Sleep Medicine 12 (2011) 110118

Contents lists available at ScienceDirect

Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Review Article

Recent worldwide sleep patterns and problems during adolescence: A review

and meta-analysis of age, region, and sleep
Michael Gradisar , Greg Gardner, Hayley Dohnt
School of Psychology, Flinders University, G.P.O. Box 2100, Adelaide, 5001 South Australia, Australia

a r t i c l e

i n f o

Article history:
Received 22 July 2010
Received in revised form 29 October 2010
Accepted 7 November 2010
Available online 22 January 2011
Keywords:
Adolescent sleep patterns
Daytime sleepiness
Insomnia
Bedtimes
Sleep measurement
Delayed Sleep Phase Disorder

a b s t r a c t
Adolescent sleep health is becoming increasingly recognized internationally as a signicant concern, with
many countries reporting high incidences of sleep disturbance in our youth. Notwithstanding the value of
ndings obtained from each large-scale survey of adolescent sleep performed within individual countries,
the eld lacks synthesis and analysis of adolescent sleep studies into a single review. This review presents
ndings from a meta-analysis of 41 surveys of worldwide adolescent sleep patterns and problems published in the last decade (19992010). Sleep patterns tended to delay with increasing age, restricting
school-night sleep. Notably, Asian adolescents bedtimes were later than peers from North America
and Europe, resulting in less total sleep time on school nights and a tendency for higher rates of daytime
sleepiness. Weekend sleep data were generally consistent worldwide, with bedtimes 2+ hours later and
more total sleep time obtained. We note a worldwide delayed sleepwake behavior pattern exists consistent with symptoms of Delayed Sleep Phase Disorder, which may be exacerbated by cultural factors.
Recommendations for future surveys of adolescent sleep patterns are discussed and provided in light
of current methodological limitations and gaps in the literature.
2010 Elsevier B.V. All rights reserved.

1. Introduction

2. Literature search and inclusion criteria

Sleep problems during adolescence are common. Recently,

Crowley et al. [1] reviewed literature over the past 30 years on
the sleep parameters of adolescents in the USA in light of how
parameters change through this period. However, no review has
covered adolescent sleep surveys worldwide. Consequently the
aim of this paper is to review and contrast the recent literature
on surveys of adolescent sleep patterns (bedtimes, sleep duration)
and problems across the globe, thus possibly providing insights
into cultural differences and similarities between countries. This
review concludes by demonstrating that many studies have assessed symptoms of Delayed Sleep Phase Disorder (DSPD) [2,3]
and provides recommendations for future surveys so that prevalence estimates of this sleep disorder during adolescence may be
determined worldwide.

Surveys of adolescent sleep problems were searched using the

search term adolescent sleep in the following electronic databases and on-line journal home pages: OVID Psyc Articles, PubMed, Behavioral Sleep Medicine, Journal of Clinical Sleep Medicine,
Journal of Pediatrics, Journal of Sleep Research, Pediatrics, Sleep, and
Sleep Medicine. Additionally, reference lists of reviews of adolescent
sleep problems were used to nd further surveys. Inclusion criteria
included: the studies contain information on adolescent sleep
parameters, sampled more than 300 participants aged 11
18 years, and published from 1999 to 2010. This last criterion is
justied given that the changes in technology (e.g., mobile phones,
internet) in the last decade may contribute to differences in sleep
parameters between the 1990s and 2000s. As this review presents
sleep parameters as a function of age (see gures to follow), studies
providing mean sleep estimates for samples extending beyond the
age limits (e.g., 815 years) were excluded. Using these criteria, 41
surveys were found (see Table 1). Each survey was analyzed in the
present review in terms of typical sleep parameters measured on
school and weekend nights. Although adolescents may experience
a range of sleep problems (e.g., Restless Legs Syndrome; Obstructive Sleep Apnea), it was clear during the review process that
two major types of sleep problems were commonly reported in
studies: insomnia (predominantly difculty initiating sleep) and

Abbreviations: DSPD, Delayed Sleep Phase Disorder; SOT, sleep onset time; WUT,
wake-up time; TST, total sleep time; BT, bedtime; SSHS, School Sleep Habits Survey;
DS, daytime sleepiness; ESS, Epworth Sleepiness Scale; PDSS, Pediatric Daytime
Sleepiness Scale; SOI, sleep-onset insomnia; DIS, difculty initiating sleep; DSM,
Diagnostic and Statistical Manual of Mental Disorders; ICSD, International Classication of Sleep Disorders.
Corresponding author. Tel.: +61 8 8201 2324; fax: +61 8 8201 3877.
E-mail addresses: michael.gradisar@inders.edu.au, grad0011@inders.edu.au
(M. Gradisar).
1389-9457/$ - see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2010.11.008

Table 1
Surveys of adolescent sleep.
Demographics

School
Country

Age

Acebo and Wolfson (2002) [44]

Danner and Phillips (2008) [30]
Johnson et al. (2006) [43]
Knutson and Lauderdale (2009) [45]
NSF (2006) [8]
Patten et al. (2000) [46]
Roberts et al. (2004) [47]
Roberts et al. (2006) [48]
Spilsbury et al. (2007) [18]
Wolfson et al. (2003) [10]
Gibson et al. (2006) [29]
Laberge et al. (2001) [49]
Iglowstein et al. (2003) [50]
Loessl et al. (2006) [51]
Meijer et al. (2000) [42]
Ohayon et al. (2000) [20]
Ohayon and Roberts (2001) [34]
Palessen et al. (2008) [52]
Giannotti et al. (2002) [41]
Russo et al. (2007) [12]
Thorleifsdottir et al. (2002) [6]
Spruyt et al. (2005) [53]
Van den Bulck (2004) [54]
Voit-Blanc et al. (2006) [35]
Gau and Soong (2003) [21]
Gau (2006) [33]
Yen et al. (2010) [55]
Liu et al. (2000) [39]
Liu et al. (2008) [19]
Chung and Cheung (2008) [13]
Mak et al. (2010) [22]
Ouyang et al. (2009) [56]
Gaina et al. (2006) [36]
Kaneita et al. (2006) [38]
Kaneita et al. (2009) [57]
Ohida et al. (2004) [32]
Tagaya et al. (2004) [58]
Chol Shin et al. (2002) [28]
Yang et al. (2005) [9]
Abdel-Kahlek (2004) [24]
Warner et al. (2007) [17]

USA
USA
USA
USA
USA
USA
USA
USA
USA
USA
Can.
Can.
Switz.
Germ.
Netherl.
Europe
Europe
Norway
Italy
Italy
Iceland
Belgium
Belgium
France
Taiwan
Taiwan
Taiwan
China
China
Hong Kong
Hong Kong
China
Japan
Japan
Japan
Japan
Japan
Korea
Korea
Kuwait
Aust.

3119
10,656
1014
2978
1602
7960
5118
4175
411
302
3235
1146
493
818
449
1125
2242
26,288
6631
1073
688
3045
2546
502
1572
2463
8319
1365
1056
1629
29,397
621
9718
102,451
516
106,297
3478
3871
1457
5044
308

1319
1417
1316
1517
1117
1218
1318
1117
1117
1319
1418
1013
016
1219
914
1518
1518
1115
1418
814
129
613
1217
1519
916
616
1219
1218
1317
1219
1218
1117
1213
1318
13
1218
1518
1617
1218
1419
1518

BT

Weekend
TST

WUT

BT

TST

Unspecied
WUT

BT

TST

Measures
WUT

SD

Act.

DS

x
x

x
x

x
x

x
x

x
x

x
x

x
x
x
x

x
x

x
x

Insomn.

Impaired funct.

SSHS
x
x

x
x

x
x
x
x

x
x
x

x
x

x
x

x
x
xa
x

x
x

x
x

x
x
x
x
x

x
x
x
x
x
x

x
x
x
x
x

x
x
x

x
x
x
x
x

x
x
x
x
x

x
x
x
x
x

x
x
x

x
x
x
x
x
xa
x
x

x
x
x
x

x
x

x
x

x
x

x
x

x
x

x
xa
x

x
x
x
x
x
x
x
x
x

x
x
x
x
x

x
x
x
x

x
x
x
x

x
x
x
x
x

xa
x
x

x
x
x

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

Studies

x
x
x

BT, bedtime; TST, total sleep time; WUT, wake-up time; SD, sleep diary; Act., actigraphy; SSHS, School Sleep Habits Survey; DS, daytime sleepiness.
a
Epworth Sleepiness Scale (ESS) used to measure DS; NSF, National Sleep Foundation (USA).

111

112

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

daytime sleepiness. A third and important theme emerged: the impact of sleep problems on adolescents general functioning. As the
assessment of sleep parameters and these three sleep problems
map closely onto a sleep disorder common during adolescence
(i.e., DSPD), this review thus highlights future researchers opportunities to assess the prevalence of this disorder. Meta-analysis involved correlations between age (in years) with sleep parameters
(in time units); where comparisons were to be made between regions, analysis of covariance (controlling for age) with Bonferroni
corrections applied. Means for regional sleep parameters are adjusted for age. Effect sizes are also reported.

3. Typical sleep parameters and their measurement

Unlike the sleep patterns of children and adults, adolescent
sleep is typically more variable across our 7-day week, with
school-night sleep shorter than sleep on weekends. What appears
to be associated with this variability in sleep duration is a developmental delay of not only bedtimes, but specically sleep times.
That is, sleep onset time (SOT) and wake-up time (WUT) become
increasingly later during adolescence. When this delayed SOT couples with the need to attend school the following morning (early
WUT), this invariantly results in a short school-night total sleep
time (TST; e.g., 58 h). Consecutive nights of short school-night
TST lead to the creation of sleep debt [4], with adolescents recovering this debt on weekends with longer TSTs (e.g., 912 h).
Sleepwake parameters can be measured in several ways. Ideally, a 7-day sleep diary or wrist actigraphy monitoring are used
[2]. However, the impracticality and expense of surveying many
adolescents with actigraphy means that sleep diaries are the measure of choice. Self-report questionnaires can also be used. The
School Sleep Habits Survey (SSHS) [5] was found to be the most
widely adopted sleep survey in this review. Wolfson et al. [5] found
no signicant difference between school-night TST and WUT when
comparing the SSHS to 8-day sleep diary and actigraphy monitoring. School-night bedtime (BT) was slightly earlier when using the
SSHS, and weekend TST and WUT were longer and later when
using the SSHS. Consequently, survey studies using the SSHS or
similar self-report questionnaires are likely to provide accurate
school-night TST, WUT, and weekend BT, but caution is needed
for school-night BT, weekend TST and WUTs.

3.1. School-night and weekend SOT (Bed time)

Of the 41 surveys analyzed, none provided information on
school-night or weekend SOT (see Table 1). But 13 surveys provided information on school-night and weekend bed time (BT).
By denition, SOT is always later than BT, and SOT has been reported to occur on average 16.8 min later than BT for adolescents
aged 1518 [6]. This average will be used to provide an estimate
of SOT for the adolescent surveys reviewed.
Fig. 1 shows that adolescent school-night BTs ranged from
8:46 pm to 12:54 am and were clearly related to age,
r(49) = 0.63, p < .0001. A longitudinal study found that adolescents
optimally need on average 9 h sleep per night regardless of their
pubertal stage [7]. Other reports state less than 8 h sleep as being
insufcient [8]. As school start times range from 7:30 to 8:30 am in
most countries, adolescents may typically wake for school between
6:30 and 7:30 am (see Fig. 5). This means that an adolescent who
intends to wake up at 7:30 am and desires the optimal 9 h of sleep
[7,8] must go to bed before 10:30 pm (i.e., in the optimal range
displayed in Figs. 1 and 2). At worst, to avoid getting insufcient
sleep (i.e., <8 h), the adolescent needs to sleep before 11:30 pm
(i.e., within the borderline range, and below the problematic
cut-off). Fig. 1 illustrates half of samples BTs (i.e., 50%) fell within
the optimal range required for adolescents to obtain 9 h sleep.
These samples derive from North American, mainland European,
Chinese, and Australian studies, and tend to be younger adolescents (i.e., most <15 years). Nearly one-third of samples lie in the
borderline range and tend to be slightly older (i.e., 1516 years).
Icelandic adolescents of all ages tended to go to bed later than
other samples, ranging from borderline BTs (younger adolescents)
to insufcient BTs (older adolescents) [6]. Korean adolescents
mean BTs were mainly in the insufcient range [9], thus preventing the majority of them obtaining sufcient school-night TST.
Worth noting is that Figs. 1 and 2 represent mean bed times.
Wolfson and colleagues [10] data show school-night BT for adolescents aged 1319 years ts a normal distribution. In a normal distribution approximately 34% of adolescents BTs will fall within
1 SD above the mean, 13.5% fall between 1 and 2 SDs above the
mean, and 2% fall between 2 and 3 SDs above the mean [11]. Table 2
shows the distribution of mean school-night BT across studies. The
mean BT for all these studies is later than 10:30 pm for all age
groups. BTs are clearly worse for adolescents outside 1 SD. For

Fig. 1. Average school night bed time. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle; Ouyang et al. [56] reported school night bed times for males and females separately, and therefore this study is not included in the above graph.

113

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

Fig. 2. Average weekend bed time. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle.
Table 2
Bedtime distribution for adolescent samples where school-night BT limits opportunity for sufcient school-night TST.

Studies

Age

Mean (SD)

01 SD above mean (i.e., 34% of sample)

12 SD above mean (i.e., 13.5% of sample)

Russo et al. (2007) [12]

Russo et al. (2007) [12]
Thorleifsdottir et al. (2002) [6]
Chung and Cheung (2008) [13]
Kaneita et al. (2009) [57]
Yang et al. (2005) [9]
Russo et al. (2007) [12]
Chung and Cheung (2008) [13]
NSF (2006) [8]
Thorleifsdottir et al. (2002) [6]
Chung and Cheung (2008) [13]
Yang et al. (2005) [9]
Wolfson et al. (2003) [10]
NSF (2006) [8]
Ohayon et al. (2000) [20]
Van den Bulck (2004) [54]
Chung and Cheung (2008) [13]
NSF (2006) [8]
Warner et al. (2008) [17]
Thorleifsdottir et al. (2002) [6]
Yang et al. (2005) [9]
Chung and Cheung (2008) [13]
Thorleifsdottir et al. (2002) [6]

12
13
13
13
13
13
14
14
15
15
15
15
15
16
16
16
16
17
17
17
17
18
18

10:31
10:33
11:10
11:00
11:15
11:12
10:43
11:23
10:32
11:55
11:26
12:00
10:59
10:51
10:36
10:54
11:35
11:02
10:47
12:05
12:54
11:47
12:15

10:3111:12
10:3911:12

11:0011:56

11:1212:18
10:4311:21
11:2312:26

11:2612:33
12:0001:06a
10:5911:52

10:3611:38
10:5411:36
11:3512:41a

10:4711:38

12:5402:18a
11:4701:03a

11:1211:53
11:1211:51

11:5612:52a

12:1801:24a
11:2111:59
12:2601:29a

12:3301:40a
01:0602:12a
11:5212:45a

11:3812:40a
11:3612:08a
12:4101:47a

11:3812:29a

02:1803:42a
01:0302:19a

(41)
(39)
(56)
(66)
(38)
(63)

(67)
(66)
(53)
(62)
(42)
(66)
(51)
(84)
(76)

Notes: Bed times within the insufcient range; SOT is likely to be 17 min later for all averages displayed.

these adolescents, bedtimes range from (at best) 15 min near the
11:30 pm insufcient BT cut-off for younger Italian adolescents
[12], through to older adolescents from Korea going to bed over
4 h later than the 11:30 pm cut-off [9]. Indeed, there is a tendency
for a large proportion of adolescents from Asian samples to lie
within the insufcient range [9,13]. Overall, although the mean
school-night BT for Asian samples (11:23 pm) was not signicantly
greater than that for European samples (10:46 pm, p = 0.12), a very
large effect nonetheless exists (i.e., d = 1.97). Statistically, the mean
Asian BT was later than that for North American samples
(10:06 pm, p = 0.02), representing a very large effect (i.e.,
d = 3.90). This difference in BT may suggest the inuence of cultural factors, as there is little difference in the latitude where surveys were conducted between North America and Asia, suggesting
environmental factors (e.g., daylight duration) play a lesser role.
For instance, one Asian study reported adolescents nished school

at 8:30 pm [19] which is likely later than the school-end time in

North America. The situation for BTs becomes worse when considering school-night BT measured using surveys is earlier than if
measured using actigraphy monitoring [10], and SOT is approximately 17 min later than BT [6]. Consequently, a higher proportion
of adolescents are likely to fall in the insufcient range when this
underestimation is taken into consideration.
Interestingly, the Icelandic study [6] demonstrated consistently
later BTs (and WUTs; see Fig. 5) when compared to other Western
samples. One explanation for such a delayed BT may be a lack of
morning sunlight to reset their circadian rhythms [23]. However,
data were collected in the springtime, when there is a substantial
amount of sunlight (e.g., approx. 18 h). Alternatively, societal
schedules could be delayed with so much daylight. But school
reportedly starts at 8 am [15]; thus these adolescents experience
ample morning light exposure. Thorleifsdottir et al. [6] argue that

114

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

the discrepancy between the sleep habits in Iceland and other

Western countries is a well-known phenomenon (p. 536), having
been found in other Icelandic studies [16]. They speculate that the
delay in BTs and WUTs may be an example of a weak dominance of
the external clock in the regulation of the biological clock, given
that Icelandic local time has adopted Greenwich Mean Time
(GMT) all year round, rather than the 1 h geographical distance
between Iceland and the UK, who use GMT solely in winter.
Fig. 2 shows results from the 13 surveys that reported average
weekend BT. These surveys show that weekend BT is related to
age, r(40) = 0.68, p < .0001, is consistently later than average
school-night BT (mean diff. = 122.3 min, t(39) = 11.17, p < .0001),
and yet is not affected by the region the adolescent resides,
F(2,12) = 2.62, p = 0.10. An adolescent is more likely to go to bed
at their preferred BT on the weekend, possibly making this more
illustrative of their circadian sleep phase preference or a behavioral
choice due to the removal of a xed wake-up time. The higher proportion (i.e., from 18% to 59%) of BTs in the insufcient range on
weekends suggests that an even higher percentage of adolescents
might have a signicantly delayed sleep circadian rhythm than
predicted by the school-night statistics.

3.2. School-night and weekend TST

Of the 41 surveys analyzed, 14 reported school-night and/or
weekend TST (see Table 1). A negative relationship exists between
age and school-night TST, r(33) = 0.66, p < .0001, but not for
weekend TST, r(34) = 0.28, p = .10. Fig. 3 shows that in 53% of
samples, average school-night TST was insufcient (i.e., <8 h)
[8,10,13,1719]. Despite the fact that some studies reviewed here
are not the same as those reviewed for BTs, there is nonetheless
a mismatch between the percentage reporting insufcient
school-night sleep, yet not an insufcient school-night BT (e.g.,
[10,17,19,20]). This anomaly may be primarily explained due to
sleep opportunity (i.e., time in bed) being compared to sleep
duration (i.e., TST). That is, even though BTs and WUTs are reported, this does not include the time spent awake in bed attempting sleep (sleep onset latency), during the night (wake after sleep
onset), or dozing on and off at the end of the sleep period. Unlike
the differences in BTs, however, the mean school-night TST for
Asian samples (7.64 h) was signicantly less than that of European
samples (8.44 h, p = .04), but not North American samples (7.46 h,
p = .64). Fig. 4 illustrates that weekend TST is on average 91.6 min

Fig. 3. Average total sleep time on school nights. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle;
Australasian sample = white circle.

Fig. 4. Average total sleep time on weekends. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle.

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

longer than school-night TST, t(12) = 9.80, p < .0001, indicating that
short school-night TSTs result in the creation of a sleep debt relieved by longer weekend TSTs. No studies reported insufcient
weekend TST, with many (71%) reporting optimal TST regardless
of age or country. The few studies reporting sufcient weekend
TST were from the USA, Korea and Australia. Somewhat similar
to the results of school-night TST, North American adolescents obtained less weekend TST than European adolescents (8.80 vs.
10.03 h, p < .0001), but not Asian adolescents (9.23 h, p = 0.11;
see Fig. 5).
3.3. School morning and weekend WUT
Thirteen of the 41 surveys reported school-night and/or weekend WUTs (see Table 1). Fig. 6 shows that school morning WUT
is relatively consistent across samples (range = 5:508:10 am,
F(2,10) = 2.48, p = 0.13) and across age, r(34) = 0.12, p = 0.50; and
likewise for weekend WUT (region: F(2,10) = 0.29, p = 0.76; age:
r(34) = 0.19, p = 0.28). However, two notable exceptions are the
Icelandic sample [6] who consistently wake later than all other
samples, and at the other extreme a Chinese sample who on school
mornings participate in exercise at 6:15 am, prior to starting
school [56]. Weekend WUT is signicantly later than average
school morning WUT (mean diff. = 2 h 31 min, p < .0001; see
Fig. 7). This is most likely a result of later weekend BTs (see

115

Fig. 2), longer weekend TSTs (see Fig. 4) and reduced weekend
morning commitments.
4. Clinical markers of adolescent sleep problems
4.1. Daytime sleepiness
Adolescent daytime sleepiness (DS) has been measured in a
variety of ways including the number of daytime or classroom naps
[8,21,22], the desire to have more sleep [23], morning sleepiness
[2426], and oversleeping [8]. The Epworth Sleepiness Scale (ESS)
[27], designed to measure adult DS, has measured DS in adolescents [2830], and scores of 10 or greater indicate DS in adults
and adolescents [27,28,30]. Nevertheless, some argue the ESS is
considered an insensitive measure of DS in adolescents because
situations used to assess DS in adults are often not applicable to
adolescents [29]. One validated measure tailored to adolescents
is the Pediatric Daytime Sleepiness Scale (PDSS) which was based
on the ESS but modied to suit school-aged children and adolescents [31].
The majority of surveys examined (i.e., 61%) reported at least
one behavioral parameter relating to DS (see Table 1). But most
only measured one aspect of DS using a variety of unstandardised
self-report or parent-report questions. For example, in surveys of
Asian adolescents, 52.7% reported feeling very or rather sleepy

Fig. 5. School-night vs. weekend total sleep times as a function of region.

Fig. 6. Average wake-up time on school mornings. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle;
Australasian sample = white circle.

116

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

Fig. 7. Average wake-up time on weekends. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle.

in the morning [13], while another found 33.3% of boys and 39.2%
of girls reported always or often feeling excessively sleepy during the daytime [32]. Some other ndings were more moderate. For
example, using parental reports, Gau [33] found that 10.9% of
Taiwanese adolescents napped inadvertently, and Ohayon and
Roberts [34] found that 5.9% of 15- to 18-year-old European
adolescents reported a tendency to fall asleep easily and anywhere
in the daytime. These assessments of only one aspect of DS may
either produce wildly differing rates due to measurement error,
or the variability may reect a natural response to variable TSTs
across cultures.
Several surveys measured a combination of DS parameters. A
large national survey of 1602 USA adolescents found that 20% of
adolescents reported at least one problem with daytime sleepiness
every day, or almost every day (e.g., fell asleep in school, while
doing homework, too sleepy in general, too sleepy for sports, overslept) [8]. The ESS was used in ve of the surveys, and scores of
greater than 10 varied from 15.9% [28] and 30% [35], to 37% [30],
40.9% [36] and 41.9% [13] in adolescents. These results support
the high rates (i.e., 2040%) of behavioral parameters of DS found
in surveys that measured one parameter of DS. The use of standardized measures was minimal, with only one study comparing
standardized DS measures against each other (i.e., the PDSS, the
sleepiness scale in the SSHS, and the authors Cleveland Adolescent
Sleepiness Questionnaire) [18]. Unfortunately, no data were presented on the prevalence of excessive sleepiness in their sample
of 411 adolescents. Nonetheless, their study provides researchers

with further options for assessing DS in adolescents using psychometrically sound instruments, and from this review it seems likely
that DS is a reasonably signicant and prevalent problem in adolescents from many countries across the world.

4.2. Insomnia
Insomnia, along with DS, is another clinical sleep parameter
that is frequently investigated, with more than half of studies reviewed (i.e., 54%) assessing at least one aspect (see Table 1). Insomnia may include difculty maintaining sleep, early morning
awakening, and unrefreshing sleep [2,3]. Most studies reviewed
in this paper, though, chose to assess difculties with sleep initiation or sleep-onset insomnia (SOI). The presence of SOI is most
commonly established through the length of sleep onset latency
(SOL; time taken to fall asleep) [2,37]. SOL is most accurately measured using a 7-day sleep diary [37], but can also be measured to
some degree of accuracy using the SSHS [5,10]. The threshold for
delineating short SOL from long SOL has been considered by some
authors to be 20 min [36] and others to be 30 min [8,12]. Another
method of evaluating SOI is through a measure of difculty initiating sleep (DIS). This commonly involves a single item that requires
adolescents to answer the question Do you have difculty falling
asleep at night? on a 5-point Likert scale, ranging from always
to never. An answer of often or always is considered by most
surveys as evidence of DIS [38,39].

Table 3
Difculty initiating sleep (DIS) and sleep onset latency (SOL) in surveys of adolescent sleep problems.
Studies

DIS (%)

Studies

SOL >30 min (%)

Abdel-Kahlek (2004) [24]

Johnson et al. (2006) [43]
Kaneita et al. (2006) [38]
Laberge et al. (2001) [49]
Liu et al. (2000) [39]
Mak et al. (2010) [22]
NSF (2006) [8]
Ohayon et al. (2000) [20]
Ohayon & Roberts (2001) [34]
Ohida et al. (2004) [32]
Pallesen et al. (2008) [52]
Roberts et al. (2004) [47]
Roberts et al. (2006) [48]

14.6 (boys) 20.3 (girls)

11.6
14.8
26.5 (boys) 36.2 (girls)
10.8
19.0
11.0
12.4
14.1
15.3 (boys) 16.0 (girls)
16.8
16.7
7.1

Chung and Cheung (2008) [13]

NSF (2006) [8]
Russo et al. (2007) [12]

20.1
26.0
20.0

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

Of the 41 surveys, 21 reported information about SOI (see Table 1). Table 3 shows that 736% of adolescents report DIS, and
2026% of adolescents report SOL greater than 30 min. What is
interesting is the most reported percentage for DIS is in the teens
(mean = 16%) despite a consistently low 20s percentage (mean
22%) for an SOL >30 min. The slight discrepancy between these
two sets of statistics might illustrate that while a sleep latency
greater than 30 min is problematic by adult standards [40], this
cut-off may be higher by adolescent standards; but this is yet to
be investigated.
4.3. Impact of sleep problems on general functioning
Of the 41 surveys analyzed, 16 surveys reported at least one
parameter indicative of distress or impairment in functioning (see
Table 1). This is a relatively understudied yet signicant component
of these surveys, as it highlights the importance of healthy sleep
needed by adolescents and its possible impact on aspects of their
lives. For example, a survey of 5044 adolescents from Kuwait found
that 9.2% of girls and 7.7% of boys reported their sleep affects social
relations, while a higher percentage said their sleep affects their
work performance (14.9% of girls, 14.2% of boys) [24]. The NSF Sleep
in America Poll found that of those adolescents who had driven in the
past year, 27% reported having had an accident or near accident due
to drowsiness, and 5% had fallen asleep while driving [8].
Several studies reported correlations between lack of sleep or
sleepiness and impaired functioning. Giannotti et al. [41] found
that adolescents with later BT and WUTs had more attention problems, poor school achievement, more injuries, and more emotional
problems. Another survey found that adolescents with an ESS score
>10 had more school absenteeism [35]. Meijer et al. [42] found that
sleep quality had a direct positive relationship with four aspects of
school functioning: receptivity with regard to the teachers inuence, self-image as a pupil, achievement motivation and control
over their own aggression. These 16 studies illustrate that impaired functioning due to sleep problems should be incorporated
into surveys of adolescent sleep.
5. Delayed Sleep Phase Disorder
From the review of these 41 studies, it is clear that adolescent
sleep is typied by late BTs and WUTs, resulting in restricted and
insufcient TST on school nights, with weekend TST being extended
and normal. Consequences of insufcient sleep include daytime
sleepiness, plus a host of broader problems in various areas of functioning. Insomnia, and particularly SOI, appears common. It is worth
noting here that these aforementioned sleep problems highly
resemble symptoms of Delayed Sleep Phase Disorder (DSPD) [2].
DSPD is a circadian rhythm disorder where the individuals sleep
pattern is timed signicantly later so that it conicts with their
weekly obligations (e.g., school, weekend morning extra-curricular
activities). The prevalence of DSPD is said to be 716% and more
common in young adults and adolescents [2,3]. We would posit that
due to cultural inuences the prevalence of adolescent DSPD may
be higher in specic regions (i.e., Asia, Iceland).
Many studies reviewed in this paper represented an opportunity to observe the percentage of adolescents who possessed a collection of DSPD symptoms to warrant the diagnosis, at least when
using diagnostic criteria from DSM-IV [3]. That is, survey questions
could target a chronic pattern of delayed sleep onset and wake-up
times with associated daytime sleepiness or insomnia (Criterion A)
as well as an associated impact on functioning (Criterion B). But
DSPD diagnostic criteria from the International Classication of
Sleep Disorders second edition (ICSD-II) require sleep monitoring
via sleep diaries or actigraphy (Criterion C) [2], which few studies
have used (e.g., [10]). Finally, if surveys coupled with sleep

117

monitoring are able to ask questions differentiating DSPD from

other sleep disorders common during adolescence (e.g., Inadequate
Sleep Hygiene, Behaviorally Induced Insufcient Sleep Syndrome,
Primary Insomnia) [2,3,43] then the remaining criteria will be
addressed, and the research and clinic elds will have a better
idea of the present prevalence of this apparently common sleep
disorder in adolescents.
6. Conclusions and recommendations
A systematic review and analysis of adolescent sleep patterns
and problems across the world is currently needed, and this review
of 41 studies published in the past decade demonstrates a number
of insights into age- and culturally-related inuences on adolescent sleep. First, there is a moderate-to-strong age inuence on
adolescent school-night bedtimes and total sleep time worldwide,
with older adolescents going to bed later and obtaining less sleep.
Second, this effect is amplied for Asian adolescents who go to bed
later (than North American adolescents), obtain less sleep (than
European samples), and tended to report higher rates of daytime
sleepiness than adolescents from other regions. Third, cultural
inuences are virtually ameliorated on the weekends with adolescents across the world demonstrating delayed bedtimes and wakeup times of greater than 2 h. Combining this common delayed
sleepwake behavior with the often reported sleep-onset insomnia
and impacts on adolescents general functioning, the ndings from
this review suggest the prevalence and impact of Delayed Sleep
Phase Disorder during adolescence may be currently under-rated.
Very few studies measured or reported the broad spectrum of
sleepwake behaviors and problems described in this review. Thus,
we recommend that studies planning to survey adolescent sleep
patterns attempt to assess multiple sleep parameters simultaneously. For large-scale surveys, the SSHS could be used, and some
translations may already exist (e.g., Italian [41], German [51],
Mandarin [19]). Ideally, sleep diaries could be used in conjunction
with surveys. During our review, we found it was unfortunately
common for large-scale studies to assess only bedtimes and thus
calculate time in bed. With the growing wealth of knowledge
about the importance of sleep, it is clear from the present review
that future studies should ask additional questions about total
sleep time, difculties initiating sleep, daytime sleepiness, and
the impact of sleep on general functioning.
Despite the large number of studies that are now investigating
adolescent sleep with large samples, we know very little about recent sleep patterns of adolescents in many regions of the world.
For instance, two continents were not featured in this review.
Despite the excellent work being performed in South America, not
one study was large enough and reported sleep characteristics consistent with this reviews inclusion criteria. Further, to our knowledge, the eld knows too little about the sleep of teens in Africa.
Although Australasia was featured in this review, only one largescale study was found that reported sleep, thus preventing this
region from being included in statistical comparisons with other
regions. Perhaps in the next decade, with more surveys of adolescent
sleep patterns and problems conducted worldwide, the eld will
have more data to better investigate similarities and differences
in sleep and sleep-related practices within and across countries
(that) may facilitate an understanding of factors that underlie
sleepwake regulation during adolescence (LeBourgeois et al., p.
264) [59].
Conict of Interest
The ICMJE Uniform Disclosure Form for Potential Conicts of
Interest associated with this article can be viewed by clicking on
the following link: doi:10.1016/j.sleep.2010.11.008.

118

M. Gradisar et al. / Sleep Medicine 12 (2011) 110118

References
[1] Crowley SJ, Acebo C, Carskadon MA. Sleep, circadian rhythms, and delayed
sleep phase in adolescence. Sleep Med 2007;8:60212.
[2] American Academy of Sleep Medicine. The International Classication of Sleep
Disorders Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American
Academy of Sleep Medicine; 2005.
[3] American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders Text Revision. 4th ed. Washington, DC: American Psychiatric
Association; 2001.
[4] Van Dongen HP, Rogers NL, Dinges DF. Sleep debt: theoretical and empirical
issues. Sleep Biol Rhythms 2003;1:513.
[5] Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in
adolescents. Child Dev 1998;69:87587.
[6] Thorleifsdottir B, Bjornsson JK, Benediktsdottir B, Gislason T, Kristbjarnarson H.
Sleep and sleep habits from childhood to young adulthood over a 10-year
period. J Psychosom Res 2002;53:52937.
[7] Carskadon MA, Orav EJ, Dement WC. Evolution of sleep and daytime sleepiness
in adolescents. In: Guilleminault C, Lugaresi E, editors. Sleep/wake disorders:
natural history, epidemiology, and long-term evolution. New York: Raven
Press; 1983. p. 20116.
[8] National Sleep Foundation. 2006 Sleep in America poll. Washington, DC: WBA
Market Research; 2006.
[9] Yang C, Kim JK, Patel SR, Lee J. Age related changes in sleep/wake patterns
among Korean teenagers. Pediatrics 2005;115:2506.
[10] Wolfson AR, Carskadon MA, Acebo C, Seifer R, Fallone G, Labyak SE, et al.
Evidence for the validity of a sleep habits survey for adolescents. Sleep
2003;26:2136.
[11] Pelham BW, Blanton H. Conducting research in psychology: measuring the
weight of smoke. Pacic Grove, CA: International Thompson Publishing; 2003.
[12] Russo PM, Bruni O, Lucidi F, Ferri R, Violani C. Sleep habits and circadian
preference in Italian children and adolescents. J Sleep Res 2007;16:1639.
[13] Chung K, Cheung M. Sleepwake patterns and sleep disturbance among Hong
Kong Chinese adolescents. Sleep 2008;31:18594.
[15] American Field Service. Focus on Iceland School Program, <http://
www.afs.org/afs_or/focus_on/high_school/39>; 2008 [retrieved 28.04.09].
[16] Kristbjarnarson H, Magnusson H, Sverrisson GI, Arnarson EO, Helgason T. A
survey on sleep habits in Iceland. Iceland Med J 1985;71:1938.
[17] Warner S, Murray G, Meyer D. Holiday and school-term sleep patterns of
Australian adolescents. J Adolesc 2008;31:595608.
[18] Spilsbury JC, Drotar D, Rosen CL, Redline S. The Cleveland Adolescent
Sleepiness Questionnaire: a new measure to assess excessive daytime
sleepiness in adolescents. J Clin Sleep Med 2007;3:60312.
[19] Liu X, Zhao Z, Jia C, Buysse DJ. Sleep patterns and problems among Chinese
adolescents. Pediatrics 2008;121:116573.
[20] Ohayon MM, Roberts RE, Zulley J, Smirne S, Priest RG. Prevalence and patterns
of problematic sleep among older adolescents. J Am Acad Child Adolesc
Psychiatry 2000;39:154956.
[21] Gau S, Soong W. The transition of sleepwake patterns in early adolescence.
Sleep 2003;26:44954.
[22] Mak K-K, Ho S-Y, Thomas GN, Lo W-S, Cheuk DK-L, Lai Y-K, et al. Smoking and
sleep disorders in Chinese adolescents. Sleep Med 2010;11:26873.
[23] Strauch I, Meier B. Sleep need in adolescents: a longitudinal approach. Sleep
1988;11:37886.
[24] Abdel-Khalek AM. Prevalence of reported insomnia and its consequences in a
survey of 5044 adolescents in Kuwait. Sleep 2004;27:72631.
[25] Henschel A, Lack L. Do many adolescents sleep poorly or just too late? Sleep
Res 1987;16:354.
[26] Tynjala J, Kannas L, Levalahti E. Perceived tiredness among adolescents and its
association with sleep habits and use of psychoactive substances. J Sleep Res
1997;6:18998.
[27] Johns MW. A new method for measuring daytime sleepiness: the Epworth
Sleepiness Scale. Sleep 1991;14:5405.
[28] Chol S, Jinkwan K, Sangduck L, Yongkyu A, Soonjae J. Sleep habits, excessive
daytime sleepiness and school performance in high school students.
Psychiatry Clin Neurosci 2003;57:4513.
[29] Gibson ES, Powles ACP, Thabane L, OBrien S, Molnar DS, Trajanovic N, et al.
Sleepiness is serious in adolescence: two surveys of 3235 Canadian students.
BMC Pub Health 2006;6:11625.
[30] Danner F, Phillips B. Adolescent sleep, school start times, and teen motor
vehicle crashes. J Clin Sleep Med 2008;4:5335.
[31] Drake C, Nickel C, Burduvali E, Roth T, Jefferson C, Badia P. The pediatric
daytime sleepiness scale (PDSS): sleep habits and school out-comes in middleschool children. Sleep 2003;6:4558.
[32] Ohida T, Osaki Y, Doi Y, Tanihata T, Minowa M, Suzuki K, et al. An
epidemiologic study of self-reported sleep problems among Japanese
adolescents. Sleep 2004;27:97885.

[33] Gau SS. Prevalence of sleep problems and their association with inattention/
hyperactivity among children aged 615 in Taiwan. J Sleep Res 2006;15:
40314.
[34] Ohayon MM, Roberts RE. Comparability of sleep disorders diagnoses using
DSM-IV and ICSD classications with adolescents. Sleep 2001;24:9205.
[35] Viot-Blanc V, Muzet A, Krieger J, Davenne D, Levy P, Tran F, et al. Sleep and
sleepiness in French adolescent population. J Sleep Res 2006;15:A42.
[36] Gania A, Sekine M, Shimako H, Xiaoli C, Hitomi K, Takashi Y, et al.
Epidemiological aspects of self-reported sleep onset latency in Japanese
junior high school children. J Sleep Res 2006;15:26675.
[37] Chesson A, Hartse K, Anderson WM, Davila D, Johnson S, Littner M, et al.
Practice parameters for the evaluation of chronic insomnia. Sleep 2000;23:
15.
[38] Kaneita Y, Ohida T, Osaki Y, Tanihata T, Minowa M, Suzuki K, et al. Insomnia
among Japanese adolescents: a nationwide representative survey. Sleep
2006;29:154350.
[39] Liu X, Uchiyama M, Okawa M, Kurita H. Prevalence and correlates of selfreported sleep problems among Chinese adolescents. Sleep 2000;23:18.
[40] Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep 2006;29:
115573.
[41] Giannotti F, Cortesi F, Sebastiani T, Ottaviano S. Circadian preference, sleep and
daytime behaviour in adolescence. J Sleep Res 2002;11:1919.
[42] Meijer AM, Habekothe HT, Van Den Wittenboer GLH. Time in bed, quality of
sleep and school functioning of children. J Sleep Res 2009;9:14553.
[43] Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in
adolescence: lifetime prevalence, chronicity, and an emergent gender
difference. Pediatrics 2006;117:24756.
[44] Acebo C, Wolfson MC. Inuence of irregular sleep patterns on waking behaviour.
In: Carskadon MA, editor. Adolescent sleep patterns. UK: Cambridge University
Press; 2002. p. 22135.
[45] Knutson KL, Lauderdale DS. Sociodemographic and behavioral predictors of
bed time and wake time among US adolescents aged 15 to 19 years. J Pediatr
2009;154:42630.
[46] Patten CA, Choi WS, Gillin JC, Pierce JP. Depressive symptoms and cigarette
smoking predict development and persistence of sleep problems in US
adolescents. Pediatrics 2000;106:19.
[47] Roberts RE, Lee ES, Hernandez M, Solari AC. Symptoms of insomnia among
adolescents in the Lower Rio Grande Valley of Texas. Pediatrics
2004;27:75160.
[48] Roberts RE, Roberts CR, Chan W. Ethnic differences in symptoms of insomnia
among adolescents. Sleep 2006;29:35965.
[49] Laberge L, Petit D, Simard C, Vitaro F, Tremblay RE, Montplaisir J. Development
of sleep patterns in early adolescence. J Sleep Res 2001;10:5967.
[50] Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to
adolescence: reference values and generational trends. Pediatrics
2003;111:3027.
[51] Loessl B, Valerius G, Kopasz M, Hornyak M, Riemann D, Voderholzer U. Are
adolescents chronically sleep deprived? An investigation of sleep habits of
adolescents in the southwest of Germany. J Sleep Res 2006;15:A207.
[52] Palessen S, Hetland J, Sivertsen B, Samdal O, Torsheim T, Nordhus H. Time
trends in sleep onset insomnia among Norwegian children and adolescents:
19832005. Scand J Pub Health 2008;36:88995.
[53] Spruyt K, OBrien LM, Cluydts R, Verleye GB, Ferri R. Odds, prevalence and
predictors of sleep problems in school-age normal children. J Sleep Res
2005;14:16376.
[54] Van den Bulck J. Television viewing, computer game playing, and internet use
and self-reported time to bed and time out of bed in secondary-school
children. Sleep 2004;27:1014.
[55] Yen C-H, King BH, Chang Y-P. Factor structure of the Athens Insomnia Scale
and its associations with demographic characteristics and depression in
adolescents. J Sleep Res 2010;19:128.
[56] Ouyang F, Lu BS, Wang B, Yang J, Li Z, Wang L, et al. Sleep patterns among rural
Chinese twin adolescents. Sleep Med 2009;10:47989.
[57] Kaneita Y, Yokoyama E, Harano S, Tamaki T, Suzuki H, Munezawa T, et al.
Associations between sleep disturbance and mental health status: a
longitudinal study of Japanese junior high school students. Sleep Med
2009;10:7806.
[58] Tagaya H, Uchiyama M, Ohida T, Kamei Y, Shibui K, Ozaki A, et al. Sleep habits
and factors associated with short sleep duration among Japanese high-school
students: a community study. Sleep Biol Rhythms 2004;2:5764.
[59] LeBourgeois MK, Giannotti F, Cortesi F, Wolfson AR, Harsh J. The relationship
between reported sleep quality and sleep hygiene in Italian and American
adolescents. Pediatrics 2005;115:25765.