Running Head: Sleep Deprivation In Adolescents of Developed Countries

The Risk Factors and Impacts of Sleep Deprivation on High-School Aged Adolescents in

Developed Countries: A Literature Review

Kayla Epps

Fall 2021

HPRB 5010
Sleep Deprivation In Adolescents of Developed Countries 2

Table of Contents

Section Page Number

Introduction 3

Methods 5

Figure 1. Search One 6

Figure 2. Search Two 7

Results 8

Impact Measures 8

Outcome Measures 11

Discussion 13

Limitations 16

Conclusion 17

References 18
Sleep Deprivation In Adolescents of Developed Countries 3

Introduction

Receiving an adequate amount of sleep each night is vital to maintaining one’s overall

health and wellbeing. This is especially important during the time of puberty when an

adolescent’s brain is going through significant development (Vijayakumar et al., 2018).

According to the American Academy of Sleep Medicine, the recommended sleep time for

adolescents aged 13-18 is eight to ten hours per day (Wheaton et al., 2015). However, 72.7% of

high school students in the United States have reported inadequate sleep duration (Wheaton et

al., 2015). When adolescents do not receive enough sleep, it increases their risk of obesity,

diabetes, injuries, poor mental health, attention and behavior problems, and poor academic

performance (Wheaton et al., 2015).

Sleep deprivation in high school students can lead to a multitude of negative side effects

including worsened academic performance, delayed mental development, and increased

automobile accidents as a result of lethargy (Killgore, 2010). The core cause of these issues is

that sleep deprivation has been linked with a slowing of response time, increased variability in

performance, decrease in alertness, and decrease in attention (Killgore, 2010). When adolescents

are not receiving enough sleep to function properly, their academic performance, physical health,

and mental health suffer.

In developed countries, adolescents experience a variety of daily stressors including

maintaining high grades in school, attending extracurricular activities, working part-time jobs,

and taking care of family members. Another reason that adolescents are chronically sleep-

deprived is that their late sleep times conflict with early school start times (Winnebeck et al.,

2019). Since these lifestyle habits are unique to the developed world, this literature review will

focus on the population of adolescents in developed countries. Countries from which the
Sleep Deprivation In Adolescents of Developed Countries 4

reviewed studies were conducted include the United States, Japan, Turkey, Germany, China,

Norway, and Taiwan. While this selection does not encapsulate all developed countries, it is

intended to assess a wide range of countries. Ideally, this selection will adequately represent all

adolescents residing in developed countries.

The original population of this literature review was intended to only include adolescents

from the US, but additional studies found in other countries provided the basis for expanding the

study population. Expanding the population to be worldwide would have required too many

assumptions, as the studies found did not adequately represent all population types. All studies

currently included are from developed countries with the exception of China and Taiwan.

However, these countries are experiencing rapid industrial growth and are anticipated to be

categorized as developed countries in the near future (Benoit et al., 2020). While the definitions

of these two countries are undergoing debate, they will be classified as developed countries for

the purposes of this literature review.

Throughout the literature, the Pittsburgh Sleep Quality Index (PSQI) is used to measure

sleep quality. It does this by asking about sleep quality from the preceding month through 19

self-rated questions. It measures sleep quality, sleep latency, sleep duration, sleep efficiency,

sleep disturbances, use of sleep medication, and daytime dysfunction. Regional changes may be

made when translating into other languages. For example, the J-PSQI is used for the Japanese

questionnaire.

This literature review aims to identify what risk factors contribute to sleep deprivation in

high school-aged adolescents (13-18 years) in developed countries along with the negative side

effects of sleep deprivation.

Sleep Deprivation In Adolescents of Developed Countries 5

Methods

A literature search was conducted to identify factors contributing to sleep deprivation in

high-school-aged adolescents of developed countries. Searches were conducted primarily

through PubMed for peer-reviewed journal articles from 2011-2021. An additional stipulation of

an adolescent age range (13-18 years) was included to filter results. After looking through the top

results, 20 articles were selected for inclusion in the literature review.

The studies’ selection criteria were that they had to be peer-reviewed, were published in

the last ten years, were conducted on adolescents aged 13-18, and are related to the effects of

sleep on students’ academic performance and development. The geographical restriction on

developed countries was developed after observing that all selected studies pertained to the

lifestyle habits of developed countries. Two studies were related to academic performance, two

were related to physical health, and three were related to mental health and development.

Specific searches included “sleep AND “high school’”, “delaying school start times”,

“adolescent sleep”, “sleep deprivation”, “adolescent[Title/Abstract] sleep deprivation”, and

“sleep adolescent academic performance.” From these searches, five sources were longitudinal

cohort studies, nine sources were review articles, four sources were cross-sectional non-

experimental studies, and two sources were experimental studies.

The tables below show the process of identifying relevant articles through PubMed. The

first table shows the preliminary searches conducted and the second table shows supplemental

searches conducted after the first draft.

Sleep Deprivation In Adolescents of Developed Countries 6

Figure 1. Search One

Database Terms Used Filters Number of Articles

Results Used

Search #1 Found “Why do we #1

through CDC need sleep
webpage cdc”
references

Search #2 PubMed “Sleep AND Scholarly (Peer- 7,272 #2, #3,

school” reviewed) Journals, #4, #5
Dates: 2011-2021, Age:
Adolescent (13-18
years)

Search #2 Used article #11

Extension #5 reference
section

Search #3 PubMed “Delaying Scholarly (Peer- 215 #6, #7,

school start reviewed) Journals, #8,
times” Dates: 2011-2021, Age:
Adolescent (13-18
years)

Search #4 PubMed “Adolescent Scholarly (Peer- 14,499 #9, #10

sleep” reviewed) Journals,
Dates: 2011-2021, Age:
Adolescent (13-18
years)
Sleep Deprivation In Adolescents of Developed Countries 7

Figure 2. Search Two

Database Terms Used Filters Number Articles

of Results Used

Search #1 PubMed “sleep Scholarly (Peer- 898 #12

deprivation” reviewed) Journals,
Dates: 2011-2021, Age:
Adolescent (13-18
years)

Search #2 PubMed “adolescent[ Scholarly (Peer- 137 #13

Title/ reviewed) Journals,
Abstract] Dates: 2011-2021, Age:
sleep Adolescent (13-18
deprivation” years)

Search #3 PubMed “sleep Scholarly (Peer- 279 #14

adolescent reviewed) Journals,
academic Dates: 2011-2021, Age:
performance Adolescent (13-18
” years)

Search #4 PubMed “adolescent[ Scholarly (Peer- 137 #15, #16,

Title/ reviewed) Journals, #17
Abstract] Dates: 2011-2021, Age:
sleep Adolescent (13-18
deprivation” years)

Search #4 Used article #18, #19

Extension #15 reference
section

Search #5 PubMed “blue light Scholarly (Peer- 308 #20

sleep” reviewed) Journals,
Dates: 2011-2021
Sleep Deprivation In Adolescents of Developed Countries 8

Results

This literature review identified several risk factors for sleep deprivation in high-school-

aged adolescents between the ages of 13-18 in developed countries. These risk factors included

grade year in school, demographics, internet usage, and delayed school start times. The most

commonly identified outcomes associated with chronic sleep deprivation were the negative

impacts on academic performance, physical health, and mental health and development.

Impact Measures

Grade year in school was one risk factor found to have an effect on how much sleep

adolescents received. A study conducted by Mitchel, et al. observed the sleeping patterns of

students from southeast Pennsylvania and southern New Jersey. In eighth grade, sleep duration

averaged 6.72 hours on school nights and 7.50 hours on nonschool nights (Mitchell et al., 2020).

In ninth grade, sleep duration decreased to 6.29 hours on school nights and experienced no

change on nonschool nights (Mitchell et al., 2020). As adolescents enter high school, the average

hours of sleep adolescents receive decreases by an average of 25.8 minutes on school nights.

This is largely due to a 22.2-minute delay in sleep onset (Mitchell et al., 2020). The increased

workload and responsibilities given to adolescents once they enter high school are hinted to be

the cause behind this decrease in sleep duration. In China, sleep quality in adolescents was also

found to decrease as students grew older and moved on to higher grade levels (Xu et al., 2011).

Specifically, 18.6% of adolescents aged 16-20 experienced poor sleep quality compared to

15.2% of 10-15-year-olds (Xu et al., 2011). These results show that grade year differences have

an effect across multiple countries. As students get older and receive more stressors and
Sleep Deprivation In Adolescents of Developed Countries 9

responsibilities, their sleep duration and quality decrease. This change is particularly noticeable

during the transition from middle to high school.

Demographic variables were also shown to have an effect on sleeping times. From the

southeast Pennsylvania and southern New Jersey study mentioned previously, males were 59%

less likely to sleep eight hours or more and had more night awakenings when compared to

females (Mitchell et al., 2020). The study also found that Black students were 51% less likely to

sleep eight hours or more when compared to White students (Mitchell et al., 2020). Additionally,

students in households with less than a $40K annual income had both later sleep onset and offset

(Mitchell et al., 2020). Sleep onset refers to the time when participants fall asleep and offset

refers to the time when they wake. Those whose parents had an undergraduate college degree

had a shorter sleep duration than those with graduate degree parents (Mitchell et al., 2020).

Overall, these results suggest that risk factors for decreased sleep include being male, being

Black, living in a low-income family, and having parents with lower levels of education.

However, there is potential for these demographic risk factors to vary between countries due to

population differences. Particularly in countries with homogenous populations or where racial

disparities are not as prevalent, race and ethnicity are not significant risk factors (Chen & Gau,

2016; Tokiya et al., 2020; Xu et al., 2011).

Internet addiction was another factor found to have a negative effect on sleep quality. The

definition of Internet addiction may vary across studies with varying measures such as the Chen

Internet Addiction Scale and Internet Use Survey (Chen et al., 2003; Rotunda et al., 2003). A

longitudinal study of Taiwanese students found that Internet usage and sleep problems have a

bidirectional effect on each other (Chen & Gau, 2016). This means that an increase in Internet

usage led to an increase in sleep problems, and the presence of sleep problems led to further
Sleep Deprivation In Adolescents of Developed Countries 10

Internet usage. Participants who exhibited Internet addiction were found to require longer

amounts of sleep but reported shorter sleep durations, resulting in greater sleep deficits (Chen &

Gau, 2016). This cyclical effect is supported by a study of Japanese high school students that

found a significant relationship between Internet addiction and sleep disturbance (Tokiya et al.,

2020). Screen time on television, computers, video games, or mobile devices is adversely

associated with sleep duration (Hale & Guan, 2015). When adolescents spend more time exposed

to electronics, they experience later sleep onset and shorter sleep duration (Hale & Guan, 2015).

Among a population of students from Notre Dame, increased social network usage was found to

have a negative effect on sleep quality (Wang et al., 2021). Students with larger social networks

found difficulties maintaining them through social media, negatively affecting sleep (Wang et

al., 2021). Extended screen time is particularly detrimental to sleep since the blue light emitted

off of screens has been shown to alter circadian rhythms (Tosini, 2016). Blue light is naturally

emitted by the sun during the daytime, but overexposure to it during the night can disrupt

sleep/wake cycles (Tosini, 2016). Ultimately, increased screen time and Internet usage have been

strongly associated with a decrease in sleep quality. These effects appear to be cyclical, with the

presence of sleep problems also resulting in further Internet usage. Differences between study

results can be attributed to the different measures used to define Internet addiction and sleep

disturbance.

Several schools have attempted to alter school start times to see whether this has an effect

on adolescent sleep times. These experiments with delayed school start times have resulted in

positive effects. One such study was conducted with five public high schools in the metropolitan

area of Minneapolis and St. Paul, Minnesota (Wildome et al., 2020). Two high schools delayed

start times by 50 and 65 minutes respectively, while three other high schools served as a
Sleep Deprivation In Adolescents of Developed Countries 11

comparison group. Students with delayed start times had on average an additional 41 minutes of

sleep a night (Wildome et al., 2020). More importantly, delayed start times were not associated

with students falling asleep later on school nights (Wildome et al., 2020). One concern with

delaying school start times is that adolescents will simply sleep later, not necessarily longer.

However, these results point towards delayed start times at schools being a viable long-term

option for improving adolescents’ sleep. Another study involved a high school in Alsdorf,

Germany that experimented with a flexible school start system (Winnebeck et al., 2019). This

system allowed them to come into school later on some days if they wished and make up the

missed time at a later date (Winnebeck et al., 2019). Students were highly satisfied with the

flexible school start system, sleeping 1.1 hours longer and having sleep onsets remaining

unchanged (Winnebeck et al., 2019). This study further supports the idea that students will use

delayed school start times to improve their sleeping times and subsequently their health.

Outcome Measures

One major outcome of reduced sleep in adolescents was worsened academic

performance. Poor sleep quality among high school students in Turkey resulted in a decrease in

cognitive function and academic performance (Tekcan et al., 2020). Similar results were found in

Norwegian adolescents, where poor sleep was also related to worsened academic performance

(Hysing et al., 2016). Lower sleep duration was most associated with poor school performance.

Weekday sleep onset was also significantly associated with academic performance, with

adolescents that went to bed between 22:00 and 23:00 having the highest GPA scores (Hysing et

al., 2016). The later students went to bed, the lower their GPA (Hysing et al., 2016). This data
Sleep Deprivation In Adolescents of Developed Countries 12

shows the direct correlation between lower sleep duration, later sleep onset, and worsened

academic performance.

Another outcome of poor sleep quality is the negative effects on physical health. A study

of students from Pittsburgh, Pennsylvania found that shorter sleep duration is associated with

increased vulnerability to the common cold (Prather et al., 2015). This is especially dangerous

for students in a public school setting since they are exposed to a multitude of illnesses from

their classmates on a daily basis. A review of data from North Carolina examined the effect of a

75-minute delayed school start time on motor vehicle crashes (Foss et al., 2019). The shift in

school start times suggests a small overall decrease in automobile crashes among 16-17-year-old

adolescents (Foss et al., 2019). However, researchers concede that the lack of a significant

decrease may also mean that the decline was not a result of reduced sleepiness (Foss et al.,

2019). While results are not confirmed, there is the potential for sleepier students to be at a

higher risk for motor vehicle crashes. Poor sleep quality negatively impacts adolescents’ physical

health through decreased immune response and an increased likelihood of motor vehicle crashes.

Adolescents’ mental health and development are also severely impacted by worsened

sleep quality. Poor sleep quality among Turkish high school students led to an increase in

depression, alcohol consumption, and suicide attempts (Tekcan et al., 2020). In China, poor sleep

quality was associated with higher levels of loneliness, depression, and anxiety (Xu et al., 2011).

On the other hand, students in Germany with delayed school start times reported cognitive and

sleep improvements (Winnebeck et al., 2019). These results suggest that sleep is a preventative

factor for adolescents’ mental health and development. Additionally, a lack of sleep can be

detrimental to an adolescent’s mental health.

Sleep Deprivation In Adolescents of Developed Countries 13

Discussion

Through a review of the literature, multiple risk factors and outcomes for sleep

deprivation were found in high school-aged adolescents of developed countries. The identified

risk factors helped to determine what circumstances put adolescents at a greater risk of

developing sleeping problems and experiencing shorter sleep duration. Among impact measures,

risk factors include grade year in school, demographic variables, Internet usage, and delayed

school start times. Outcomes of sleep deprivation were reviewed to identify the negative side

effects an insufficient amount of sleep has on adolescents. Outcomes of lack of sleep include

worsened academic performance, physical health, and mental health and development.

The greatest risk factor among impact measures appeared to be Internet usage, which had

a bidirectional effect. Students that experienced sleeping problems found themselves spending

more time on the Internet, and those who spent more time online had shorter sleep durations. The

recent escalation of adolescent screen time is in part due to the rise in popularity of social media,

streamable media, and video games. With so much online media grappling for the attention of

adolescents, this age group is at risk for Internet addiction. Internet addiction disorder can be

defined in several forms, but generally is characterized by excessive Internet usage and poor

impulse control when limiting screen time. Additionally, screens emit blue light, which is

typically associated with daytime and signals our brains to stay awake. This exposure to blue

light disrupts the body’s natural circadian rhythm, leading to difficulty sleeping.

Grade year in school and demographic variables also had a noticeable effect on sleep

duration. As students progressed from middle to high school, they were found to experience
Sleep Deprivation In Adolescents of Developed Countries 14

decreases in both sleep duration and sleep quality. This effect may be due to students receiving

more responsibilities at school and the added burden of extracurriculars and part-time jobs.

Building off of the issue of Internet addiction, there is also the possibility of intersectionality

between the two. As adolescents enter high school, they may be exposed to more social media,

streamable media, and video games, leading to increased Internet usage. Demographic studies

conducted in the United States found that being male, being Black, living in a low-income

family, and having parents with lower levels of education were the greatest risks for sleep

deprivation. In the US, these characteristics are often associated with lower standards of living.

This may lead to students having to spend more time working part-time jobs as they enter

adolescence. These differences held true across reviewed studies from other developed countries

with the exception of race. In countries with more homogenous populations or where racial

disparities are not as prevalent, race and ethnicity were not seen as notable risk factors for shorter

sleep duration and poorer sleep quality.

A protective factor for adolescents getting proper amounts of sleep was delaying school

start times. A common critique of this approach is the belief that adolescents will simply sleep

later, not necessarily longer. However, the two experimental studies reviewed both observed a

longer sleep duration among adolescents without the side effect of delayed sleep onset times.

This may be due to adolescents having naturally later circadian rhythms that are interrupted by

early school start times. The results of these studies point towards delayed school start times

being a sustainable solution for increasing adolescent sleep duration. A potential barrier to

implementation is that altering school times may result in scheduling conflicts within school

districts. Districts may not have the resources available to reschedule buses, teacher work hours,

and mealtimes. Additionally, moving school times back means that students’ extracurriculars
Sleep Deprivation In Adolescents of Developed Countries 15

will need to be delayed as well. Ultimately, it is a well-founded solution but will need more

altering before it is attainable for all school districts.

Among outcome measures, the most widespread was worsened academic performance.

Students who got fewer hours of sleep performed poorly on exams and assignments. This

phenomenon has been observed across several developed countries and in a variety of

populations. However, the most worrying outcomes of poor sleep were the negative effects on

physical and mental health. Adolescence is a time in which the brain is undergoing development,

meaning that sleep is vital for health. Poor sleep was associated with weakened immune

response, which is particularly dangerous in a public school setting where adolescents are

exposed to a wide variety of illnesses on a daily basis. Additionally, some studies have found

links between sleep deprivation and automobile crashes among adolescents. In the Foss et al.

study previously reviewed, the relationship between delayed school start times and automobile

crashes was analyzed. While the rate of automobile crashes did decrease, it was undetermined

whether this was a result of increased sleep times or other confounding factors such as having

fewer cars on the road during commute times. Regardless, it is a possibility worth considering

and that future research might look into.

In terms of mental health, sleep deprivation and poor sleep quality resulted in negative

effects. Adolescents across several developed countries who experience poor sleep report an

increase in depression, alcohol consumption, and suicide attempts. They also report a decrease in

cognitive function and academic performance. The positive effect of increased sleep duration is

supported by students from high schools with delayed start times, who reported cognitive and

sleep improvements. It is vital for adolescents to get an adequate amount of sleep each night to

maintain their mental health and development.

Sleep Deprivation In Adolescents of Developed Countries 16

Limitations

Although this literature review has identified several impact and outcome measures of

sleep deprivation in adolescents of developing countries, some important findings may have been

overlooked. Only two of the studies reviewed were experimental, making it difficult to determine

causality. Additionally, many of the studies used self-reported data or asked participants to

describe their prior sleep experience, putting results at risk of recall bias. The reviewed studies

looked at high schools from seven different countries: the United States, Japan, Turkey,

Germany, China, Norway, and Taiwan. However, these results may overlook themes present in

other developed nations.

Additionally, the search process may have resulted in selection bias. Only the first page

of results was viewed for each search before moving on to another search term. In many cases,

articles were identified from the references section of other articles included in this literature

review. While this helps to strengthen the background of this topic, it may overlook other views

in this field. Since it is impossible to assess every research article on the topic, articles were

selected for their relevance in their title and abstract.

Finally, some of the measure indexes involving Internet usage and sleep quality were

inconsistent. Some studies experienced differing results and were difficult to compare since they

used differing measures. By using a more standardized measurement index such as the PSQI for

sleep quality, these issues could be avoided.

Sleep Deprivation In Adolescents of Developed Countries 17

Conclusion

Sleep deprivation among high school students is influenced by a variety of factors such as

being in a higher school grade, increased Internet usage, and being in a school that starts earlier.

Males, Black students, and students with a household income <$40,000 were also found to have

disproportionately less sleep on school nights. Sleep deprivation among high school students can

result in worsened academic performance, weaken immune systems, the likelihood of increased

automobile accidents, and higher levels of mental health disorders.

There are several opportunities for future research. The specific effects of

extracurriculars, part-time jobs, and taking care of family members on sleep duration needs to be

observed. Current research does not separate these factors, making it difficult to determine what

events are most contributing to decreased sleep duration in this age group. More research can be

conducted on the impact of sleep deprivation on automobile accidents in adolescents. Existing

research has not come to a consensus, and if there is a connection it should be identified.

Additionally, the impact of Internet usage is a great opportunity for future research. Internet

addiction is a relatively new concept and online platforms have only gotten more popular the last

few years. More research can also be done into the application of delayed school start times and

their impacts on students with extracurriculars. Future intervention programs may tackle Internet

dependence to improve sleep duration among high school students.

Researchers in this field have not come to a consensus as to how detrimental a lack of

sleep is for adolescents. While the studies reviewed have found supporting evidence, they often

reference previous articles that have had contradicting results. More research into the topic will
Sleep Deprivation In Adolescents of Developed Countries 18

help to identify gaps in how we support adolescents and what needs to be done to improve

adolescent sleep and health.

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