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Sleep Medicine 12 (2011) 110–118

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Review Article

Recent worldwide sleep patterns and problems during adolescence: A review
and meta-analysis of age, region, and sleep
Michael Gradisar ⇑, Greg Gardner, Hayley Dohnt
School of Psychology, Flinders University, G.P.O. Box 2100, Adelaide, 5001 South Australia, Australia

a r t i c l e

i n f o

Article history:
Received 22 July 2010
Received in revised form 29 October 2010
Accepted 7 November 2010
Available online 22 January 2011
Adolescent sleep patterns
Daytime sleepiness
Sleep measurement
Delayed Sleep Phase Disorder

a b s t r a c t
Adolescent sleep health is becoming increasingly recognized internationally as a significant concern, with
many countries reporting high incidences of sleep disturbance in our youth. Notwithstanding the value of
findings obtained from each large-scale survey of adolescent sleep performed within individual countries,
the field lacks synthesis and analysis of adolescent sleep studies into a single review. This review presents
findings from a meta-analysis of 41 surveys of worldwide adolescent sleep patterns and problems published in the last decade (1999–2010). Sleep patterns tended to delay with increasing age, restricting
school-night sleep. Notably, Asian adolescents’ bedtimes were later than peers from North America
and Europe, resulting in less total sleep time on school nights and a tendency for higher rates of daytime
sleepiness. Weekend sleep data were generally consistent worldwide, with bedtimes 2+ hours later and
more total sleep time obtained. We note a worldwide delayed sleep–wake behavior pattern exists consistent with symptoms of Delayed Sleep Phase Disorder, which may be exacerbated by cultural factors.
Recommendations for future surveys of adolescent sleep patterns are discussed and provided in light
of current methodological limitations and gaps in the literature.
Ó 2010 Elsevier B.V. All rights reserved.

1. Introduction

2. Literature search and inclusion criteria

Sleep problems during adolescence are common. Recently,
Crowley et al. [1] reviewed literature over the past 30 years on
the sleep parameters of adolescents in the USA in light of how
parameters change through this period. However, no review has
covered adolescent sleep surveys worldwide. Consequently the
aim of this paper is to review and contrast the recent literature
on surveys of adolescent sleep patterns (bedtimes, sleep duration)
and problems across the globe, thus possibly providing insights
into cultural differences and similarities between countries. This
review concludes by demonstrating that many studies have assessed symptoms of Delayed Sleep Phase Disorder (DSPD) [2,3]
and provides recommendations for future surveys so that prevalence estimates of this sleep disorder during adolescence may be
determined worldwide.

Surveys of adolescent sleep problems were searched using the
search term ‘‘adolescent sleep’’ in the following electronic databases and on-line journal home pages: OVID Psyc Articles, PubMed, Behavioral Sleep Medicine, Journal of Clinical Sleep Medicine,
Journal of Pediatrics, Journal of Sleep Research, Pediatrics, Sleep, and
Sleep Medicine. Additionally, reference lists of reviews of adolescent
sleep problems were used to find further surveys. Inclusion criteria
included: the studies contain information on adolescent sleep
parameters, sampled more than 300 participants aged 11–
18 years, and published from 1999 to 2010. This last criterion is
justified given that the changes in technology (e.g., mobile phones,
internet) in the last decade may contribute to differences in sleep
parameters between the 1990s and 2000s. As this review presents
sleep parameters as a function of age (see figures to follow), studies
providing mean sleep estimates for samples extending beyond the
age limits (e.g., 8–15 years) were excluded. Using these criteria, 41
surveys were found (see Table 1). Each survey was analyzed in the
present review in terms of typical sleep parameters measured on
school and weekend nights. Although adolescents may experience
a range of sleep problems (e.g., Restless Legs Syndrome; Obstructive Sleep Apnea), it was clear during the review process that
two major types of sleep problems were commonly reported in
studies: insomnia (predominantly difficulty initiating sleep) and

Abbreviations: DSPD, Delayed Sleep Phase Disorder; SOT, sleep onset time; WUT,
wake-up time; TST, total sleep time; BT, bedtime; SSHS, School Sleep Habits Survey;
DS, daytime sleepiness; ESS, Epworth Sleepiness Scale; PDSS, Pediatric Daytime
Sleepiness Scale; SOI, sleep-onset insomnia; DIS, difficulty initiating sleep; DSM,
Diagnostic and Statistical Manual of Mental Disorders; ICSD, International Classification of Sleep Disorders.
⇑ Corresponding author. Tel.: +61 8 8201 2324; fax: +61 8 8201 3877.
E-mail addresses:,
(M. Gradisar).
1389-9457/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved.

(2000) [46] Roberts et al. sleep diary. TST. total sleep time. (2002) [6] Spruyt et al. (2007) [12] Thorleifsdottir et al. / Sleep Medicine 12 (2011) 110–118 Studies x x x x x BT. (2003) [50] Loessl et al. x DS x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Insomn. Can. (2006) [48] Spilsbury et al. (2004) [58] Chol Shin et al. DS. (2001) [49] Iglowstein et al.Table 1 Surveys of adolescent sleep. daytime sleepiness. (2007) [17] USA USA USA USA USA USA USA USA USA USA Can. NSF.297 3478 3871 1457 5044 308 13–19 14–17 13–16 15–17 11–17 12–18 13–18 11–17 11–17 13–19 14–18 10–13 0–16 12–19 9–14 15–18 15–18 11–15 14–18 8–14 1–29 6–13 12–17 15–19 9–16 6–16 12–19 12–18 13–17 12–19 12–18 11–17 12–13 13–18 13 12–18 15–18 16–17 12–18 14–19 15–18 BT Weekend TST WUT BT TST Unspecified WUT BT TST Measures WUT SD Act. (2010) [55] Liu et al. Netherl. Europe Europe Norway Italy Italy Iceland Belgium Belgium France Taiwan Taiwan Taiwan China China Hong Kong Hong Kong China Japan Japan Japan Japan Japan Korea Korea Kuwait Aust. (2006) [38] Kaneita et al. SSHS x x x x x x x x x x x x x x x x x x x x x x x x xa x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x xa x x x x x x x x x x x x x x x x x x x x x x xa x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x xa x x x x x x x x x M.. (2006) [43] Knutson and Lauderdale (2009) [45] NSF (2006) [8] Patten et al. (2005) [53] Van den Bulck (2004) [54] Voit-Blanc et al. (2002) [41] Russo et al. (2010) [22] Ouyang et al. actigraphy. (2009) [57] Ohida et al.288 6631 1073 688 3045 2546 502 1572 2463 8319 1365 1056 1629 29. School Sleep Habits Survey. bedtime. Gradisar et al. (2005) [9] Abdel-Kahlek (2004) [24] Warner et al. SD. (2003) [10] Gibson et al. WUT. Act. (2006) [29] Laberge et al. SSHS. (2000) [20] Ohayon and Roberts (2001) [34] Palessen et al. (2004) [32] Tagaya et al. 3119 10. Demographics School Country N Age Acebo and Wolfson (2002) [44] Danner and Phillips (2008) [30] Johnson et al. (2008) [19] Chung and Cheung (2008) [13] Mak et al. 111 .397 621 9718 102. National Sleep Foundation (USA). (2006) [36] Kaneita et al. (2000) [42] Ohayon et al. wake-up time.451 516 106. (2000) [39] Liu et al. Germ. (2002) [28] Yang et al.656 1014 2978 1602 7960 5118 4175 411 302 3235 1146 493 818 449 1125 2242 26. Impaired funct. Switz. (2006) [35] Gau and Soong (2003) [21] Gau (2006) [33] Yen et al. (2004) [47] Roberts et al. (2008) [52] Giannotti et al. (2007) [18] Wolfson et al. (2006) [51] Meijer et al. a Epworth Sleepiness Scale (ESS) used to measure DS. (2009) [56] Gaina et al.

where comparisons were to be made between regions. 5–8 h). and weekend TST and WUT were longer and later when using the SSHS. and 2% fall between 2 and 3 SDs above the mean [11]. Consecutive nights of short school-night TST lead to the creation of ‘‘sleep debt’’ [4]. this invariantly results in a short school-night total sleep time (TST.. adolescent sleep is typically more variable across our 7-day week. Typical sleep parameters and their measurement Unlike the sleep patterns of children and adults. 1 and 2). in the ‘‘optimal’’ range displayed in Figs. with school-night sleep shorter than sleep on weekends. with adolescents recovering this debt on weekends with longer TSTs (e. and therefore this study is not included in the above graph. Table 2 shows the distribution of mean school-night BT across studies. School-night and weekend SOT (Bed time) Of the 41 surveys analyzed. But 13 surveys provided information on school-night and weekend bed time (BT). . The mean BT for all these studies is later than 10:30 pm for all age groups. As school start times range from 7:30 to 8:30 am in most countries.1. survey studies using the SSHS or similar self-report questionnaires are likely to provide accurate school-night TST. Means for regional sleep parameters are adjusted for age. Worth noting is that Figs.e.. to avoid getting insufficient sleep (i. Nearly one-third of samples lie in the borderline range and tend to be slightly older (i. and Australian studies.8] must go to bed before 10:30 pm (i. <8 h). the impracticality and expense of surveying many adolescents with actigraphy means that sleep diaries are the measure of choice. and tend to be younger adolescents (i. e. r(49) = 0. within the ‘‘borderline’’ range. but caution is needed for school-night BT. Gradisar et al.63. This average will be used to provide an estimate of SOT for the adolescent surveys reviewed. DSPD).e.112 M. Self-report questionnaires can also be used. 15–16 years). 1 and 2 represent mean bed times. However.8 min later than BT for adolescents aged 15–18 [6]. p < .e. By definition. SOT is always later than BT. weekend TST and WUTs. 1 shows that adolescent school-night BTs ranged from 8:46 pm to 12:54 am and were clearly related to age.. Other reports state less than 8 h sleep as being insufficient [8]. A third and important theme emerged: the impact of sleep problems on adolescents’ general functioning. most <15 years). Meta-analysis involved correlations between age (in years) with sleep parameters (in time units). Note: North American samples = black diamond. and weekend BT. Chinese. adolescents may typically wake for school between 6:30 and 7:30 am (see Fig. This means that an adolescent who intends to wake up at 7:30 am and desires the optimal 9 h of sleep [7. Consequently. [5] found no significant difference between school-night TST and WUT when comparing the SSHS to 8-day sleep diary and actigraphy monitoring. thus preventing the majority of them obtaining sufficient school-night TST. These samples derive from North American. When this delayed SOT couples with the need to attend school the following morning (early WUT). 1. Effect sizes are also reported. BTs are clearly worse for adolescents outside 1 SD. For Fig.0001. this review thus highlights future researchers’ opportunities to assess the prevalence of this disorder.. none provided information on school-night or weekend SOT (see Table 1). 3. The School Sleep Habits Survey (SSHS) [5] was found to be the most widely adopted sleep survey in this review. a 7-day sleep diary or wrist actigraphy monitoring are used [2]. Sleep–wake parameters can be measured in several ways. At worst. School-night bedtime (BT) was slightly earlier when using the SSHS. As the assessment of sleep parameters and these three sleep problems map closely onto a sleep disorder common during adolescence (i. sleep onset time (SOT) and wake-up time (WUT) become increasingly later during adolescence.e. but specifically sleep times. Fig.5% fall between 1 and 2 SDs above the mean. ranging from borderline BTs (younger adolescents) to insufficient BTs (older adolescents) [6]. European samples = white diamond. / Sleep Medicine 12 (2011) 110–118 daytime sleepiness.g. Asian samples = grey circle.e.. Australasian sample = white circle.e.. Wolfson and colleagues’ [10] data show school-night BT for adolescents aged 13–19 years fits a normal distribution. A longitudinal study found that adolescents optimally need on average 9 h sleep per night regardless of their pubertal stage [7]. Fig. Korean adolescents’ mean BTs were mainly in the insufficient range [9]. Wolfson et al. 13.. Ouyang et al. Average school night bed time. and below the ‘‘problematic’’ cut-off). What appears to be associated with this variability in sleep duration is a developmental delay of not only bedtimes.e. 1 illustrates half of samples’ BTs (i. 9–12 h). 50%) fell within the optimal range required for adolescents to obtain 9 h sleep.g. WUT. Icelandic adolescents of all ages tended to go to bed later than other samples. the adolescent needs to sleep before 11:30 pm (i. analysis of covariance (controlling for age) with Bonferroni corrections applied.. 3. mainland European. Ideally.. That is. 5). In a normal distribution approximately 34% of adolescents’ BTs will fall within 1 SD above the mean. and SOT has been reported to occur on average 16. [56] reported school night bed times for males and females separately.

13]. (2005) [9] Wolfson et al.. Asian samples = grey circle. bedtimes range from (at best) 15 min near the 11:30 pm insufficient BT cut-off for younger Italian adolescents [12]. data were collected in the springtime. Indeed. (2005) [9] Russo et al. the Icelandic study [6] demonstrated consistently later BTs (and WUTs. through to older adolescents from Korea going to bed over 4 h later than the 11:30 pm cut-off [9].90)..5% of sample) Russo et al. (2007) [12] Chung and Cheung (2008) [13] NSF (2006) [8] Thorleifsdottir et al. (2000) [20] Van den Bulck (2004) [54] Chung and Cheung (2008) [13] NSF (2006) [8] Warner et al. these adolescents. p = 0. Thorleifsdottir et al. 2. (2002) [6] Chung and Cheung (2008) [13] Yang et al. a higher proportion of adolescents are likely to fall in the ‘‘insufficient’’ range when this underestimation is taken into consideration. Overall.12). see Fig. / Sleep Medicine 12 (2011) 110–118 Fig. one Asian study reported adolescents finished school at 8:30 pm [19] which is likely later than the school-end time in North America.02). SOT is likely to be 17 min later for all averages displayed. (2007) [12] Thorleifsdottir et al.. European samples = white diamond. and SOT is approximately 17 min later than BT [6].e.113 M.. Gradisar et al. 13. d = 1. The situation for BTs becomes worse when considering school-night BT measured using surveys is earlier than if measured using actigraphy monitoring [10]. 18 h).. (2003) [10] NSF (2006) [8] Ohayon et al. [6] argue that . a Studies Age Mean (SD) 0–1 SD above mean (i. approx. (2002) [6] Chung and Cheung (2008) [13] Kaneita et al. although the mean school-night BT for Asian samples (11:23 pm) was not significantly greater than that for European samples (10:46 pm. p = 0. when there is a substantial amount of sunlight (e.. (2002) [6] Yang et al. (2008) [17] Thorleifsdottir et al. Average weekend bed time.g.97). Alternatively. Australasian sample = white circle. 5) when compared to other Western samples. But school reportedly starts at 8 am [15]. This difference in BT may suggest the influence of cultural factors. (2007) [12] Russo et al. the mean Asian BT was later than that for North American samples (10:06 pm. Note: North American samples = black diamond. societal schedules could be delayed with so much daylight. as there is little difference in the latitude where surveys were conducted between North America and Asia. a very large effect nonetheless exists (i. Statistically.e. 34% of sample) 1–2 SD above mean (i. (2009) [57] Yang et al. thus these adolescents experience ample morning light exposure. Consequently.g. However. d = 3. suggesting environmental factors (e. (2005) [9] Chung and Cheung (2008) [13] Thorleifsdottir et al. daylight duration) play a lesser role.e. Interestingly. (2002) [6] 12 13 13 13 13 13 14 14 15 15 15 15 15 16 16 16 16 17 17 17 17 18 18 10:31 10:33 11:10 11:00 11:15 11:12 10:43 11:23 10:32 11:55 11:26 12:00 10:59 10:51 10:36 10:54 11:35 11:02 10:47 12:05 12:54 11:47 12:15 10:31–11:12 10:39–11:12 – 11:00–11:56 – 11:12–12:18 10:43–11:21 11:23–12:26 – – 11:26–12:33 12:00–01:06a 10:59–11:52 – 10:36–11:38 10:54–11:36 11:35–12:41a – 10:47–11:38 – 12:54–02:18a 11:47–01:03a – 11:12–11:53 11:12–11:51 – 11:56–12:52a – 12:18–01:24a 11:21–11:59 12:26–01:29a – – 12:33–01:40a 01:06–02:12a 11:52–12:45a – 11:38–12:40a 11:36–12:08a 12:41–01:47a – 11:38–12:29a – 02:18–03:42a 01:03–02:19a – (41) (39) (56) (66) (38) (63) (67) (66) (53) (62) (42) (66) (51) (84) (76) Notes: Bed times within the insufficient range. Table 2 Bedtime distribution for adolescent samples where school-night BT limits opportunity for sufficient school-night TST. One explanation for such a delayed BT may be a lack of morning sunlight to reset their circadian rhythms [23]. For instance. there is a tendency for a large proportion of adolescents from Asian samples to lie within the insufficient range [9.e. representing a very large effect (i.

Australasian sample = white circle. Fig. 4.e. They speculate that the delay in BTs and WUTs may be an example of a weak dominance of the external clock in the regulation of the biological clock.. p < .20]). 4 illustrates that weekend TST is on average 91.0001). 3.46 h.e.28.g. r(40) = 0. Fig. A negative relationship exists between age and school-night TST. or dozing on and off at the end of the sleep period.68. p = . there is nonetheless a mismatch between the percentage reporting insufficient school-night sleep. Fig. but not for weekend TST. Average total sleep time on school nights. Note: North American samples = black diamond.19. Unlike the differences in BTs.0001. given that Icelandic local time has adopted Greenwich Mean Time (GMT) all year round. . from 18% to 59%) of BTs in the insufficient range on weekends suggests that an even higher percentage of adolescents might have a significantly delayed sleep circadian rhythm than predicted by the school-night statistics. rather than the 1½ h geographical distance between Iceland and the UK. An adolescent is more likely to go to bed at their preferred BT on the weekend.. p = . yet not an insufficient school-night BT (e. <8 h) [8.0001. this does not include the time spent awake in bed attempting sleep (sleep onset latency). These surveys show that weekend BT is related to age. time in bed) being compared to ‘‘sleep duration’’ (i. European samples = white diamond. but not North American samples (7. Fig. however. That is. and yet is not affected by the region the adolescent resides.04).2.64 h) was significantly less than that of European samples (8. t(39) = 11.6 min Fig. during the night (wake after sleep onset). The higher proportion (i.13. p = . [10. Asian samples = grey circle. even though BTs and WUTs are reported. = 122. is consistently later than average school-night BT (mean diff. This anomaly may be primarily explained due to ‘‘sleep opportunity’’ (i. average school-night TST was insufficient (i. Australasian sample = white circle. 2 shows results from the 13 surveys that reported average weekend BT.10. the mean school-night TST for Asian samples (7.10. possibly making this more illustrative of their circadian sleep phase preference or a behavioral choice due to the removal of a fixed wake-up time.64).e..10.17. Gradisar et al. Average total sleep time on weekends. p < . School-night and weekend TST Of the 41 surveys analyzed.114 M. 14 reported school-night and/or weekend TST (see Table 1). Asian samples = grey circle. Note: North American samples = black diamond. r(33) = 0. who use GMT solely in winter.62.e. F(2. having been found in other Icelandic studies [16]. 536).44 h.3 min.17.66. European samples = white diamond... 3 shows that in 53% of samples.12) = 2. / Sleep Medicine 12 (2011) 110–118 the discrepancy between the sleep habits in Iceland and other Western countries is a ‘‘well-known phenomenon’’ (p. p < . r(34) = 0.17–19]. p = 0. TST). 3. Despite the fact that some studies reviewed here are not the same as those reviewed for BTs.

28. see Fig. p = 0. and at the other extreme a Chinese sample who on school mornings participate in exercise at 6:15 am. p = 0. 5). in surveys of Asian adolescents. Daytime sleepiness Adolescent daytime sleepiness (DS) has been measured in a variety of ways including the number of daytime or classroom naps [8. 6 shows that school morning WUT is relatively consistent across samples (range = 5:50–8:10 am. . p < .11. p < . 3. European samples = white diamond.10) = 0. p = 0.13) and across age. and oversleeping [8].e. some argue the ESS is considered an insensitive measure of DS in adolescents because situations used to assess DS in adults are often not applicable to adolescents [29].0001. No studies reported insufficient weekend TST. has measured DS in adolescents [28–30]. 6. longer weekend TSTs (see Fig.0001).76. Korea and Australia.29. Australasian sample = white circle.10) = 2. However. but not Asian adolescents (9. p = 0. This is most likely a result of later weekend BTs (see 115 Fig.M.23 h. The Epworth Sleepiness Scale (ESS) [27]. 7). Note: North American samples = black diamond.80. / Sleep Medicine 12 (2011) 110–118 longer than school-night TST. Fig. Nevertheless. But most only measured one aspect of DS using a variety of unstandardised self-report or parent-report questions.22]. p < . School morning and weekend WUT Thirteen of the 41 surveys reported school-night and/or weekend WUTs (see Table 1). One validated measure tailored to adolescents is the Pediatric Daytime Sleepiness Scale (PDSS) which was based on the ESS but modified to suit school-aged children and adolescents [31].80 vs. Clinical markers of adolescent sleep problems 4. and scores of 10 or greater indicate DS in adults and adolescents [27. two notable exceptions are the Icelandic sample [6] who consistently wake later than all other samples.21. r(34) = 0. School-night vs. The few studies reporting sufficient weekend TST were from the USA.30]. indicating that short school-night TSTs result in the creation of a sleep debt relieved by longer weekend TSTs. 52. The majority of surveys examined (i.. Fig. p = 0. Somewhat similar to the results of school-night TST. designed to measure adult DS. Weekend WUT is significantly later than average school morning WUT (mean diff. and likewise for weekend WUT (region: F(2.3.28).03 h. t(12) = 9. prior to starting school [56]. morning sleepiness [24–26].12.7% reported feeling ‘‘very’’ or ‘‘rather’’ sleepy Fig.19. F(2. 4) and reduced weekend morning commitments.48. 2). North American adolescents obtained less weekend TST than European adolescents (8. weekend total sleep times as a function of region. 5. = 2 h 31 min. the desire to have more sleep [23]. Asian samples = grey circle. For example. age: r(34) = 0. with many (71%) reporting optimal TST regardless of age or country.0001. 10. Average wake-up time on school mornings.50. see Fig.1. Gradisar et al. 61%) reported at least one behavioral parameter relating to DS (see Table 1). 4.

early morning awakening. overslept) [8]. These results support the high rates (i. Table 3 Difficulty initiating sleep (DIS) and sleep onset latency (SOL) in surveys of adolescent sleep problems.g. European samples = white diamond. The threshold for delineating short SOL from long SOL has been considered by some authors to be 20 min [36] and others to be 30 min [8. using parental reports. The use of standardized measures was minimal. or almost every day (e. the sleepiness scale in the SSHS. 40. and Ohayon and Roberts [34] found that 5. Gradisar et al.10].. and scores of greater than 10 varied from 15.1 Chung and Cheung (2008) [13] NSF (2006) [8] Russo et al. (2006) [38] Laberge et al. The ESS was used in five of the surveys. (2001) [49] Liu et al.3 (boys) 16. Note: North American samples = black diamond. (2007) [12] 20.e. Australasian sample = white circle.e. Insomnia Insomnia. Several surveys measured a combination of DS parameters..116 M.8 16.3% of boys and 39. and the authors’ Cleveland Adolescent Sleepiness Questionnaire) [18]. and from this review it seems likely that DS is a reasonably significant and prevalent problem in adolescents from many countries across the world.39]. Gau [33] found that 10.2. and unrefreshing sleep [2. in the morning [13]. Unfortunately.7 7. (2010) [22] NSF (2006) [8] Ohayon et al.0 . fell asleep in school. (2004) [47] Roberts et al. too sleepy in general. their study provides researchers with further options for assessing DS in adolescents using psychometrically sound instruments.5 (boys) 36. with only one study comparing standardized DS measures against each other (i. Insomnia may include difficulty maintaining sleep. is another clinical sleep parameter that is frequently investigated.37].2 (girls) 10. too sleepy for sports. while another found 33.8 26. A large national survey of 1602 USA adolescents found that 20% of adolescents reported at least one problem with daytime sleepiness every day. Studies DIS (%) Studies SOL >30 min (%) Abdel-Kahlek (2004) [24] Johnson et al. Nonetheless. to 37% [30]. 4. These assessments of only one aspect of DS may either produce wildly differing rates due to measurement error.4 14.0 20. while doing homework. 54%) assessing at least one aspect (see Table 1).9% [28] and 30% [35].6 14. This commonly involves a single item that requires adolescents to answer the question ‘‘Do you have difficulty falling asleep at night?’’ on a 5-point Likert scale.3 (girls) 11. Average wake-up time on weekends. Asian samples = grey circle.6 (boys) 20. ranging from ‘‘always’’ to ‘‘never. 18-year-old European adolescents reported a tendency to fall asleep easily and anywhere in the daytime.1 26.. chose to assess difficulties with sleep initiation or sleep-onset insomnia (SOI). (2000) [39] Mak et al.12].8 19. time taken to fall asleep) [2.e. the PDSS. along with DS. The presence of SOI is most commonly established through the length of sleep onset latency (SOL. but can also be measured to some degree of accuracy using the SSHS [5. For example. though.3]. SOL is most accurately measured using a 7-day sleep diary [37].2% of girls reported ‘‘always’’ or ‘‘often’’ feeling excessively sleepy during the daytime [32].0 (girls) 16. (2008) [52] Roberts et al.9% [13] in adolescents.9% of 15. with more than half of studies reviewed (i. (2000) [20] Ohayon & Roberts (2001) [34] Ohida et al. no data were presented on the prevalence of excessive sleepiness in their sample of 411 adolescents.0 11.9% [36] and 41.’’ An answer of ‘‘often’’ or ‘‘always’’ is considered by most surveys as evidence of DIS [38. (2006) [43] Kaneita et al.0 12.1 15..9% of Taiwanese adolescents napped inadvertently. / Sleep Medicine 12 (2011) 110–118 Fig. 20–40%) of behavioral parameters of DS found in surveys that measured one parameter of DS. (2006) [48] 14. Another method of evaluating SOI is through a measure of difficulty initiating sleep (DIS). Some other findings were more moderate. Most studies reviewed in this paper. or the variability may reflect a natural response to variable TSTs across cultures. (2004) [32] Pallesen et al.

this effect is amplified for Asian adolescents who go to bed later (than North American adolescents). 21 reported information about SOI (see Table 1). and some translations may already exist (e. Gradisar et al. the findings from this review suggest the prevalence and impact of Delayed Sleep Phase Disorder during adolescence may be currently under-rated. but this is yet to be investigated. It is worth noting here that these aforementioned sleep problems highly resemble symptoms of Delayed Sleep Phase Disorder (DSPD) [2].’’ With the growing wealth of knowledge about the importance of ‘‘sleep. Very few studies measured or reported the broad spectrum of sleep–wake behaviors and problems described in this review.. self-image as a pupil. and the research and clinic fields will have a better idea of the present prevalence of this apparently common sleep disorder in adolescents. 14. the SSHS could be used. For example. [10]). / Sleep Medicine 12 (2011) 110–118 Of the 41 surveys. the field will have more data to better investigate ‘‘similarities and differences in sleep and sleep-related practices within and across countries (that) may facilitate an understanding of factors that underlie sleep–wake regulation during adolescence’’ (LeBourgeois et al.. Many studies reviewed in this paper represented an opportunity to observe the percentage of adolescents who possessed a collection of DSPD symptoms to warrant the diagnosis.g. The NSF Sleep in America Poll found that of those adolescents who had driven in the past year. Meijer et al. What is interesting is the most reported percentage for DIS is in the ‘‘teens’’ (mean = 16%) despite a consistently low 20s percentage (mean 22%) for an SOL >30 min. 27% reported having had an accident or near accident due to drowsiness. German [51]. Perhaps in the next decade.e. as it highlights the importance of healthy sleep needed by adolescents and its possible impact on aspects of their lives. Second. poor school achievement.3]. more injuries. appears common. 6. we recommend that studies planning to survey adolescent sleep patterns attempt to assess multiple sleep parameters simultaneously. Thus. Combining this common delayed sleep–wake behavior with the often reported sleep-onset insomnia and impacts on adolescents’ general functioning. Iceland). That is. sleep diaries could be used in conjunction with surveys. We would posit that due to cultural influences the prevalence of adolescent DSPD may be higher in specific regions (i. two continents were not featured in this review. Asia. Another survey found that adolescents with an ESS score >10 had more school absenteeism [35].2010.. and this review of 41 studies published in the past decade demonstrates a number of insights into age. not one study was large enough and reported sleep characteristics consistent with this review’s inclusion criteria. to our knowledge. Behaviorally Induced Insufficient Sleep Syndrome. which few studies have used (e. Table 3 shows that 7–36% of adolescents report DIS. it is clear that adolescent sleep is typified by late BTs and WUTs. weekend morning extra-curricular activities).g. with more surveys of adolescent sleep patterns and problems conducted worldwide. .9% of girls. Impact of sleep problems on general functioning Of the 41 surveys analyzed. Further. For large-scale surveys.. there is a moderate-to-strong age influence on adolescent school-night bedtimes and total sleep time worldwide. 264) [59]. 4. Finally.g. school.and culturally-related influences on adolescent sleep. For instance. Several studies reported correlations between lack of sleep or sleepiness and impaired functioning. Conflict of Interest The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10. we found it was unfortunately common for large-scale studies to assess only bedtimes and thus calculate ‘‘time in bed. cultural influences are virtually ameliorated on the weekends with adolescents across the world demonstrating delayed bedtimes and wakeup times of greater than 2 h.1016/j. difficulties initiating sleep. During our review. Third. 16 surveys reported at least one parameter indicative of distress or impairment in functioning (see Table 1). These 16 studies illustrate that impaired functioning due to sleep problems should be incorporated into surveys of adolescent sleep.. a survey of 5044 adolescents from Kuwait found that 9.7% of boys reported their sleep affects social relations. Despite the excellent work being performed in South America. Despite the large number of studies that are now investigating adolescent sleep with large samples.2% of boys) [24]. Giannotti et al. and 5% had fallen asleep while driving [8]. survey questions could target a chronic pattern of delayed sleep onset and wake-up times with associated daytime sleepiness or insomnia (Criterion A) as well as an associated impact on functioning (Criterion B). with weekend TST being extended and ‘‘normal. Mandarin [19]). daytime sleepiness. Delayed Sleep Phase Disorder From the review of these 41 studies. this cut-off may be higher by adolescent standards. Primary Insomnia) [2. and 20–26% of adolescents report SOL greater than 30 min. [42] found that sleep quality had a direct positive relationship with four aspects of school functioning: receptivity with regard to the teacher’s influence. if surveys coupled with sleep 117 monitoring are able to ask questions differentiating DSPD from other sleep disorders common during adolescence (e. p.’’ Consequences of insufficient sleep include daytime sleepiness. with older adolescents going to bed later and obtaining less sleep. The slight discrepancy between these two sets of statistics might illustrate that while a sleep latency greater than 30 min is problematic by adult standards [40]. only one largescale study was found that reported sleep. at least when using diagnostic criteria from DSM-IV [3].. First. and the impact of sleep on general functioning.11. and more emotional problems. resulting in restricted and insufficient TST on school nights. plus a host of broader problems in various areas of functioning. achievement motivation and control over their own aggression. The prevalence of DSPD is said to be 7–16% and more common in young adults and adolescents [2. thus preventing this region from being included in statistical comparisons with other regions. we know very little about recent sleep patterns of adolescents in many regions of the world.008.M. Inadequate Sleep Hygiene. DSPD is a circadian rhythm disorder where the individual’s sleep pattern is timed significantly later so that it conflicts with their weekly obligations (e. Conclusions and recommendations A systematic review and analysis of adolescent sleep patterns and problems across the world is currently needed.’’ it is clear from the present review that future studies should ask additional questions about total sleep time. This is a relatively understudied yet significant component of these surveys. obtain less sleep (than European samples). Italian [41].3.43] then the remaining criteria will be addressed. [41] found that adolescents with later BT and WUTs had more attention problems. and tended to report higher rates of daytime sleepiness than adolescents from other regions. Although Australasia was featured in this review. Ideally. 5. and particularly SOI.3. while a higher percentage said their sleep affects their work performance (14.sleep. Insomnia. But DSPD diagnostic criteria from the International Classification of Sleep Disorders second edition (ICSD-II) require sleep monitoring via sleep diaries or actigraphy (Criterion C) [2]. the field knows too little about the sleep of teens in Africa.2% of girls and 7.g.

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