A recent study by Lyall and colleagues, published in The Lancet Psychiatry in May 2018, analyzed circadian rhythm measurements from more than 91,000 adults in the UK, specifically looking at the relative amplitude of the rhythm.1 The findings are significant, and alert us to the dangers of poor sleep. The study researchers found that lesser ‘relative amplitude’ or circadian rhythm disruption was associated with greater likelihood of major depressive disorder, bipolar disorder, ‘mood instability’, feelings of loneliness and lower happiness levels. (Circadian rhythm is the body’s internal biological clock associated with the sleep-wake cycle, and affected by light, temperature). This study is one of the relatively fewer studies that utilizes objective measures of circadian rhythm, rather than a subject’s self-report. 1
Benefits of Adequate, Good Quality Sleep in Children and Teens
Quality, adequate sleep is a vital necessity for optimal daily functioning, mood, attention, behavior, energy levels, learning and overall physical health. This is especially true for children and adolescents, who, unlike adults, are undergoing rapid growth and maturational changes from a physiological and cognitive standpoint. Growth hormone secretion, memory consolidation, and other important physiological functions (metabolic, endocrine and others) take place during sleep. A recent study (involving 715 child participants) conducted by Wong and colleagues, published in 2018, revealed that having greater ‘rhythmicity of sleep’, lesser tiredness and less frequent sleep challenges was associated with greater ‘behavioral control’ among teenagers which was further linked even with resilience.2 The study authors found that this finding held true for children whose parents were alcoholics, as well as children whose parents were not alcoholics.2
We now know that sleep disruption has many deleterious effects not only in adults, but also, poor sleep can have a strong negative impact on the health and functioning of children and adolescents. Considering the significant percentage of children and teens suffering from sleep difficulty, the subject of sleep in children and adolescents has received relatively lesser attention so far, although the last few years have seen an increase in the amount of research done on this important subject. Given how important sleep is, the prevalence of sleep difficulties is of growing concern to parents and treatment providers alike. This article discusses some evidence-based aspects of sleep difficulty in older children and teens, with the goal to raise awareness and promote positive sleep practices.
How Much Sleep Do Children and Teens Need?
According to the American Academy of Pediatrics, 8-12 hours of sleep are recommended for children and adolescents, depending on age (9-12 hours for children from 6-12 years of age, and 8-10 hours for teens).3
How Common Is Sleep Difficulty Among Children and Adolescents?
According to the National Sleep Foundation Sleep in America Poll (2014), among children and teens age 6-17, sleep duration was found to decrease as age increased.4 Other studies show that the percentage of children with sleep problems may be approaching 50%.5 Some literature estimates 1/4th of adolescents to be sleeping less than 6 hours nightly.6 These numbers indicate that sleep difficulty may be approaching the level of a public health concern.
A common consequence of sleep difficulty is daytime sleepiness and tiredness.5,6
Poor sleep or sleep deprivation can have far reaching consequences on the older child/ teen’s mood, attention, behavior, cognitive development, academic performance, physiological development, can increase risk for motor vehicle accidents (if your teen is driving) and can potentially further impact family’s life and functioning.6,7
Sleep difficulty has also been shown to be a risk factor for depression in adolescence.6 Anxiety, fatigue, increased likelihood of substance use are additional potential sequelae of inadequate sleep.6 A study by Roberts and Duong, involving >3,000 participants from ages 11-17 years, revealed that the presence of sleep deprivation (defined, per this study, as less than 6 hours of sleep per night) was associated with increased rates of major depression (25 to 38% greater risk of depressive symptoms).6
In addition, some research has shown lesser response to psychotherapy treatment among sleep-deprived teens suffering from certain psychiatric disorders. Some studies show that sleep difficulty is correlated with exacerbating or precipitating certain medical disorders. Studies indicate that short sleep duration is associated with weight gain and the development of obesity.
Consistently Implement Sleep Hygiene Measures
Talk to your pediatrician or health care provider, who will determine the cause of the sleep difficulty and the appropriate treatment intervention targeted to your child/teen’s specific situation.
Below, this post discusses sleep hygiene measures which, when insufficient (sleep hygiene is commonly found lacking in adolescents), contribute to inadequate sleep.7 Not only is the sleep duration affected, but also, sleep quality can be affected. Both adequate sleep duration and good quality are important for restful sleep.
Parents can take these steps to promote better sleep for their child/teen:
Ensuring a regular bedtime: Having an irregular or frequently changing bedtime confuses the circadian rhythm or ‘body clock’ (which is the clock that cues or tells the body when to fall asleep), leading to difficulty falling asleep. A regular bedtime is essential. Children or teens may resist going to bed at the same every day, but, it is important to stay consistent.7
Especially with the onset of puberty, adolescents experience a delay in release of the brain‘s melatonin and thus, a delay in sleep onset.7 This, in combination with, hectic after school schedules, extra-curricular activities, social engagements, and media use, can create a set of conditions that makes it harder to fall asleep on a timely basis. A pediatrician/psychiatrist/psychotherapist can help to create a sleep schedule that moves your teen’s sleep onset time earlier in a step-by-step fashion.
Restricting screen time to 1-2 hours a day: Although technology and electronic media use have certain benefits, the deleterious effects of technology and electronic media devices on sleep in children and teenagers have been well documented.8 Despite a decrease in TV use among children in the last several years, older children still watch greater than 2 hours of TV a day.8 Most technology devices emit blue light, which has been found to suppress the natural melatonin production in the brain and thus, delay sleep onset.8 Use of other electronic/technology/media device use (smartphones, tablets, laptops, video games) is burgeoning among children and adolescents. Also, the time-consuming and often addictive nature of electronic media devices can hinder sleep. Studies have shown that the quality as well as the duration of sleep is negatively impacted due to presence of electronic media devices in the bedroom. Especially important is to limit screen exposure 1 hour prior to bedtime.7
In addition, scientific evidence shows that parental behavior and expectations can also influence sleep time and media use.4
Regular physical activity, especially before 6 pm: Regular, moderate exercise/physical activity (as permitted by your child/teen’s pediatrician) can promote improved sleep.7,9 One hour of daily physical activity has been recommended by the American Academy of Pediatrics.
In a survey of adolescents by Reut Gruber and colleagues, 38.71 % of the study teens identified physical exercise as a promoter of good quality sleep.10 This study also showed that some adolescents found exercising late in the evening to be one of the factors that delayed sleep.
In another study, Awad and team assessed the sleep of 319 children via questionnaires and home sleep studies, and found exercise to be corelated with an increase in a specific phase of sleep- the stage 2 sleep.9
Limiting caffeine: Caffeinated drinks were identified as one of the barriers to timely sleep onset, by 12.5% adolescents in the Reut Gruber’s survey.10 Sodas can have a significant amount of caffeine, and any food item with caffeine should be avoided.7
Limiting parents’ use of electronic devices in their bedrooms: Buxton and team, through their study, suggested a link between parental use of electronic devices at night with use by children and adolescents.4 When parents use electronic media devices in their bedroom or around bedtime, children and teens are more likely to follow suit.
Ensuring comfortable room temperature: When the room is too warm or too cold, it can be difficult to get comfortable enough to fall asleep. Ask your child/teen about how they feel about their night-time room temperature and adjust it if needed.7
Using the bed only for sleep: When a child uses the bed for multiple other activities besides sleep (such as playing, doing homework, or time-outs 7), the brain does not associate the bed with sleep. Let your child/teen use their bed only for sleep.
Scheduling positive, low stimulation activities prior to bedtime 7: Avoid activities that involve bright lights, high noise levels or too much stimulation, during evenings. A soothing, positive bedtime routine can make sleep an inviting prospect for your child. Help your child make their bedtime and bedroom a stress-free zone.
Be Consistent7: Remember that with children and teens, consistency is key. Fluctuating and inconsistent implementation of sleep hygiene measures is associated with less beneficial outcomes for children’s sleep.
The Many Potential Causes of Sleep Difficulty
You now know that a well-functioning circadian rhythm and sleep hygiene are vital, but, they are just part of what constitutes adequate and good quality sleep.
It is important to be aware that sleep difficulty can be due to various underlying disorders (obstructive sleep apnea, narcolepsy, restless legs syndrome and others), or secondary to a psychiatric condition (including but not limited to, anxiety, autism, post-traumatic stress disorder, depression, ADHD).5,7 Sometimes, sleep difficulty can be secondary to medications (for example, stimulant medications for ADHD). Night terrors, nightmares can affect sleep in children.7 In addition, stressful events, bullying, conflict can have a deleterious impact on sleep. Finding and addressing the underlying cause is key.
Get Help and Address the Cause
In any sleep difficulty, (but, particularly, if a child or teen experiences sleep difficulty often, and/or if the sleep difficulty is significant/persistent/worsening) parents should consult their child’s pediatrician and discuss concerns with them. A pediatrician will explore the underlying cause and address it and may refer you to a pediatric sleep specialist or a psychiatrist, if needed, depending on the specific circumstance. A sleep specialist may ask you to keep a sleep log or may conduct a sleep study or other diagnostic tests when appropriate. Ear nose throat specialists, pulmonologists often closely collaborate with pediatric sleep specialists, for diagnostic and treatment purposes. Treatment of the sleep difficulty (which is not being discussed in this article) will depend on the specific cause found, the age of the child and other factors.
Remember that children and teens cannot function well without adequate and quality sleep.
Note: This article is for informational purposes only and is not intended to provide medical or psychiatric advice or recommendations, or diagnostic or treatment opinion. This is not a complete review or description of this subject. If you suspect a medical or psychiatric condition, consult a health care provider. All decisions regarding an individual’s care must be made in consultation with your healthcare provider, considering the individuals’ unique condition. A link or an association does not mean causation.
Originally published at www.psychologytoday.com
Lyall LM, Wyse CA, Graham N, et al. Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank. The Lancet Psychiatry.2018; 5(6):507-514. doi: 10.1016/S2215-0366(18)30139-1.
Wong MM, Puttler LI, Nigg JT, Zucker RA. Sleep and behavioral control in earlier life predicted resilience in young adulthood: A prospective study of children of alcoholics and controls. Addict Behav. 2018;82:65–71.
American Academy of Pediatrics. American Academy of Pediatrics Supports Childhood Sleep Guidelines. https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/American-Academy-of-Pediatrics-Supports-Childhood-Sleep-Guidelines.aspx. Published 2016. Accessed June 7, 2018.
Buxton OM, Chang AM, Spilsbury JC, Bos T, Emsellem H, Knutson KL. Sleep in the modern family: Protective family routines for child and adolescent sleep. Sleep Health. 2015;1(1), 15-27. DOI: 10.1016/j.sleh.2014.12.002.
Carter KA, Hathaway NE, Lettieri CF. Common sleep disorders in children. American Family Physician. 2014; 89(5):368-377.
Roberts RE, Duong HT. The prospective association between sleep deprivation and depression among adolescents. Sleep. 2014;37(2):239-244. doi:10.5665/sleep.3388.
Nunes ML, Bruni O. Insomnia in childhood and adolescence: clinical aspects, diagnosis, and therapeutic approach. J Pediatr (Rio J). 2015;91(6 Suppl 1):S26-S35.
AAP Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592.
Awad KM, Drescher AA, Malhotra A, Quan SF. Effects of exercise and nutritional intake on sleep architecture in adolescents. Sleep and Breathing. 2013; 17(1), 117-124. doi: 10.1007/s11325-012-0658-6.
Gruber R, Somerville G, Paquin S, Boursier J. Determinants of sleep behavior in adolescents: A pilot study. Sleep Health. 2017;3(3):157-162.