track, however, do devote more time to school work. Many adolescents are involved in extracurricular activities for many hours a week. For some young people in team sports, this may involve 20 hours or more a week. Many coaches help students plan their sleep, but some youngsters report that practice requirements are a significant factor in their not getting enough sleep, according to Carskadon. 1   REM sleep is one of two basic sleep states. This type of sleep is indicated by rapid eye movements similar to those that occur in wakefulness and characteristic brain wave patterns. More REM sleep occurs toward the end of the night.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP BOX 1 A Teacher's Perspective Fairfax County teacher Catherine Colglazier described a typical day at her McLean, Virginia, high school, where the doors open at 7:15 a.m. Students come in either fired up on caffeine or straggly and sleepy eyed. Because McLean High School has block scheduling, she has 90 minutes at 7:20 a.m. to keep students awake and learning through a variety of activities, including SAT preparation, writing, and literature. At 8:30 a.m., no matter how good the teacher is, some kids are dozing off. Why are they so sleepy? Most students in Colglazier's class reported going to bed well after midnight. One of the issues teachers face in identifying kids with sleep problems is that parents are reluctant to have such a problem be part of any kind of record or referral for their child because it could be misconstrued as a sign of possible drug use. Another reason that adults seem stymied in helping kids with sleep difficulties is that people don't yet know about or believe the research. In many schools, high SAT scores are evidence that young people are successful. While a student may be taking caffeine pills on a regular basis, acceptance to an Ivy League school speaks louder than any concerns teachers or parents might have. A second issue is money. There are many competing demands on school systems, such as reducing class size and providing competitive salaries. When it comes to devoting substantial funds to adjust school bus availability and scheduling, a change to an earlier starting time doesn't seem to be worth the money. A third issue is the impact on extracurricular programs. Since the recent tragic shootings in U.S. schools, most school administrators are working hard to provide a range of activities and clubs that make kids feel connected to school, happier, less violent, and less depressed. The young person who wants to create a club for those interested in computer games is just the sort of teenager schools want in their after-school programs. But doing this is difficult if school starts later. Cultural factors play a role as well. Americans thrive on stress and admire those who are very active. This is reflected in advertisements and movies, and teenagers respond to the popular culture.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP All these things take place in an environment in which television, computers, telephones, video games, and socializing with friends are widely available to most young people, often without parental monitoring and regulation of time spent on these activities. Also, the majority of adolescents have part-time jobs, and many work more than 20 hours a week. Beyond 20 hours is considered to be the point at which working becomes problematic for kids going to school (National Research Council and Institute of Medicine, 1998). A 1994 survey of Rhode Island high school students found that 40 percent of 9th through 12th graders worked on average 20 hours a week (Wolfson, in press). Working is understood to be an important adult role, Jeylan Mortimer, professor, Department of Sociology, University of Minnesota, observed at the workshop. Studies show that all adolescents, both boys and girls, expect to work during a good part of their adulthood (Mortimer et al., 1999). As noted earlier, adolescence is a time when young people are projecting themselves into the future, and some believe that working encourages “planful competence,” a capacity to think about opportunities, potentials, and interests and to plan for desirable outcomes in the future. Working also fosters work readiness—the importance of getting to work on time, proper attire and behavior in the work environment, and so on. Parents are very positive about their children's jobs, reporting that their children become more capable in managing their time and money and in developing social skills and other benefits (Mortimer et al., 1999). They recall the place of work in their own lives in encouraging these same positive traits. There is, however, a case against adolescent work. It involves concerns that working too much draws young people away from school, reducing the amount of time available for homework and families. There is also growing evidence that working more than 20 hours a week during the school year is associated with a range of problems, including poor academic performance, use of alcohol and other drugs, and risk of involvement in sexual activity and delinquent behaviors (National Research Council and Institute of Medicine, 1998). Working too much also impinges on the amount of sleep young people

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP get. In the Rhode Island study noted above, analysis of sleep to work time revealed that, for every 10 hours worked, students lost 14 minutes of sleep per night. A student who works 20 hours a week loses approximately 3 hours of sleep per week. In the 5 percent of the sample who worked full time, students lost an hour of sleep per night or 7 hours weekly (Wolfson, in press). International Comparisons How do young people in the United States compare with those in other countries as far as sleep is concerned? Amy R. Wolfson, associate professor of psychology at Holy Cross College, presented findings from a number of studies that reveal both similarities and differences. It is important to note, she said, that a comprehensive dataset using similar measurement tools across countries does not exist. Challenges to International Data Comparisons A number of issues make comparisons difficult across countries. Definitions of key terms, for example, vary greatly. In surveys done outside the United States, researchers discussing sleep latency—the time it takes to fall asleep—generally describe it as insomnia. It is not clear whether this corresponds to what in this country would result in a diagnosis of insomnia. Rather, it may refer to delaying bedtimes as opposed to genuine difficulty falling asleep. It is also difficult to discern in studies conducted abroad whether total sleep time is based on an average across both weeknights and weekends. Obviously, what is considered a weekend varies. For example, in Israel the weekend is Friday afternoon through Saturday evening, with students returning to school on Sunday. In addition, minimal information exists regarding school schedules, so the research presented at the workshop reflected only what little could be determined about school start times in other countries. Research conducted in Amsterdam looked at 1,500 12- to 18-year-olds with school starting times from 8 to 9 a.m. (Hofman and Steenhof, 1998). A second study, in Brazil, looked at a small sample of 12-to 16-year-olds with school starting times of 7:20 a.m. (Andrade et al., 1993). A third study, in Taiwan, assessed more than 900 13-to 15-year-olds (Gau and Soong, 1995); because Taiwan categorizes students academically very

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP As mentioned throughout the workshop, depression is not only a symptom of sleep deprivation but can also be a cause. A number of teenagers who are depressed have disturbed sleep and insomnia. In teenagers, as in adults, many who are depressed don't seek help from mental health care professionals. They will, however, often see their primary care physicians because of sleep difficulties, which can provide an opportunity to diagnose and intervene in the depression. Anxiety disorders, specifically panic attacks, can occur during the day as well as at night. Such nocturnal attacks can contribute to sleepiness during the day. Substance Abuse As noted by workshop presenters, smoking has increased significantly among teenagers, especially among young women who smoke to control their appetite and weight as well as in response to peer pressure and other factors. A number of surveys have shown that those who smoke cigarettes have increased problems falling asleep and staying asleep (Phillips and Danner, 1995). They have daytime sleepiness, increased incidence of depression and minor accidents, and, interestingly, a higher consumption of caffeine than nonsmokers. It is not clear whether the sleep problems reported by smokers are related specifically to nicotine or something else in cigarettes or to their associated increased use of caffeine. No studies of teenagers have examined alcohol use in relation to sleep cycles, but the adult literature clearly shows that alcohol use is associated with truncated or nonexistent slow-wave sleep episodes and longer REM periods (Lands, 1999). Alcohol has been thought of primarily as a problem of teenage boys, but the gender difference has disappeared. Not only have girls caught up, but in certain studies, particularly of binge drinking on college campuses, girls exceed boys in terms of alcohol ingestion. Amphetamine use also is being seen more and more in girls, who take amphetamines because they suppress appetite. When amphetamine users stop using the drug, part of the withdrawal syndrome includes sleepiness as well as depression. Sexual and Physical Abuse Rarely discussed in the context of sleep disturbance is the role that abuse might play. For example, Litt discussed a survey of more than 3,800 girls in a nationally representative cross section of schools. The findings

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP indicated that one in five girls in grades 9 through 12 reported that they had been physically or sexually abused. Among those who reported such abuse, more than 50 percent said they were abused at home. More than half of that group said they were abused by a family member. Two-thirds of those abused at home by family members say it has occurred repeatedly (Schoen et al., 1997). Those who evaluate sleep disorders in teenage girls can ask questions to determine how safe teens feel in their beds and homes. Some teenage girls seek care for sleep disorders, creating an opportunity for clinicians to identify their physical or sexual abuse. Educating Clinicians About Adolescent Sleep Problems Many workshop participants observed that training for medical personnel was necessary at all levels—teaching sleep medicine to not only medical students but also pediatricians and primary care physicians. The American Medical Association's Guidelines for Adolescent Preventive Services recommend that all physicians who see teenagers should evaluate certain aspects of each young person's history, including parenting, development, diet, fitness, lifestyle, injury prevention, eating disorders, sexual activity, substance abuse, school performance, and depression (Elster and Kuznets, 1993). Litt noted that the guidelines do not include statements about surveying patients to determine the extent of sleep difficulties. While it is important to teach physicians how to identify sleep difficulties, it is equally important to inform them about remedies, beyond prescribing drugs for sleep. Understanding Adolescent Sleep Disorders Mark Mahowald, director of the Minnesota Regional Sleep Disorders Center, noted that sleepiness has long been seen as a sign of laziness, boredom, slothfulness, work or school avoidance, depression, and drug and alcohol abuse. Sleepiness in anyone, certainly adolescents, is due to either volitional sleep deprivation or, more importantly from a clinician's standpoint, a diagnosable and treatable sleep disorder. Until sleepiness is recognized as more than a character defect, individuals with diagnosable and treatable sleep disorders may not receive appropriate diagnosis or treatment (see Box 2). According to Mahowald, parents need to know that adolescents stay up late because they are not sleepy; they sleep in on weekends not to avoid

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP BOX 2 Diagnosing Sleep Disorders Mark Mahowald described several cases at the Minnesota Regional Sleep Disorders Center. One involved an 18-year-old referred to the center for excessive daytime sleepiness, which began at 10 years of age. Initially diagnosed with a psychiatric condition, the patient was hospitalized at the University of Minnesota Hospital adolescent psychiatry ward for months with the diagnosis of avoidance behavior. Unable to stay awake in class, he had to leave school. Sleepiness ended his academic career, and the same thing happened when he went into the work force. He couldn't stay awake at work and was assumed to be lazy or avoiding tasks and was fired. Formal evaluation indicated he had classic narcolepsy. Consider whether his academic and employment record might have been different if his sleepiness at age 10 had been recognized as a symptom of a medical disease rather than a psychiatric one and treated accordingly. Another case is that of a 10-year-old boy with a diagnosis of attention deficit disorder and poor school performance who was in special education classes and taking Ritalin. Fortunately, someone in the school system remembered that one of the first symptoms of sleepiness is impaired sustained attention. After a sleep evaluation, he was discovered to have severe obstructive sleep apnea. With treatment came a dramatic reversal in his school performance, and he was able to go without medication. A 17-year-old was in danger of being expelled for his inability to get to school on time because of oversleeping. When he did go to school, he fell asleep in morning classes. Actigraphy—monitoring by means of a wrist device to measure daily activity levels—revealed a striking delayed sleep phase syndrome. He was awake until 3:00 a.m. because his biological clock did not permit him to fall asleep before then. But he attended a typical high school, which meant he had to get up at 6:30 a.m. He was expelled even after school administrators learned that he had a diagnosed medical problem. morning chores but because they are calling in their sleep debt. Students need to understand that sleep is important. Teachers need to be aware that sleepiness in the classroom is not necessarily related to drug abuse or boredom. Other school officials need to know that true sleepiness is a serious sign and symptom, Mahowald said.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP Physicians at sleep centers routinely see adolescents who have been expelled from school because of sleepiness that is in fact due to an unrecognized and untreated sleep disorder. Mahowald pointed out that students are not expelled when they have seizures, asthma, or other medical problems, but that they are expelled for sleeping in class or not being able to get to class on time in the mornings, when the problem may in fact be due to a diagnosable and treatable sleep disorder. Qualified sleep centers exist in almost every large community in this country. Most have staff available to talk to teachers, school nurses, school psychologists, and school board members. Sleep medicine experts have both an opportunity and a professional responsibility to integrate scientific data and help broaden understanding of sleep problems and their treatment. CHANGING SCHOOL STARTING TIMES Among the responses proposed to alleviate adolescent sleep problems, some school districts have considered changing their school starting times. Workshop participants learned of research in the Minneapolis metropolitan area on attitudes toward such a change and preliminary findings from schools that actually implemented later starting times. During the 1996-1997 school year in Edina, Minnesota (a suburb of Minneapolis), the high school day shifted from a 7:20 a.m. start to 8:30. In the following school year the Minneapolis Public Schools changed the starting time from 7:15 to 8:40 a.m. at seven of its high schools. Kyla Wahlstrom, associate director of the Center for Applied Research and Educational Improvement of the University of Minnesota, reviewed early findings from studies of these schools as well as data collected in surveys and focus groups involving key stakeholders, including students, teachers, and parents (Wahlstrom and Freeman, 1997; Kubow et al., 1999). The schools studied represent different socioeconomic groups and levels of diversity among student populations. In Minneapolis the schools were in an urban, low-income setting with 12,000 students, including a large immigrant population, where half of the students fail to complete high school. Suburban Edina, in contrast, has high socioeconomic levels and about 1,800 high school students. In Edina, enrollment is stable and most students go on to college. Early findings from studies in these Minnesota schools showed that a majority of teachers reported that a greater number of students were more

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP alert during the first two school periods than they had been with an earlier start time. Slightly more than half said they saw fewer students sleeping at their desks. In Minneapolis, teachers were evenly divided about whether student behavior improved. Edina teachers indicated markedly improved student behavior. School nurses and counselors also reported fewer students seeking help for physical complaints or stress. In Minneapolis schools, both teachers and students reported a drop in the number of students involved in extracurricular activities; later schedules also posed difficulties for some students who worked after school. Edina students and teachers saw no significant change in after-school activities, including work. Wahlstrom emphasized that these were early findings and that both additional data and further analysis are needed on the effects of changes in school starting times (Wahlstrom, 1999). Wahlstrom also summarized key results from surveys conducted with more than 7,000 students in three Minnesota school districts, using the Brown University School Sleep Habits Survey. The main purpose was to discover any differences among students in one district that had changed to a later starting time and two others in which the earlier starting time was maintained. Researchers found significant differences in students' responses regarding their sleep habits. Where the later time was instituted, students reported getting a full hour more of sleep than those with the earlier starting time. These students also reported less overall sleepiness, less daytime sleepiness, and less depression, as well as higher grades than their peers in the other schools. These findings do not indicate causality —that a later starting time will cause improvement in academic grades —but do show a statistical relationship between these two variables that may be explained by such things as less struggle to stay awake in class when starting times are later. Attitudes Toward School Starting and Dismissal Times To shed light on how teachers and other school professionals view current starting and dismissal times, researchers also surveyed more than 3,000 secondary school teachers. More than half of the high school teachers surveyed said the optimal time to start school is 8:00 a.m. or later. When asked what would be the latest time to end the instructional day without negative impact on such activities as sports, debate club, or choir, almost 44 percent said that a 3:00 p.m. dismissal time would not have a negative impact on these activities.

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP A telephone survey of 765 parents included a question about preferred time for their children to leave home in the morning. For senior high school students, most parents preferred a time of 8:00 a.m. Forty-five percent said they gave that reason because it allows more sleep. Workshop participants emphasized that later school starting times are not a panacea for adolescent sleep problems, nor do they work well for all students or all school districts. Regardless of what time school starts, some adolescents may need to get up earlier to take care of siblings or to get a ride to school. For those considering such a change, it is essential to glean data from sleep research. Armed with the available knowledge, school boards and communities can have an informed debate. Any change in education systems requires gathering all stakeholders to review the data and debate the range of possible options. Public awareness and education also are crucial, as is the involvement of key education officials. EDUCATING THE PUBLIC ABOUT ADOLESCENT SLEEP NEEDS Workshop participants agreed that the issue of helping adolescents get more sleep is complex. Several identified a need for the public to be better informed about the biological (circadian and homeostatic) influences on adolescent sleep patterns. At the same time, social and behavioral influences play a critical role and need to be recognized. In the laboratory or another setting, such as a camping trip, it is possible to strip away such distractions as television, computers, phones, social events, and lights, and adolescents are more likely to go to sleep early and get up early, getting their required amount of sleep without problems. But returning to society, current cultural influences, and their own habits, they revert to the sleeping patterns that have been documented as causing problems. How can more informed practices be developed? Workshop participants looked at public education and social marketing approaches that have had positive effects in other public health areas. Lloyd Kolbe, director of the Division of Adolescent and School Health at the Centers for Disease Control and Prevention, discussed the public health perspective, with its focus on treatment and prevention. These approaches attempt to change not only the population at risk —young people—but also the societal institutions that most influence their health and development. Public health approaches are necessarily long term and gain synergy from cooperation and collaboration. Changing existing cul-

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP tural norms around teenagers' sleep behaviors probably will require a decade-long effort. More than a single institution, whether that be schools or health care providers, must be involved. Each of these institutions faces competing demands—improving SAT scores, coping with the HIV (human immunodeficiency virus) epidemic, or drug and alcohol use—that require attention. Successful efforts to change attitudes and behaviors, Kolbe said, would be based on population-based data on educational or health outcomes, increases in productivity, decreases in impulsivity, and other conclusions from studies of adolescent sleep, such as those presented at the workshop. The financial and practical implications of implementing changes also need to be spelled out. To avoid patchwork approaches, it may be useful to think about addressing the issue simultaneously from the local, state, and national perspectives. This would tap the creativity and communication channels of both government and the private sector (see Box 3 andBox 4). The array of institutions and groups is very broad: parents and families; schools, including teachers and their organizations, school counselors and psychologists, school administrators and superintendents; health care professionals, including physicians and nurses and their associations, such as the American Academy of Pediatrics and the Society for Adolescent Medicine; businesses that employ youth; and higher education, including medical schools, schools of public health, colleges of education, and schools of government and public affairs. Government has a critical role to play, as U.S. Representative Zoe Lofgren discussed at the workshop (see Box 5). Particularly important are state legislatures, especially on issues of education. With the necessary leadership to bring these and other key stakeholders together, it may be possible to bring about more coherent and comprehensive change than could be achieved one school at a time or one district at a time. NEXT STEPS Workshop participants agreed that raising public and professional awareness of the sleep needs of adolescents and the consequences of insufficient sleep is critical. Research findings presented at the workshop on the effects of inadequate sleep on mood, academic and work performance, physical and mental health, and traffic safety are compelling but need to be more widely known among policy makers, parents, young people, and the public. According to a poll conducted by the National Sleep Foundation,

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP BOX 3 Getting the Word Out “Back to Sleep” Campaign One of the most successful public health campaigns of the past decade is the “Back to Sleep” campaign carried out in this country and throughout the developed world to help prevent sudden infant death syndrome (SIDS). Marian Willinger, special assistant for sudden infant death syndrome at the National Institute on Child Health and Human Development (NICHD), reported on the campaign's evolution, planning, and implementation. In contrast to concerns about adolescent sleep, both the medical community and the public were generally aware of the risk of SIDS. Several population-based studies had been carried out, revealing a strong association between infants' sleeping on their stomachs and the incidence of SIDS. With the impetus of the American Academy of Pediatrics Task Force on Infant Positioning and Sudden Infant Death as well as continuing research by NICHD and others in this country and abroad showing promising results, especially overseas, a coalition of the medical community, parents' advocacy organizations, and state-level alliances initiated the public education campaign. The message was simple, a catchy phrase was selected—“Back to Sleep ”—based on a similar British campaign, and a public service announcement campaign was launched. Target audiences were chosen, and dissemination of materials to parents, hospitals, and day care providers was free and widespread. Evaluations of the campaign indicate a high level of impact on public awareness and on behavior. most Americans get less sleep than they need, with 30 percent usually sleeping 6.5 hours a night or less during the work week; 40 percent report that daytime sleepiness interferes with their daily activities. More than 60 percent have driven while feeling drowsy, and 27 percent report that they have dozed off while driving, if only for a moment. This poll also found that 60 percent of children complained to their parents about being tired. Nearly a quarter of parents with children living at home and 23 percent of adults without children favor later school starting times (National Sleep Foundation, 1999). Workshop participants noted the complexities involved in changing awareness and understanding of sleep needs in a culture in which high

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP BOX 4 Getting the Message into the Media Another approach taken by organizations that seek to raise awareness of a problem and change behavior is the National Campaign to Prevent Teen Pregnancy, which was launched in 1997. One of its key approaches is working with the media. The campaign has developed partnerships with people in the entertainment industry to help them reach audiences with messages about teen pregnancy prevention. Sarah Brown, campaign director, discussed issues relating to whether and how to engage the mass entertainment media—television, radio, magazines—in conveying important health information. The campaign always begins with the facts, drawing on the best science and research, and reaching out to include key stakeholders, including parents, schools, the faith community, business, and teens themselves. In developing their media program, they recognized that the impact of media messages in changing behavior is still not clear. Research on public service announcements, for example, indicates that kids tune these out. So the campaign focuses on engaging media leaders as partners and friends. The approach involves getting messages into the story lines of entertainment programs and media that reach the target audience. The campaign offers a range of messages that are based on research; the choice to use them is, of course, up to the media. To date, the campaign has been successful in getting messages in such magazines as Teen People, the story line of such television programs as ABC's “One Life to Live” and Black Entertainment Television's “Teen Summit” series. levels of activity and extended work schedules symbolize success. Similarly, young people themselves deal with the distractions of social life and entertainment media that impinge on their sleep. In the policy arena, consideration of such issues as changes in school starting times must compete against very real concerns about the financial implications, the impact on the variety of reform efforts, and the effect on extracurricular activities seen as important to strengthening adolescents' connection to their schools. A starting point for both education and policy analysis is the science behind adolescent sleep needs and difficulties. While time and other constraints at the workshop limited the amount of detailed information presented, the wealth of research available is suggested by both the references

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP BOX 5 The Zzzzz's to A's Act Workshop participants also learned of one policy maker's response to concerns about adolescent sleep. Representative Zoe Lofgren (D-CA) reported that she had introduced legislation to provide a small amount of funds to encourage school districts to consider whether school starting times should be changed. Known as the “Zzzzz 's to A's Act,” the bill was proposed in March 1999 in conjunction with National Sleep Awareness Week. The legislation would make it easier for high schools to cover the increased operating costs associated with changing school starting times by providing up to $25,000. Prominent researchers, including those present at the workshop, have endorsed the bill. Representative Lofgren acknowledged that the money would simply be an incentive rather than funding for all the costs involved. She also candidly acknowledged that her bill stands little chance of passing. However, the bill officially recognizes what researchers, parents, and teachers know: high school students are suffering from sleep loss while trying to cope with the stresses of school, work, and social activities. She called experiences in jurisdictions that have tried later starting times promising. She also noted the “morality” issue that comes into play when discussing adolescents and sleep that is not present in looking at other problems. As other participants noted, sleepiness is seen as a character defect. She urged that science-based information on the effects of inadequate sleep on learning, academic achievement, and accidents be brought to the attention of school boards. and the sources for additional information that appear at the end of this report. Greater awareness and understanding of this research can help parents, teachers, and teens themselves see the problem from a different perspective. Participants noted that additional research on young people would help to both disentangle the factors contributing to adolescent sleep problems and assess their long-term effects. In particular, more documentation of sleep debt and its size in high school students is needed, comparing students without a sleep debt to those with a large sleep debt. More indepth studies also should focus on the perspective of teens themselves on their sleep habits and problems. Other questions for research include the following:

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SLEEP NEEDS, PATTERNS, AND DIFFICULTIES OF ADOLESCENTS: SUMMARY OF A WORKSHOP How can we better understand the sensitivity of the circadian system to changes in ambient light? Would providing bright light in the morning in homes and schools help students who are drowsy? What is the parental role in monitoring adolescents' sleep schedules in both the United States and other countries? What are the contextual and cultural issues related to sleep that require investigation? How can more complete and methodologically sound comparisons be drawn between adolescent sleep patterns in the United States and those in other industrialized countries? What are the costs and benefits of measures to counter the problem of inadequate adolescent sleep? As research on these and other important questions continues, the growing knowledge should be applied to designing interventions that promote better sleep habits and improve the health and safety of adolescents. These indude more effective identification of sleep problems in young people and approaches for reducing automobile accidents caused by drowsy drivers. Similarly, broad dissemination of research findings is essential. As workshop participants noted, such communication efforts could draw on a variety of disciplines and organizations that have a stake in understanding adolescent sleep difficulties and possible approaches to help young people, their families, their schools, and the health care system promote healthy adolescent development.