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Pediatric Endocrinology Nursing Society Department| Volume 54, P114-115, September 2020

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Biopsychosocial Outcomes of Poor Sleep in Adolescents

      “Sleep is a vital biopsychosocial state, a naturally occurring process necessary for brain activity and body functions, psychological health and behavior, and individual, family and sociocultural norms “(
      • Snyder C.K.
      • Chang A.M.
      Mobile technology, sleep, and circadian disruption.
      , p. 160). Adolescence, defined as the second decade of life (), is a normal transitional period of physical, emotional, and social change. Puberty-mediated changes in sleep include a circadian time shift and phase delay with later sleep and wake times, and longer time to fall asleep. Suppression of melatonin release, needed for sleep promotion, reinforces later bedtimes and difficulty falling asleep (
      • Crowley S.J.
      • Acebo C.
      • Carskadon M.A.
      Sleep, circadian rhythms, and delayed phase in adolescents.
      ). On a social level, adolescents become increasingly independent from parents with enhanced reliance on the social network as they pass through the normal adolescent developmental task of identity versus role confusion (
      • Erikson E.H.
      Identity: Youth and crisis (No. 7).
      ).

      Sleep insufficiency in adolescents

      Sleep insufficiency among adolescents is a worldwide public health concern (
      • Gradisar M.
      • Gardner G.
      • Dohnt H.
      Recent worldwide sleep patterns and problems during adolescence: A review and meta-analysis of age, region, and sleep.
      ). The American Academy of Sleep Medicine (
      • Paruthi S.
      • Brooks L.J.
      • D’Ambrosio C.
      • Hall W.A.
      • Kotagal S.
      • Lloyd R.M.
      • Rosen C.L.
      Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine.
      ) recommendation of 8–10 h of sleep daily for teenagers for optimal health outcomes is rarely achieved. The percentage of high school students obtaining adequate sleep has decreased from 31.1% in 2007 to 25.4% in 2017 in the National Youth Risk Behavior Surveys (
      • Centers for Disease Control and Prevention
      YRBSS results: 2017 high school results.
      ). Factors contributing to adolescent sleep insufficiency include unique developmental sleep patterns (
      • Crowley S.J.
      • Acebo C.
      • Carskadon M.A.
      Sleep, circadian rhythms, and delayed phase in adolescents.
      ), early school start times (
      • Bowers J.M.
      • Moyer A.
      Effects of school start time on students’ sleep duration, daytime sleepiness, and attendance: A meta-analysis.
      ;
      • Minges K.E.
      • Redeker N.S.
      Delayed school start times and adolescent sleep: A systematic review of the experimental evidence.
      ), greater sleep variability between weekdays and weekends (
      • Gradisar M.
      • Gardner G.
      • Dohnt H.
      Recent worldwide sleep patterns and problems during adolescence: A review and meta-analysis of age, region, and sleep.
      ), and nighttime use of mobile phones and tablets (
      • Bartel K.A.
      • Gradisar M.
      • Williamson P.
      Protective and risk factors for adolescent sleep: A meta-analytic review.
      ;
      • Carter B.
      • Rees P.
      • Hale L.
      • Bhattacharjee D.
      • Paradkar M.S.
      Association between portable screen-based media device access or use and sleep outcomes: A systematic review and meta-analysis.
      ;
      • Hale L.
      • Guan S.
      Screen time and sleep among school-aged children and adolescents: A systematic literature review.
      ). Early school start times disrupt the normal physiologic sleep and wake delay associated with puberty, making it difficult for adolescents to arise with sufficient alertness to function during the school day. As a consequence of excessive daytime sleepiness, adolescents are prone to caffeine use to maintain alertness during the day (
      • Calamaro C.J.
      • Mason T.B.
      • Ratcliffe S.J.
      Adolescents living the 24/7 lifestyle: Effects of caffeine and technology on sleep duration and daytime functioning.
      ). Use of technology devices prior to sleep impairs sleep by time displacement with electronic media activities, suppressed melatonin release by blue light exposure, and positive or negative psychological stimulation by media content (
      • LeBourgeois M.K.
      • Hale L.
      • Chang A.M.
      • Akacem L.D.
      • Montgomery-Downs H.E.
      • Buxton O.M.
      Digital media and sleep in childhood and adolescence.
      ).
      The combination of puberty-induced altered sleep patterns, external influences of early school start times and nighttime use of electronic media devices, places the adolescent at heightened risk for chronic sleep insufficiency and disruption of the normal biopsychosocial state. Chronic sleep insufficiency, including short sleep duration, poor sleep quality, and increased daytime sleepiness, is associated with negative health outcomes, with a predisposition for extension of these health outcomes into the adult period.

      Biological consequences of sleep insufficiency

      Biological effects of chronic sleep insufficiency are associated with negative cardiometabolic health effects. Cardiometabolic abnormalities in adolescence are a precursor to poor adult health outcomes. An increased incidence of pre-hypertension and hypertension, combined with obesity, is associated with short sleep duration and increased risk of cardiovascular disease (
      • Bal C.
      • Öztürk A.
      • Çiçek B.
      • Özdemir A.
      • Zararsız G.
      • Ünalan D.
      • İsmailoğulları S.
      The relationship between blood pressure and sleep duration in Turkish children: A cross-sectional study.
      ). Chronic very short sleep duration of less than 5 h nightly has a significant association with an overweight and metabolically unhealthy state. Poor eating patterns with increased energy consumption, lower leptin levels, and higher ghrelin levels lead to increased hunger and appetite, increased fat storage, and weight gain (
      • Felso R.
      • Lohner S.
      • Hollody K.
      • Erhardt E.
      • Molnar D.
      Relationship between sleep duration and childhood obesity: Systematic review including the potential underlying mechanisms.
      ;
      • Li L.
      • Zhang S.
      • Huang Y.
      • Chen K.
      Sleep duration and obesity in children: A systematic review and meta-analysis of prospective cohort studies.
      ). Risks associated with obesity increase with the higher amounts of sleep insufficiency. These factors contribute to metabolic dysregulation and an increased risk of insulin resistance and type 2 diabetes (
      • Dutil C.
      • Chaput J.P.
      Inadequate sleep as a contributor to type 2 diabetes in children and adolescents.
      ).

      Psychosocial consequences of sleep insufficiency

      Academic performance and associations with sleep are well documented, with short sleep duration and the resultant daytime sleepiness leading to poorer academic performance in adolescents (
      • Fuligni A.J.
      • Arruda E.H.
      • Krull J.L.
      • Gonzales N.A.
      Adolescent sleep duration, variability, and peak levels of achievement and mental health.
      ;
      • Wheaton A.G.
      • Chapman D.P.
      • Croft J.B.
      School start times, sleep, behavioral, health, and academic outcomes: A review of the literature.
      ). Shorter sleep duration and poorer sleep quality may be accompanied by increased daytime sleepiness, greater sleep variability, and increased depressive symptoms contributing to worse academic performance (
      • Short M.A.
      • Gradisar M.
      • Lack L.C.
      • Wright H.R.
      The impact of sleep on adolescent depressed mood, alertness and academic performance.
      ). Adolescents with sleep insufficiency have an increase in risk-taking behaviors with enhanced risk of injury. Sleep deprived teen drivers, with excessive daytime sleepiness have altered reaction times and diminished vigilance and are more likely to fall asleep while driving and sustain a motor vehicle crash (
      • Hansen S.L.
      • Capener D.
      • Daly C.
      Adolescent sleepiness: Causes and consequences.
      ). Other risk-taking behaviors associated with short sleep with include substance use, and drunk driving (
      • Shochat T.
      • Cohen-Zion M.
      • Tzischinsky O.
      Functional consequences of inadequate sleep in adolescents: A systematic review.
      ), participation in sexual activity, increased physical aggression, and suicidal attempts (
      • McKnight-Eily L.R.
      • Eaton D.K.
      • Lowry R.
      • Croft J.B.
      • Presley-Cantrell L.
      • Perry G.S.
      Relationships between hours of sleep and health-risk behaviors in US adolescent students.
      ).

      Conclusions and clinical implications

      Adolescence is a critical time to promote healthy sleep habits to maximize good health as a window into the future for optimal adult health outcomes. Although biological outcomes of poor sleep are detrimental to good health, psychosocial outcomes can be equally destructive. Pediatric nurses are well-placed to advocate for healthy sleep habits in adolescents. to provide anticipatory guidance on healthy sleep for teens, and to model good sleep hygiene behaviors. Adolescents should be strongly encouraged to limit their use of small screen technology devices within the last hour prior to sleep and to refrain from use of these devices during the overnight period to minimize sleep disturbances and negative effects from technology device exposure. On a policy level, nurses can be instrumental in advocating for later school start times for adolescent students to maximize academic function at the most physiologic time of day. Although adolescents may not see value in sleep promotion during this time, it is critical for healthy biopsychosocial function.

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