Pamela J. Brown - Sleep Education Synthesis (Final Draft) - NNU Master's Degree

Running head: INTERVENTIONS FOR ADOLESCENT SLEEP DEPRIVATION 1
Sleep Education as an Intervention in Adolescent Sleep Deprivation
Pamela J. Brown
Northwest Nazarene University

INTERVENTIONS FOR ADOLESCENT SLEEP DEPRIVATION 2
The Synthesis
Sleep Education as Intervention in
Adolescent Sleep Deprivation
Is presented to the Northwest Nazarene University Counselor Education Department in partial
fulfillment of the degree requirements of the completions of the Master of Science in
Counseling.
__________________________________
Faculty Advisor; Dr. Michael Pitts
__________________________________
Pamela J. Brown

Abstract
This synthesis covers current research in the science of sleep and teen sleep deprivation
outcomes. It covers a brief history of sleep including past and current theories of the purposes of
sleep and then move on into sleep structure through developmental stages. Next, it covers
adolescent struggles with sleep; including how the biology and developing chronotype
(morningness-eveningness trait) can affect adolescents making it twice as hard for some of them
to succeed. Finally, this paper will cover possible interventions that can, have, and need to
happen in all schools and homes if we hope to help our children succeed at their optimal levels
and give them hope for a better future in an increasing technological world. As demands on
adolescents increase, interventions teaching them about sleep hygiene should be addressed not
only by adjusting environmental schedules but also by introducing programs to curriculum that
will facilitate learning and understanding of the construct of sleep.

Table of Contents
1. Introduction....................................................................................................5
2. The Basics of Sleep........................................................................................7
3. Sleep Theories................................................................................................10
4. Sleep Structure...............................................................................................12
5. Chronotype, Chronobiology and Circadian Rhythm .....................................14
6. Opponent-process and Two-process Model...................................................15
7. Sleep Disorders..............................................................................................20
8. Sleep Debt......................................................................................................21
9. Sleep requirements and development ............................................................23
10. Teens and Sleep Deprivation .........................................................................25
11. Negative Impacts of Sleep Deprivation on Teens..........................................28
12. Possible Solutions..........................................................................................40
13. Later School Times........................................................................................40
14. Double Shift School System..........................................................................44
15. Educational Interventions ..............................................................................45
16. Parental Education and Involvement .............................................................47
17. Conclusion .....................................................................................................48
18. References......................................................................................................50
19. Figures............................................................................................................61
20. Appendix A: Horne & Ostberg Questionnaire..............................................68
21. Permission for Use of Images........................................................................76

Introduction
One could argue that the problem started with the light bulb. Before then human beings
entrained their bodies to the light and dark schedule of the day, because lighting candles
throughout the night used up too many resources. People slept when it was dark instead of
watching television on our big-screens, playing 3D animated video games on game consoles, and
updating our Facebook status until two in the morning. We didn’t have personal digital
assistants (PDA) with backlit screens that we could not only arrange our schedules at three or
four in the morning when the idea struck, but also stream instant movies and television that we
may have missed due to other engagements we were involved in throughout the earlier evening.
Sleep, next to the digital demands of society, is getting less and less important to many when it is
what we should be paying attention to in our own lives, and the lives of our children.
An increasing body of research is showing how important it is for children to get the
appropriate sleep for their growing bodies. Parents give them early bed times, which fit in fairly
well and work to their advantage. Due to their development, children are more morning types
anyway so they have hardly any trouble getting along on this schedule. For adolescents it is a
little more difficult.
Until the recent two decades, researchers had no idea why adolescents had such a hard
time with getting to sleep on time. Sleepy teens seemed to have a stubborn attitude and a desire
just to stay up and play video games. Parents blamed sleep onset delay on the teenage years and
how difficult that time is supposed to be anyway. However, recent research has given us many
reasons to believe that for adolescents, sleep is not so easy (Carskadon, 2011; Colrain & Baker,
2011; Cowley, Acebo, & Carskadon, 2007; Dagys, et al., 2012; Giannotti, Cortesi, Sebastiani, &
Ottaviano, 2002; Golombek & Cardinali, 2008; Kelley, Lockley, Foster, & Kelley, 2014; Lange

& Randler, 2011). There are many things that they just do not have as easy. If there is one thing
they could look forward to, it is that this time of struggling with sleep could end once they leave
adolescence.
During adulthood, for reasons unknown to researchers, sleep cycles and the need for
sleep decreases. It becomes easier to program again with the societal demands of scheduling the
seven to eight hours of sleep per night that an adult requires on average (National Sleep
Foundation, 2007). However, because of many troubles adolescents have with sleep, often times
they grow to have equally poor habits as adults. They continue with poor sleep hygiene habits
because they do not know any different. What if they are educated on the multi-faceted subject
of sleep before adolescence hits and the struggle begins? What might happen if they have the
opportunity to head the problem off at the pass?
This synthesis is a brief look at many parts of sleep that every person should learn about
in some form or another. It will begin with a brief history of sleep including past and current
theories of the purposes of sleep and then move on into sleep structure through developmental
stages. Next, we will cover adolescent struggles with sleep; including how the biology and
developing chronotype (morningness-eveningness trait) can affect adolescents making it twice as
hard for some of them to succeed. Finally, this paper will cover possible interventions that can,
have, and need to happen in all schools and homes if we hope to help our children succeed at
their optimal levels, and give them hope for a better future in an increasingly technological
world. As demands on adolescents increase, interventions teaching them about sleep hygiene
should be addressed not only by adjusting environmental schedules, but also by introducing
programs to curriculums within schools that will facilitate learning and understanding of the
construct of sleep.

Literature Review
Basics of Sleep
Every individual needs sleep. Mammals, reptiles, birds, all types of living creatures need
some sort of sleep. Over the years, there have been reports of people who either do not sleep, or
sleep very few hours a night and seem to function at a normal level. A search on the internet will
give a few examples of people who have suffered from some severe health scares and are
afterwards unable to sleep at all.
There have been other studies done that have shown the more devastating results of total
sleep deprivation. In a landmark series of studies done in 1989 by Rechtshaffen et al. rats were
put on an apparatus that would keep them awake at all times. Rats were able to live for up to 32
days but suffered severe reactions from the sleep deprivation from skin lesions to full sepsis and
organ failure. Either way you look at it, every person needs to sleep. They need time for their
body to heal and regenerate from the energy they have used throughout the day.
If an individual is asked to define what sleep is, the answer may be difficult for anyone to
think of. Most would answer that it is the opposite of being awake. Evidence has shown that
even when people believe they have been awake, they have actually been having what is called a
micro-sleep. An operational definition of a microsleep is a sleep episode lasting less than five
minutes (Dement & Vaughan, 1999). Microsleeps can occur without an individual even being
aware of them. Microsleeps were not even something that were know about until a researcher
started attempting to find the exact moment a person fell asleep, and he came across the
discovery.
William C. Dement, a major contributor and trusted physician in sleep communities
authored a book titled The Promise of Sleep in 1999. In his book, he gave two points to justify

the definitions of sleep. The first of the essential features of sleep is that “sleep erects a
perceptual wall between the conscious mind and the outside world.” (p. 17) He gives an
example of this in an experiment he did which featured a participant having a strobe light flash
placed six inches in front of their eyes. Experimenters asked participants to restrict their sleep to
only four hours the night before to induce sleep deprivation. After a few minutes, after strobe
flashes took place, the participant missed pushing the button to identify when they saw the flash.
Dement clarified that the only way for the participant to have missed the flash was if they had
actually fallen asleep for two seconds with their eyes open. Within those two seconds, sleep had
built a perceptual wall between the conscious mind and the outside world (Dement & Vaughan,
1999).
The second quality that Dement uses to define sleep is that the person must be able to be
awakened. If no amount of stimulation wakes the person, the state they are in is not sleep. They
would be either unconscious or dead (Dement & Vaughan, 1999). While he was able to
determine a definition of sleep, he also used this example to explain how microsleeps occur in
daily life even when we are not aware of them. The individual was not aware of a strobe light
flashing inches from his face when his eyes were open. He was asleep for what was only a
second or two, but enough to lose consciousness of his surroundings.
In early history, sleep was seen as a time of inactivity. However, as has been discussed
earlier, sleep is anything but inactivity. The human body is hard at work even while sleeping.
There are different biological functions that occur during sleep starting from the brain and
radiating throughout the body just as the circulation system does. Figure 8 illustrates the areas of
the human brain where scientists have found an increase of activity during sleep.

With such a wealth of information, one might think we could figure out why a person
needs to sleep, or what actually goes on inside a person’s head while they are sleeping.
However, this is not the case. Because of the mystical nature of sleep and our inability now to
know for sure what goes on, we are left, just as before, with theories and hypotheses.
Human beings spend one third of their life sleeping. That is equal to 112 days each year.
Even with the amount of time human beings spend sleeping, we have yet to discover the reasons
why we would die without it. Great discoveries throughout history have brought numerous ideas
and knowledge about what happens during sleep. Philosophers and scientists have posited many
theories and hypotheses about the function of sleep. However, with the advances made in
science and sleep research, scientists are getting closer to answers.
History is filled with ideas of why people sleep. While Aristotle’s theory of human sleep
may be preposterous to us in the 21st
century, it may have started people thinking more in depth
about what sleep is. In 350 B.C., Aristotle believed that after a person ate, digestive processes in
the stomach would release vapors. In his book, On Sleep and Sleeplessness, he wrote, “when the
external nutriment enters the parts fitted for its reception, the evaporation arising from it enters
into the veins, and there, undergoing a change, is converted into blood, and makes its way to
their source, [the heart]”. He goes on to say these vapors rise to the top (the head) and then turn
to mass again. The head will become heavy, causing drowsiness, and then cause the person to go
to sleep (Aristotle, 2007). Thomas Cogan carried on Aristotle’s theory even as late as 1584. He
took the vapor idea even further by saying that different foods can produce the vapors more
quickly such as wine, meat, and milk (Cogan, 1584). Centuries later, researchers have developed
better ideas for why sleep actually occurs.

Sleep theories. A theory proposed by Oswald (1980), and then expanded upon by Horne
(1988), started with the idea that people obtain only two types of sleep. Van Dongen, Rogers
and Dinges (2003) refer to the initial hours of sleep that a person gets as ‘core sleep’. According
to this theory, the body and brain repair the effects of waking wear and tear during core sleep.
After core sleep hours are completed ‘optional sleep’ hours take place (Horne, 1988; Oswald,
1980; Pa Van Dongen, Rogers, & Dinges, 2003). For Horne this explained why many
individuals didn’t need to have the same amount of sleep as other people and why a person could
still function if they had only gotten four or five hours of sleep (Pa Van Dongen, Rogers, &
Dinges, 2003; Horne, 1988). While this theory alone may not have been able to be substantiated
completely, it proposed ideas that have stuck around until now.
The inactivity theory, also referred to as the adaptive or evolutionary theory of sleep, is
an old theory that states sleep is a method of preservation for animals or different species. The
concept is based in evolutionary theories that would ensure an animal’s survival because of a
certain trait. According to the inactivity theory an organism would sleep and therefore draw less
attention to them thus preventing being hunted by predators. While this theory seems much less
logical, it paved the way for more sound theories in current science (Harvard Medical School,
2008).
Another past theory for why people sleep is the energy conservation theory. The idea
behind the energy conservation theory (also referred to as conservation of energy theory) is if we
did not sleep, we would expend too much of our bodies needed resources and would not survive.
It says that the metabolic slowdown and heat dissipation experienced during sleep are tools for
conserving needed energy for survival (Sleep Research Society, 1997; Harvard Medical School,
2008)

A more current theory of what happens when people sleep is the restorative function
theory. This theory illustrates the idea that people regenerate when they sleep. It says that when
a person goes to sleep at night, the body repairs itself from stress exerted throughout the day. At
first glance, it would seem that humans have the ability to regenerate. “This is further supported
by findings that many of the major restorative functions in the body like muscle growth, tissue
repair, protein synthesis, and growth hormone release occur mostly, or in some cases only,
during sleep” (Harvard Medical School, 2008). However, science has not identified for sure
what is restored (Sleep Research Society, 1997). Another part of the restorative theory is the
buildup of adenosine in the human body. Adenosine in the brain acts as a neural brake that
slows down several different processes. Throughout the day, the body builds up its level of
adenosine. Adenosine contributes to sleep pressure and once sleep occurs then the buildup is
decreased and then sloughed off (Dement & Vaughan, 1999).
The most recent, and possibly most logical reason for why people sleep, is the brain
plasticity theory. Throughout each day the human brain learns, collects, and attempts to organize
loads of information (Dement & Vaughan, 1999; Harvard Medical School, 2008). Each night
when a person goes to sleep the brain uses the time to reorganize all of the information and
format the brain much like a hard drive on a computer with files upon files (Harvard Medical
School, 2008; National Sleep Foundation, 2007). The brain needs this time to form new
connections with new information and memories or it will fail to take in the new information.
With so many theories explaining why researchers suggest people need to sleep, over 74% of the
population do not get the adequate amount of sleep recommended by the scientific community
(National Sleep Foundation, 2007). Sleep disorders are a large cause of this problem.

As stated earlier, theories of sleep and the stages of sleep have evolved and changed as
technology has allowed us to study the area more in depth. The latest development happened in
2007. The American Academy of Sleep Medicine published a revision of the sleep stages that
all accredited AASM professionals will use to decipher EEG recordings.
Sleep structure. With current and ongoing research in the area of sleep, the American
Academy of Sleep medicine determined that a set of standard stages needed to be agreed upon
when measuring sleep. In the new AASM guidelines, there are REM stages and NREM stages.
Rapid Eye Movement (REM) is the first stage of sleep and can be visually identifiable when
sleep occurs by the eyes rolling and moving around under the eyelids of the sleeping individual
(Siegel, 2005). The other sleep stages go deeper in succession and are labeled as Non-REM
stages (NREM). All of the REM stages are the same; however, they can vary in length (Iber,
Ancoli-Israel, Chesson, & Quan, 2007). The REM stages are experienced intermittently
throughout the night. Stages of sleep cycle through at different times throughout the night, but a
person will go back to REM sleep before moving back into a NREM stage. NREM stages are
split into N1, N2, and N3.
The Electroencephalogram (EEG) is a way for researchers to be able to measure stages of
sleep in humans a reliable and valid way. It gives them a way to see what is going on inside the
brain without doing a surgical procedure. “Tiny flat metal disks called electrodes are placed all
over your scalp. The disks are held in place with a sticky paste. The electrodes are connected by
wires to a recording machine. The machine changes the electrical signals into patterns that can
be seen on a monitor or drawn on paper. It looks like wavy lines” (Campellone, 2014).
An EEG measures brainwaves in a human being during sleep without disrupting the sleep
process. For use in sleep studies, a person’s brainwaves are measured for a desired amount of

sleep or normal amount of sleep. During this time the EEG measures the waves that the brain
emits during sleep. When looking at the output of waves for sleep, doctors and scientists can
measure the amount of REM sleep and NREM sleep depending on what the lines drawn by the
EEG show them (Dement & Vaughan, 1999). Figure 1 shows placement of three different types
of electrodes such as the EEG, EOG (electrooculogram), and the EMG (electromyogram). Figure
2 illustrates the parts of the brain that show activity during sleep that can be measured by an
EEG.
The latter two of these function quite similarly as the EEG in that they use small
electrodes and give output of small squiggly lines to show activity of the corresponding areas.
An electrooculogram shows the eye movement involved while being measured, and the
electromyogram shows the level of tension within the jaw muscles while being measured.
Different brainwaves and amounts of activity within the body are measured depending on what
stage of sleep a person is. The deeper a person is sleeping, the less the spindle moves on the
EEG also shown in Figure 1. During N1 stage, a person is falling asleep. When the person is
awake, they have alpha waves measuring normally between 8 and 13 Hz. During N1, the brain
will move from these alpha waves to theta waves (4-7 Hz). This is the stage in which people are
seen twitching or jerking and the person loses awareness of the outside world (Sleep Research
Society, 1997).
The next stage of sleep, N2, is where the brain moves from alpha waves (8-13 Hz) to
theta waves (4-7 Hz). It also introduces something called sleep spindles. Sleep spindles are
spikes in an EEG reading (12-16 Hz). Some suggest that this could be partly due to the body
trying to stay asleep. Another occurrence in this stage is a K-complex. A K-complex is a very

brief high amplitude EEG spike at times triggered by a loud noise. K-complexes usually follow
sleep spindles and can happen many times throughout the N2 stage of sleep.
Stage N3 is deep sleep or slow-wave sleep (SWS) and makes up almost 50% of all sleep
waves for a person. Many troublesome things can occur during this stage. Sleepwalking,
bedwetting, and night terrors can happen during these stages. A person awakened during this
stage of sleep may suffer from something referred to as sleep inertia. Sleep inertia is when a
person has had the adequate amount of sleep, but still feels as if they need to go back to bed. It
can last anywhere from 45 minutes to 3 hours depending on the time that the person is awakened.
The main feeling accompanying sleep inertia is grogginess.
Most theorists agree that the most restful sleep happens during SWS; though some say
dreaming can happen in REM also. A misleading attribute of the sleep stages is the order of
their occurrence. Sleep stages occur almost in waves themselves. While the body will start in
REM sleep and move to N1, move through N2 and then to N3 and N4, it will then move back to
N3 and up to N2, to N1 and back into REM sleep once again before starting another cycle
through the stages. Though the stages will cycle through repeatedly throughout the night, it is
most likely that N3 and N4 or SWS will only occur once or twice more during the night. Figure
3 shows an average sleep structure of a healthy young adult through a full eight-hour sleep
session.
Circadian Rhythm, Chronobiology, and Chronotype
Franz Halberg, from the University of Minnesota, coined the term “circadian rhythm” in
1969 when he was measuring different hormones in the blood of mice. He combined the term
“circa”, in Latin, to show that it was near or similar to a “dies”, or day, also in Latin (Dement &
Vaughan, 1999). He noticed that some hormones in the mice he was studying were present at

some times of the day but then were not at others. He also noticed that these times were on an
oscillatory cycle over a 24-hour period. When referring to circadian rhythms, many processes
are structured within the oscillatory structure also termed as the opponent-process model and the
two-process model.
Opponent Process Model and Two-Process Model.
Sleep for human beings is a homeostatic process on an approximately 24 hour cycle
(Dement & Vaughan, 1999, p. 79; Millman, 2005). Millman (2005) states, “These 2 systems,
working together or in opposition, influence the activities of the endocrine, thermoregulatory,
neurobehavioral, renal, cardiovascular, digestive, and sleep/wake systems.”(p. 1175) The easiest
way to imagine a homeostatic process is with a teeter-totter; the old childhood toy with a child
sitting on each end and balancing upon something sturdy in the middle. Each child will take
turns going into the air while the other goes toward the ground; the same way a homeostatic
process occurs. Process one builds enough pressure to overpower the other. Once process two
builds up enough pressure, it will regain control. Sleep works much in this same way. The two
opposing processes in this case are sleep and wakefulness. Sleep pressure builds throughout the
day until it has increased enough to overpower wakefulness. Once wakefulness has allowed the
sleep pressure to dissipate throughout the night, it again takes over and wakes us each morning.
According to Dement and colleagues at Stanford, sleep is the stronger of the opposing
processes. He says that the sleep drive is always active and is always either keeping us asleep at
night, or building pressure throughout the day. However, wakefulness is not always active
because human beings are able to utilize it enough during the day to stay awake. Once sleep
time arrives, the sleep drive takes over.

Another name used for this same concept is the two-process model. Rosen (2005) helps
to explain the two-process model previously introduced by Borbely (1982) by further saying that
once again it is a homeostatic process where sleep (S) builds pressure throughout the day until an
individual goes to sleep and the circadian rhythm (C) has a chance to help the sleep pressure
dissipate. Figure 4 illustrates this concept with the shaded area identifying when the person is
asleep and S is allowed to dissipate. If sleep deprivation continues further, the dashed line in this
illustration shows how sleep pressure would continue to build until sleep occurs.
An individuals’ chronotype has been synonymously referred to as circadian typology.
The term chronotype refers to one’s individual time-of-day preference. It has also been used to
determine whether a person has higher levels of morningness or eveningness. To explain this
concept it helps to learn a little about chronotypes. The scale of morningness to eveningness is a
concept that dates back to the work of O’Shea (1900). However, systematic studies did not
begin until almost 4 decades later with Freeman and Hovland (1934) and Kleitman (1939)
measuring body temperature throughout the day (Hines, 2004).
Within the construct of chronotype, there are three different possibilities. The first of
these types is the morning type (MT). MTs are the type of individual that wake at an early hour,
have a peak level of performance early in the day and then go to bed at an early hour (Adan, et
al., 2012). Morning chronotype individuals prefer arising early, and they often feel they do their
best work before noon and would rather do their most difficult work early in the day (Hines,
2004).
The next level on the scale would be neither type (NT). When an individual is scored as
a neither type that means they get up at an average hour, have peak performance at an average
time of day and they go to bed at an average time in the evening.

Finally, there are the evening types (ET). Evening types wake at later hours in the
morning, have a later time of day for peak performance and then they go to bed later in the
evening or sometimes into the very early morning hours. “If the individual has an intermediate
or morning chronotype, performance will be best early in the school day; in the case of evening
types, subjective feelings and mental performance during the early part of the school day are
likely to be submaximal.” (Valdez, Reilly, & Waterhouse, 2008)
There are different factors that go into identifying morningness and eveningness of an
individual which are biological factors and personality factors. Biological factors that have been
used to measure chronotype of an individual are the sleep-wake cycle, body temperature
fluctuations, and the release of the hormones melatonin and cortisol (Adan, et al., 2012).
The human body has an endogenous (internal) ‘circadian’ clock that runs on an
exogenous (external) 24 hour light to dark cycle provided by nature (Maire, Reichert, &
Schmidt, 2013). This ‘master clock’ in charge of these cycles is a pair of cell groupings called
the suprachiasmatic nuclei (SCN) located within the hypothalamus in the brain, as pictured in
Figure 5 (Maire, Reichert, & Schmidt, 2013; Sharma & Feinsilver, 2009). The SCN receives
signals from other sensory stimuli throughout the day to trigger the processes of the body
involved in the sleep-wake schedule. Variables encountered throughout the day that stimulate
the SCN are called zeitgebers (German for “time-giver” (Sharma & Feinsilver, 2009). Possibly
the most important zeitgeber in this context would be light. The 24-hour light to dark exogenous
sensory cycle in nature can be a good example of how the processes within the SCN work
(Sharma & Feinsilver, 2009). First, the retina contains specific cells (photoreceptor cells)
devoted to perception of light. Photoreceptor cells then send messages to the SCN to tell what

time of day it is based on the intensity of the light perception (Schulz & Steimer, 2009; Sharma
& Feinsilver, 2009).
Another process is the secretion of hormones within the brain that prompt sleep. The
pineal gland in the brain secretes different hormones measured for peak levels throughout the
day to determine circadian rhythmicity. It secretes melatonin in the evening to signal our bodies
when it is time to go to sleep and then secretes cortisol to tell our body to wake up and be active.
Sleep pressure begins to build upon waking in the morning and will continue until one goes to
sleep. When an individual goes to sleep the sleep pressure dissipates (Borbely, 1982). This
balance between sleep pressure and its’ dissipation in many studies is a part of homeostasis. A
scientific explanation for the sleep pressure buildup and dissipation process is homeostasis of the
sleep pressure. Homeostasis is defined as “coordinated physiological processes which maintain
most of the steady states in the organism” (Maire, Reichert, & Schmidt, 2013). Together, these
processes include more markers which can be measured to determine what state of wakefulness
one’s body is in.
Kelley, Lockly, Foster and Kelley (2014) introduce a term called the “wake maintenance
zone” (WMZ) which they say occurs a few hours before sleep occurs. This period generally
does not have a sleep pressure that is high enough to “counteract the circadian drive for
alertness”. They also say that teens have a later WMZ, which causes adolescents to stay up later
due to low sleep pressure. They suggest that because the WMZ is “still promoting wakefulness”;
adolescents are simply unable to go to sleep as early as they are required to for early school times
and other activities. When they are forced to wake too early in the mornings, they are
experiencing increasing sleep deprivation on a daily basis. (Kelley, Lockley, Foster, & Kelley,
2014)

Another marker signaling chronotype and chronobiology is body temperature. Body
temperature was the first indicator to be measured in identifying individuals’ biological rhythms
and preferred arising or bed times (Hines, 2004). The body temperature drops and changes much
as sleep pressure does during sleep. It drops measurably during sleep and starts to rise again
once sleep pressure dissipates. Figure 6 illustrates this concept. It has further been studied and
is now accepted to be regulated by melatonin secretion when sleep onset is about to occur
(Krauchi, Cajochen, Mori, Graw, & Wirz-Justice, 1997). When melatonin is introduced into the
body’s system its’ thermoregulatory system then starts to drop core body temperature to mark the
beginning of a sleep phase (Krauchi, Cajochen, Mori, Graw, & Wirz-Justice, 1997). Researchers
are able to introduce melatonin at an earlier hour thereby inducing a slow drop in core body
temperature and triggering other sleep processes.
Time of day differences for performance in people can be attributed to their chronotype.
Because of the costly nature of physiological testing that is needed to track circadian phase
markers and determine chronotype such as core body temperature, melatonin secretion and light
sensitivity cues in the brain, a much more user-friendly tool was designed in the late 1970s.
The most widely used measurement tool for morningness-eveningness in an individual is
the self-report measure from Horne and Ostberg (1976) that identifies each individual into one of
three categories which are morning type (MT), neutral or neither type (NT), and evening type
(ET) (Adan, et al., 2012). It is translated into many different languages and tests for reliability
and validity show that all versions are quite highly rated. (Hines, 2004; Adan, et al., 2012) Even
though a diagnosis of definitely morning type or definitely evening type is relatively rare there is
still enough evidence to show that teens shift toward a definite evening type during puberty
(Hines, 2004).

Sleep Disorders
Probably the most common of the sleep disorders is insomnia. However, most people do
not understand that there are many different symptoms of insomnia (Mayo Foundation for
Medical Education and Research, 2007). Professionals have agreed that the general amount of
sleep needed is 7 ½ to 8 hours of sleep. Some people may even require nine to ten hours of sleep
per night. Some of the symptoms of insomnia are waking up too early, daytime sleepiness,
irritability throughout the day, and the most common symptom is not being able to fall asleep
when desired. So, what causes insomnia? It can be caused by stress, depression, medications,
change in environment, change in activity levels, and can even be caused by eating too much too
late at night. It almost seems that avoiding insomnia is like walking on a tight rope. Insomnia
may be the most common form of sleep disorder, but by far is not the only type. Medicines have
been developed to battle insomnia and help people fall asleep and stay asleep throughout the
night; though, even over-the-counter antihistamines (diphenhydramine), taken in appropriate
quantities, can have the same effect for some people (Mayo Foundation for Medical Education
and Research, 2007).
Sleep apnea is also a common sleep disorder. Of the three sleep apnea disorders (central,
mixed and obstructive), OSA, or Obstructive Sleep Apnea is the most common. Obstructive
sleep apnea is a period of sleep where the person actually stops breathing for a time. The airway
collapses and air is cut off from the lungs. The brain interrupts the sleep cycle to wake up just
enough to breathe. Loss of breathing can occur hundreds of times each night. The cessation of
breathing can last for fifteen seconds to one minute before the brain interrupts sleep (Sleep
Research Society, 1997).

The final type of sleep disorder covered is circadian rhythm disorder. As discussed later,
a person’s circadian rhythm slows down the metabolism and lower’s the body temperature at
certain times of the day. These times vary for each individual, which accounts for the terms
night owl and morning person. Because of the high variability of circadian rhythms, societal
constraints may put some people (night owls) at a disadvantage. Some individuals stay up late at
night because of a little known circadian disorder called Delayed Sleep Phase Syndrome (DSPS).
This disorder’s main symptom is the inability to fall asleep within two hours of the desired sleep
time (Sharma & Feinsilver, 2009). Because a person is unable to fall asleep at the desired hour,
they are forced to get up at a time that their body is not set for (Sharma & Feinsilver, 2009). The
general idea here is that a person’s circadian clock is pushed back by two or more hours. They
usually need the same amount of sleep that others need, but the problem arises when they are
forced to cut their sleep time short by waking up according to the schedule society has laid out
(Sharma & Feinsilver, 2009).
An increasing amount of literature is showing adolescents are at a higher risk of
developing DSPS because of their biology. Hagenauer, Perryman, Lee, and Carskadon (2009)
identified several different reasons that are contributing to DSPS in adolescents including light
exposure and hormone fluctuations. They also theorize that this problem is not limited to only
the human species but that when different animals are put under the same conditions they also
exhibit similar symptoms (Hagenauer, Perryman, Lee, & Carskadon, 2009).
Sleep Debt
Each night that that an individual is deprived of a portion of this sleep accrues over time
until the person is able to catch up. Another way to think of this is with the homeostatic sleep
pressure. If a person is unable to get sufficient sleep to take sleep pressure down to its lowest

level, they will build the pressure back to its highest point much quicker than before. To explain
this concept an example can be used. If an adult requires, on average, eight and a half hours of
sleep each night to feel fully rested that would be their required sleep amount. If over a one-
week period this person were to go to bed one hour later each night but wake up at the normal
time each day, they would only receive seven and a half hours each night. By the end of the
seven days, they would accrue a seven-hour sleep debt that must be accounted for. Some
researchers have used a bank account as a metaphor to help explain this concept. If you accrue a
sleep debt, you will owe your body that much sleep and somehow it will make you pay up. The
question then becomes, where do we end up making up for this sleep debt? For many
individuals the sleep debt is reconciled each weekend when they finally get to sleep in. Sleeping
in two to three hours each day on the weekends will normally fulfill a person’s sleep debt and
leave them feeling better rested and functioning better.
Dr. William C. Dement has become one of the leading researchers on sleep, and has
strong interests in the area of the sleep debt. Sleep debt is based on research that says individuals
have a certain number of hours they need of sleep each night. According to the idea of sleep
debt, a person must reach the appropriate number of hours they are supposed to sleep or else
missed hours add up throughout the week. An example of this would be a normal adult who
requires eight hours of sleep each night. If this adult has a stressful week and only attains an
average of about six hours of sleep per evening, he will acquire a sleep debt of 14 hours.
According to Dement, a person will sleep off the debt over the weekend. However, because
Friday night is the most prominent time for social activities, driving around with a sleep debt of
14 hours can cause driving hazards. In addition, after a prolonged time of sleep debt and sleep

deprivation, a person can start to have serious detrimental health issues (National Sleep
Foundation, 2007).
Other hazards of sleep deprivation have been noted in other recent studies. A study in
2004 done by a researcher at Harvard University suggested that “hospitals could reduce the
number of medical errors by as much as 36 percent by limiting an individual doctor’s work shifts
to 16 hours and reducing the total work schedule to no more than 80 hours per week” (Harvard
Medical School, 2008). In addition, basic human functioning suffers. Sleep deprivation
negatively influences our mood, our ability to focus, and our ability to access higher-level
cognitive functions (2008). These are just a few of the negative impacts that sleep has on an
individual. With these included, many problems have been further studied throughout current
research.
With these and all other identified problems as side effects of sleep deprivation, the
mystery of how to regain control of sleep is still being studied. Many people have their own
ideas of how to increase productivity and cut down on sleep so they can get further ahead in our
society. However, they are putting themselves in dangerous territory for problems in many areas
of their lives because of the sleep deficit.
Sleep Requirements and Development
Sleep also changes throughout the developmental stages ranging from babies needing 18
hours of sleep each day to the elderly who seemingly need approximately 6 to 7 hours each
night. Figure 7 shows a chart of the average number of hours of sleep required each night as
opposed to the average amount of REM sleep per night throughout the developmental lifespan.
Though when asked how many hours of sleep humans need most of the population might
say eight hours, as stated earlier, each person needs a different amount of sleep to function at an

optimal level. This number is also based on developmental stages. Newborn babies through two
months will sleep between 10 and 18.5 hours on average. Between three months and eleven
months infants will typically sleep nine to twelve hours during the night and take 30 minute to
two-hour naps, one to four times a day. At ages one through three, toddlers usually need
between 12 and 14 hours of sleep in a 24-hour period. When they reach about 18 months of age
their naptimes will decrease to once a day lasting about one to three hours. Preschoolers
between ages three and five will need approximately 11 to 13 hours of sleep and they might take
naps in midday but not usually after the age of five. School aged children, ages five to twelve,
average a need of 10 to 11 hours of sleep each night. That means that if school starts at 7:30 in
the morning, a child will probably need to be up and getting ready one hour prior and bedtime
would be 8:00 each evening.
Adolescence is a “period marked by dramatic biological and social changes that can
affect health and behavior, including sleep” (Colrain & Baker, 2011). Several different studies
support different sleep patterns within the adolescent stage of life. These changes not only take
place within behavioral differences but in the basic structure of adolescence. Sleep changes
affect sleep quality, quantity and the increased demands in social and academic workloads of an
adolescent (Colrain & Baker, 2011; Wolfson & Carskadon, 1998).
Many different things are attributable to getting a good night’s sleep during adolescence.
A study written by Chen, Wang, Jeng (2006) found three different major findings. The first of
these is “adequate sleep is positively correlated with the frequency of health-promoting
behaviors.” (p. 6) This is based on the idea that when an adolescent gets the sleep they need they
are more frequently found to have better “stress management, healthy diet, life appreciation,
health responsibility and exercise” (p. 6) These habits can be attributed to adequate sleep.

Another finding is adolescents getting adequate sleep have a higher probability of not becoming
overweight and having fewer appointments with doctors. Lastly, they found “middle school
students had a higher frequency of adequate sleep than high school students.” (p. 6)
Sleep based beliefs are another facet of sleep education that are understood less than
optimally. Diaz-Morales, Prieto, Barreno, Mateo and Randler (2012) looked into the sleep
beliefs of adolescents and their correlation with eveningness and morningness. They showed
that evening type students had a higher likelihood to have improper sleep beliefs. They also
posited that this could be because evening types generally have different beliefs because of their
eveningness. (Diaz-Morales, Prieto, Barreno, Mateo, & Randler, 2012) However, for
adolescents that have to abide in a morning type schedule to go to school, evening type beliefs
may not be appropriate.
Teens and Sleep Deprivation
The National Sleep Foundation published a report in 2000 that identifies teens need at
least 8.5 hours of sleep each night and once puberty hits there is a phase delay in teen sleep
habits. According to this report, teens have a hard time falling asleep earlier than 11:00pm.
They also listed an increase in daytime sleepiness as an attribute of teen sleep (National Sleep
Foundation Sleep and Teens Task Force, 2000). In research done by Gibson et al. (2006) over
1000 Canadian adolescent students were surveyed to identify how prevalent their subjective level
of sleepiness was and whether it has an impact on curricular or extracurricular activities. They
found that over 70% of students were sleep deprived according to the necessary 8.5 hours of
sleep requirement. The researchers also suggested that “parents and educators need to know that
adolescents’ tendency to go to bed late and wake late is normal, and this must be considered in

addressing sleep habits and in academic scheduling and transportation” (p. 6). Gibson et al.
continues to say:
There is a need for educators to be more aware of the impact of school start times and
academic scheduling, and to consider sleep problems as potential factors in students who
fail to achieve or who exhibit behavioral problems. … Perhaps the most significant
impact of sleep deprivation may be on the secondary development of the brain that
commences during puberty. The lag between attainment of sexual maturity and
emotional development of high intensity feelings, such as risk taking, and the
development of a set of neurobehavioral systems for self-control and affect regulation
may be accentuated by sleep deprivation.
As mentioned earlier, teens have a difficult time getting the sleep they need on a regular
basis. This brings to question, why is it so much more of a problem for them than adults? At
first glance, it seems simple to determine that the reason why teenagers are so much more sleep
deprived than their younger peers is increases in homework, social demands and the
opportunities for getting a job. However, another factor is contributing to the problem that in the
past may have been thought of as part of the rebellious stage. Teenagers have a biological
tendency to stay up later in the evening, which leads to them getting decreased amounts of sleep
as they get older (Wiggins & Freeman, 2014). That is to say, teens are more likely to display
evening type traits that may contribute to more problems with waking early in the morning and
life demands.
According to the two-process model, sleep pressure builds throughout the day and only
dissipates upon sleep. Jenni, Achermann, and Carskadon (2005) further established this concept

when using a controlled experimental design to measure sleep deprivation on adolescents
between the ages of 10 and 19. Through the process, they deprived the adolescents of sleep for
36 hours and measured their brain activity using an EEG. Results echoed previous research
showing a correlation between the age of the child and a steady decrease in sleep pressure
depending on the child’s age (Jenni, Achermann, & Carskadon, 2005).
Fischer et al. (2008) summarized the findings of over 11,000 European student surveys
by saying, “we can conclude that adolescents around the world shorten sleep according to age
mainly by delaying timing of sleep due to biological and psychosocial reasons and that they are
subjected to premature forced awakenings in connection to school days” (p. 19). Other studies
have found similar results in studies with adolescents in other countries around the world
suggesting the adolescent population affected by sleep deprivation might be worldwide (Fischer,
et al., 2008; Gradisar, Gardner, & Dohnt, 2011; Loessl, Valerius, Hornyak, Riemann, &
Voderholzer, 2008).
A study written by Hansen, Janssen, Schiff, Zee and Dubocovich (2005) used sleep
diaries and bright light therapy to determine if early school start times were making a difference
on students sleep habits. In addition to finding that bright light therapy had no effect on school
performance in mornings for students, they concluded that school start times do contribute to
sleep deprivation for students. The high school students involved were asked to keep a sleep
diary starting two weeks before the beginning of school and then for another six weeks during
the school year intermittently. The average sleep time before school started was 8.7 hours and
dropped to 7 hours once school started. This number was significantly different from weekdays
during the summer. However, weekend sleep times were not significantly different from the

summer averages. This contributed to the conclusion that school start times directly contribute
to sleep deprivation in adolescents (Hansen, Janssen, Schiff, Zee, & Dubocovich, 2005).
Another factor often overlooked in adolescent sleep research is the difference in
appropriate sleep times among different socioeconomic classes. Marco, Wolfson, Sparling and
Azparje (2012) used data from questionnaires, actigraphs and sleep diaries to determine the
levels of sleep deprivation among urban adolescents. They used the results to determine that
adolescents with a low socioeconomic status (SES) obtain significantly less sleep on a regular
basis. While this study does not discuss specific factors within environments, the researchers
mention that even different parenting styles could be contributing factors among the sleep
problems within low SES adolescent sleep problems (Marco, Wolfson, Sparling, & Azuaje,
2012).
Negative Impacts of Sleep Deprivation
One research article combines several studies ranging from correlational to quasi-
experimental and draws conclusions regarding how sleep or a lack thereof affects mental health,
academic performance and behavior. In the article, Beebe (2011) states that “findings from
studies that used complementary research methods have converged to strongly suggest that
inadequate sleep quality and quantity are causally linked to sleepiness, inattention, and probably
other cognitive and behavioral deficits that impact daytime functioning, with potential
implications for long-term development.” (p. 7) When adding a developmental context to all of
the studies he looked at in the study, he found that even “short-term sleep deprivation can alter
neural plasticity,” which is one of the brain’s major building blocks for memory and pathway
maintenance. (Beebe, 2011, p. 6)

Another article used frequently in adolescent sleep research and covers many different
facets of the problems facing teens is Excessive Sleepiness by Millman (2005). In the article
Millman discusses many of the concepts including biological, emotional, and behavioral
problems that may occur due to sleep. Daytime sleepiness is a leading contributor to many of the
problems that face teens with within their daily lives such as school performance, cognitive
function, and mood. (Millman, 2005)
Mood. Many studies have found problems with mood and affect when mixed with sleep
problems. Mood disorders, sleep disorders and other problems have a higher prevalence among
those who experience sleep deprivation due to school schedules (Giannotti, Cortesi, Sebastiani,
& Ottaviano, 2002; Wiggins & Freeman, 2014). Mood is also affected more by partial sleep
deprivation, such as one or two hours per day over a period of time, than a full day of sleep
deprivation is on a human being by an entire standard deviation (Durmer & Dinges, 2005).
Talbot, McGlinchy, Kaplan, Dahl, and Harvey (2010) completed a study in which they
identified characteristics in the moods of sleep-deprived individuals and non-sleep-deprived
individuals. They found participants reported less positive affect characteristics such as
“interested, excited, happy, strong, energetic, cheerful, active, proud, and delighted” when sleep
deprived (Talbot, McGlinchey, Kaplan, Dahl, & Harvey, 2010). They also found that there were
increased levels of anxiety in the sleep deprived participants as opposed to those who were rested
(Talbot, McGlinchey, Kaplan, Dahl, & Harvey, 2010).
Depression. Those who are sleep deprived are at a higher risk for depressive symptoms
and have an increased amount of irritability that can change their outlook on life. This outlook
on life can then become irrational and influence their overall mood. Most research within
adolescent sleep deprivation has used correlations among grades and school performance when

supporting hypotheses. Correlational design makes it impossible to define direct causal
relationships between two different variables. However, Dagys, McGlinchey, Talbot, Kaplan,
Dahl and Harvey (2011) used an experimental design to determine the effects of sleep
deprivation and chronotype on adolescent affect. Through their research they were able to
support their hypothesis stating that “participants reported less PA (positive affect) when sleep
deprived than when well rested.” This meant that when an adolescent is sleep deprived they are
less likely to have a positive affect though they also found contrary results to their hypotheses
saying that negative affect did not increase because of sleep deprivation. When looking at
chronotype in adolescents, the research showed that evening type adolescents were indeed more
likely to have decreased positive affect and a higher level of negative affect. This could be due
to sleep deprivation but also due to the evening chronotype being forced to function outside of
its’ optimal performance time (Dagys, et al., 2012).
There is also a genetic link between mood and sleep problems. Mendlewicz (2009)
discusses the genes within the human bodies that influence depressive symptoms such as sleep
phase problems. While the research does not draw conclusion as to whether one causes the
other, circadian genes are linked to mood genes through behavior and the brain. (Mendlewicz,
2009)
Suicide risk. One element of sleep deprivation, and the most lethal, is its effect on
mental health. Mental health professionals many times know to check if an individual has had
enough sleep when suicidal ideation and attempts take place. However, there are times when
sleep is overlooked as a possible reason for symptoms. Research indicates, “Fatigue resulting
from sleep difficulties may lead to hopelessness and decreased impulse control.” (Goldstein,
Bridge, & Brent, 2008)

People who complete suicide are more likely to have higher rates of difficulty with sleep
than controls even during their most recent depressive episode according to research. This same
study found that suicide completers were 10 times more likely to experience sleep problems
during the episode, and 4 to 5 times more likely to experience sleep problems or insomnia in the
week before death. “Sleep deprivation may impair problem-solving ability which when paired
with a decreased capacity to regulate emotional states when tired, vulnerable adolescents may
utilize limited alternatives for tolerating emotional distress.” (Goldstein, Bridge, & Brent, 2008)
Within the adolescent population, “adolescents sleeping less than 8 hours at night were
approximately 3 times more likely to make a suicide attempt than those who slept 9 hours or
more” (Liu, 2004). While there is no one sure way to determine whether or not an individual or
adolescent is thinking of suicide without self-reports, suicidal behavior may be due to poorer
judgement, concentration and impulse control and the increased risk of fatigue, hopelessness and
mental disorders.
Health. Other serious health problems are linked to sleep deprivation in past studies
including obesity, which can lead to high blood pressure, stroke, heart attack, and diabetes
(Wells & Vaughn, 2012).
Obesity. There is a large amount of research emerging on the link between sleep
deprivation in adolescents and obesity (Owens, 2014; Schmid, Hallschmid, Jauch-Chara, Born,
& Schultes, 2008; Spruijt-Metz, 2011; Taheri, Lin, Austin, Young, & Mignot, 2004). One
avenue of research has identified late sleepers as eating a higher amount of calories on average
and eating more after the 8:00pm mark than regular sleepers. Its’ findings also suggested that
those with a higher level of sleep deprivation had a higher BMI (Body Mass Index) and ate less
fruits and vegetables than others (Baron, Reid, Kern, & Zee, 2011). A population that is possibly

of even more concern is children that are struggling with their weight. When trying to
understand the reasons why children are struggling about their weight more and more as the
years go by there have been a few possible theories as to how sleep habits or the lack thereof
could be part of the problem.
One of the suggested reasons for this might be because of a similar hormonal fluctuation
as is seen with melatonin and cortisol. However, the hormones that are seen in weight gain are
leptin and ghrelin. When one goes to sleep at night the hormone leptin is secreted. This prevents
hunger from occurring while sleeping (Schmid, Hallschmid, Jauch-Chara, Born, & Schultes,
2008). When sleep duration is cut short or depleted this hormone does not flow and ghrelin, its’
counterpart is then released more throughout the waking hours. Ghrelin is a hormone that
triggers hunger. With more ghrelin running through the system, the body will feel hunger more
often (Taheri, Lin, Austin, Young, & Mignot, 2004; Schmid, Hallschmid, Jauch-Chara, Born, &
Schultes, 2008). An individual becomes sleep deprived, ghrelin in their system increases, and
they end up eating more because of the increase in food cravings throughout the day (Schmid,
Hallschmid, Jauch-Chara, Born, & Schultes, 2008). This shows that there is increasing evidence
that when children are getting less sleep at night they have increased ghrelin in their system and
this can be a cause for overweight and obese children (Buckhalt, Wolfson, & El-Sheikh, 2009;
Taheri, Lin, Austin, Young, & Mignot, 2004).
In their research, Knutson, Spiefel, Penev, and Van Cauter (2007) wanted to review
literature that added to the evidence of an imbalance of leptin and ghrelin in sleep-deprived
individuals and how this imbalance can affect metabolic systems within the body. They
identified at least three pathways that are at risk due to sleep deprivation which are the way the
body metabolizes glucose, an increase in appetite due to the hormonal imbalance, and a decrease

in energy expenditure (Knutson, Spiegel, Penev, & Van Cauter, 2007). These three things put
together make a combination that adds to the problems facing adolescents who are already at a
loss because of sleep deprivation.
A smaller and yet possibly more important avenue of research is between childhood
sleep, adolescent sleep, and obesity. Chen, Beydoun and Wang completed a meta-analysis of
over 42 different studies on children’s sleep habits and obesity. What they found was “strong
evidence to quantify the relationship between sleep duration and overweight/obesity in children
and adolescents.” They also found that “children with shorter sleep duration had a 58% higher
risk for overweight or obesity, and children with shortest sleep duration had an even higher risk
(92%) when compared with children having longer sleep duration. For each hour increase in
sleep, the risk of overweight/obesity was reduced on average by 9%.” (p. 271) They were able to
show an association with short sleep duration and an increased likelihood of obesity in the future.
The study suggests, “A combination of strategies targeting both earlier bedtime and later wake
time to increase sleep duration may help prevent childhood obesity.” (p. 272)
Cognitive function and academic performance. Academic performance has been a
difficult way to measure negative impacts of sleep deprivation. A reason for this might be no
way to control for academic performance across an entire population. Even though most
research agrees adolescent students need around nine hours of sleep each night, many surveys
suggest that students only get an average of seven hours (Louzada, da Silva, Peixoto, & Menna-
Barreto, 2008). Other school and life commitments make it difficult for teens to get that much
sleep on a nightly basis such as social demands, jobs, additional homework loads and
extracurricular activities (Dahl, 1999; Eliasson, Eliasson, King, Gould, & Eliasson, 2002).
Researchers have identified that academic performance is linked to sleep deprivation and

adjustments must be made to increase adolescent performance (Randler & Frech, 2009).
However, instead of using one measurement for academic performance, most researchers rely on
many different factors.
The first factor that sleep researchers look to is daytime sleepiness. Students sleep
through classes, have a decreased amount of attention on classroom activities and struggle to
follow basic instructions (Louzada, da Silva, Peixoto, & Menna-Barreto, 2008; Buckhalt,
Wolfson, & El-Sheikh, 2009; Hahn, et al., 2012). Sleep deprivation of one to two hours each
day for a week can cause symptoms of sleepiness (Louzada, da Silva, Peixoto, & Menna-Barreto,
2008).
Daytime sleepiness is most often measured using the Multiple Sleep Latency Test
(MSLT). During the MSLT a participant is monitored by a trained sleep technologist. It consists
of four 20-minute naps separated in two-hour intervals (Littner, et al., 2005). The amount of
time that it takes a participant to fall asleep is then given a score between 1 and 20; 20 being
falling asleep within the first 30 seconds and a score of 1 taking longer than 20 minutes to fall
asleep. The scores of the four naps are averaged which is then used as a score for daytime
sleepiness. The faster the individual falls asleep the higher the score for daytime sleepiness
(Littner, et al., 2005). Another study, done on over 6600 students found that evening type
students subjectively reported more problems with academic performance (Giannotti, Cortesi,
Sebastiani, & Ottaviano, 2002)
Wolfson and Carskadon (1998) published an article on adolescents sleep schedules and
academic performance. The researchers state that students who reported getting poor grades or
who were failing school were getting at least a half hour less sleep each night than those who

were doing well. They also found that those same students slept more on weekends than those
who get more sleep during the week (Wolfson & Carskadon, 1998).
According to a meta-analysis written by Curcio, Ferrara and De Gennaro (2006) of sleep
research, the first study to show that a sleep restriction of 5 hours one night is enough to affect
abstract learning in children negatively was by Randazzo et al. A follow-up study had similar
results and supported the findings that executive functioning in children is impaired even after a
small sleep impairment of 7h of sleep. The sleep restriction affected their verbal fluency and
creative thinking in both studies. Curcio, Ferrara and De Gennaro concluded based on the 9
major sleep research studies they included in their analysis, that “The effects of sleep loss are
mainly evident on higher cognitive functions (attention, memory, problem-solving, etc); as a
result, learning capacity and academic performance may seriously be affected.” (Curcio, Ferrara,
& De Gennaro, 2006)
Lim and Dinges (2010) completed a meta-analysis of 147 articles about the effects of
total sleep deprivation on cognitive variables. In their analysis, they found that “although total
sleep deprivation does produce statistically significant differences in most cognitive domains, the
largest effects are seen in tests of simple, sustained attention.” (p. 386) Because many activities
including driving a car are included in the sustained attention activity domain, adolescents are at
an increased risk because long-term partial sleep deprivation may be even worse.
Buckhalt, Wolfson and El-Sheikh (2009) found that “total sleep time, erratic sleep/wake
schedules, late bedtimes and rise times, and poor sleep quality are associated with poorer school
performance when rated by teacher ratings, grades, individual and group achievement tests,
specialized tests of neurocognitive functioning, and comprehensive norm-referenced intelligence
batteries.” (p. 61) They went on to say that “self-reported eveningness, delayed sleep schedules,

and early school start times are associated with daytime sleepiness, dozing in class, attention
difficulties, and lower grades.” (p. 61) Also, “there is strong evidence based on research that
lower academic performance of children under stress is related to sleep.” (p. 62)
Durmer and Dinges (2005) wrote an article evaluating and identifying current research on
the neurocognitive consequences of sleep deprivation. They identified many of the problems
that are associated with not only full sleep deprivation but also partial sleep deprivation over
time. They reported that when comparing 2 weeks of partial sleep deprivation to 4 hours sleep
restriction each night, they showed equivalent deficits as those with two full days of sleep
deprivation in attention, working memory, and cognitive functions (Durmer & Dinges, 2005).
One article suggests mental performance deteriorates the longer a person is awake and
activities using mental performance are probably better done earlier in the day while artistic and
physical activities should be in the afternoon because of this. (Valdez, Reilly, & Waterhouse,
2008) Similarly, Durmer and Dinges (2005) suggest that sleep propensity increases the more a
person is sleep deprived and as a result cognitive performance is more variable due to the sleep
deprivation. (p. 118)
Gillen-O’Neel, Huynh, and Fuligni (2013) is another study demonstrating the effects of
sleep deprivation on academic performance. In their study, the researchers followed a sample of
students over their high school career. They had the students fill out diaries for two weeks each
year to assess daily study and sleep time and daily academic problems. They found that even
though study time remained the same across the years of high school, the amount of sleep the
students obtained decreased each year. Another finding was that when students stay up to study
late one night, they will have decreased performance the following day. They found that no
matter how much a student studies each day, if they sacrifice sleep to study more, they “will

have more trouble understanding material taught in class and be more likely to struggle on an
assignment the following day” (p. 139).
Behavioral. Most parents can attest to times that their children have been lacking
enough sleep and how that can negatively affect their child’s behavior. Research on this topic is
narrow for adolescents because many have accepted the teen years as a time of rebellion and in
so much toss aside possibilities of an improved demeanor with a little added sleep. Clinkenbeard
et. al (2011) found support for a hypothesis that “adolescents who sleep fewer hours than are
recommended are engaged in more delinquency” and that “even mild sleep deprivation has
immediate effects on cognitive functioning, which may increase an adolescent’s risk of
involvement in delinquent behavior.” (Clinkinbeard, Simi, Evans, & Anderson, 2011) They went
even further and said “individuals with diminished cognitive functioning are prone to a broad
range of poor decisions that include delinquent and criminal conduct. (Clinkinbeard, Simi,
Evans, & Anderson, 2011) “Sleep deprivation increases irritability which can then make teens
more prone to violence and higher levels of aggression throughout adolescence.” (Clinkinbeard,
Simi, Evans, & Anderson, 2011)
One link to behavioral issues in adolescence due to sleep deprivation might be
chronotype. As mentioned earlier, chronotype refers to an individual’s preference towards
morningness or eveningness or neither one. Adolescents are predominantly evening types
because of their later wake times, later optimal performance times, and later bed times.
Problems linked to this are behavioral problems. According to a study by Lange and Randler
(2011) students who have a higher level of eveningness on the Composite Scale of Morningness
(CSM), are more likely to have more behavioral and emotional problems than those with higher
morningness levels (Lange & Randler, 2011; World Health Organization: Europe, 2004).

Risk-taking and impulsivity. Teens lacking the appropriate amount of sleep and
operating on a sleep debt are more likely to take part in risky behavior that they otherwise might
not have. “Inadequate sleep has been shown to adversely affect a person’s decision-making by
elevating the expectation of gains and diminishing the perceived likelihood of loss following
risky decisions”. (Clinkinbeard, Simi, Evans, & Anderson, 2011) Some research that lends
support to the theory of teens being more likely to have a higher level of eveningness is “highly
impulsive individuals perform better in the evening than in the morning due to differences in
their arousal rhythms when compared to others” (Hines, 2004).
Hildebrand, Daly, Nicholls, Brooks-Holliday and Kloss (2013) found that students who
had insufficient sleep had an increased risk in taking part in “school violence-related behaviors”
such as interpersonal violence and resulting injuries, including those that occur within the school
setting”. (p. 1) The data set they used for analysis was from the 2009 Youth Risk Behavior
Survey that was developed by the Centers for Disease Control and Prevention to assess different
areas of adolescent behavior. Combining the results of the data set on the amount of sleep with
the National Sleep Foundation’s recommendation for sufficient sleep, researchers found
correlations between many of the violence-related behavior characteristics and insufficient sleep
(Hildebrand, Daly, Nicholls, Brooks-Holliday, & Kloss, 2013).
Contributing to these studies, in a study on over 6600 students in 2002, Gianotti, Cortesi,
Sebastiani and Ottaviano reported that their evening type participants “to counteract the effect of
daytime sleepiness…used more frequently psychoactive substances such as caffeine, caffeine-
containing beverages and tobacco.” (p. 197) Substance abuse can be a heavy impact on sleep
deprived adolescents (Wong, Rowland, & Dyson, 2014; Giannotti, Cortesi, Sebastiani, &
Ottaviano, 2002; O'Brien & Mindell, 2005).

Safety. The National Sleep Foundation’s 2011 Sleep in America poll found that among
those polled who drove, about one-half (52%) indicated that they had driven drowsy, with more
than one-third (37%) doing so in the previous month (Young People More Likely to Drive
Drowsy, 2012).
In an article on DrowsyDriving.org, which is an affiliate of the National Sleep
Foundation, the article Young People More Likely to Drive Drowsy gives a few of the signs that
you might be too tired to be driving. These signals include a difficulty focusing, frequent
blinking and/or heavy eyelids, difficulty in keeping daydreaming and thought navigation on
driving, trouble keeping your head up, drifting from your lane, swerving, tailgating and/or hitting
rumble strips, inability to clearly remember the last few miles driven, missing exits or traffic
signs, yawning repeatedly, and feeling restless, irritable, or aggressive (Young People More
Likely to Drive Drowsy, 2012; Inoue & Komada, 2014).
In an article written in 1995, David Dinges states there is no “agreed upon reliable
estimate of the extent to which sleepiness contributes to the incidence and costs of accidents
resulting from human error.” However, at that time he stated, “Recent estimates for the
percentage of accidental injuries and deaths attributable to sleepiness vary from as low as 1-2%
to as high as 41%.” (Dinges, 1995) Estimates have gotten much better in the last 19 years with
better indicators for law enforcement and tools for identifying accident causes.
Most recently, the American Automobile Association (AAA) did a study that estimates
that “one out of every six (16.5%) deadly traffic accidents, and one out of eight (12.5%) crashes
requiring hospitalization of car drivers or passengers is due to drowsy driving.” (Tefft, 2010)

Forty one percent of drivers admitted to having fallen asleep at the wheel at some point with one
in ten of those reporting they did so within the past year (Tefft, 2010).
Pertaining specifically to teenagers, one in seven licensed drivers ages 16 to 24 admitted
to nodding off at least once while driving in the past year as compared to one in ten of all
licensed drivers who confessed to falling asleep during the same period (Young People More
Likely to Drive Drowsy, 2012). The same article reports that being awake for more than 20
hours results in impairment equal to a blood alcohol concentration of 0.08%, the legal limit in all
states and a 3-4 second microsleep can occur without realizing it (Young People More Likely to
Drive Drowsy, 2012). A report done by the Department of Transportation on distracted driving
indicated that five seconds is the average time a person’s eyes are off the road while texting.
When traveling at 55 miles per hour, in five seconds, one can cover the length of a football field
(U.S. Department of Transportation, 2009). Most highway and freeway speed limits are now
reaching between 65 and 80 miles per hour.
Possible Solutions
Later school time. One possible solution that many states, districts and at times
individual schools have either adopted or considered is later school times.
In an article written by Edwards (2012) over 150,000 middle school students’
standardized test scores were observed as they transitioned through a full one-hour delay of
school start time. Edwards reported that math scores improved an average of two full percentile
points and one full point in reading when school start time changed from 7:30am to 8:30am. He
also found that students with a delay of one hour in school start time will have approximately
twenty-five percent less absences.

Many research studies recommend more research into later school times and how that
may improve the current problems with lack of sleep in adolescents in not only North America
but also many other countries (Colrain & Baker, 2011; Wolfson, Spaulding, Dandrow, & Baroni,
2007). A study published in Sleep and Biological Rhythms by Borlase, Gander and Gibson
(2013) utilized a questionnaire handed out in 1999 at a high school in New Zealand. School start
times were unchanged for the entire school except for high school seniors. Researchers then
returned to the same school nine years later with the same questionnaire to determine what may
have changed due to technology and other factors. Based on their research, “students with the
later start time were less likely to report sleep loss on school nights and were less sleepy than
their counterparts nine years earlier, despite perceived sleep need and an increase in the number
of technologies in their bedroom.” Later school times would give teens a chance to add
approximately forty-five minutes to an hour to their sleep time each night depending on when
they start to begin with.
Another study completed by Carskadon (1999) shows that because of biological
differences in melatonin secretion during adolescence, even when an older teen has the same
amount of time to sleep as a younger teen, they are unable to go to sleep any earlier in the
evening to make up for the discrepancy in sleep necessity. This would also suggest that later
school time would be beneficial for older teens. However, Carskadon also notes that teens may
use the later school start time as permission to stay up later at night. She suggests, “if students
learned about sleep, they have a basis to use changed school starting time to best advantage.
Adding information about sleep to the school curriculum can certainly help.” (1999)
Carskadon, Wolfson, Acebo, Tzischinsky and Seifer (1998) completed a study of the
effects of school time transition on a group of ninth graders throughout their shift to the tenth

grade. During the shift, the students experienced an advance in time of sixty-five minutes
(8:25am to 7:20am). Researchers included surveys of sleep and wake times, actigraphy
measuring, and self-report monitoring at different times throughout the transition. They were
able to conclude that the “imposition of an early school start time may require unrealistic -- if not
unattainable -- bedtimes to provide adequate time for sleeping.” They went on to say:
Our study clearly showed that early school start times for adolescents were
associated with significant sleep deprivation. The consequences of insufficient sleep in
adolescents are substantial. Excessive sleepiness of the degree documented here can be
associated with performance decrements, memory lapses, and mood changes, as well as
behavior problems. In susceptible young people, this pattern may lead to academic,
behavioral, and psychological problems, as well as increased risk for accidents and
injuries, particularly for teenaged automobile drivers. (Carskadon, Wolfson, Acebo,
Tzischinsky, & Seifer, 1998, p. 880)
Researchers in Brazil studied adolescent students and their teachers using sleep diaries,
surveys and actigraphs to determine daytime sleepiness, activity, and sleep wake cycles. Their
conclusion in the study was also that early wake times are difficult on both groups and schools
should consider the possibility of changing school start times to improve not only student
performance but also the work performance of the teachers (de Souza, de Souza, Maia, & de
Azevedo, 2012). With the many benefits of pushing back school starting times for teenagers,
problems also arise.
One of the first reasons why later school times might be a problem is busing schedules.
At this point, most elementary school students bus to school after a bus drops off middle and

high school students. This means that the elementary students are able to leave their homes after
their older sibling or at least the older children to catch the bus. For later school times, the last
option would be all schools having the same times and all kids going home at the same time.
Having all children go to school and come home at the same time would solve the issues for both
populations of students. The older children would be able to accompany their younger siblings
when parents are not with them. The problem with this option is the most obvious to most.
School district budgets do not allow enough money to purchase more buses, pay for more bus
parking, maintain more buses and pay enough drivers to maintain all routes for that many
children all at one time
However, Edwards (2012) suggested a one tier busing system that would increase test
scores by delaying school times for all students and sending them all at the same time. This
system would increase cost overall for a district. However, many districts look to decreasing
class sizes to increase test scores. According to Edwards, comparable improvements to test
scores are possible while spending $150 per child to change to a one-tier bus schedule versus
over $2000 per child to decrease a class size per child (p. 57).
Opponents also use the athletic department scheduling conflicts to shut down
conversation of later school times (Wolfson & Carskadon, 2005). Many sports use after school
schedules to practice or to schedule games during the season. An example of this would be
football. Football teams in the fall might spend an extra hour after school each day to practice
with their teams before Thursday night, Friday night or other weekend-scheduled games. If later
school times are introduced the students on sports teams will be home even an hour later than
they are now.

One possible alternative to later school times that there is very little research at this time
is adjusting student class schedule to their chronotype. It has been shown that evening-type
students are at a disadvantage because they perform optimally at later times of day. If school
officials were to implement a screening each year to identify a student’s eveningness or
morningness preferences, they could schedule the classes needing higher cognitive functioning to
later in the day and easier classes to later in the day (Preckel, et al., 2013; Valdez, Reilly, &
Waterhouse, 2008).
While science is in the corner of changing school start times, recommendations from
those who have implemented the time changes should be taken into account. Wahlstrom (1999)
indicated that 17 districts in the state of Minnesota changed their school start times in 1996 and
found that attitudes of stakeholders within the districts were the “same kind of emotional
reaction…as closing a school or changing a school’s attendance area. A school’s starting time
sets the rhythm of the day for teachers, parents, students, and members of the community”
(Wahlstrom, 1999).
Double shift school system. An even less popular, but equally effective, solution to
getting more sleep for our adolescent students is a double shift school system. Double shift (DS)
systems are organized in two shifts of school times. One shift starts early in the morning, for
example between 7:00 and 8:00 in the morning. The second shift would start an hour after the
first shift goes home at approximately 12:00 to 1:00pm. This system has been utilized many
times and has had studies linked to its effects on students.
One article written by Fischer, Radosevic-Vidacek, Koscec, Teixeira, Moreno and
Lowden (2008) gives a summary of studies done on DS systems. They discuss that some DS
systems allow students to either stay on a “fixed shift”, meaning they chose to attend all of their

classes either in the morning or in the evening. Other students in the study changed shifts if
needed and sometimes this would happen on a weekly basis. They discussed the findings stating
that “on weekdays, adolescents who attended school in the afternoon slept on average longer (8
hr 35 min) than adolescents to attended school in the morning (6 hr 40 min)” (p. 19). Similar
results were in another study Fischer et al. looked at with Croatian students between ages 11 and
18. A difference with those students was that they switched each week between morning and
afternoon shifts. A student diary reported that sleep on the weekend after an afternoon school
schedule was not delayed, whereas the weekend after a morning school schedule, students
needed to sleep in to catch up on their sleep.
Most districts utilize a DS system due to budget concerns and function less adequately
due to mismanagement and factors such as overworking teachers, increased wear and tear on the
school, and inability to fit a full school year into the normal school year constraints.
Educational interventions. A lesser-applied solution to the problem of sleep
deprivation in teens that may have the best outcomes and provide the most help is educational
interventions with not only the teens themselves but also with parents and community members.
There are few research studies to show the long-term benefits of sleep education in children and
teens and whether or not it can make a lasting impact on appropriate sleep habits in their future,
it is worth exploring much more with the seriousness of the problem emerging. One study done
in 2012 by Beijamini and Louzada found no changes in the sleep habits of students after an
educational intervention. At the time of their study they did not know of any other studies being
done like theirs. (Beijamini & Louzada, 2012) Other researchers in the field are also reporting
that an increase in research on communities, teachers, parents and students sleep education is

essential to combat problems occurring with adolescents’ sleep habits (Borlase, Gander, &
Gibson, 2013).
In a paper that is the first one to introduce three trials of the same education curriculum
with adolescents in school, the findings from Blunden, Kira, Hull and Maddison (2012) pertain
to introducing a sleep education program. Throughout the three trials that took place in Australia
and New Zealand high schools researchers introduced a curriculum called ACES to students
using teachers within the schools trained identically to introduce the materials. The problems
that they faced were mostly due to added time constraints on teachers, and the idea that
individual teachers have different teaching styles that may have affected student learning. In
spite of the problems, findings suggested, “that this sleep education programme can improve
sleep knowledge and/or sleep duration in adolescents.” (Blunden, Kira, Hull, & Maddison, 2012,
p. 16) One recommendation from the article that should be taken into future considerations is
parents should be included in the education programs are introduced to adolescents. They stated
because sleep is a behavior that is more and more loosely controlled by parents and adolescent
habits “may not improve…without parental guidance…parents should be informed about sleep
hygiene.” (Blunden, Kira, Hull, & Maddison, 2012, p. 16)
Kira, Maddison, Hull, Blunden and Olds (2014) did a recent study on educational
intervention in schools to improve sleep. The researchers wanted to determine whether an
educational program was feasible through a pilot study. In the study, high school students were
given a sleep education program through four classroom sessions. They were then asked to
complete a sleep diary and questionnaire at three different intervals (at the beginning, at 4 weeks,
and at 10 weeks). The results were not what the researchers had expected. They found that
while the Australian Centre for Education in Sleep (ACES) program and the Improving

Adolescent Well-Being (IAWB): Day and Night program have shown positive results in other
studies, and there was an initial positive effect on weekend sleep for adolescents, the overall
effects on weekday sleep were not significant (Kira, Maddison, Hull, Blunden, & Olds, 2014).
In their discussion of the feasibility of the ACES program Kira et al. (2014) discussed
many issues that should be considered in future studies and program utilization. First, they
discussed the fact that students were unenthusiastic to have added homework for the program in
the form of sleep diaries and other work included. This problem has occurred with other studies
in which researchers identify a lack of motivation to change by students (Moseley & Gradisar,
2009) In addition, staff perceptions of the program may have been problematic because of
already increasing time constraints and task loads. Lastly, the time given to the program was
only ten weeks for education. The researchers would have liked the time for the program to be
longer to get a sustained effect of the intervention (Kira, Maddison, Hull, Blunden, & Olds,
2014).
Moran and Everhart (2012) thoroughly reviewed literature on current interventions and
their effectiveness on adolescent populations. They recommend some sort of collaboration
between school officials and researchers to find a school-wide screening to identify students who
would benefit from a small group intervention to educate them on appropriate sleep behaviors.
This would be different from other programs attempted to date and would give researchers an
opportunity to be more interactive with each participant instead of overwhelming educators with
more materials (Moran & Everhart, 2012).
Parent education and involvement. Parental involvement in sleep education and
reinforcement of positive sleep habits can be crucial to adolescents’ futures. Carskadon (2011)
suggests that because of other research, adolescents who have their parents setting bedtimes after

midnight were “more likely to suffer from depression or suicidal ideation.” (p. 5) She continues
by suggesting that pediatricians “support and encourage parents to identify and set an appropriate
bedtime [and] remind families of the utility of a relaxing pre-sleep ritual.” (p. 7) Millman (2005)
also addressed parental involvement in sleep habits of adolescents. The article states during the
transition to adolescence parents change the way they influence the sleep habits of their children.
Parents switch roles from setting bedtimes during childhood and early adolescence to becoming
an alarm clock and waking the children in the morning while not setting bed times in the
evening. This change can have negative impacts on the adolescent’s development (Millman,
2005). Parents have also been found to depend more heavily on daytime indicators of sleep
deprivation than attending to sleep needs at the point of falling asleep each night (Short,
Gradisar, Gill, & Camfferman, 2013). Parents are in need of education of current sleep needs
just as much as adolescents to improve the problem overall (Short, Gradisar, Gill, &
Camfferman, 2013).
An increase in parental involvement in adolescent sleep behavior is appropriate and
necessary at this point, but parents also need to remain educated about the problems their teens
face (Noland, Price, Dake, & Telljohann, 2009). Wong, Rowland, and Dyson (2014) suggest not
only an increase in parent involvement but also in community education to ensure adolescents
understand the mechanisms within sleep and how this affects their behavior.
Conclusion
As demands on adolescents increase, interventions teaching teens about sleep hygiene
should be addressed not only by adjusting environmental schedules but also by introducing
programs to curriculum that will facilitate learning and understanding of the construct of sleep.
This paper aims at identifying past and current literature within the field of adolescent sleep to

gain a better understanding of problems teens in today’s culture face. Students are facing
increasing challenges for attending universities and finding full time employment after high
school. This forces them to start even earlier than past generations when applying
extracurricular activities to their daily lives. However, this application comes with a price.
Teens are sacrificing sleep to supplement their time for additional homework, work, sports and
other activities demands. This sacrifice leads to serious and at times fatal results when sleep
deprivation is at its highest. When given later school times, students perform better academically
and school attendance improves. Research shows decreases in daytime sleepiness which would
indicate safer behaviors by teens overall.
An intervention for sleep deprivation among teens is a new area of research in education.
Many educators and parents believe it is a parent’s responsibility to attend to their child’s sleep
needs. However, biology suggests teens are at a disadvantage from the beginning. Most parents
are unaware of the current biological factors that govern their adolescent’s sleep starting at
puberty. There were no studies found indicating parent knowledge of appropriate sleep hygiene
for adolescents. This area is important for future research to identify whether parents of
adolescents are contributing to the poor sleep habits of their children.
Current research studies on interventions within a school environment are very limited.
More work is needed in the area using different curriculums. Limitations included the lack of
current studies on sleep interventions used within a school environment at any age. This could
be because schools tend to group sleep hygiene in with health classes and thus decide that
parents should give any additional information on sleep. Also, there is a lack of experimental
design studies completed to date that demonstrate how to improve adolescent sleep as opposed to
adult sleep (Taras & Potts-Datema, 2005). This is a possible area for future research. Students

are at an extreme disadvantage due to their biology and increasing sleep deprivation. Increased
awareness of the sleep construct and the overall importance of better sleep can improve not only
adolescent’s lives but also their parents’ and communities’.

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