Journal of Adolescence 36 (2013) 1025–1033

Contents lists available at ScienceDirect

Journal of Adolescence
journal homepage: www.elsevier.com/locate/jado

The impact of sleep on adolescent depressed mood, alertness

and academic performance
Michelle A. Short a, b, *, Michael Gradisar a, Leon C. Lack a, Helen R. Wright a
a
Flinders University of South Australia, Sturt Road, Bedford Park, Adelaide 5041, Australia
b
Centre for Sleep Research, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia

a b s t r a c t

Keywords: The present study developed and tested a theoretical model examining the inter-
Adolescence relationships among sleep duration, sleep quality, and circadian chronotype and their ef-
Sleep fect on alertness, depression, and academic performance. Participants were 385 adoles-
Depression
cents aged 13–18 years (M ¼ 15.6, SD ¼ 1.0; 60% male) were recruited from eight
School performance
socioeconomically diverse high schools in South Australia. Participants completed a bat-
Alertness
tery of questionnaires during class time and recorded their sleep patterns in a sleep diary
for 8 days. A good fit was found between the model and the data (c2/df ¼ 1.78, CFI ¼ .99,
RMSEA ¼ .04). Circadian chronotype showed the largest association with on adolescent
functioning, with more evening-typed students reporting worse sleep quality (b ¼ .50,
p < .001) and diminished alertness (b ¼ .59, p < .001). Sleep quality was significantly
associated with poor outcomes: adolescents with poorer sleep quality reported less sleep
on school nights (b ¼ .28, p < .001), diminished daytime alertness (b ¼ .33, p < .001), and
more depressed mood (b ¼ .47, p < .001). Adolescents with poor sleep quality and/or more
evening chronotype were also more likely to report worse grades, through the association
with depression. Sleep duration showed no direct effect on adolescent functioning. These
results identified the importance of two lesser-studied aspects of sleep: circadian chro-
notype and sleep quality. Easy-to-implement strategies to optimize sleep quality and
maintain an adaptive circadian body clock may help to increase daytime alertness, elevate
mood, and improve academic performance.
Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier
Ltd. All rights reserved.

Introduction

Poor sleep in adolescents has been associated with sleepiness, fatigue, impairments in academic functioning, poor
working memory performance and memory consolidation, depression, anxiety, risk-taking, suicidal ideation, use of
drugs and alcohol, and diminished quality of life (Carskadon, Wolfson, Acebo, Tzischinsky, & Seifer, 1998; Cavallera &
Guidici, 2008; Dahl, 1999; Dewald, Meijer, Oort, Kerkhof, & Bogels, 2009; Gangwisch et al, 2010; Gau et al., 2007;
Gradisar, Terrill, Johnson, & Douglas, 2008; Roane & Taylor, 2006; Short et al., 2011; Yang, Soong, Kuo, Chang, &
Chen, 2004). A comprehensive perspective of adolescent sleep and its consequences is needed for a number of rea-
sons. First, while sleep duration is often the focus of adolescent sleep research, aspects of sleep, such as sleep quality
and circadian chronotype, are increasingly recognised for their substantial contribution to adolescent well-being

* Corresponding author. Centre for Sleep Research, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia. Tel.: þ61 8 8302 6624;
fax: þ61 8 8302 6623.
E-mail address: michelle.short@unisa.edu.au (M.A. Short).

0140-1971/$ – see front matter Ó 2013 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.adolescence.2013.08.007
1026 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033

(Dewald et al., 2009; Garcia, Rosen, & Mahowald, 2001; Giannotti, Cortesi, Sebastiani, & Ottaviano, 2002; Warner,
Murray, & Meyer, 2007).
Sleep quality encompasses two broad aspects of sleep: the ability to initiate and maintain sleep and a subjective feeling of
rejuvenation or refreshment following sleep (Akerstedt, Hume, Minors, & Waterhouse, 1994). Circadian chronotype refers to
an individual’s tendency toward greater activity and alertness at certain times of the day and is underpinned by features of
endogenous biological rhythms (Crowley, Acebo, Fallone, & Carskadon, 2006; Kerkhof, Korving, Willemse-vd Geest, & Riet-
veld, 1980; Lack, Bailey, Lovato, & Wright, 2009; Lavie & Segal, 1989). Subjective measures of circadian chronotype classify
individuals as being morning, evening, or intermediate chronotypes. Not only are sleep duration, sleep quality and circadian
chronotype important contributors to daytime functioning, their influence likely interacts with one another, highlighting the
importance of considering these factors together to understand their impact. Therefore, the present study considers the
combined influence of these three aspects of sleep on the adolescent outcomes of depression, alertness, and academic
performance.

Sleep duration

Early experimental sleep research used sleep deprivation or sleep restriction protocols to investigate the effects of
insufficient sleep, with the very robust finding that the fundamental consequence of too little sleep is increased daytime
sleepiness (Babkoff, Caspy, & Mikulincer, 1991; Carskadon et al., 1989; Carskadon, Harvey, & Dement, 1981; Dinges, Pack,
Williams, et al, 1997; Fallone, Owens, & Deane, 2002; Gau & Soong, 1995; Gibson et al., 2006; Wolfson & Carskadon, 1998).
These findings are also borne out by cross-sectional studies of adolescent sleep (Gau & Soong, 1995; Gibson et al., 2006).
Numerous large-scale cross-sectional studies, experimental studies, and meta-analytic reviews also report an association
between shorter sleep duration and poor school/academic performance (Curcio, Ferrara, & de Gennaro, 2006; Dewald
et al., 2009; Fallone, Acebo, Seifer, & Carskadon, 2005; Gibson et al., 2006; Gradisar et al., 2008; NSF, 2006; Sadeh,
Gruber, & Raviv, 2003; Wolfson & Carskadon, 1998). For example, one study of 3120 Rhode Island adolescents found
that survey-reported sleep duration differentiated those students obtaining grades of C’s or worse from those students
with A’s and B’s (Wolfson & Carskadon, 1998). Those students who met the researchers’ a priori criteria for inadequate
sleep (less than 6 h 45 m sleep duration and more than 2 h bedtime delay on weekends) also reported greater levels of
daytime sleepiness, more depressed mood, and lower grades. Other studies highlight an association of short sleep
duration with more depressive symptoms in adolescents (Fredriksen, Rhodes, Reddy, & Way, 2004; NSF, 2006). Such
mood changes as greater irritability, lower frustration tolerance, and increased variability of mood states occur following
sleep loss (Dinges, Rogers, & Baynard, 1999). Adolescents’ control or modulation of emotional responses also diminishes,
in particular the modification of emotional responses in accordance with long-term goals (Dahl & Lewin, 2002). Sleep
problems are one of nine key criteria for depression (APA, 2000), and various mechanisms have been proposed as
influencing the association between insufficient sleep and depressed mood (Dahl, 1999; Dahl & Lewin, 2002; Fuster,
2001; Horne, 1993; Moore, Adler, Williams, & Jackson, 2002; Ramos & Arnsten, 2007; Walker & Stickgold, 2006).
Longitudinal and cross-sectional research supports the notion that poor sleep is not simply a prodromal symptom of
mood disturbance but is likely to have a causal role (Fredriksen et al., 2004; Johnson, Roth, & Breslau, 2006). Thus,
pathways from sleep duration to daytime sleepiness and then to grades and depression will be tested in the present paper
(see Fig. 1).

Fig. 1. Standardized coefficients of the relationships among measures of sleep and measures of functioning in adolescents. All p < .001 unless otherwise
indicated.
 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033 1027

Circadian chronotype

Adolescence is a time of biological and psychosocial propensity for a phase delay of circadian rhythms (as reviewed in
Crowley, Acebo, & Carskadon, 2007). Circadian chronotype shows a consistent relationship with sleepiness, in that more
evening-typed individuals report greater daytime sleepiness (Gibson et al., 2006; Russo, Bruni, Lucidi, Ferri, & Violani, 2007).
A study of over 1000 Italian students aged 8–14 years found that evening types reported going to bed later and getting less
sleep on school nights, due to a fixed wake-up time in order to prepare, travel to, and attend school (Russo et al., 2007).
Evening (compared to morning) chronotypes reported more difficulty initiating sleep (47.7% vs. 17.9%), more difficulty waking
in the morning (69.4% vs. 23.1%), greater frequency of arriving late to classes after sleeping in (24.3% vs. 11.1%), and less
satisfaction with their sleep (24.3% vs. 9.4%). Thus, evening-typed adolescents may attend their morning lessons across the
time of maximal daily subjective sleepiness (around 10am) and maximal circadian sleep propensity (just before 11am; Lack
et al., 2009), when their body is at its lowest point for cognitive performance (Monk, 1987). Indeed, a study by Carskadon and
colleagues showed greater sleep propensity on multiple sleep latency tests, including shorter sleep latency and REM sleep
onset, for teens with an early school start and a delayed circadian phase (Carskadon et al., 1998). Mood difficulties also vary
according to circadian type, with evening types experiencing more mood disturbances, including depression, as well as
decreased satisfaction with life and more suicidal behaviour, (Cavallera & Guidici, 2008; Gau, Soong and Merikangas, 2004;
Giannotti et al., 2002; Randler, 2008). Thus, similar to sleep duration, pathways from chronotype to sleepiness and then to
grades and depression will be tested (see Fig. 1).

Sleep quality

In both adults and children, poor sleep quality has been associated with worse psychological health, poorer quality of life,
tension, fatigue and depression (Meijer, Habekothe, & Van Den Wittenboer, 2001; Moore et al., 2002; Pilcher et al., 1997;
Sickel, Moore, Adler, Williams, & Jackson, 1999). Indeed, the associations between sleep quality and poor outcomes may be
stronger than those associated with sleep duration (Pilcher, Ginter, & Sadowsky, 1997). A meta-analytic review of adolescent
sleep and school performance showed that sleep quality plays an important part in school performance (Dewald et al., 2009).
Other studies show associations of poor sleep quality with higher levels of depressed mood and diminished academic
functioning (Curcio et al., 2006; Hoffman & Steenhof, 1997; Meijer, Habekothe, & Van Den Wittenboer, 2000, 2001; Pilcher
et al., 1997; Sadeh, Raviv, & Gruber, 2002). Thus, pathways from sleep quality to sleep duration, daytime sleepiness, and
depressed mood will be tested in the present paper (see Fig. 1).

The intermediate role of alertness upon mood and school performance

An implicit assumption in much of the literature is that the effects of sleep duration on mood and academic performance
are mediated by sleepiness (National Institutes of Health [NIH], 1997). A meta-analysis on the effect of sleep on adolescent
school performance showed that sleepiness was the strongest predictor of poor academic performance, more so than sleep
duration or sleep quality (Dewald et al., 2009). Sleepiness has been associated with poor school performance and mood
deficits in a number of studies, possibly due to the occurrence of microsleeps and napping during class time (Gibson et al.,
2006; Millman, 2005; Mitru, Millrood, & Mateika, 2002; Pagel, Forister & Kwiatkowki, 2007; Schneerson, 2000). The Na-
tional Institutes of Health Working Group Report on Problem Sleepiness (NIH, 1997) reported associations between sleepiness
and difficulty concentrating, reduced initiative, memory lapses, cognitive slowing, slower motor response, and more errors of
working memory in both adults and adolescents. Experimental work showed that the effect of sleep loss on sleepiness occurs
prior to its effect on cognitive performance (Dinges et al., 1997). Thus, a large body of both experimental and cross-sectional
work supports the notion that insufficient sleep leads to increased sleepiness and that increased sleepiness leads to
diminished school performance.
Subjective sleepiness has also been implicated as a contributor to the development and maintenance of depressed mood
(Fallone et al., 2002; Pavlova, Koff, Weidler, & Regestein, 1997). Sleepy adolescents may have more difficulty dealing with
stressful situations and lower tolerance to frustration (Dahl, 1999; NIH, 1997). Thus, another hypothesis of this study is that
daytime alertness will mediate the effect of sleep duration, sleep quality, and circadian chronotype on mood and school
performance, as shown in Fig. 1.

Method

Participants

Three hundred and eighty five adolescents (60% male) from 8 South Australian high schools participated in the study from
April 2008 to April 2010. Schools included 4 public co-educational schools, 3 private co-educational schools, and one private
same-sex boys’ school. Stratified random sampling was used to select one school from each of 8 strata spanning the socio-
economic spectrum. Participants included 130 adolescents in each of high school Years 9 and 10 and 125 in Year 11. Par-
ticipants ages ranged from 13 to 18 years (M ¼ 15.6, SD ¼ .95). Seventy-seven percent resided with two parents and 82.7% had
their own bedroom. The majority (71.5%) of participants came from families with two or three children, 6.4% were only
1028 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033

children, and 21.2% came from families with four or more children. Most (86.3%) participants were born in Australia. Just over
80% of adolescents’ fathers were in fulltime paid employment as were 30.4% of mothers.
Participants’ participation was reimbursed with a gift voucher to the value of $40. The Flinders University Social and
Behavioural Research Ethics Committee and the Department of education and Children’s Services approved this study.
Response rate was 84%. The study had no exclusion criteria.

Measures

Sleep duration was measured using sleep diary reports of total sleep time on school nights for 5 nights to allow for reliable
estimates of sleep duration to be made (Acebo et al., 1999). Sleep diaries have shown good correspondence with poly-
somnographic (objective) measures of sleep (kappa ¼ .87) and high sensitivity and specificity (92.3% and 95.6%, respectively)
(Rogers, Caruso, & Aldrich, 1993).
Circadian typology was measured using the Smith Morningness/Eveningness Questionnaire (SMEQ; Smith, Reilly, &
Midkiff, 1989). The SMEQ is a 13-item self-report questionnaire used to measure circadian phase preference, or the time
of the day that people feel most alert or energetic. Items include “Considering your own “feeling best” rhythm, at what time
would you go to bed if you were entirely free to plan your evening?” and “During the first half hour after having awakened in the
morning, how tired do you feel?” Items were summed to give a total score ranging from 13 to 55, with higher scores
indicating greater morningness. Circadian phase preference has been shown to reflect an individual’s phase entrainment as
measured by physiological indicators such as dim light melatonin onset and core body temperature minimum (Crowley
et al., 2006; Kerkhof et al., 1980; Lack et al., 2009; Lavie & Segal, 1989). Cronbach’s alpha for the Smith scale in the cur-
rent sample was .83.
Daytime alertness was operationalized using subjective measures of sleepiness (Pediatric Daytime Sleepiness Scale) and
fatigue (Flinders Fatigue Scale). It is likely that feelings of fatigue and sleepiness are felt by individuals at different times across
the day due to variations in environmental, motivational and circadian factors. Subjective sleepiness is sensitive to inter-
ference from both internal and external stimuli, with higher levels of arousal mask feelings of sleepiness (Babkoff et al., 1991;
Curcio, Casagrande, & Bertini, 2001; Eriksen, Akerstedt, Kecklund, & Akerstedt, 2005; Monk, 1987; Nilsson et al., 2005).
Cluydts, De Valck, Verstraeten, & Theys (2002) suggest that high sleep drive coupled with low arousal leads to feelings of
sleepiness, while high sleep drive coupled with high arousal more commonly leads to subjective fatigue. As such, daytime
alertness was operationalized using sleepiness and fatigue constructs.
The Pediatric Daytime Sleepiness Scale (PDSS, Drake et al., 2003) is an 8-item self-report scale that asks participants
about their experiences of sleepiness in the past two weeks. Items include “How often do you fall asleep or feel drowsy in
class” and “Are you usually alert during the day?” Responses total scores could range from 0 to 32, with higher scores
indicating more daytime sleepiness. The PDSS was developed and validated on a sample of 450 children and adolescents,
aged 11–15 years. Factor analyses of two split-half samples supported a one-factor solution which accounted for 32% of the
variance. Higher scores on the PDSS were associated with poorer school achievement, less enjoyment of school, absen-
teeism, illness, and worse mood. The PDSS showed adequate internal consistency for the data of the current study, with a
Cronbach’s alpha of .80.
The Flinders Fatigue Scale (FFS, Gradisar et al., 2007) is a 7-item scale assessing the experience of fatigue over the prior two
weeks. Items in the FFS include “Was fatigue a problem for you?” and “How severe was the fatigue you experienced?” Total scores
could range from 0 to 31, with higher scores indicate greater fatigue. Previous research has reported good reliability and
validity of this scale amongst adult good sleepers and adults with insomnia (Gradisar et al., 2007). Gradisar and colleagues
compared FFS scores between good sleepers (N ¼ 626) and poor sleepers (N ¼ 467). Poor sleepers reported significantly
greater levels of fatigue than good sleepers, t (1091) ¼ 15.07, p < .0001, showing good discriminant validity. Amongst adults
with insomnia, the FFS was not significantly correlated with sleepiness, as measured by the Epworth Sleepiness Scale, r
(110) ¼ .06, p ¼ .54 (Johns, 1991). While the FFS has shown sound psychometric properties in adult samples, they have not
been examined in an adolescent population. Cronbach’s alpha for these data was .91, indicating excellent internal consistency.
Depressed mood was measured using the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). The
CES-D is a 20-item scale assessing feelings of depressed mood in the previous week. Individual items relate to ways a person
may have felt or behaved, including items such as “I felt sad” and “I had crying spells”. Total scores could range from 0 to 60,
with higher scores indicating greater depressed mood. This scale showed good internal consistency within this sample, with a
Cronbach’s alpha of .90. This measure has been used extensively in adolescent populations (Mottl, Dishman, Birnbaum, &
Lytle, 2005; Radloff, 1991; Rey, Grayson, Mojarrad, & Walter, 2002; Yang et al., 2004). Adolescents with depression show
higher scores on the CES-D (M ¼ 31.10, SD ¼ 11.30) than non-depressed adolescents (M ¼ 21.01, SD ¼ 11.77).
School Performance was measured using one item taken from the School Sleep Habits Survey (Wolfson & Carskadon, 1998)
to assess self-reported grades. This item asked participants “Are your grades at school mostly?” Participants chose one of eight
response categories: “A’s”, “A’s and B’s”, “B’s”, “B’s and C’s”, “C’s”, “C’s and D’s”, “D’s” or “D’s and E’s”. The item assessing aca-
demic achievement was coded such that lower scores reflected better grades. Self-reported grades have been found to closely
approximate academic transcripts (Dornbusch, Ritter, Leiderman, Roberts, & Fraleigh, 1987) and in the present sample, self-
reported grades correlated strongly with parent-reports of their teens’ grades, r ¼ .81, p < .001. Further, because grades
provide a gauge of students’ academic achievement, which encompasses many more things than just intellectual capacity,
this provides an ecologically important outcome (Wolfson & Carskadon, 2003).
 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033 1029

Development of a sleep quality scale

A sleep quality scale was developed using items contained within the survey measures used. The present study used much
of the theoretical framework from the Pittsburgh Sleep Quality Index (PSQI, Buysse, Reynolds, Monk, Berman, & Kupfer, 1989)
to develop a scale suitable for adolescents. The PSQI contains seven equally weighted components: subjective sleep quality,
sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, sleep medication and daytime dysfunction. In-
formation on the items used is provided in Table 1. The two components of the PSQI that have not been included in this sleep
quality scale are sleep duration and daytime dysfunction. As previous research has shown either modest or no overlap be-
tween measures of sleep quality and sleep quantity (Dewald et al., 2009; Meijer et al., 2001; Pilcher et al., 1997), we reason
that these should be regarded as separate constructs. Daytime dysfunction was not included as it is better regarded as a
potential outcome of poor sleep quality and not an essential part of what constitutes sleep quality. Overall, this scale is
consistent with previous recommendations that indices of sleep quality need to consider subjective sleep quality, ease of
falling asleep, continuity of sleep, and refreshingness of sleep (Akerstedt et al., 1994). Responses for all items were on a Likert-
type scale from 0 to 4, although responses for two items (restless sleep and sleep medication) were measured from 0 to 3. For
all items, higher scores were indicative of poorer sleep quality. The time frame for all items referred to the prior two weeks.

Factor analysis of the sleep quality scale

A principal components analysis was used to assess the factor structure of these 9 items. The Kaiser-Meyer-Olkin value was
.87 and the Bartlett’s Test of Sphericity was significant, indicating that these data were suitable for analysis. The analysis
revealed two components with eigenvalues greater than 1 that explained 45.36% and 11.39% of the variance. Only one factor
was retained for analyses for several reasons. First inspection of the scree plot revealed a clear break after the first component.
Second, the eigenvalue of the second component was only just greater than the cut-off value of one (1.02). Last, only one item
(sleep medication) loaded on this second factor. As such, 8 items remained in the sleep quality scale. The pattern matrix and
structure matrix from the principal components analysis are presented in Table 2. A Principal Component Analysis with a one
factor solution was conducted using the remaining 8 items. The one factor solution explained 53.23% of the variance.
Cronbach’s alpha for this scale was .87, indicating good internal reliability.

Procedure

This study utilized a cross-sectional design. Informed consent was obtained from the Principal of each school, the student
and a parent or guardian. On the first day of the study, participants completed the SSHS during class time. For the subsequent
8 days, students filled out a Sleep Diary. On the final day of the study, participants completed the Flinders Fatigue Scale.

Statistical analyses

Path analysis, using AMOS 17.0 was performed to test goodness of the model fit. Traditional path analysis involves the
analysis of separate pathways in a model, frequently using multiple regression analyses. While these analyses can determine
the statistical significance of each pathway separately, they cannot quantify the overall agreement, or ‘fit’ between the model
and the data. The use of Structural Equation Modelling (SEM) for path analysis enables the simultaneous analysis of multiple
regression equations and the calculation of the direct and indirect effects of multiple variables (Hair, Anderson, Tatham, &
Black, 1998). The indices of model fit used for this analysis are: Root Mean Square of Approximation (RMSEA), which

Table 1
Items, source and construct for adolescent sleep quality scale.

Item Source Construct

1. In the last two weeks, how often have School Sleep Habits Survey (SSHS) (Wolfson & Carskadon, 1998) Subjective sleep quality
you had a good nights sleep?
2. Do you have difficulty falling asleep? Insomnia Severity Index (ISI) (Bastien, Valliéres & Morin, 2001) Sleep latency
3. Do you have difficulty staying asleep? Insomnia Severity Index (ISI) (Bastien et al., 2001) Sleep disturbances
4. How often do you experience restless sleep? Insomnia Severity Index (ISI) (Bastien et al., 2001) Sleep maintenance
5. In the last two weeks, how often did you use Author added item Sleep medication
prescription sleeping tablets to help you sleep?
6. How worried/distresses are you about your Insomnia Severity Index (ISI) (Bastien et al., 2001) Sleep satisfaction
sleep at the moment?
7. Do you wake up feeling that your sleep has Insomnia Severity Index (ISI) (Bastien et al., 2001) Sleep refreshment
not been refreshing?
8. How happy/unhappy are you with your Insomnia Severity Index (ISI) (Bastien et al., 2001) Sleep satisfaction
current sleep pattern?
9. In the last two weeks, how often have you School Sleep Habits Survey (SSHS) (Wolfson & Carskadon, 1998) Sleep satisfaction
felt satisfied with your sleep?
1030 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033

Table 2
Pattern and structure matrix for PCA of sleep quality items.

Item Pattern coefficientsa Structure coefficientsb Communalitiesc

Comp. 1 Comp. 2 Comp. 1 Comp. 2

2. Sleep worry .758 .761 .600
8. Sleep happy .746 .748 .565
5. Good sleep .744 .744 .554
3. Restless .740 .740 .548
1. Fall asleep .727 .727 .529
6. Satisfied .708 .706 .517
4. Refreshing .708 .705 .507
7. Stay asleep .703 .703 .495
9. Medication .983 .983 .967
a
Pattern coefficients show the variance in each item that loads onto its factor.
b
Structure coefficients show the correlation between each item and its component for a rotated solution.
c
Communalities show the variance in each item that is explained by both factors.

should be less than .08; Chi-square value divided by degrees of freedom (c2/df), which should be less than 3; and the
Comparative Fit Index (CFI), whereby good model fit is indicated by a value greater than .90.

Results

Path analysis showed that the fit between the model and the data was satisfactory, c2/df ¼ 1.78, CFI ¼ .99, RMSEA ¼ .04. As
the cut-off values for these indices were c2/df value of less than 3, CFI greater than .90, and RMSEA less than .08, these results
indicate a good fit between this theoretical model and the data. The results, including the standardized coefficients, are shown
in Fig. 1. Standardized coefficients indicate (in standard deviation units) the degree of change in the dependent variable for
every standard deviation increase in the independent variable, which are useful to evaluate the relative importance of several
independent variables on a dependent variable. These values highlight the important effect of circadian typology, showing a
large effect on sleep quality and daytime alertness. Circadian typology, in turn, had a significant and large effect on depressed
mood and a small-to-medium indirect effect on academic performance. Self-reported sleep quality also had a significant
direct effect on sleep duration, with sleep of poorer quality associated with in shorter sleep duration. Sleep quality also had a
significant, medium-sized effect on daytime alertness and a significant, large effect on mood, as hypothesized. Poorer sleep
quality was associated with greater feelings of depression and less daytime alertness.
Two of the proposed paths did not reach statistical significance. These were the paths from sleep duration to daytime
alertness and the direct path from daytime alertness to grades. A second path analysis was run after deleting these non-
significant paths, which substantially changed neither the remaining standardized coefficients nor the model fit, (CMIN/
df ¼ 1.86, CFI ¼ .99, RMSEA ¼ .047). Descriptive statistics and bivariate relationships for model variables are included in Tables
3 and 4.

Discussion

A substantial body of work has examined different aspects of adolescent sleep in association with alertness, depression, or
academic performance; however, few have evaluated these relationships simultaneously or provided a theoretical framework
for understanding the direct and indirect effects of sleep on daytime functioning. The present study provides a broad
theoretical framework for path analysis, which showed a good fit between the theoretical model developed and the data. For
adolescents, having a more evening-typed circadian typology was directly associated with poorer sleep quality and dimin-
ished alertness, both directly and indirectly, through the effect of circadian typology on sleep quality. The effect that circadian
typology has on sleep quality is likely to result from adolescents trying to initiate and maintain sleep according to socially-
conventional sleep/wake times (in order to rise for school) and not during the time of greatest circadian sleep propensity.
Adolescents reporting poorer sleep quality reported less sleep on school nights, reported diminished daytime alertness, and

Table 3
Descriptive statistics for model variables.

Mean S.D.
Sleep quantity 8 h 17 m 58 m
Sleep quality 8.05 5.71
Circadian chronotype 33.25 6.66
Daytime alertness 21.68 10.20
Mood 13.92 10.17
Grades 2.75 1.27
 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033 1031

Table 4
Correlation coefficients for model variables.

Gradesa Mooda Alertnessa Circadian chronotypeb Sleep qualitya

Sleep quantity .09 .22*** .24*** .10 .27***
Sleep quality .04 .62*** .64*** .39***
Circ. chronotype .10 .33*** .57***
Alertness .05 .56***
Mood .20***

***p < .001.

a
Higher scores indicate poorer functioning.
b
Higher scores indicate greater morning chronotype.

endorsed more symptoms of depressed mood. The association between worse sleep quality and shorter sleep duration may
arise when adolescents take a longer time to fall asleep, or if they have nighttime awakenings and have trouble re-initiating
sleep (all aspects of sleep quality). Because they need to get up at a relatively fixed time to go to school the next day, their sleep
may be truncated.
Sleep duration was not shown to have a direct effect on daytime alertness. This may be due to a number of reasons. In-
dividual differences exist in the sleep duration required for optimal daytime functioning (Carskadon, 1990; Mercer, Merritt, &
Cowell, 1998), and measures of sleep duration do not take into account the extent to which that duration meets the in-
dividual’s sleep need (Dewald et al., 2009; Meijer, 2008; Pilcher et al., 1997). Indeed, this difficulty has prompted the
development of other methods of assessing sleep reduction by considering the daytime deficits associated with insufficient
sleep and not just sleep obtained (Meijer, 2008). Thus, large individual differences in sleep need and response to sleep re-
striction impede assessing the association between sleep duration and daytime alertness in cross-sectional designs. Addi-
tionally, the sample of Australian adolescents reported sleep durations substantially longer than those found in teens in other
countries. In addition, the range of values was somewhat restricted to more “adequate” sleepers and contained only one
adolescent reporting severely restricted sleep (averaging less than 6 h per night).
Students reporting diminished alertness during the day had higher levels of depressed mood, with higher levels of
depressed mood associated with reduced academic performance. The proposed direct relationship between daytime alert-
ness and academic performance was not supported. Rather, the results showed that this relationship was indirect, occurring
through the effect of daytime alertness on depressed mood.
When considering the three aspects of sleep together, our results highlight the relative importance of circadian chro-
notype (being the most influential aspect of sleep according to standardized Beta coefficients) to adolescent functioning.
Evening-chronotyped adolescents reported significantly reduced alertness, more depressed mood and poorer grades. While
there is a biological propensity for circadian rhythms to delay during adolescence, this is likely to be moderated by adolescent
sleep patterns. Keeping a regular schedule of bedtime and wake times across the school week and weekends, morning
exposure to sunlight and avoiding late bedtimes may minimize this risk (Barrion & Zee, 2007; Manber, Bootzin, Acebo &
Carskadon, 1996; Wyatt, 2004).
Sleep quality was also associated with poorer outcomes, consistent with previous findings (Curcio et al., 2006; Dewald
et al., 2009; Hoffman & Steenhof, 1997; Meijer et al., 2000, 2001; Pilcher et al, 1997). Adolescents can maintain good sleep
quality by practicing good sleep hygiene prior to bed (by avoiding caffeine, strenuous physical exercise and evening bright
light and providing opportunities to de-arouse before bedtime), and looking after their physical and mental well-being. Given
the importance of two of these lesser studied aspects of sleep, it is important that greater focus is given to them, particularly
in regard to understanding the precursors of sleep quality and circadian typology.
The strong association between sleep quality and mood may be underpinned by similar etiological factors. Additionally,
aspects of sleep quality, including difficulty falling asleep or maintaining sleep, are part of the diagnostic criteria for major
depression (APA, 2000). More depressed adolescents may also have a more negative response bias toward answering other
subjectively assessed items, such as those in the sleep quality scale. Nonetheless, while this may inflate the association be-
tween sleep quality and depressed mood, there is little doubt that these factors have important causal links, as borne out by
longitudinal findings (Johnson et al., 2006).

Limitations of the present study

While the present model displayed an acceptable fit with data, this does not rule out alternative models that may also have
an adequate fit. This study has taken a theory-driven, and not a data-driven approach to model development. As such, model
development has relied upon reviewing the extensive body of work in this field and distilling these broad and occasionally
divergent findings into a coherent explanatory framework. The resultant analyses are purely confirmatory. A data-driven
approach relies upon the analysis itself to provide recommendations for model modification and refinement. This is a
much weaker approach and is more likely to result in a model that will only fit to the data used. Further testing on other data
derived from divergent populations is needed in order to determine the generalizability of this model, and so strengthen
these findings. In addition, as the findings of this study were based on cross-sectional data, it will also be important to see if
the directions of these relationships (and their relative strengths) hold up in a prospective study design.
1032 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033

The present study included students from schools that spanned the socioeconomic spectrum. However, as these schools all
resided within the Australian Bureau of Statistics Statistical divisions of Adelaide and Outer Adelaide, this sample is largely
urban. It would be beneficial to broaden the scope of data collection to include adolescents from rural and remote regions.

Concluding remarks

The present study found that, irrespective of sleep duration, being more evening typed or obtaining poor quality sleep was
associated with poorer outcomes. Means for protecting adolescents from poor quality sleep and circadian phase delay were
discussed. From a clinical perspective, it is imperative that greater emphasis is placed on understanding and educating young
people and their families on the important aspects of sleep quality and circadian typology. Easily translatable means are
available to optimize adolescents sleep across these domains, which may help to optimize their well-being across domains of
alertness, mood and academic performance.

Conflict of interest

The authors wish to declare no conflicts of interest.

Acknowledgements

This work was conducted at the Flinders University of South Australia and was funded by Australian Research Council
grant DP0881261.

References

Acebo, C., Sadeh, A., Seifer, R., Tzischinsky, O., Wolfson, A. R., Hafer, A., et al. (1999). Estimating sleep patterns with activity monitoring in children and
adolescents: how many nights are necessary for reliable measures? Sleep, 22, 95–103.
Akerstedt, T., Hume, K., Minors, D., & Waterhouse, J. (1994). The meaning of good sleep: a longitudinal study of polysomnography and subjective sleep
quality. Journal of Sleep Research, 3, 152–158.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington DC: Author.
Babkoff, H., Caspy, T., & Mikulincer, M. (1991). Subjective sleepiness ratings: the effects of sleep deprivation, circadian rhythmicity and cognitive perfor-
mance. Sleep, 14, 534–539.
Barrion, A., & Zee, P. C. (2007). A clinical approach to circadian rhythm sleep disorders. Sleep Medicine, 8, 566–577.
Bastien, C. H., Vallières, A., & Morin, C. M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2,
297–307.
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice
and research. Psychiatry Research, 28, 193–213.
Carskadon, M. A. (1990). Patterns of sleep and sleepiness in adolescents. Pediatrician, 17, 5–12.
Carskadon, M. A., Harvey, K., & Dement, W. C. (1981). Sleep loss in young adolescents. Sleep, 4, 299–312.
Carskadon, M. A., Rosekind, M. R., Galli, J., Sohn, J., Herman, K. B., & Davis, S. S. (1989). Adolescent sleepiness during sleep restriction in the natural
environment. Sleep Research, 18, 115.
Carskadon, M. A., Wolfson, A. R., Acebo, C., Tzischinsky, O., & Seifer, R. (1998). Adolescent sleep patterns, circadian timing, and sleepiness at a transition to
early school days. Sleep, 21, 871–881.
Cavallera, G. M., & Guidici, S. (2008). Morningness and eveningness personality: a survey in literature from 1995 up till 2006. Personality and Individual
Differences, 44, 3–21.
Cluydts, R., De Valck, E., Verstraeten, E., & Theys, P. (2002). Daytime sleepiness and its evaluation. Sleep Medicine Reviews, 6, 83–96.
Crowley, S. J., Acebo, C., & Carskadon, M. A. (2007). Sleep, circadian rhythms, and delayed phase in adolescence. Sleep Medicine, 8, 602–612.
Crowley, S. J., Acebo, C., Fallone, G., & Carskadon, M. A. (2006). Estimating Dim Light Melatonin Onset (DLMO) in adolescents using summer or school-year
sleep/wake schedules. Sleep, 29, 1632–1641.
Curcio, G., Casagrande, M., & Bertini, M. (2001). Sleepiness: evaluating and quantifying methods. International Journal of Psychophysiology, 41, 251–263.
Curcio, G., Ferrara, M., & de Gennaro, L. (2006). Sleep loss, learning capacity and academic performance. Sleep Medicine Reviews, 10, 323–337.
Dahl, R. E. (1999). The consequences of insufficient sleep for adolescents: links between sleep and emotional regulation. Phi Delta Kappan, 80, 354–360.
Dahl, R. E., & Lewin, D. S. (2002). Pathways to adolescent sleep and behaviour. Journal of Adolescent Health, 31, 175–184.
Dewald, J. F., Meijer, A. M., Oort, F. J., Kerkhof, G. A., & Bogels, S. M. (2009). The influence of sleep quality, sleep duration and sleepiness on school per-
formance in children and adolescents: a meta-analytic review. Sleep Medicine Reviews, 14, 179–189.
Dinges, D., Pack, F., Williams, K., Gillen, K. A., Powell, J. W., Ott, G. E., et al. (1997). Cumulative sleepiness, mood disturbance, and psychomotor vigilance
performance decrements during a week of sleep restricted to 4–5 hours per night. Sleep, 20, 267–277.
Dinges, D., Rogers, N., & Baynard, M. B. (1999). Chronic sleep deprivation. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep
medicine (4th ed.). Philadelphia: Elsevier/Saunders.
Dornbusch, S. M., Ritter, P. L., Leiderman, P. H., Roberts, D. F., & Fraleigh, M. J. (1987). The relation of parenting style to adolescent school performance. Child
Development, 58, 1244–1258.
Drake, C., Nickel, C., Burduvali, E., Roth, T., Jefferson, C., & Badia, P. (2003). The Pediatric Daytime Sleepiness Scale (PDSS): sleep habits and school outcomes
in middle-school children. Sleep, 26, 455–458.
Eriksen, C. A., Akerstedt, T., Kecklund, G., & Akerstedt, A. (2005). Comment on short-term variation in subjective sleepiness. Perceptual and Motor Skills, 101,
943–948.
Fallone, G., Acebo, C., Seifer, R., & Carskadon, M. A. (2005). Experimental restriction of sleep opportunity in children: effects on teacher ratings. Sleep, 28,
1561–1567.
Fallone, G., Owens, J. A., & Deane, J. (2002). Sleepiness in children and adolescents: clinical implications. Sleep Medicine Reviews, 6, 287–306.
Fredriksen, K., Rhodes, J., Reddy, R., & Way, N. (2004). Sleepless in Chicago: tracking the effects of adolescent sleep loss during the middle school years. Child
Development, 75, 84–95.
Fuster, J. M. (2001). The prefrontal cortex- an update time is of the essence. Neuron, 30, 319–333.
Gangwisch, J. E., Babiss, L. A., Malaspina, D., Turner, J. B., Zammit, G. K., & Posner, K. (2010). Earlier parental set bedtimes as a protective factor against
depression and suicidal ideation. Sleep, 33, 97–106.
 M.A. Short et al. / Journal of Adolescence 36 (2013) 1025–1033 1033

Garcia, J., Rosen, G., & Mahowald, M. (2001). Circadian rhythms and circadian rhythm disorders in children and adolescents. Seminars of Pediatric Neurology,
8, 229–240.
Gau, S. F., Shang, C.-Y., Merikangas, K. R., Chiu, Y.-N., Soong, W.-T., & Cheng, T. A. (2007). Association between morningness–eveningness and behavioral/
emotional problems among adolescents. Journal of Biological Rhythms, 22, 268–274.
Gau, S. F., & Soong, W. T. (1995). Sleep problems of junior high school students in Taipei. Sleep, 18, 667–673.
Gau, S. F., Soong, W. T., & Merikangas, K. R. (2004). Correlates of sleep-wake patterns among children and young adolescents in Taiwan. Sleep, 27, 512–519.
Giannotti, F., Cortesi, F., Sebastiani, T., & Ottaviano, S. (2002). Circadian preference, sleep and daytime behaviour in adolescence. Journal of Sleep Research, 11,
191–199.
Gibson, E. S., Powles, A. C. P., Thabane, L., O’Brien, S., Sirriani Molnar, D., Trajanovic, N., et al. (2006). “Sleepiness” is serious in adolescence: two surveys of
3235 Canadian students. BMC Public Health, 6, 1–9.
Gradisar, M., Lack, L., Richards, H., Harris, J., Gallasch, J., Boundy, et al.. (2007). The Flinders Fatigue Scale: preliminary psychometric properties and clinical
sensitivity of a new scale for measuring daytime fatigue associated with insomnia. Journal of Clinical Sleep Medicine, 3, 722–728.
Gradisar, M., Terrill, G., Johnson, A., & Douglas, P. (2008). Adolescent sleep and working memory performance. Sleep and Biological Rhythms, 6, 146–164.
Hair, J. F., Anderson, R. E., Tatham, R. L., & Black, W. C. (1998). Multivariate data analysis (5th ed.). New Jersey: Prentice Hall Inc.
Hoffman, W. F., & Steenhof, L. (1997). Sleep characteristics of Dutch adolescents are related to school performance. In D. G. M. Beersma, J. B. A. M. Arends, A.
L. van Bemmel, W. F. Hofman, & G. S. F. Ruigt (Eds.), Sleep–wake research in the Netherlands. Netherlands: Dutch Society for Sleep–Wake Research.
Horne, J. A. (1993). Human sleep, sleep loss and behavior: implications for the prefrontal cortex and psychiatric disorders. British Journal of Psychiatry, 162,
413–419.
Johns, M. W. (1991). A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep, 14, 540–545.
Johnson, E. O., Roth, T., & Breslau, N. (2006). The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. Journal
of Psychiatric Research, 40, 700–708.
Kerkhof, G. A., Korving, H. J., Willemse-vd Geest, H. M., & Rietveld, W. J. (1980). Diurnal differences between morning-type and evening-type subjects in self-
rated alertness, body temperature and the visual and auditory evoked potential. Neuroscience Letters, 16, 11–15.
Lack, L. C., Bailey, M., Lovato, N., & Wright, H. (2009). Chronotype differences in circadian rhythms of temperature, melatonin, and sleepiness as measured in
a modified constant routine protocol. Nature and Science of Sleep, 1, 1–8.
Lavie, P., & Segal, S. (1989). Twenty-four-hour structure of sleepiness in morning and evening persons investigated by ultra short sleep–wake cycle. Sleep, 12,
522–528.
Manber, R., Bootzin, R. R., Acebo, C., & Carskadon, M. A. (1996). The effects of regularizing sleep-wake schedules on daytime sleepiness. Sleep, 19, 432–441.
Meijer, A. M. (2008). Chronic sleep reduction, functioning at school and school achievement in preadolescents. Journal of Sleep Research, 17, 395–405.
Meijer, A. M., Habekothe, R. T., & Van Den Wittenboer, G. L. H. (2000). Time in bed, quality of sleep and school functioning of children. Journal of Sleep
Research, 9, 145–153.
Meijer, A. M., Habekothe, R. T., & Van Den Wittenboer, G. L. H. (2001). Mental health, parental rules and sleep in pre-adolescents. Journal of Sleep Research, 10,
297–302.
Mercer, P. W., Merritt, S. L., & Cowell, J. M. (1998). Differences in reported sleep need among adolescents. Journal of Adolescent Health, 23, 259–263.
Millman, R. P. (2005). Excessive sleepiness in adolescents and young adults: causes, consequences, and treatment strategies. Pediatrics, 115, 1774–1786.
Mitru, G., Millrood, D. L., & Mateika, J. H. (2002). The impact of sleep on learning and behavior in adolescents. Teachers College Record, 104, 704–726.
Monk, T. H. (1987). Subjective ratings of sleepiness – the underlying circadian mechanisms. Sleep, 10, 343–353.
Moore, P. J., Adler, N. E., Williams, D. R., & Jackson, J. S. (2002). Socioeconomic status and health: the role of sleep. Psychosomatic Medicine, 64, 337–344.
Mottl, R. W., Dishman, R. K., Birnbaum, A. S., & Lytle, L. A. (2005). Longitudinal invariance of the Centre for Epidemiological Studies-Depression Scale among
girls and boys in middle school. Educational and Psychological Measurement, 65, 90–108.
National Institutes of Health. (1997). Working group report on problem sleepiness. Maryland: National Institutes of Health.
Nilsson, J. P., Soderstrom, M., Karlsson, A. U., Lekander, M., Akerstedt, T., Erixon Lindroth, N., et al. (2005). Less effective executive functioning after one
night’s sleep deprivation. Journal of Sleep Research, 14, 1–6.
NSF. (2006). Sleep in America Poll. Washington: National Sleep Foundation.
Pagel, J. F., Forister, N., & Kwiatkowski, C. (2007). Adolescent sleep disturbance and school performance: the confounding variable of socioeconomics. Journal
of Clinical Sleep Medicine, 3, 19–23.
Pavlova, M., Koff, M., Weidler, D., & Regestein, Q. (1997). Sleepiness may predict CES-D depression scores in psychology students. Sleep Research, 26, 208.
Pilcher, J. J., Ginter, D. R., & Sadowsky, B. (1997). Sleep quality versus sleep quantity: relationships between sleep and measures of health, well-being and
sleepiness in college students. Journal of Psychosomatic Research, 42, 583–596.
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.
Radloff, L. S. (1991). The use of the Centre for Epidemiologic Studies Depression Scale in adolescents and young adults. Journal of Youth and Adolescence, 20,
149–166.
Ramos, B. P., & Arnsten, A. F. T. (2007). Adrenergic pharmacology and cognition: focus on the prefrontal cortex. Pharmacology and Therapeutics, 113, 523–536.
Randler, C. (2008). Morningness–eveningness and satisfaction with life. Social Indicators Research, 86, 297–302.
Rey, J. M., Grayson, D., Mojarrad, T., & Walter, G. (2002). Changes in the rate of diagnosis of major depression in adolescents following routine use of a
depression rating scale. Australian and New Zealand Journal of Psychiatry, 36, 229–233.
Roane, B. M., & Taylor, D. J. (2006). Adolescent insomnia as a risk factor for early adult depression and substance abuse. Sleep, 31, 1351–1356.
Rogers, A. E., Caruso, C. C., & Aldrich, M. S. (1993). Reliability of sleep diaries for assessment of sleep/wake patterns. Nursing Research, 42, 368–371.
Russo, P. M., Bruni, O., Lucidi, F., Ferri, R., & Violani, C. (2007). Sleep habits and circadian preference in Italian children and adolescents. Journal of Sleep
Research, 16, 163–169.
Sadeh, A., Gruber, R., & Raviv, A. (2003). The effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child
Development, 74, 444–455.
Sadeh, A., Raviv, R., & Gruber, A. (2002). Sleep, neurobehavioral functioning, and behavior problems in school-age children. Child Development, 73, 405–417.
Schneerson, J. M. (2000). Handbook of sleep medicine. UK: Blackwell Science.
Short, M. A., Gradisar, M., Wright, H., Lack, L. C., Dohnt, H., & Carskadon, M. A. (2011). Time for Bed: parent-set bedtimes associated with improved sleep and
daytime functioning in adolescents. Sleep, 34, 797–800.
Sickel, A. E., Moore, P. J., Adler, N. E., Williams, D. R., & Jackson, J. S. (1999). The differential effects of sleep quality and quantity on the relationship between
SES and health. Annals New York Academy of Sciences, 896, 431–434.
Smith, C. S., Reilly, C., & Midkiff, K. (1989). Evaluation of three circadian rhythm questionnaires with suggestions for an improved measure of morningness.
Journal of Applied Psychology, 74, 728–738.
Walker, M. P., & Stickgold, R. (2006). Sleep, memory and plasticity. Annual Review of Psychology, 57, 139–166.
Warner, S., Murray, G., & Meyer, D. (2007). Holiday and school-term sleep patterns of Australian adolescents. Journal of Adolescence, 31, 595–608.
Wolfson, A., & Carskadon, M. (1998). Sleep schedules and daytime functioning in adolescents. Child Development, 69, 875–887.
Wolfson, A. R., & Carskadon, M. A. (2003). Understanding adolescents’ sleep patterns and school performance: a critical appraisal. Sleep Medicine Reviews, 7,
491–506.
Wyatt, J. K. (2004). Delayed sleep phase syndrome: pathophysiology and treatment options. Sleep, 27, 1195–1203.
Yang, H.-J., Soong, W.-T., Kuo, P. H., Chang, H. L., & Chen, W. J. (2004). Using the CES-D in a two-phase survey for depressive disorders among nonreferred
adolescents in Taipei: a stratum-specific likelihood ration analysis. Journal of Affective Disorders, 82, 419–430.