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Sleep problems in adolescence: A study of senior high school students in

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Article  in  European Child & Adolescent Psychiatry · August 2005

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Eur Child Adolesc Psychiatry (2005)

14:237–243 DOI 10.1007/s00787-005-0460-0 ORIGINAL CONTRIBUTION

Helen Lazaratou Sleep problems in adolescence

Dimitris G. Dikeos
Dimitris C. Anagnostopoulos A study of senior high school students
Ourania Sbokou
Costantin R. Soldatos in Greece

■ Abstract Objectives The aim of
this study was to evaluate sleep
habits and sleep-related problems
in high school adolescent students
in Greece through the Athens In-
somnia Scale and to assess the rela-
tion of these problems to demo-
graphic and other variables.
Methods The Athens Insomnia
Scale 5-item version (AIS-5) was
Accepted: 3 December 2004
H. Lazaratou (
) · D. G. Dikeos ·
D. C. Anagnostopoulos · O. Sbokou ·
C. R. Soldatos
Dept. of Psychiatry
Athens University Medical School
72 Vas. Sofias
11528 Athens, Greece
E-Mail: elazar@med.uoa.gr
administered to 713 adolescent se-
nior high school students in the
Greater Athens Area. Data such as
age, sex, school records, and time
spent per week in school-related
and extracurricular activities were
collected. Results The sample’s
mean sleep duration was 7.5 h,
mean bedtime 00.20 a.m. and
wake-up time 7.15 a.m. Total sleep
time was not affected by gender,
but was influenced by time spent in
various activities. Sleep complaints
were related to delayed sleep, onset
latency and insufficient total dura-
tion of sleep. Of the respondents,
30 % estimated that their sleep on-
set latency was markedly delayed
and 30 % reported that their total
sleep time was markedly insuffi-
cient. Girls complained more than
boys, while correlations showed
that students with lower academic
performance and those in second
grade were more likely to have
higher AIS-5 scores. Conclusions
The results show that the sleep
time of high school students is
dependent on practical matters
such as school schedule and other
activities, while sleep complaints
are related to female gender, bad
school performance as well as to
the second grade. The difference
between actual sleep time and
sleep complaints should be consid-
ered when studying the sleep of
adolescents.
■ Key words adolescent – sleep
disturbances – sleep complaints

frequent among high school students and often leads to

Introduction
Many biological as well as psychological and social
changes occur during adolescence, making this period
one of the most critical and unstable during life [11, 25].
Among the usual problems of adolescents are those re-
lated to sleep disturbance; while parasomnias (i. e. sleep
walking, night terrors, etc.) in the adolescents represent
the continuation of problems from younger age and are
rather rare, dyssomnias (i. e. insomnia, sleep problems
related to circadian rhythm disorders, etc.) are by far the
most prevalent, mainly as circadian rhythm disorders
[19, 23, 27]. Most studies of adolescent sleep habits show
increased daytime sleepiness [3, 4, 7] and to a significant
influence on daytime functioning and academic
achievement [12, 36].
Differences in prevalence of sleep complaints and to-
tal hours of nocturnal sleep have been noted among ado-
lescents from various countries and have been attributed
to differences in socio-cultural factors [24, 33]. A com-
mon finding, however, concerns complaints about sleep
quantity and quality. Most high school students sleep for
6–8 h on weekdays and the majority feel that their sleep is
insufficient [14, 26]. Additionally, in most studies, girls
complain more than boys about their sleep and girls’
sleep problems are usually manifested at an earlier age
ECAP 460

that total sleep time tends to decrease and the timing of than those of boys; these differences are believed to be
sleep tends to be delayed; this pattern seems to be quite due to different social requirements for the two sexes,but
237_243_Lazaratou_ECAP_460 15.06.2005 07:16 Uhr Seite 238
238 European Child & Adolescent Psychiatry (2005) Vol. 14, No. 4
© Steinkopff Verlag 2005
also to differences in the process of physiological changes
related to puberty [10, 20]. Regarding the relationship of
sleep with academic requirements and school schedules,
it has been noticed that there are differences in sleep
problems between groups of students according to the
pressure for achievement they experience [16].Also, dif-
ferences have been attributed to different school pro-
grammes,mainly based in variations of starting time and
time needed for commuting to school [5]. Behavioural,
emotional and somatic disorders [16, 26], smoking, sub-
stance use and alcohol consumption [9, 15, 32], and vari-
ous psychological stressors [34] are also associated with
sleep disorders in adolescents.
The aim of the present study was to evaluate sleep
habits and the presence of sleep problems and com-
plaints in an adolescent population of senior high school
students in Athens, Greece, through a self-completed
questionnaire. The association of sleep parameters with
various demographic factors, as well as with academic
requirements, performance and school programme was
also examined. The existence in Greece of two different
academic tracks (one with a lot of pressure for achieve-
ment and another without), as well as, for certain
schools, of an alternating schedule according to which
those schools function in the morning for one week and
in the afternoon for the next, allowed us to compare the
sleep parameters across groups defined by these varying
tracks and schedules.
Material and methods
■ Subjects
Our sample consisted of 713 adolescent students (396
girls and 317 boys, age 15–18) of grades 1–3 of Senior
High School (SHS) of the Greater Athens Metropolitan
Area. The subjects comprised the whole student popula-
tion of three state-run senior high schools which were
selected to represent the different academic tracks and
school schedules. Two of these schools are general edu-
cation institutions (GE1 and GE2), while the third is a
technical one (TE). Students of general education
schools are required to take part in the national bac-
calaureate exams at the end of both the second and third
grade with the aim of gaining entry to university; stu-
dents following the technical education also take part in
national-level exams, but these are much easier, with
considerably less competition, and lead to a polytechnic
type of technical higher education. The starting time of
schools in the morning is 8.20 a.m.; GE2 has a weekly al-
ternation of programme with all students attending
school in the morning for one week and in the afternoon
for another (starting time 2.10 p.m.). The vast majority
of students live within some minutes’ walking distance
from their schools.
■ Assessment
Self-administered questionnaires were distributed by a
social worker or a psychologist with the help of teachers
to all students of the three grades of the participating
schools during morning classes, around the middle of
the school year. The questionnaire had an introductory
part in which the following personal and family data
were recorded: school, grade, sex, time spent per week in
school-related (tutorials, courses, etc.) and extracurric-
ular (sports, music, etc.) activities, and school records in
the previous year (categorised as 0–5 with 0 = very bad
and 5 = excellent student). The sleep questionnaire con-
sisted of a series of questions on sleep habits (what time
do you usually wake up in the morning on school days;
what time do you go to school; what time do you return
from school; what time do you go to bed in the evening/
night; if you nap during the day, for how much time; and
how often do you nap during the day on weekdays and
at weekends). All questions were required to be an-
swered separately for morning and afternoon class
schedules. The questionnaire also contained the first five
questions of the Athens Insomnia Scale (AIS-5) [30] as-
sessing subjective complaints with sleep induction, noc-
turnal awakenings, final awakening, total sleep time and
sleep quality in a four-point Likert-type scale. The AIS
has been validated on a sample of 299 individuals and its
diagnostic reliability and validity have been assessed
against the ICD-10 diagnosis of insomnia, yielding high
sensitivity and specificity (93 % and 85 %, respectively)
[31], while its scale properties were very satisfactory
with a Cronbach’s alpha of around 0.9, mean item-total
correlation coefficient 0.7 and test-retest reliability al-
most 0.9 at a 1-week interval [30].
■ Statistical analysis
Comparisons of mean values among student groups
were statistically evaluated through t-tests and ANOVAs
as appropriate, while the association of sleep difficulties
and complaints with sociodemographic characteristics
and data regarding school-related and extracurricular
activities were assessed by multiple regression analyses.
Results
■ Sleep duration
Based on the self-reported times of sleep and awaken-
ing, the mean nocturnal sleep duration of the students
was 6 h and 58 min (SD = 70 min). Mean for bedtime
was 00.18a.m. ± 1h 8min and for rise time 07.15a.m. ±
32min. About 60 % of the students considered them-
selves to be regular afternoon nappers (napping from 30
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H. Lazaratou et al. 239

Sleep problems in adolescence

Table 1 Total reported duration of sleep (in hours,

mean ± SD) of Greek adolescent students according Schedule School Grade Male Female Total sample
to school schedule, school, grade and gender
Morning GE1 1 7.89±1.29 7.87±1.11 7.88±1.18
2 7.54±1.18 7.12±1.19 7.29±1.20
3 7.53±0.95 7.08±0.96 7.28±0.98
GE2 1 7.30±1.66 7.53±1.19 7.41±1.44
2 7.78±1.09 7.74±1.07 7.75±1.06
3 7.62±1.23 7.62±0.75 7.62±1.00
TE 1 7.28±1.53 7.24±1.47 7.26±1.49
2 7.53±1.46 7.57±1.23 7.55±1.36
3 7.73±1.46 6.69±1.23 7.03±1.37
Afternoon GE2 1 8.54±1.47 8.96±1.18 8.75±1.34
2 8.94±1.78 9.13±1.34 9.08±1.45
3 8.73±1.67 8.59±1.29 8.66±1.47

Means

Morning schedule GE1 7.65±1.16 7.36±1.16 7.48±1.17

GE2 7.51±1.40 7.64±1.02 7.58±1.20*
TE 7.42±1.49 7.24±1.39 7.33±1.44
First grade 7.48±1.51 7.54±1.31 7.51±1.40
Second grade 7.57±1.28 7.39±1.19 7.47±1.23
Third grade 7.59±1.12 7.18±1.01 7.36±1.08
Total 7.53±1.35 7.40±1.21 7.46±1.27
Afternoon schedule GE2 8.69±1.59 8.91±1.28 8.82±1.42*

* Difference between the two values statistically significant, p < 0.001

min up to 4 h) for a mean of 2.7 ± 1.3 times during work- Table 2 Multiple linear regression of total sleep duration (for the morning school
ing weekdays, while 68.5 % napped at least three times schedule) from gender, grade, school, school record, and time spent in school-re-
lated and extracurricular activities (SRA and ECA, respectively). Three independent
per week. The mean time per napping was about 2 h (1 analyses, one for each gender and one on the whole sample
h 56 min ± 1h 2 min). Mean sleeping time taking into ac-
count nocturnal sleep and afternoon napping was 7 h 28 Beta±SE p
min ± 1 h 16 min; 9.3 % of the sample slept for a mean of
Gender (0 = M, 1 = F) –0.194±0.101 0.055
less than 6 h per day, 31.1 % between 6 and 7 h, 32.5 % be-
Grade first 0.024±0.115 0.835
tween 7 and 8 h, 18.1 % between 8 and 9 h, and 9 % longer
second col.
than 9 h. third –0.049±0.043 0.264
The values for sleeping time by school, school sched-
School GE1 0.123±0.123 0.318
ule, grade and gender are presented in Table 1. There GE2 col.
were no significant differences between mean sleeping TE –0.388±0.138 0.005
times of the total of male and female students (7.53 School record 0.007±0.050 0.882
vs. 7.40 h). Similarly, no differences were found among
SRA –0.020±0.008 0.016
the three groups of students attending the morning
ECA –0.009±0.004 0.018
school programme, neither for the different schools nor
for the grades 1, 2 and 3. On the other hand, as shown in col. removed due to co-linearity
Table 1, students of school GE2 slept considerably longer SRA school-related activities
during the weeks that they were attending school in the ECA extra curricular activities
afternoon hours than when classes took place in the
morning (t = 11.35, df = 161, p < 0.001). When multiple
linear regression analysis of the factors potentially in- the main factor influencing the total hours of sleep was
fluencing total sleeping time for morning school sched- the time spent in various activities. Separate analysis of
ule was performed (Table 2), those students attending the two sexes showed that activities causing less sleep
the technical education school were found to sleep sig- were for boys mainly those associated with social life
nificantly less than students attending the general edu- and for girls those associated with tutorials and other
cation schools, while there was also an indication that educative activities supplementary to the school pro-
boys slept slightly more than girls. For the whole sample, gramme.
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240 European Child & Adolescent Psychiatry (2005) Vol. 14, No. 4
© Steinkopff Verlag 2005

Table 3 Prevalence of sleep complaints in Greek

adolescent students in total and by gender, as re- Male Female Total sample
ported in the AIS-5 (total score ± standard deviation).
AIS-5 individual items
Number (and percentage in brackets) of responders
who estimate they have at least a marked problem Sleep induction (n = 696) 76 (24.6 %) 125 (32.4 %) 201 (29.2 %)
with relevant items Nocturnal awakenings (n = 697) 39 (12.6 %) 99 (25.1 %) 136 (19 %)
Morning awakening (n = 695) 50 (16.2 %) 85 (22 %) 135 (18.9 %)
Total sleep duration (n = 697) 83 (26.7 %) 154 (39.8 %) 237 (33.3 %)
Sleep quality (n = 697) 31 (10 %) 70 (18.1 %) 101 (14.1 %)
Any item of AIS-5 (n = 697) 156 (50.3 %) 238 (61.5 %) 394 (56.5 %)

■ Sleep complaints Table 4 AIS-5 total score (mean ± SD) of Greek adolescent students according to
school grade and gender
Regarding sleep complaints as reflected in AIS, these School Grade Male Female Total sample
were mainly related to delayed sleep onset and insuffi-
cient total duration of sleep (Table 3). Of the total of 713 GE1 1 3.40±2.42 4.34±3.17 3.96±2.91
adolescent students of our sample, 697 gave valid re- 2 4.00±2.65 5.62±3.25 4.96±3.11
sponses in the majority of items of the AIS, and, of those, 3 3.83±2.47 4.37±2.34 4.13±2.40
56.5 % had at least one of the items of AIS-5 rated as GE2 1 3.03±1.99 5.23±3.43 4.08±2.96
markedly or severely impaired. In all, 29.2 % estimated 2 4.07±2.43 5.33±3.14 4.96±2.99
that their sleep onset latency was at least markedly de- 3 4.21±3.08 4.43±2.49 4.33±2.77
layed, while 33.3 % reported that their total sleep time TE 1 4.18±2.78 4.64±3.34 4.43±3.09
was at least markedly insufficient. Complaints for each 2 4.51±3.20 5.24±3.47 4.83±3.32
one of the other variables examined by AIS-5 (nocturnal 3 3.83 ± 2.17 4.62±3.56 4.33±3.11
awakening, early morning awakening, and sleep quality)
Means
were made by between 10 % and 20 % of the responders
(Table 3). GE1 3.76±2.52 4.87±3.06 4.40±2.89
The total score of AIS by school, grade and gender is GE2 3.67±2.56 5.02±3.05 4.42±2.91
presented in Table 4. Regarding the mean values, no dif-
TE 4.27±2.88 4.80±3.40 4.55±3.16
ferences were found among students of the three schools, First grade 3.64±2.52 4.64±3.29 4.19±3.00*
but there was a significant difference regarding the three Second grade 4.22±2.84 5.45±3.26 4.92±3.14*
grades (ANOVA F = 4.58, df = 696, p = 0.011). A signifi- Third grade 3.97±2.65 4.45±2.67 4.24±2.66*
cant difference was also observed between the two gen- Total 3.92±2.67** 4.89±3.16** 4.46±2.99
ders; sleep complaints were significantly more pro-
nounced among girls than among boys (t = 4.38, * Difference among the three values statistically significant, p = 0.011
** Difference between the two values statistically significant, p < 0.001
df = 693.1, p < 0.001). Multiple linear regression of the
AIS score is presented in Table 5. As shown in this table,
gender difference is confirmed, as well as the difference Table 5 Multiple linear regression of AIS-5 score from gender, grade, school,
among the three grades; students of the second grade are school record, and time spent in school-related and extracurricular activities (SRA
found to complain more about their sleep than either stu- and ECA). Three independent analyses, one for each gender and one on the whole
sample
dents of the first or third grade. In addition, school per-
formance is negatively correlated to sleep complaints: beta±SE p
students with lower academic performance are more
likely to have higher AIS-5 scores (Table 5). When analy- Gender (0 = M, 1 = F) 1.105±0.232 0.001
sis was performed by sex, it was shown that the above- Grade First –0.775±0.263 0.003
mentioned differences regarding the three grades and Second col.
school performance are much more pronounced among Third –0.240±0.099 0.016
girls than among boys.Finally,sleep complaints were not School GE1 0.164±0.283 0.563
found to be associated with the time spent in various GE2 col.
school-related or extracurricular activities (Table 5). TE 0.105±0.315 0.738
School record –0.390±0.114 0.001
SRA 0.002±0.019 0.916
Discussion ECA 0.010±0.009 0.260

col. removed due to co-linearity

In this study, a sample of 713 adolescents was investi- SRA school-related activities
gated by using a self-administered questionnaire. We ECA extra-curricular activities
237_243_Lazaratou_ECAP_460 15.06.2005 07:16 Uhr Seite 241
H. Lazaratou et al.
Sleep problems in adolescence
found that mean reported sleep duration was 7 h and 28
min ± 1 h and 16 min. This finding is consistent with
other surveys on students of Taiwan, Mainland China,
and the U. S. A. [8, 16, 36]. On the other hand, Tynjala
et al. [33] found that the total sleeping time of students
of various countries was somewhat longer, ranging from
8 h and 18 min (for the students from Israel) to 9 h and
12 min (for the Swiss students). However, the age range
of subjects in the latter study was 11–16 years, while the
age of our sample was between 15 and 18 years, and it is
well known that sleeping time is considerably longer in
early than in late adolescence [13, 22, 28].
Time of going to bed at night was later for Greek stu-
dents when compared to students from other countries
[16, 17]. In general, however, sleeping time in Greece is,
for all ages, considerably later than sleeping time in
other countries, usually being around or later than mid-
night for the vast majority of the population. Mean ris-
ing time was also later than that found in other studies
[1, 16, 17] and could be explained by the proximity of
schools, usually not more than 5–10 min away from the
vast majority of the students’ homes, as well as by the
fact that, in Greece, breakfast is not considered an im-
portant meal.
The results of the present study also show that the dif-
ference between mean total sleeping time of the two
sexes does not exceed 8 min. In other studies, gender was
not found to influence substantially the duration of
sleep [8,33].In accordance with the results of the present
study, educational programme, school schedule and var-
ious activities have been found to influence total sleep-
ing time of adolescents [2, 5, 6, 32].
One particular characteristic of our sample is that
about 70 % of the students regularly napped in the after-
noon. Two other studies report on napping habits in
other student populations; in both, the frequency for ha-
bitual napping is lower than among Greek students [8,
17].Napping is quite a widespread habit among the Greek
population, although it seems to be on the decline [29].
While mean nap time was about 2 h for the regular nap-
pers, their total sleeping time did not exceed that of stu-
dents who did not nap regularly by more than about 40
min. This shows that napping is mainly used as a factor
compensating for the reduced hours of nocturnal sleep.
The main sleep complaints in our study were related
to delayed sleep onset latency (29 %) and insufficient to-
tal duration of sleep (33 %), while nocturnal awakening
and early morning awakening were reported to be more
rarely problematic. These findings are partially in ac-
cordance with a study on Chinese students, 27 % of
whom reported problems with delayed sleep latency [8],
and with another on Italian students among whom 20 %
had difficulties in initiating sleep [17]. In two other stud-
ies, even lower rates were reported for problems with
falling asleep [18, 38]. Of our population, 56.5 % had at
least one of the items of AIS-5 rated as markedly or se-
241
verely impaired. This is in agreement with the respective
percentage in a study of 763 French students of sec-
ondary school [35], while it is much higher than respec-
tive findings in a study of Mainland Chinese students
[16]. The varying percentages of sleep complaints
among different studies and populations may be due to
cultural and demographic differences, as well as the dif-
ferent assessment methods used in the various studies.
Regarding sleep complaints, these have been found to
increase with age [16]. Our finding that second grade
students complain more about their sleep, while com-
plaints are somewhat reduced in the third grade, may be
a result of particularities of the Greek society and the
schooling system. In general, in Greece, there is strong
emotional and financial investment of the parents in
their children’s education, particularly regarding enter-
ing university through the national baccalaureate ex-
ams. On the other hand, in the Greek educational sys-
tem, students are not familiar with examinations in their
early school years and examinations in the first years of
high school are not decisive for their progress. There-
fore, they have to face examinations of determinative
importance for their future for the first time at the end
of the second and third (and last) year of their studies at
senior high school. In addition, the educational system
in Greece has changed many times in the last 20 years
and these changes provoke great anxiety in the students
and their families. Consequently, it is possible that sleep
complaints are worst when the students are first con-
fronted (in the second grade) with the higher require-
ments and become less as they get used to the demands.
Similarly to the findings of our study, two other stud-
ies report complaints about sleep to be more frequent
among girls than among boys [10, 17]. No studies have
assessed the relationship of sleep complaints with aca-
demic performance. In our sample, students with lower
academic performance are more likely to present sleep
complaints. It seems, thus, that hard-working students
who perform better at school do not complain about
their reduced sleep, as they realise the need for system-
atic and continuous effort in order to respond to the re-
quirements of the educational system.
The most interesting finding of the present study was
that the factors associated with the reduction of re-
ported total sleep time were not the same as those influ-
encing complaints about sleep. Sleep duration was inde-
pendent of gender, school grade and academic
performance, while it depended on type of school (be-
ing less for students attending the technical education
school), and time spent in activities (boys slept less the
more extracurricular activities they had, while girls
slept less the more curricular activities they had). Com-
plaints about sleep on the other hand, were independent
of type of school and time spent in activities either cur-
ricular or extracurricular, but dependent on school
grade, gender and school performance.
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242 European Child & Adolescent Psychiatry (2005) Vol. 14, No. 4
© Steinkopff Verlag 2005

The main limitation of the present study is that no
history of sleep disorders based on clinical examination
was taken from the participating adolescents. Thus,
sleep disorders other than insomnia (e. g. restless leg
syndrome or breath-related sleep disorders) could not
be excluded. There is, consequently, the possibility that a
number of the sleep complaints we identified are associ-
ated with these disorders, although the prevalence of the
latter in this age-group is quite low and numerous arti-
cles have shown that the main reason for disturbed sleep
and its consequences among adolescents is circadian
rhythm aberrations rather than leg movements, snoring
or sleep apnoea [13, 21, 32, 36].Another limitation of our
study is that certain of its findings relate to the Greek sit-
uation. On the other hand, in many countries of Europe
and the rest of the world, there are schools and academic
tracks with different pressures and requirements for
achievement. Therefore, we believe that our results of
differences between schools of general and technical ed-
ucation are comparable to those of other studies and
may be useful to research outside Greece as well.
Previous studies on adolescents’ sleep have based
their approach on either sleep duration or sleep com-
plaints and no direct comparison of the factors influ-
encing each one of them has, thus, been made. The re-
sults of our study point out that the factors which
influence sleeping time have more to do with practical
matters such as school schedule and other activities,
while sleep complaints are mainly a result of other in-
fluences related either to gender or specific psychologi-
cal characteristics of the students. The difference be-
tween actual sleeping time and sleep complaints should
be taken into account in future studies on sleep in ado-
lescents.
■ Special note This paper is dedicated to the memory of our de-
creased colleague and co-author Ourania Sbokou.

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