Sleep Medicine Reviews 32 (2017) 45e57

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Sleep Medicine Reviews

journal homepage: www.elsevier.com/locate/smrv

CLINICAL REVIEW

Effects of sleep manipulation on cognitive functioning of adolescents:

A systematic review
Eduard J. de Bruin*, Chris van Run, Janneke Staaks, Anne Marie Meijer
Research Institute of Child Development and Education, University of Amsterdam, The Netherlands

a r t i c l e i n f o s u m m a r y

Article history: Adolescents are considered to be at risk for deteriorated cognitive functioning due to insufficient sleep.
Received 30 November 2015 This systematic review examined the effects of experimental sleep manipulation on adolescent cognitive
Received in revised form functioning. Sleep manipulations consisted of total or partial sleep restriction, sleep extension, and sleep
17 February 2016
improvement. Only articles written in English, with participants' mean age between 10 and 19 y, using
Accepted 23 February 2016
Available online 3 March 2016
objective sleep measures and cognitive performance as outcomes were included. Based on these criteria
16 articles were included. The results showed that the sleep manipulations were successful. Partial sleep
restriction had small or no effects on adolescent cognitive functioning. Sleep deprivation studies showed
Keywords:
Sleep manipulation
decrements in the psychomotor vigilance task as most consistent finding. Sleep extension and sleep
Deprivation improvement contributed to improvement of working memory. Sleep directly after learning improved
Restriction memory consolidation. Due to the great diversity of tests and lack of coherent results, decisive conclu-
Extension sions could not be drawn about which domains in particular were influenced by sleep manipulation.
Treatment Small number of participants, not accounting for the role of sleep quality, individual differences in sleep
Cognitive functioning need, compensatory mechanisms in adolescent sleep and cognitive functioning, and the impurity
Cognition problem of cognitive tests might explain the absence of more distinct results.
Memory
© 2016 Elsevier Ltd. All rights reserved.
Adolescence
Attention

Introduction analysis, using a sample of 86 studies of 5e12 y, authors concluded

Issues concerning sleep, cognitive functioning and learning ca-
pacity in adolescents have attracted much attention in recent years.
Several reviews and meta-analyses have stressed associations of
sleep quantity and quality with academic performance and effects
of sleep loss on memory, attention, and more complex cognitive
functions [1e4]. Due to the decreasing sleep time of adolescents
worldwide and high prevalence of adolescent sleep problems
[5e7], conclusive knowledge about the relation between adoles-
cent sleep and cognitive functioning is highly needed.
Kopasz et al. [4] concluded in a review of 15 studies focusing on
sleep and memory, that most studies support the hypothesis that
sleep facilitates working memory as well as memory consolidation
in children and adolescents, and that there is some evidence that
decline of performance after sleep deprivation in abstract and
complex tasks is stronger than in simple memory tasks. In a meta-
* Corresponding author. Research Institute of Child Development and Education,
University of Amsterdam, PO Box 15776, 1001 NG Amsterdam, The Netherlands.
Tel.: þ31 20 525 1327; fax: þ31 20 525 1500.
E-mail address: E.J.deBruin@UvA.nl (E.J. de Bruin).
that executive functioning and school performance are associated
with sleep duration but that sleep is not associated with intelli-
gence, sustained attention, or memory [1]. As indicated by another
meta-analysis of 50 studies in children and adolescents, improved
school performance is associated with increased sleep quality and
sleep duration [3]. This analysis also suggests that sleepiness shows
the strongest relation with school performance, followed by sleep
quality and sleep duration. In a clinical review Curcio et al. [2]
stated that what jeopardizes memory consolidation most is sleep
loss or fragmentation.
The need for sleep is known to differ strongly between in-
dividuals and the debate on what constitutes 'optimal sleep' is still
ongoing. General consensus on what amount is sufficient is mainly
based on expert opinion and not on bias-free evidence [8].
Notwithstanding the discussion on adolescent sleep need, surveys
of adolescent sleep duration report increased adolescent sleepiness
and increased desire for more sleep [5e7]. In addition, adolescents
with high chronic sleep reduction and short sleep duration showed
impaired daytime functioning, including attention problems and
worse school performance [9]. Taking these findings together, there
are sufficient indications that sleep debt due to short sleep duration

http://dx.doi.org/10.1016/j.smrv.2016.02.006
1087-0792/© 2016 Elsevier Ltd. All rights reserved.
46 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57

Abbreviations RT reaction time

SE sleep efficiency
AVLT auditory verbal learning task SOL sleep onset latency
AWM arithmetic working memory task SQ sleep quality
CBTI cognitive behavioral therapy for insomnia STS spatial temporal span
CPT continuous performance test SVWM simple verbal working memory task
CVWM complex verbal working memory task TST total sleep time
DSS digit symbol substitution TTCT Torrance tests of creative thinking
FI feature identification VDS visual digit span
fMRI functional magnetic resonance imaging WASO wake after sleep onset
GDS Gordon diagnostic system WCST Wisconsin card sorting test
MSL memory search letters WM working memory
PVT psychomotor vigilance test WWM Williams word memory test

or worse sleep quality is prevalent among adolescents and that this
generally results in impaired cognitive functioning.
There are several theories that explain deteriorated cognition
by sleep debt. One theory concerning memory consolidation
states that two processes take place during sleep: the consoli-
dating process and resetting process. The information obtained
during wakefulness is contained within the brain circuits and has
to be consolidated to ensure future accessibility. One approach to
model this is the synaptic-homeostasis hypothesis [10]. It sug-
gests that because of a net increase of synaptic strength during
wakefulness and to maintain synaptic homeostasis, synaptic
downscaling occurs during slow-wave sleep. It solidifies
the already strong memory traces while liquefying the weaker
ones [11].
Another model explaining memory consolidation is the more
active trace-reactivation hypothesis [12]. Transient memory traces
(hippocampus based for declarative memory) are short-term and
are thought to be copied to long-term memory (mainly neocortex
based) via reactivation of memory traces during slow wave sleep
[12,13]. Reactivation of a trace promotes gradual strengthening of
the synaptic corticocortical connections and eventually results in a
memory trace that is more stable and (mostly) independent of the
hippocampus [14,15].
For attention processes, studies have found that after sleep
deprivation the divergence between activation and deactivation of
task positive and task negative networks becomes attenuated,
which may influence attention-demanding tasks in adults [16,17].
These networks are associated with distinct neuronal structures in
the brain, which undergo changes in both structure and connec-
tivity during adolescent development [18] and interact with the
consolidation and resetting processes. Sleep loss might therefore be
especially perilous for adolescents as brain changes in adolescence
interfere with these processes and can have lasting effects well into
adulthood because of the neuronal malleability during adolescence
[18].
Taken together, adolescents seem to be at risk for insufficient or
bad sleep and may therefore be at risk for deteriorated cognitive
functioning. The first aim of this systematic review is to examine
the general effect of sleep manipulation on cognitive functioning of
adolescents. We chose to examine the influence of both sleep
deprivation (i.e., a prolonged period without sleep, also referred to
as acute sleep restriction), sleep restriction (i.e., a prolonged period
with a limited amount of sleep, also referred to as partial sleep
deprivation) and sleep improvement, such as sleep extension and
sleep treatment, to get insight into the possible differential effects
of these two distinct forms of sleep manipulations on cognitive

Fig. 1. Database search and article selection.

Table 1
Description of studies.

Reference Participants Design Sleep manipulation Sleep measurement

N % male Age (y) (range) Healthye Baseline sleeptimef Manipulation Sleep hrs Nights Method Place
g
Carskadon et al. 1981 [34] 12 67 13.5 (11.9e13.3) Yes 10 W Deprivation 0 1 PSG Lab.
Carskadon et al. 1981 [33] 9 33 12.3 (11.0e13.2) Yes 10g W Restriction 4 1 PSG Lab.
Randazzo et al. 1998 [35] 16 44 11.9 (10e14) Yes >9g RCT Restriction 5 or 11 1 PSG Home

E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57

Fallone et al. 2001 [45] 82 53 11.9 (8.6e15.8) Yes 10g RCT Restriction 4 or 10 1 PSG/Act. Lab.
Sadeh et al. 2003 [28] 77 51 10.6 (9.1e12.2) Yes 8.12h RCT Restriction and extension normal  1 h 3 Actigraphy Home
Gais et al. 2006 [40],a 12 50 17.4 (na) e e W Deprivation normal 1 Sleep logs Home/Lab.
Gais et al. 2006 [40],a 14 100 18.1 (na) e e CO Deprivation 0 vs normal 1 Sleep logs Lab.
Peters et al. 2009 [26] 14 0 10.6 (10e11) Yes 10g CO Restriction 5 or 10 1 Actigraphy Lab.
Beebe et al. 2009 [38] 6 67 15.3 (na) Yes 7.7h CO Restriction 6.5 or 10 5 Actigraphy Home
Biggs et al. 2010 [41],b 14 0 10.6 (10e11) Yes 10.12h CO Restriction 5 or 10 1 Actigraphy Lab.
Kopasz et al. 2010 [42] 22 46 15.5 (14e16) Yes 8.5g CO Restriction 4 or 9 1 PSG Lab.
Voderholzer et al. 2011 [43] 76 45 15.0 (14e16) Yes 8.5h RCT Restriction 9,8,7,6, or 5 4 Actigraphy Home/Lab.
Jiang et al. 2011 [36],a 17 50 15.0 (13e16) Yes 8.35h CO Restriction 6 or 8 5 Actigraphy Home
Jiang et al. 2011 [36],a 20 50 18.9 (18e20) Yes 8.06h CO Restriction 6 or 8 5 Actigraphy Home
Dewald-K. et al. 2013 [29],c 55 15 15.4 (12.8e18.5) Sleep reducedc 6.55h RCT Extension þ 5 min a day 10 Actigraphy Home
Piosczyk et al. 2013 [44] 49 0 16 (na) Yes 8g CO Active vs passive nap i
naps 13:30 he14:30 h PSG Lab.
Louca & Short 2014 [27] 12 50 16.2 (14e18) Yes >8g W Deprivation 0 1 PSG/Act. Lab.
De Bruin et al. 2015 [21],d 32 18 15.9 (13e19) Insomniad 6.33h RCT Improvement (CBTI) 42 Actigraphy Home

Note: Act., actigraphy; CBTI, cognitive behavioral therapy for insomnia; CO, cross-over; Lab., laboratory; PSG, polysomnography; RCT, randomized controlled trial; W, within groups.
a
Two different groups, one publication.
b
Same participants as in the study of Peters et al. [26].
c
Participants were selected on chronic sleep reduction (score > 40 on the chronic sleep reduction questionnaire [29]).
d
Participants were selected on DSM-5 insomnia.
e
Healthy ¼ no sleep problems and no psychiatric problems.
f
Baseline sleep time.
g
Self or parent reported mean sleep time.
h
Total sleep time based on actigraphy or PSG.
i
Nap compared to active or passive waking between 13:30 h - 14:30 h after learning during the day.

47
48 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
functioning. Cognitive functioning is operationalized by perfor-
mance on cognitive tests.
The second aim of this study is to examine which cognitive
domains are in particular affected by sleep manipulation. Knowl-
edge about this aspect might explain the underlying causes of sleep
debt on academic performance in adolescents.
Finally, as a third aim we investigated whether studies could
indicate if worsening or improvement of sleep was causally related
to cognitive functioning. In order to be able to compare the sleep
manipulations between the studies and to see whether sleep was
significantly changed after the sleep manipulation, only studies
that experimentally studied the effects of sleep on cognitive func-
tioning and measured sleep objectively or involved sleep depriva-
tion are included. Another important inclusion criterion is that of
brain-developmental stage. As many studies did not report on
pubertal development, we chose age as an acceptable replacement
for pubertal development [19]. To exclude studies that did not
actually study adolescents we used the age range criterion of the
World Health Organization [20], of 10e19 y. Participants of the
studies also had to be in good health to ensure a generalization
towards the general adolescent population. Health issues that
involve sleep are an exception, but study samples with sleep apnea
are excluded because the detrimental effect of oxygen deprivation
on the brain rather than sleep deprivation might confound any
experimental results.
Method
Search strategy and selection
Two databases were accessed; Medline and PsycINFO. Search
queries consisted of synonyms of 'cognition', 'sleep', 'deprivation',
and 'adolescence'. See Appendix for the search syntax. Articles had
to be written in English. Study participants had a mean age be-
tween 10 and 19 y [20] and were preferably in good health. Studies
of participants with sleep problems were included with the
exception of breath-related disorders (e.g., sleep apnea). Studies of
participants with psychiatric problems, such as attention deficit
problems, were excluded. Sleep had to be measured objectively.
Outcomes had to include measures of cognitive performance.
Based on these criteria 15 articles were included. Cross-
referencing did not result in additional articles. One recent article
[21] of a study by the authors was added, resulting in a total of 16
included articles (see Tables 1 and 2, and Fig. 1). After the selection
process two coders categorized the tests, the cognitive results, and
the sleep results. In case of disagreement, conclusion was reached
after discussion. The initial search was carried out in November
2014. An update on 21 December 2015 did not result in additional
articles.
Categorization of cognitive tests
Five cognitive domains, including their sub-domains, were
derived from the literature [22e25]. These domains are attention
(including selective, divided and sustained attention), working
memory (including visuospatial and phonological working mem-
ory), declarative memory (including learning, immediate and
delayed recall), executive functions (including cognitive flexibility
and cognitive control/inhibition), and creative and abstract
thinking (including reasoning).
We categorized cognitive tests under cognitive domains based
on the description from the researchers in the studies that we used
in this review. If researchers from two separate studies reported
different sub-domains for a similar test (e.g., digit symbol substi-
tution task), we followed the literature [22e25]. If researchers did
not describe the (sub)domain that a cognitive test was operation-
alized to measure, we derived the cognitive domain from the
literature. See Appendix for a description of the cognitive tests.
Results
Descriptives
The 16 articles were published from 1981 to 2015. Study details
are described in Table 1. The studies show a variety in age ranges,
sleep manipulations, and cognitive tests. The lowest mean age of
subjects was 10.6 y and the highest was 18.1 y. As two articles con-
tained two separate studies, in total 18 studies were examined. Four
studies examined the effects of sleep deprivation, ten studies
examined sleep restriction, one examined sleep before memory
consolidation during the day, one examined sleep extension, one
examined sleep extension and restriction, and one study investigated
the effects of cognitive behavioral therapy for insomnia (CBTI) of
adolescents with clinical insomnia (see Table 1). Forty-five cognitive
tests were reported assessing different aspects of cognition. Fourteen
of these tests mainly relied on attention, seven relied on working
memory, 12 involved declarative memory, eight involved executive
functions, and four assessed creative and abstract thinking.
Cognitive performance after sleep manipulation in adolescents
In the following sections we discuss the studies according to
their cognitive domains (see also Table 2). In each section we
consider consecutively: studies on sleep restriction, sleep depri-
vation, and sleep improvement (sleep extension or CBTI treatment).
Psychomotor performance
Psychomotor performance consists of the coordination of a
sensory or ideational (cognitive) process and a motor activity, and
plays an important part in many cognitive tests, since most cognitive
tests require a person to execute some form of motor-action or
motor-response to a stimulus. However, from two tests that
measured psychomotor performance exclusively there appeared no
effects on performance after either sleep restriction or extension
[28,43].
Tests of attention
The psychomotor vigilance test (PVT) is widely used to measure
vigilance. The task is to respond as quickly as possible to a simple
stimulus. After sleep restriction of 5 h participants in the study of
Peters et al. [26] became significantly slower in responding, and
they showed a significantly higher increase in lapses (i.e., late or no
response) than the control condition. Louca and Short [27] found a
significant and strong deterioration in both reaction time (RT) and
lapses from the PVT in 12 adolescents after a night of sleep depri-
vation compared to two baseline nights of 10 h sleep opportunity.
Interestingly, in a study with 32 adolescents with insomnia, De
Bruin et al. [21] found no change in performance on the PVT after
sleep improvement (6 wk of CBTI).
In a study that manipulated sleep for three consecutive nights at
home, Sadeh et al. [28] found a deterioration of RT in a simple RT
task for the restriction and no-change groups, but RT remained
stable for the extension group. However, only the sleep extension
group became significantly quicker in responding on the contin-
uous performance test (CPT). For another cognitive test used in this
study, digit symbol substitution (DSS) measuring selective atten-
tion, none of the groups showed significant changes on the scores.
However, in the study by Louca and Short [27], after sleep depri-
vation participants made fewer correct responses on the DSS task.
The difference in sleep manipulation between these two studies
Table 2
Cognitive tests categorized under cognitive domains, and scores after sleep manipulation.
Reference and cognitive tests
Restriction/deprivation
Attention
Carskadon et al. 1981 [34]
Carskadon et al. 1981 [34]
Carskadon et al. 1981 [33]
Randazzo et al. 1998 [35]
Randazzo et al. 1998 [35]
Fallone et al. 2001 [45]
Fallone et al. 2001 [45]
Sadeh et al. 2003 [28]
Sadeh et al. 2003 [28]
Sadeh et al. 2003 [28]
Sadeh et al. 2003 [28]
Peters et al. 2009 [26]
Kopasz et al. 2010 [42]
Kopasz et al. 2010 [42]
Kopasz et al. 2010 [42]
Voderholzer et al. 2011 [43]
Voderholzer et al. 2011 [43]
Kopasz et al. 2010 [42]
Voderholzer et al. 2011 [43]
Louca & Short 2014 [27]
Louca & Short 2014 [27]
Working memory
Carskadon et al. 1981 [34]
Carskadon et al. 1981 [33]
Randazzo et al. 1998 [35]
Sadeh et al. 2003 [28]
Sadeh et al. 2003 [28]
Beebe et al. 2009 [38]
Kopasz et al. 2010 [42]
Serial alternation
Listening attention
Listening attention
Digit symbol substitution
Steer clear
GDS standard delay
GDS vigilance
Finger tapping test
Simple reaction-time test
Continuous performance test
Symbol-digit substitution
Psychomotor vigilance task
TAP (divided attention)
TAP (flexibility)
D2 (sustained attention)
TAP (divided attention)
Trail-making test, part A
Trail-making test, part B
Trail-making test, part B
Psychomotor vigilance task
Digit symbol substitution
Wilkinson addition test
Wilkinson addition test
Wisconsin card sorting test
Visual digit span test
Serial digit learning test
N-back task
Tower of London
Phonological working memory
Visuospatial working memory
Vigilance=sustained attention
Cognitive control=inhibition
Memory immediate recall
Higher=abstract thinking
Memory delayed recall
Cognitive flexibility
Selective attention
Divided attention
Psychomotor
Efficiency
Accuracy
Learning
Speed
Score
 ¼
 ¼
E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
 ¼
  ±
  ¼
 ¼ ¼ ¼
  ¼ ¼ ¼
 ¼
  Y
   ¼ ¼
  ¼
  Y Y
 ¼
 ¼
 ¼
 ¼
 ¼
    ¼
    ¼
  YY YY
  Y
 YY ¼
 ¼ ¼
    Y
 ¼
  ¼
 ¼ ¼
   ¼
(continued on next page)
49
Table 2 (continued )
Reference and cognitive tests
Voderholzer et al. 2011 [43]
Jiang et al. 2011 [36],a
Jiang et al. 2011 [36],a
Jiang et al. 2011 [36],a
Jiang et al. 2011 [36],a >18yr
Jiang et al. 2011 [36],a >18yr
Jiang et al. 2011 [36],a >18yr
Learning and memory
Carskadon et al. 1981 [34]
Carskadon et al. 1981 [33]
Randazzo et al. 1998 [35]
Randazzo et al. 1998 [35]
Randazzo et al. 1998 [35]
Randazzo et al. 1998 [35]
Randazzo et al. 1998 [35]
Sadeh et al. 2003 [28]
Memory consolidation during sleep
Gais et al. 2006 [40],a
Biggs et al. 2010 [41]
Kopasz et al. 2010 [42]
Kopasz et al. 2010 [42]
Kopasz et al. 2010 [42]
Voderholzer et al. 2011 [43]
Voderholzer et al. 2011 [43]
Piosczyk et al. 2013 [44] nap
Piosczyk et al. 2013 [44] sigma
Executive functions
Randazzo et al. 1998 [35]
Sadeh et al. 2003 [28]
Fallone et al. 2001 [45]
Fallone et al. 2001 [45]
Kopasz et al. 2010 [42]
Kopasz et al. 2010 [42]
Voderholzer et al. 2011 [43]
Creative/abstract thinking
Randazzo et al. 1998 [35]
Digit span task (WAIS)
Simple verbal working memory
Complex verbal working memory
Arithmetic working memory task
Simple verbal working memory
Complex verbal working memory
Arithmetic working memory task
Williams word memory test
Williams word memory test
WRAML verbal
WRAML visual
Children's category test
Wisconsin card sorting test
California verbal learning test
Serial digit learning test
English-German vocabulary list
Auditory verbal learning task
Visual verbal memory test
AVLT
Paired-associate word list task
Paired-associate word list task
Mirror tracing task (procedural)
Paired-associate word list task
Paired-associate word list task
Wisconsin card sorting test
Continuous performance test
GDS vigilance
GDS standard delay
Tower of London
Trail-making test, part B
Trail-making test, part B
Children's category test
50
Phonological working memory
Visuospatial working memory
Vigilance=sustained attention
Cognitive control=inhibition
Memory immediate recall
Higher=abstract thinking
Memory delayed recall
Cognitive flexibility
Selective attention
Divided attention
Psychomotor
Efficiency
Accuracy
Learning
Speed
Score
 ¼
 Y ¼
 ¼ ¼
 Y ¼
E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
 ¼ ¼
 ¼ ¼
 ¼ ¼
 Y
 ¼
  [
  ¼
  ¼
    Y
   ¼
  ¼
 Y
  ¼
 ¼
 ¼
 ¼
 ¼
 ¼ ¼
 ¼
 [
    Y
   ¼ ¼
  ¼ ¼ ¼
 ¼ ¼
   ¼
    ¼
    ¼
  ¼
 Randazzo et al. 1998 [35] Wisconsin card sorting test     Y
Randazzo et al. 1998 [35] TTCT verbal  Y
Randazzo et al. 1998 [35] TTCT figural  ¼
Extension/improvement
Attention
Sadeh et al. 2003 [28] Finger tapping test  ¼
Sadeh et al. 2003 [28] Simple reaction-time test   ¼
Sadeh et al. 2003 [28] Continuous performance test    [ ¼
Sadeh et al. 2003 [28] Symbol-digit substitution (visual)   ¼
Dewald-K. et al. 2013 [29] Baseline speed  ¼
Dewald-K. et al. 2013 [29] Memory search letters (phonol. WM)   [ Y ¼
De Bruin et al. 2015 [21] Baseline speed  ¼ ¼ ¼
De Bruin et al. 2015 [21] Memory search letters (phonol. WM)   ¼ ¼ [
De Bruin et al. 2015 [21] Psychomotor vigilance task   ¼ ¼ ¼
Working memory
Sadeh et al. 2003 [28] Visual digit span test  [
Sadeh et al. 2003 [28] Serial digit learning test   ¼

E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57

Dewald-K. et al. 2013 [29] Memory search letters (phonol. WM)   [ Y ¼
Dewald-K. et al. 2013 [29] Feature identification (vis.spat. proc.)  [[ ¼ [[[
De Bruin et al. 2015 [21] Memory search letters (phonol. WM)   ¼ ¼ [
De Bruin et al. 2015 [21] Feature identification (vis. spat. proc.)  [ [[ [[[
De Bruin et al. 2015 [21] Spatial temporal span (visual WM)  ¼ ¼ ¼
De Bruin et al. 2015 [21] Category fluency   ¼
De Bruin et al. 2015 [21] Letter fluency   ¼
Learning and memory
Sadeh et al. 2003 [28] Serial digit learning test   ¼
De Bruin et al. 2015 [21] Auditory verbal learning task   ¼ ¼ ¼
Executive functions
Sadeh et al. 2003 [28] Continuous performance test    [ ¼
De Bruin et al. 2015 [21] Response organization arrows   ¼ ¼ ¼
De Bruin et al. 2015 [21] Category fluency   ¼
De Bruin et al. 2015 [21] Letter fluency  x ¼

Note: AVLT, auditory verbal learning test; GDS, Gordon diagnostic system; phonol. WM, phonological working memory; TAP, test for attentional performance; TTCT, Torrance test of creative thinking; vis. spat. proc., visuo spatial
processing; visual WM, visual working memory; WAIS, Wechsler adult intelligence scale; WRAML, wide range assessment of memory and learning.
a
Two different groups, one publication.

51
52 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
(sleep restriction versus deprivation) may account for the contra-
dictory findings.
Two studies showed improvements after sleep extension [29] or
sleep improvement after CBTI [21] on the memory search letters
(MSL) task measuring divided attention and phonological working
memory (WM). Compared to a control group, participants with
chronic sleep reduction showed improvements in RT on the MSL
after sleep extension [29], but they also made more errors, with the
result that overall performance, that takes both measures into ac-
count (i.e., efficiency) [30,31], remained at the same level as base-
line. For the same task De Bruin et al. [21] found no significant
change in either speed or accuracy, but the efficiency score did
improve significantly compared to a control group. Since this
cognitive test also contained a WM component, the improvement
of the treated group from the study of De Bruin et al. may have been
related to WM.
Finally, no effects were found after either sleep deprivation or
extension/improvement, in any of the remaining six studies that
are reviewed here. These tests involved vigilance, selective atten-
tion and divided attention.
To summarize, the effects of sleep restriction or deprivation on
scores for the PVT indicate that this test and the cognitive sub-domain
of vigilance appear sensitive to sleep deprivation in adolescents, but
not to sleep restriction or improvement of sleep in adolescents who
were treated for insomnia. Other tests of cognitive components of
attention showed inconsistent results of either no effects, or effects that
are difficult to differentiate from simultaneous effects on components
of more complex cognitive functions such as WM or cognitive
inhibition.
Tests of working memory
Tests of WM evaluate the ability to cognitively maintain and
manipulate relevant information over a brief period of time [32]. In
the earliest two studies in this review, Carskadon et al. [33,34]
investigated effects of sleep restriction on cognitive performance
of 12 and nine children respectively, all between 11 and 14 y. In the
first study [34] participants were deprived of sleep for one night,
and in the second study [33] sleep was restricted to 4 h for one
night. Only in the group that had undergone sleep deprivation the
researchers found a decrease of speed on the Wilkinson addition
test that measured WM. The accuracy (number of errors), however,
remained stable. The authors commented that the decrements in
scores were due to actual sleep during the tests, as was detected by
EEG/EOG recordings during the testing.
In a study on sleep restriction of 5 h with 16 adolescents be-
tween 10 and 14 y Randazzo et al. [35] measured performance on
the Wisconsin card sorting test (WCST), measuring WM, learning,
cognitive flexibility and abstract thinking. In the sleep restriction
group the number of correct responses declined significantly, but
not the speed of learning, or the number of perseverations after
change of criterion. As speed of learning and number of persever-
ation entail a more explicit demand for WM to function, it seems
unlikely that the decrement in performance on the WCST in the
study of Randazzo et al. [35] is due to a distinct decline of WM
functioning alone.
In a study on sleep restriction of 6 h Jiang et al. [36] tested 17
adolescents with the simple verbal working memory task (SVWM)
which tests maintenance in WM, the complex verbal working
memory task (CVWM) which tests both maintenance and manip-
ulation of information, and the arithmetic working memory task
(AWM) which tests also maintenance and manipulation of infor-
mation. The authors found a significantly decreased performance in
RT for the SVWM and AWM. Accuracy appeared unaffected. How-
ever, the decline of performance was found in the most simple
(SVWM) and most complex (AWM) WM tasks. As all three tasks
required a visual processing of the information, distinct from the
phonological WM component, it is unclear from the results
whether this concerns a possible interaction of verbal WM with
other processing such as increased visuospatial processing or
increased workload of the central executive [37]. Of note is that in
the remaining studies [28,36] with sleep restriction or deprivation
that included tasks for WM exclusively, the scores did not change.
Finally, six participants in a sleep restriction study of 6.5 h [38]
completed a computerized n-back task while undergoing fMRI
monitoring. The participants showed no decrements in perfor-
mance on the 2-back task after sleep restriction. Interestingly, fMRI
monitoring indicated that the sleep-deprived brain compensated
performance by higher activation of regions that are normally
active in the well-rested brain during attention-demanding WM
tasks (task positive attention network), and greater suppression of
activity in areas that normally show suppression in the well-rested
brain (task negative network).
In all three studies that extended or improved sleep, several WM
tests showed improvements. In the study of Sadeh et al. [28], the
performance on the visual digit span (VDS) task improved, for only
the forward part, in the sleep extension group. Strikingly, although
the extension group also improved on the VDS backward part, the
deprivation and no-change groups also improved, possibly indi-
cating a learning effect rather than an effect of sleep. The authors
commented that the decreased performance of the children in all
three groups, may point to a loss of interest of the children, because
of the repetitive and ‘boring’ nature of the WM tasks. This ‘lack of
interest’ points to the relevance of possible confounder variables
such as motivation and learning in the interpretation of results of
cognitive tests in general, and WM specifically.
Both the sleep extension study by Dewald-Kaufmann et al. [29]
and the sleep improvement study by De Bruin et al. [21] showed
improvements on the MSL. As the MSL tests components of
phonological WM, and also of divided attention, it is unclear which
cognitive component was affected. These authors tested adoles-
cents also on feature identification (FI), which measures visuo-
spatial processing [39]. The improvements in speed, accuracy and
efficiency on this task in both studies indicate a distinct sensitivity
to extended or improved sleep, although it remains unclear which
cognitive component is affected. This is further underlined by a lack
of change in the more exclusive visual WM task spatial temporal
span (STS) in this study. De Bruin et al. comment that the results
from all WM tests may point to an improvement of visuospatial
processing and phonological WM, but not of visuospatial WM.
To summarize, studies with sleep restriction or deprivation show
conflicting results, with some studies indicating a decrease of WM
performance, and other studies showing no change. The lack of
dysfunction on exclusive WM tasks in many studies seems to indi-
cate that incidental worse WM performance after sleep deprivation
may be attributable to other cognitive sub-domains in general, and
attentional processes specifically. This is underlined by the results
from the study by Beebe et al. showing that a compensatory cerebral
attention network mechanism is activated in the sleep deprived
brain that keeps performance stable, highlighting the important role
of attention in WM. Conversely, results from studies that extended or
improved sleep suggest a more consistent improvement of WM
performance.
Learning and memory
Learning and memory consist of the ability to acquire new
information, commit such information to long-term storage, and
effectively retrieve that information when needed [32]. Tests of
learning and memory therefore typically require subjects to learn
information and to reproduce that information after a short or
longer interval with or without other tasks (interference). The
 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
information can be visual, verbal, procedural, and episodic in
nature.
Effects of sleep on memory consolidation
Five studies investigated the effect of sleep restriction or
deprivation after learning on subsequent consolidation of memory.
Gais et al. [40] showed a much higher rate of forgetting in morning
learning conditions (which were not directly followed by sleep)
compared to evening learning conditions (which were directly
followed by sleep). Strikingly, there were no significant differences
between the recall in 24 or 36 h conditions, indicating that sleep
after learning, and not length of interval between learning and
recall, had a strong positive influence on consolidation of learned
word-pairs. To investigate whether sleep or whether time of day
caused the higher retention rate in the first experiment, the re-
searchers conducted a second experiment in which participants
learned English-German word-pairs in the evening, but in one
condition participants went to sleep afterwards, while in the sec-
ond condition participants had to postpone their sleep until
06:00 h the next morning. Results showed a significantly higher
rate of words retained in the group of participants who had slept,
compared to the group who had not slept the night following
learning. This study shows quite convincingly that consolidation of
declarative memory is aided by sleep, and sleep deprivation after
learning interferes with consolidation.
Two studies did not find decreased memory performance after
sleep restriction. In a study of 14 girls with 5 h sleep Biggs et al. [41]
tested learning and memory with the auditory verbal learning task
(AVLT) before and after the experimental night. The researchers
found no significant differences in the delayed recall after time in
bed of either 5 or 10 h. Kopasz et al. [42] tested 22 adolescents aged
14e16 y in a sleep restriction study of 4 h with three memory tests.
The results showed no differences between the two experimental
conditions, indicating that one night of sleep restriction had no
significant effects on auditory or visual/verbal memory
consolidation.
In a large study by Voderholzer et al. [43], 88 adolescents,
14e16 y, were randomized to five conditions with either 9, 8, 7, 6, or
5 h of time in bed for four consecutive nights, and tested for
declarative and procedural memory performance. The results
showed no significant effects of a stepwise increase of sleep re-
striction on declarative and procedural memory. As the authors
point out in the discussion, there is evidence that 1e2 h of sleep
might be sufficient for optimal consolidation of declarative mem-
ories, which is underlined by the results from this study, and from
the studies by Biggs et al. and Kopasz et al.
Piosczyk et al. [44] investigated the effects of daytime sleep
versus active or passive waking on declarative memory consolida-
tion in a study with 49 female adolescents aged 16 y. Contrary to
the hypothesis of this study, there appeared no differences in
memory performance between the sleep and active or passive
waking conditions. When dividing participants by median split into
two subgroups with high versus low EEG sigma activity during
sleep, the researchers found a significant effect of sleep on memory
consolidation in participants with high sigma activity, but not in the
group with low sigma activity, indicating that sigma activity during
sleep is positively related to consolidation of declarative memory,
and suggesting that not so much the amount of sleep after learning,
but rather the type and timing of sleep are important for memory
consolidation.
Learning and memory after sleep restriction, deprivation, extension
or improvement
Two studies that investigated learning and memory after sleep
deprivation, found a decrease in performance. In the study of
53
Carskadon et al. [34] the participants showed a decrease due to
actual sleep during testing in immediate recall of words of the
Williams word memory test (WWM) if they were sleep deprived. In
the study of Randazzo et al. [35], contrary to expectation, the re-
searchers found better performance in a verbal memory test in
children whose sleep was restricted to 5 h in bed compared to the
performance of children with 11 h in bed. However, the authors
commented that this was not so much the result of an increased
performance by the sleep-restricted group but of a decreased per-
formance of the control group. In two studies applying sleep
extension or improvement [21,28], no effects were found on any of
the memory tests.
To summarize, results from studies on learning and recall after
sleep restriction or deprivation showed no effects of sleep on perfor-
mance, other than the decrements because of actual sleep during
testing. The same was found in studies with extension or improvement
of sleep. Studies that investigated effects of sleep on memory consoli-
dation, however, indicate that sleep is essential for consolidation, and
particularly sleep deprivation after learning can interfere with
consolidation. Furthermore, the results also indicate that not so much
the amount of sleep, but rather the timing (directly after learning) and
stage of sleep are important for consolidation.
Executive functions
Executive functions are cognitive processes that serve goal-
directed behavior, and that control and regulate information pro-
cessing across the brain [32]. Five studies tested executive functions
after sleep restriction or deprivation. In their sleep restriction study
of 5 h Randazzo et al. [35] administered the WCST and found a
decreased performance in the number of correct responses. As
noted earlier, the WCST addresses several cognitive sub-domains,
making it difficult to ascribe dysfunctions to one of them. In the
study by Sadeh et al. [28] the CPT was administered after sleep
restriction over three nights, and the results indicated no change on
this test.
In a sleep restriction study of 4 h with 82 participants Fallone
et al. [45] administered the Gordon diagnostic system (GDS), an
electronic assessment device for attention problems and impul-
sivity in children. The results indicated no significant differences
between the normal and restricted sleep groups. Finally, in the
previously discussed studies of Kopasz et al. [42] and Voderholzer
et al. [43] the trail making part B test was administered. Similar to
part A, in part B circles have to be connected but now contain
numbers and letters, and the participants must alternate between
the two sequences. Besides shifting between the two sequences,
part B requires attention, complex visual scanning and motor speed
[23]. The sleep-restricted participants from both studies of Kopasz
et al. and Voderholzer et al. did not show impaired performance
compared to those with a normal time in bed.
The study by Sadeh et al. [28] showed that, as described in the
section on attention, the group with extended sleep performed
better on the CPT, compared to those with no change or restriction
of sleep. De Bruin et al. [21] administered three tests measuring
executive functions to adolescents with insomnia: the response
organization arrows (ROA) testing cognitive inhibition, and two
fluency tests, category and letter fluency, requiring a participant to
name in 1 min as many words beginning with a letter or words
from a certain category. None of these tests differed between the
CBTI and control group.
To summarize, the results indicated that for only one test of exec-
utive functions, the WCST, there appeared decrements in performance
after sleep restriction, and for another test, the CPT, there appeared
improved scores after sleep extension. All tests for executive functions
also require multiple, lower level cognitive functions, making it hard to
conclude that this domain is affected.
 54
Table 3
Sleep manipulation and effects on sleep measures.

Reference Design Manipulation Measure Sleep after manipulation Mediated by sleep

Actigraphy/PSG Sleep logs MSLT Questionnaires

SOL TST SE SOL TST SQ HSDQi CSRQg PSG Act. Logs Quest.

Carskadon et al. 1981 [34] W Deprivation PSG YYY [ yesa

Carskadon et al. 1981 [33] W Restriction PSG YY YY YY
Randazzo et al. 1998 [35] RCT Restriction vs control PSG YYY [[[ YY

E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57

Fallone et al. 2001 [45] RCT Restriction vs control PSG YYYa YY
Sadeh et al. 2003 [28] RCT Restriction vs extension Act. [[[ YY [ ¼
Gais et al. 2006 [40] W Sleep vs waking after learning Logs
Gais et al. 2006 [40] CO Sleep vs deprivation after learning Logs
Peters et al. 2009 [26] CO Restriction vs control Act. YYY YYY yesb
Beebe et al. 2009 [38] CO Restriction vs control Act. YY YY [
Biggs et al. 2010 [41] CO Restriction vs control Act. YYY [[ YY YYY [
Kopasz et al. 2010 [42] CO Restriction Act. YY YY [
Voderholzer et al. 2011 [43] RCT Restriction vs control Act./PSG ¼ YYY ¼ Y YYY [ [[[
Jiang et al. 2011 [36] CO Restriction vs control Act. YY YY [[ ¼
Jiang et al. 2011 [36] CO Restriction vs control Act. YY YY [[ [[[
Dewald-K et al. 2013 [29] RCT Extension vs control Act. [ [ ¼ yesc
Piosczyk et al. 2013 [44] CO Active vs passive (nap) waking PSG yesd
Louca & Short 2014 [27] W Deprivation Act./PSG [[
De Bruin et al. 2015 [21] RCT CBTI vs control Act. ¼ ¼ [ YY [[ [[ YYY YYY e no yese yesf

Note: Act., actigraphy; CBTI, cognitive behavioral therapy for insomnia; CO, cross-over; CSRQ, chronic sleep reduction questionnaire; HSDQi, Holland sleep disorders questionnaire insomnia scale; MSLT, multiple sleep latency
test; PSG, polysomnography; Quest., questionnaires; RCT, randomized controlled trial; SE, sleep efficiency; SOL, sleep onset latency; SQ, sleep quality; TST, total sleep time; W, within groups. Outcome: ‘¼’ ¼ no significant effect,
[ ¼ p < .05, [[ ¼ p < .01, [[[ ¼ p < .001. Arrows point up for an increase and down for a decrease.
a
EEG/EOG measures were related to cognitive performance for adolescents who fell asleep during performance tests.
b
Memory performance in paired associate word list task correlated with non-REM sleep after sleep curtailment (r ¼ 0.521, p ¼ 0.003).
c
Adolescents in the experimental group did advance significantly their bedtimes and statistical results show that the more the adolescents advanced their bedtimes, the more they improved on the cognitive performance
tasks [29].
d
Follow-up analyses revealed a beneficial effect of sleep over waking selectively under conditions of high EEG spindle (sigma) activity [44].
e
Improvements in visuospatial processing were correlated with improvements of wake after sleep onset and subjective sleep quality from the sleep logs and improvements in selective attention and working memory were
correlated with wake after sleep onset from sleep logs [21].
f
Improvements in visuospatial processing and selective attention and working memory were correlated with improvements on the CSRQ [21].
g
Results for other tests, measuring sleepiness (Beebe et al. [39] and Louca & Short [27]) or fatigue (Voderholzer et al. [43]), are also reported in this column.
 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
Higher/abstract thinking including reasoning
Only one study tested the effects of sleep restriction on higher/
abstract thinking and reasoning. This cognitive domain is very
complex and touches on an intricate interplay of many cognitive
functions that together lead to higher cognitive functions, and
contributes to performance on measures of IQ.
In the sleep restriction study of 5 h by Randazzo et al. [35]
participants had to perform the Torrance tests of creative
thinking (TTCT), consisting of a verbal version testing creative
development and originality and a version testing figural creativity.
The sleep restriction group scored significantly lower on verbal
creativity. None of the scores on figural creativity were significantly
different between the sleep restricted and normal sleep groups. On
the children's category test, evaluating learning and problem
solving, the groups showed no significant differences in the total
number of errors made while identifying the ideas. On the WCST,
which was described before, performance after sleep restriction
showed a decrease of correct responses, but not of speed of learning
or increase of perseverations.
To summarize, two of the four tests for higher/abstract thinking and
creativity indicated a decreased performance after sleep restriction in
the only study that examined abstract thinking. Although this might
point to a sensitivity of this higher cognitive domain to sleep restric-
tion, it has to be kept in mind that these tests comprise multiple
cognitive domains that can only partially be differentiated by the
multiple scores derived from each test.
Relations between sleep and performance due to sleep manipulation
All reviewed studies showed clear effects of the sleep manipu-
lation on actigraphic sleep measures, but also on sleep logs and
questionnaires (Table 3). Interestingly, sleep restriction studies
showed a decrease in total sleep time (TST), but also a decrease in
sleep onset latency (SOL) and an increase in sleep efficiency (SE).
The two sleep extension studies showed both an increase in TST,
but also a decrease in SE [28] and an increase in SOL [29]. Dewald
et al. did not find a significant change in SE. De Bruin et al. [21], who
applied CBTI for adolescents with insomnia, found no change in SOL
or TST, but a higher SE on actigraphy data, and shorter SOL, longer
TST, and better SE on sleep log data. These findings point to an
improved sleep quality (e.g., less sleep fragmentation, better sleep
consolidation) after sleep restriction and a decreased sleep quality
in sleep extension studies.
Only five studies executed analyses to establish whether change
in cognitive functioning was related to sleep manipulation. In a
sleep deprivation study Carskadon et al. [34] found decreased
cognitive performance for adolescents who fell asleep (as measured
with EEG) during performance tests. However, if no sleep occurred,
test scores showed little decrement. Kopasz et al. [42] concluded
that memory performance in a paired associate word list task
correlated with non-REM sleep after sleep curtailment, and Piosc-
zyk et al. [44] stated that follow-up analyses revealed a beneficial
effect of naps over waking selectively under conditions of high EEG
spindle (sigma) activity. The two studies in adolescents with sleep
problems showed several relations between sleep improvement
and cognitive functioning. The more adolescents with chronic sleep
reduction advanced their bedtimes, the more they improved on the
cognitive performance tasks [29]. Improvements on visuospatial
processing in adolescents with insomnia were correlated with less
wake after sleep onset (WASO) (sleep logs) and better sleep quality
[21]. Moreover, improvements in selective attention and working
memory in these adolescents were related to less chronic sleep
reduction.
To summarize, all reviewed studies showed that the sleep manip-
ulation was successfully executed. Sleep quality seemed to improve
55
after sleep restriction and to decrease after sleep extension. The
question whether a change in cognitive functioning was related to the
sleep manipulation was investigated in five studies. Although these
studies could indicate that sleep manipulation was related to change
in cognitive functioning, it has to be concluded that the results did not
show a coherent pattern.
Discussion
The first aim of this study was to examine the general effect of
sleep manipulation on cognitive functioning of adolescents. The
largest effects are found in sleep deprivation studies [27,34], with
decrements in the vigilance tasks such as the PVT as most consis-
tent finding, and in the two studies in adolescents with sleep
problems [21,29]. Sleep extension in adolescents with chronic sleep
reduction and sleep improvement in adolescents with insomnia
contribute to improvement in working memory. Sleep directly after
learning improves memory consolidation [40,42].
Generally, the sleep restriction studies show absent or small
effects on cognitive functioning. Considering the small number of
participants in most studies, lack of power might restrain signifi-
cant results. Because the study-results indicate that the sleep
manipulation had effectively changed sleep, as shown by objective
sleep parameters, absent or small effects cannot be ascribed to a
failure of the manipulation. Several explanations can be given for
the lack of results. Firstly, sleep reduction might improve sleep
efficiency [46], as also is indicated in several studies from this re-
view [26,28,35,36,38,41], and the better sleep quality might
compensate for the loss of sleep time. Conversely, longer sleep
schedules than usual in the control condition might worsen sleep
quality and as a consequence cognitive functioning. Secondly,
compensatory mechanisms might play a role. The extent to which
sleep restriction impairs alertness and performance may vary as a
function of the amount of sleep obtained before the sleep restric-
tion period [47]. As the participants in the sleep restriction studies
were good sleepers, banking of sleep might be considered as an
explanation. Furthermore, sleep restricted adolescents showed
greater activation in the task positive attention network and
deactivation in the task negative network on fMRI, suggesting
compensation of sleep loss [38]. To avoid this compensatory
response we recommend to execute sleep restriction over longer
time (e.g., more than 1 wk). Thirdly, also individual sleep need
might play a role with different effects for habitual long and short
sleepers [48]. As the number of participants in most studies was
small, individual differences in sleep need might obscure the effects
of sleep manipulation on adolescent cognitive functioning.
The second aim of this review was to investigate which cogni-
tive domains in particular are affected by sleep manipulation. In
total 45 cognitive tests have been performed assessing different
aspects of cognition. With the exception of the PVT, sleep manip-
ulation shows inconsistent results or even no effects on tests that
contain cognitive components of attention. The PVT appears most
sensitive to substantial sleep loss in adolescents, but not to sleep
improvement. Studies with sleep restriction and deprivation show
conflicting results on WM and the lack of dysfunction on exclusive
WM tasks in many studies suggests that worse WM performance
after sleep deprivation may be attributed to other cognitive sub-
domains in general, and attentional processes in particular. This
concurs with studies in adults suggesting that not so much the
actual WM is affected by sleep deprivation, but rather an atten-
tional component [49]. In contradiction, results from sleep
improvement studies [21,28,29] indicate better WM functioning. In
WM tasks several studies show that sleep has differential effects on
visual and phonological information processing. Therefore, the
need for differentiation of language/phonological components
56 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
from other cognitive components in cognitive tasks seems self-
evident. Concerning learning and memory it can be stated that
sleep restriction or deprivation, as well as sleep improvement does
not show effects of sleep on subsequent performance. Studies that
investigated effects of sleep on memory consolidation [40,44],
however, indicate that sleep is essential for consolidation, and that
particularly sleep deprivation after learning interferes with
consolidation. Furthermore, some studies indicate that not so much
the amount of sleep, but rather the timing (directly after learning)
[40,42] and stage of sleep [38,44] are of importance for consoli-
dation. For executive functions, and higher and abstract thinking
effects on performance were reported after sleep restriction and
extension for some, but not all, cognitive tests [28,35]. These effects
are difficult to differentiate for distinct cognitive domains due to
the task impurity problem, which is pervasive in tests for higher
cognitive functions [25].
Taken together, it can be concluded that total sleep deprivation
affects attention in general, and most consistently vigilance in
particular [26e28], but also WM [34], and that sleep improvement
results in improved WM [21,28,29]. The explanations above for the
inconclusive results of sleep restriction on general cognitive func-
tioning of adolescents may also apply to the results concerning the
specific cognitive domains. Compensatory mechanisms, individual
sleep need, better sleep quality after sleep reduction, and probably
also individual differences in cognitive functioning [51] might have
affected the results. In addition, specific factors concerning cogni-
tive tests and testing might also be of importance. So, task duration
[34], test sensitivity [45], period of time before testing after sleep
(restriction) [41], time of learning [40], lack of interest [28], and
circadian factors [40,52] may play a role. Finally, it should be kept in
mind that also decreased motivation due to insufficient or bad sleep
may contribute to decreased cognitive functioning in adolescents
[50].
The third aim of this study was to examine whether studies
could indicate if deterioration or improvement of sleep was caus-
ally related to cognitive functioning. Only five studies tested
whether change in cognitive functioning was related to sleep
manipulation. Although several relations were found between
sleep loss or sleep improvement and cognitive functioning, no
distinct conclusions can be drawn from these results due to the
variety in findings (EEG/EOG recordings [34]; non-REM sleep [42];
high EEG spindle (sigma) activity [44]; advanced bedtimes [29];
less WASO (sleep logs), better sleep quality, and less chronic sleep
reduction [21]). Routinely testing whether sleep manipulation
causally affects cognitive functioning is therefore recommended.
Based on this review, it can be concluded that sleep restriction
shows small or no effects on adolescent cognitive functioning.
Larger effects are found in studies investigating sleep deprivation,
sleep extension, and sleep improvement. Due to the great diversity
of tests and the lack of coherence in results, it is impossible to
conclude as to which domains in particular are influenced by sleep
manipulation and whether change in sleep is causally related to
change in cognitive functioning. A small number of participants,
not accounting for individual differences in sleep need, the role of
sleep quality, and compensatory mechanisms in adolescent sleep
and cognitive functioning, might explain the absence of more
distinct results.
These results concur with findings from most studies in adults,
showing that sleep deprivation (as compared to sleep restriction)
has the strongest detrimental effect on cognitive functioning, and
that effects are largest for vigilance tasks [24]. Some studies in
adults, however, indicate decrements after sleep deprivation and
sleep restriction in a wider range of cognitive domains, including
attention, memory, and reasoning [24,53]. These studies also
indicate that cognitive deficits accumulate over time during sleep
restriction [53]. However, from studies in adolescents conclusions
on these topics cannot be drawn due to the limitations of the
studies as described above. This is important because in adoles-
cents the brain, and more specifically the frontal cortex, is still
developing. Imaging studies indicate that the prefrontal cortex may
be specifically sensitive to sleep loss [22,54], and it is unclear which
effects chronic sleep loss has on the developing brain and associ-
ated cognitive functions in adolescents.
To conclude, although the results to date do not give a coherent
picture, there are indications that sleep is related to adolescent
cognitive functioning. As sleep manipulation studies should eluci-
date the function of sleep for adolescent academic performance, we
strongly advocate to execute more experimental studies in this
important field.
Practice points
1. Sleep directly after learning improves memory consoli-
dation and might contribute to better academic
functioning.
2. Sleep extension in adolescents with chronic sleep
reduction and sleep improvement in adolescents with
insomnia contribute to improvement in working
memory.
3. Sleep deprivation shows clear decrements in vigilance
tasks.
Research agenda
1. To prevent compensation of sleep loss by temporary
improvement of sleep quality, sleep restriction studies
should be executed during preferably more than 1 wk.
2. Participants' sleep prior to the sleep manipulation should
be evaluated, as banking of sleep might preserve
cognitive functioning in the experimental group and
longer sleep schedules than usual might affect sleep
quality and consequently cognitive functioning in the
control group.
3. As individual differences in sleep need might obscure the
effects of sleep manipulation on cognitive functioning,
larger groups or control for individual differences in
sleep is recommended.
4. For better comparability of results and resolving the
impurity problem of cognitive tests, researchers are
advised to install a task force for establishing which
cognitive tests are suitable for investigating the effects of
sleep on adolescent cognitive functioning.
5. In WM tasks several studies showed that sleep has dif-
ferential effects on visual and phonological information
processing. Therefore, differentiation of language/
phonological components from other cognitive compo-
nents in cognitive tasks seems important.
Conflict of interest
The authors have no conflict of interest to declare. All authors
contributed significantly to this manuscript.
 E.J. de Bruin et al. / Sleep Medicine Reviews 32 (2017) 45e57
Appendix A. Supplementary data
Supplementary data on the literature search, and the descrip-
tion of cognitive tests related to this article can be found at http://
dx.doi.org/10.1016/j.smrv.2016.02.006.
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