pamela j. brown - sleep education synthesis (final draft) - nnu master's degree

Running head: INTERVENTIONS FOR ADOLESCENT SLEEP DEPRIVATION 1

Sleep Education as an Intervention in Adolescent Sleep Deprivation

Pamela J. Brown

Northwest Nazarene University

INTERVENTIONS FOR ADOLESCENT SLEEP DEPRIVATION 2

The Synthesis

Sleep Education as Intervention in

Adolescent Sleep Deprivation

Is presented to the Northwest Nazarene University Counselor Education Department in partial

fulfillment of the degree requirements of the completions of the Master of Science in

Counseling.

__________________________________

Faculty Advisor; Dr. Michael Pitts

__________________________________

Pamela J. Brown


Abstract

This synthesis covers current research in the science of sleep and teen sleep deprivation

outcomes. It covers a brief history of sleep including past and current theories of the purposes of

sleep and then move on into sleep structure through developmental stages. Next, it covers

adolescent struggles with sleep; including how the biology and developing chronotype

(morningness-eveningness trait) can affect adolescents making it twice as hard for some of them

to succeed. Finally, this paper will cover possible interventions that can, have, and need to

happen in all schools and homes if we hope to help our children succeed at their optimal levels

and give them hope for a better future in an increasing technological world. As demands on

adolescents increase, interventions teaching them about sleep hygiene should be addressed not

only by adjusting environmental schedules but also by introducing programs to curriculum that

will facilitate learning and understanding of the construct of sleep.


Table of Contents

1. Introduction ....................................................................................................5

2. The Basics of Sleep ........................................................................................7

3. Sleep Theories ................................................................................................10

4. Sleep Structure ...............................................................................................12

5. Chronotype, Chronobiology and Circadian Rhythm .....................................14

6. Opponent-process and Two-process Model...................................................15

7. Sleep Disorders ..............................................................................................20

8. Sleep Debt ......................................................................................................21

9. Sleep requirements and development ............................................................23

10. Teens and Sleep Deprivation .........................................................................25

11. Negative Impacts of Sleep Deprivation on Teens ..........................................28

12. Possible Solutions ..........................................................................................40

13. Later School Times ........................................................................................40

14. Double Shift School System ..........................................................................44

15. Educational Interventions ..............................................................................45

16. Parental Education and Involvement .............................................................47

17. Conclusion .....................................................................................................48

18. References ......................................................................................................50

19. Figures............................................................................................................61

20. Appendix A: Horne & Ostberg Questionnaire ..............................................68

21. Permission for Use of Images ........................................................................76


Introduction

One could argue that the problem started with the light bulb. Before then human beings

entrained their bodies to the light and dark schedule of the day, because lighting candles

throughout the night used up too many resources. People slept when it was dark instead of

watching television on our big-screens, playing 3D animated video games on game consoles, and

updating our Facebook status until two in the morning. We didn’t have personal digital

assistants (PDA) with backlit screens that we could not only arrange our schedules at three or

four in the morning when the idea struck, but also stream instant movies and television that we

may have missed due to other engagements we were involved in throughout the earlier evening.

Sleep, next to the digital demands of society, is getting less and less important to many when it is

what we should be paying attention to in our own lives, and the lives of our children.

An increasing body of research is showing how important it is for children to get the

appropriate sleep for their growing bodies. Parents give them early bed times, which fit in fairly

well and work to their advantage. Due to their development, children are more morning types

anyway so they have hardly any trouble getting along on this schedule. For adolescents it is a

little more difficult.

Until the recent two decades, researchers had no idea why adolescents had such a hard

time with getting to sleep on time. Sleepy teens seemed to have a stubborn attitude and a desire

just to stay up and play video games. Parents blamed sleep onset delay on the teenage years and

how difficult that time is supposed to be anyway. However, recent research has given us many

reasons to believe that for adolescents, sleep is not so easy (Carskadon, 2011; Colrain & Baker,

2011; Cowley, Acebo, & Carskadon, 2007; Dagys, et al., 2012; Giannotti, Cortesi, Sebastiani, &

Ottaviano, 2002; Golombek & Cardinali, 2008; Kelley, Lockley, Foster, & Kelley, 2014; Lange


& Randler, 2011). There are many things that they just do not have as easy. If there is one thing

they could look forward to, it is that this time of struggling with sleep could end once they leave

adolescence.

During adulthood, for reasons unknown to researchers, sleep cycles and the need for

sleep decreases. It becomes easier to program again with the societal demands of scheduling the

seven to eight hours of sleep per night that an adult requires on average (National Sleep

Foundation, 2007). However, because of many troubles adolescents have with sleep, often times

they grow to have equally poor habits as adults. They continue with poor sleep hygiene habits

because they do not know any different. What if they are educated on the multi-faceted subject

of sleep before adolescence hits and the struggle begins? What might happen if they have the

opportunity to head the problem off at the pass?

This synthesis is a brief look at many parts of sleep that every person should learn about

in some form or another. It will begin with a brief history of sleep including past and current

theories of the purposes of sleep and then move on into sleep structure through developmental

stages. Next, we will cover adolescent struggles with sleep; including how the biology and

developing chronotype (morningness-eveningness trait) can affect adolescents making it twice as

hard for some of them to succeed. Finally, this paper will cover possible interventions that can,

have, and need to happen in all schools and homes if we hope to help our children succeed at

their optimal levels, and give them hope for a better future in an increasingly technological

world. As demands on adolescents increase, interventions teaching them about sleep hygiene

should be addressed not only by adjusting environmental schedules, but also by introducing

programs to curriculums within schools that will facilitate learning and understanding of the

construct of sleep.


Literature Review

Basics of Sleep

Every individual needs sleep. Mammals, reptiles, birds, all types of living creatures need

some sort of sleep. Over the years, there have been reports of people who either do not sleep, or

sleep very few hours a night and seem to function at a normal level. A search on the internet will

give a few examples of people who have suffered from some severe health scares and are

afterwards unable to sleep at all.

There have been other studies done that have shown the more devastating results of total

sleep deprivation. In a landmark series of studies done in 1989 by Rechtshaffen et al. rats were

put on an apparatus that would keep them awake at all times. Rats were able to live for up to 32

days but suffered severe reactions from the sleep deprivation from skin lesions to full sepsis and

organ failure. Either way you look at it, every person needs to sleep. They need time for their

body to heal and regenerate from the energy they have used throughout the day.

If an individual is asked to define what sleep is, the answer may be difficult for anyone to

think of. Most would answer that it is the opposite of being awake. Evidence has shown that

even when people believe they have been awake, they have actually been having what is called a

micro-sleep. An operational definition of a microsleep is a sleep episode lasting less than five

minutes (Dement & Vaughan, 1999). Microsleeps can occur without an individual even being

aware of them. Microsleeps were not even something that were know about until a researcher

started attempting to find the exact moment a person fell asleep, and he came across the

discovery.

William C. Dement, a major contributor and trusted physician in sleep communities

authored a book titled The Promise of Sleep in 1999. In his book, he gave two points to justify


the definitions of sleep. The first of the essential features of sleep is that “sleep erects a

perceptual wall between the conscious mind and the outside world.” (p. 17) He gives an

example of this in an experiment he did which featured a participant having a strobe light flash

placed six inches in front of their eyes. Experimenters asked participants to restrict their sleep to

only four hours the night before to induce sleep deprivation. After a few minutes, after strobe

flashes took place, the participant missed pushing the button to identify when they saw the flash.

Dement clarified that the only way for the participant to have missed the flash was if they had

actually fallen asleep for two seconds with their eyes open. Within those two seconds, sleep had

built a perceptual wall between the conscious mind and the outside world (Dement & Vaughan,

1999).

The second quality that Dement uses to define sleep is that the person must be able to be

awakened. If no amount of stimulation wakes the person, the state they are in is not sleep. They

would be either unconscious or dead (Dement & Vaughan, 1999). While he was able to

determine a definition of sleep, he also used this example to explain how microsleeps occur in

daily life even when we are not aware of them. The individual was not aware of a strobe light

flashing inches from his face when his eyes were open. He was asleep for what was only a

second or two, but enough to lose consciousness of his surroundings.

In early history, sleep was seen as a time of inactivity. However, as has been discussed

earlier, sleep is anything but inactivity. The human body is hard at work even while sleeping.

There are different biological functions that occur during sleep starting from the brain and

radiating throughout the body just as the circulation system does. Figure 8 illustrates the areas of

the human brain where scientists have found an increase of activity during sleep.


With such a wealth of information, one might think we could figure out why a person

needs to sleep, or what actually goes on inside a person’s head while they are sleeping.

However, this is not the case. Because of the mystical nature of sleep and our inability now to

know for sure what goes on, we are left, just as before, with theories and hypotheses.

Human beings spend one third of their life sleeping. That is equal to 112 days each year.

Even with the amount of time human beings spend sleeping, we have yet to discover the reasons

why we would die without it. Great discoveries throughout history have brought numerous ideas

and knowledge about what happens during sleep. Philosophers and scientists have posited many

theories and hypotheses about the function of sleep. However, with the advances made in

science and sleep research, scientists are getting closer to answers.

History is filled with ideas of why people sleep. While Aristotle’s theory of human sleep

may be preposterous to us in the 21st century, it may have started people thinking more in depth

about what sleep is. In 350 B.C., Aristotle believed that after a person ate, digestive processes in

the stomach would release vapors. In his book, On Sleep and Sleeplessness, he wrote, “when the

external nutriment enters the parts fitted for its reception, the evaporation arising from it enters

into the veins, and there, undergoing a change, is converted into blood, and makes its way to

their source, [the heart]”. He goes on to say these vapors rise to the top (the head) and then turn

to mass again. The head will become heavy, causing drowsiness, and then cause the person to go

to sleep (Aristotle, 2007). Thomas Cogan carried on Aristotle’s theory even as late as 1584. He

took the vapor idea even further by saying that different foods can produce the vapors more

quickly such as wine, meat, and milk (Cogan, 1584). Centuries later, researchers have developed

better ideas for why sleep actually occurs.


Sleep theories. A theory proposed by Oswald (1980), and then expanded upon by Horne

(1988), started with the idea that people obtain only two types of sleep. Van Dongen, Rogers

and Dinges (2003) refer to the initial hours of sleep that a person gets as ‘core sleep’. According

to this theory, the body and brain repair the effects of waking wear and tear during core sleep.

After core sleep hours are completed ‘optional sleep’ hours take place (Horne, 1988; Oswald,

1980; Pa Van Dongen, Rogers, & Dinges, 2003). For Horne this explained why many

individuals didn’t need to have the same amount of sleep as other people and why a person could

still function if they had only gotten four or five hours of sleep (Pa Van Dongen, Rogers, &

Dinges, 2003; Horne, 1988). While this theory alone may not have been able to be substantiated

completely, it proposed ideas that have stuck around until now.

The inactivity theory, also referred to as the adaptive or evolutionary theory of sleep, is

an old theory that states sleep is a method of preservation for animals or different species. The

concept is based in evolutionary theories that would ensure an animal’s survival because of a

certain trait. According to the inactivity theory an organism would sleep and therefore draw less

attention to them thus preventing being hunted by predators. While this theory seems much less

logical, it paved the way for more sound theories in current science (Harvard Medical School,

2008).

Another past theory for why people sleep is the energy conservation theory. The idea

behind the energy conservation theory (also referred to as conservation of energy theory) is if we

did not sleep, we would expend too much of our bodies needed resources and would not survive.

It says that the metabolic slowdown and heat dissipation experienced during sleep are tools for

conserving needed energy for survival (Sleep Research Society, 1997; Harvard Medical School,

2008)


A more current theory of what happens when people sleep is the restorative function

theory. This theory illustrates the idea that people regenerate when they sleep. It says that when

a person goes to sleep at night, the body repairs itself from stress exerted throughout the day. At

first glance, it would seem that humans have the ability to regenerate. “This is further supported

by findings that many of the major restorative functions in the body like muscle growth, tissue

repair, protein synthesis, and growth hormone release occur mostly, or in some cases only,

during sleep” (Harvard Medical School, 2008). However, science has not identified for sure

what is restored (Sleep Research Society, 1997). Another part of the restorative theory is the

buildup of adenosine in the human body. Adenosine in the brain acts as a neural brake that

slows down several different processes. Throughout the day, the body builds up its level of

adenosine. Adenosine contributes to sleep pressure and once sleep occurs then the buildup is

decreased and then sloughed off (Dement & Vaughan, 1999).

The most recent, and possibly most logical reason for why people sleep, is the brain

plasticity theory. Throughout each day the human brain learns, collects, and attempts to organize

loads of information (Dement & Vaughan, 1999; Harvard Medical School, 2008). Each night

when a person goes to sleep the brain uses the time to reorganize all of the information and

format the brain much like a hard drive on a computer with files upon files (Harvard Medical

School, 2008; National Sleep Foundation, 2007). The brain needs this time to form new

connections with new information and memories or it will fail to take in the new information.

With so many theories explaining why researchers suggest people need to sleep, over 74% of the

population do not get the adequate amount of sleep recommended by the scientific community

(National Sleep Foundation, 2007). Sleep disorders are a large cause of this problem.


As stated earlier, theories of sleep and the stages of sleep have evolved and changed as

technology has allowed us to study the area more in depth. The latest development happened in

2007. The American Academy of Sleep Medicine published a revision of the sleep stages that

all accredited AASM professionals will use to decipher EEG recordings.

Sleep structure. With current and ongoing research in the area of sleep, the American

Academy of Sleep medicine determined that a set of standard stages needed to be agreed upon

when measuring sleep. In the new AASM guidelines, there are REM stages and NREM stages.

Rapid Eye Movement (REM) is the first stage of sleep and can be visually identifiable when

sleep occurs by the eyes rolling and moving around under the eyelids of the sleeping individual

(Siegel, 2005). The other sleep stages go deeper in succession and are labeled as Non-REM

stages (NREM). All of the REM stages are the same; however, they can vary in length (Iber,

Ancoli-Israel, Chesson, & Quan, 2007). The REM stages are experienced intermittently

throughout the night. Stages of sleep cycle through at different times throughout the night, but a

person will go back to REM sleep before moving back into a NREM stage. NREM stages are

split into N1, N2, and N3.

The Electroencephalogram (EEG) is a way for researchers to be able to measure stages of

sleep in humans a reliable and valid way. It gives them a way to see what is going on inside the

brain without doing a surgical procedure. “Tiny flat metal disks called electrodes are placed all

over your scalp. The disks are held in place with a sticky paste. The electrodes are connected by

wires to a recording machine. The machine changes the electrical signals into patterns that can

be seen on a monitor or drawn on paper. It looks like wavy lines” (Campellone, 2014).

An EEG measures brainwaves in a human being during sleep without disrupting the sleep

process. For use in sleep studies, a person’s brainwaves are measured for a desired amount of


sleep or normal amount of sleep. During this time the EEG measures the waves that the brain

emits during sleep. When looking at the output of waves for sleep, doctors and scientists can

measure the amount of REM sleep and NREM sleep depending on what the lines drawn by the

EEG show them (Dement & Vaughan, 1999). Figure 1 shows placement of three different types

of electrodes such as the EEG, EOG (electrooculogram), and the EMG (electromyogram). Figure

2 illustrates the parts of the brain that show activity during sleep that can be measured by an

EEG.

The latter two of these function quite similarly as the EEG in that they use small

electrodes and give output of small squiggly lines to show activity of the corresponding areas.

An electrooculogram shows the eye movement involved while being measured, and the

electromyogram shows the level of tension within the jaw muscles while being measured.

Different brainwaves and amounts of activity within the body are measured depending on what

stage of sleep a person is. The deeper a person is sleeping, the less the spindle moves on the

EEG also shown in Figure 1. During N1 stage, a person is falling asleep. When the person is

awake, they have alpha waves measuring normally between 8 and 13 Hz. During N1, the brain

will move from these alpha waves to theta waves (4-7 Hz). This is the stage in which people are

seen twitching or jerking and the person loses awareness of the outside world (Sleep Research

Society, 1997).

The next stage of sleep, N2, is where the brain moves from alpha waves (8-13 Hz) to

theta waves (4-7 Hz). It also introduces something called sleep spindles. Sleep spindles are

spikes in an EEG reading (12-16 Hz). Some suggest that this could be partly due to the body

trying to stay asleep. Another occurrence in this stage is a K-complex. A K-complex is a very


brief high amplitude EEG spike at times triggered by a loud noise. K-complexes usually follow

sleep spindles and can happen many times throughout the N2 stage of sleep.

Stage N3 is deep sleep or slow-wave sleep (SWS) and makes up almost 50% of all sleep

waves for a person. Many troublesome things can occur during this stage. Sleepwalking,

bedwetting, and night terrors can happen during these stages. A person awakened during this

stage of sleep may suffer from something referred to as sleep inertia. Sleep inertia is when a

person has had the adequate amount of sleep, but still feels as if they need to go back to bed. It

can last anywhere from 45 minutes to 3 hours depending on the time that the person is awakened.

The main feeling accompanying sleep inertia is grogginess.

Most theorists agree that the most restful sleep happens during SWS; though some say

dreaming can happen in REM also. A misleading attribute of the sleep stages is the order of

their occurrence. Sleep stages occur almost in waves themselves. While the body will start in

REM sleep and move to N1, move through N2 and then to N3 and N4, it will then move back to

N3 and up to N2, to N1 and back into REM sleep once again before starting another cycle

through the stages. Though the stages will cycle through repeatedly throughout the night, it is

most likely that N3 and N4 or SWS will only occur once or twice more during the night. Figure

3 shows an average sleep structure of a healthy young adult through a full eight-hour sleep

session.

Circadian Rhythm, Chronobiology, and Chronotype

Franz Halberg, from the University of Minnesota, coined the term “circadian rhythm” in

1969 when he was measuring different hormones in the blood of mice. He combined the term

“circa”, in Latin, to show that it was near or similar to a “dies”, or day, also in Latin (Dement &

Vaughan, 1999). He noticed that some hormones in the mice he was studying were present at


some times of the day but then were not at others. He also noticed that these times were on an

oscillatory cycle over a 24-hour period. When referring to circadian rhythms, many processes

are structured within the oscillatory structure also termed as the opponent-process model and the

two-process model.

Opponent Process Model and Two-Process Model.

Sleep for human beings is a homeostatic process on an approximately 24 hour cycle

(Dement & Vaughan, 1999, p. 79; Millman, 2005). Millman (2005) states, “These 2 systems,

working together or in opposition, influence the activities of the endocrine, thermoregulatory,

neurobehavioral, renal, cardiovascular, digestive, and sleep/wake systems.”(p. 1175) The easiest

way to imagine a homeostatic process is with a teeter-totter; the old childhood toy with a child

sitting on each end and balancing upon something sturdy in the middle. Each child will take

turns going into the air while the other goes toward the ground; the same way a homeostatic

process occurs. Process one builds enough pressure to overpower the other. Once process two

builds up enough pressure, it will regain control. Sleep works much in this same way. The two

opposing processes in this case are sleep and wakefulness. Sleep pressure builds throughout the

day until it has increased enough to overpower wakefulness. Once wakefulness has allowed the

sleep pressure to dissipate throughout the night, it again takes over and wakes us each morning.

According to Dement and colleagues at Stanford, sleep is the stronger of the opposing

processes. He says that the sleep drive is always active and is always either keeping us asleep at

night, or building pressure throughout the day. However, wakefulness is not always active

because human beings are able to utilize it enough during the day to stay awake. Once sleep

time arrives, the sleep drive takes over.


Another name used for this same concept is the two-process model. Rosen (2005) helps

to explain the two-process model previously introduced by Borbely (1982) by further saying that

once again it is a homeostatic process where sleep (S) builds pressure throughout the day until an

individual goes to sleep and the circadian rhythm (C) has a chance to help the sleep pressure

dissipate. Figure 4 illustrates this concept with the shaded area identifying when the person is

asleep and S is allowed to dissipate. If sleep deprivation continues further, the dashed line in this

illustration shows how sleep pressure would continue to build until sleep occurs.

An individuals’ chronotype has been synonymously referred to as circadian typology.

The term chronotype refers to one’s individual time-of-day preference. It has also been used to

determine whether a person has higher levels of morningness or eveningness. To explain this

concept it helps to learn a little about chronotypes. The scale of morningness to eveningness is a

concept that dates back to the work of O’Shea (1900). However, systematic studies did not

begin until almost 4 decades later with Freeman and Hovland (1934) and Kleitman (1939)

measuring body temperature throughout the day (Hines, 2004).

Within the construct of chronotype, there are three different possibilities. The first of

these types is the morning type (MT). MTs are the type of individual that wake at an early hour,

have a peak level of performance early in the day and then go to bed at an early hour (Adan, et

al., 2012). Morning chronotype individuals prefer arising early, and they often feel they do their

best work before noon and would rather do their most difficult work early in the day (Hines,

2004).

The next level on the scale would be neither type (NT). When an individual is scored as

a neither type that means they get up at an average hour, have peak performance at an average

time of day and they go to bed at an average time in the evening.


Finally, there are the evening types (ET). Evening types wake at later hours in the

morning, have a later time of day for peak performance and then they go to bed later in the

evening or sometimes into the very early morning hours. “If the individual has an intermediate

or morning chronotype, performance will be best early in the school day; in the case of evening

types, subjective feelings and mental performance during the early part of the school day are

likely to be submaximal.” (Valdez, Reilly, & Waterhouse, 2008)

There are different factors that go into identifying morningness and eveningness of an

individual which are biological factors and personality factors. Biological factors that have been

used to measure chronotype of an individual are the sleep-wake cycle, body temperature

fluctuations, and the release of the hormones melatonin and cortisol (Adan, et al., 2012).

The human body has an endogenous (internal) ‘circadian’ clock that runs on an

exogenous (external) 24 hour light to dark cycle provided by nature (Maire, Reichert, &

Schmidt, 2013). This ‘master clock’ in charge of these cycles is a pair of cell groupings called

the suprachiasmatic nuclei (SCN) located within the hypothalamus in the brain, as pictured in

Figure 5 (Maire, Reichert, & Schmidt, 2013; Sharma & Feinsilver, 2009). The SCN receives

signals from other sensory stimuli throughout the day to trigger the processes of the body

involved in the sleep-wake schedule. Variables encountered throughout the day that stimulate

the SCN are called zeitgebers (German for “time-giver” (Sharma & Feinsilver, 2009). Possibly

the most important zeitgeber in this context would be light. The 24-hour light to dark exogenous

sensory cycle in nature can be a good example of how the processes within the SCN work

(Sharma & Feinsilver, 2009). First, the retina contains specific cells (photoreceptor cells)

devoted to perception of light. Photoreceptor cells then send messages to the SCN to tell what


time of day it is based on the intensity of the light perception (Schulz & Steimer, 2009; Sharma

& Feinsilver, 2009).

Another process is the secretion of hormones within the brain that prompt sleep. The

pineal gland in the brain secretes different hormones measured for peak levels throughout the

day to determine circadian rhythmicity. It secretes melatonin in the evening to signal our bodies

when it is time to go to sleep and then secretes cortisol to tell our body to wake up and be active.

Sleep pressure begins to build upon waking in the morning and will continue until one goes to

sleep. When an individual goes to sleep the sleep pressure dissipates (Borbely, 1982). This

balance between sleep pressure and its’ dissipation in many studies is a part of homeostasis. A

scientific explanation for the sleep pressure buildup and dissipation process is homeostasis of the

sleep pressure. Homeostasis is defined as “coordinated physiological processes which maintain

most of the steady states in the organism” (Maire, Reichert, & Schmidt, 2013). Together, these

processes include more markers which can be measured to determine what state of wakefulness

one’s body is in.

Kelley, Lockly, Foster and Kelley (2014) introduce a term called the “wake maintenance

zone” (WMZ) which they say occurs a few hours before sleep occurs. This period generally

does not have a sleep pressure that is high enough to “counteract the circadian drive for

alertness”. They also say that teens have a later WMZ, which causes adolescents to stay up later

due to low sleep pressure. They suggest that because the WMZ is “still promoting wakefulness”;

adolescents are simply unable to go to sleep as early as they are required to for early school times

and other activities. When they are forced to wake too early in the mornings, they are

experiencing increasing sleep deprivation on a daily basis. (Kelley, Lockley, Foster, & Kelley,

2014)


Another marker signaling chronotype and chronobiology is body temperature. Body

temperature was the first indicator to be measured in identifying individuals’ biological rhythms

and preferred arising or bed times (Hines, 2004). The body temperature drops and changes much

as sleep pressure does during sleep. It drops measurably during sleep and starts to rise again

once sleep pressure dissipates. Figure 6 illustrates this concept. It has further been studied and

is now accepted to be regulated by melatonin secretion when sleep onset is about to occur

(Krauchi, Cajochen, Mori, Graw, & Wirz-Justice, 1997). When melatonin is introduced into the

body’s system its’ thermoregulatory system then starts to drop core body temperature to mark the

beginning of a sleep phase (Krauchi, Cajochen, Mori, Graw, & Wirz-Justice, 1997). Researchers

are able to introduce melatonin at an earlier hour thereby inducing a slow drop in core body

temperature and triggering other sleep processes.

Time of day differences for performance in people can be attributed to their chronotype.

Because of the costly nature of physiological testing that is needed to track circadian phase

markers and determine chronotype such as core body temperature, melatonin secretion and light

sensitivity cues in the brain, a much more user-friendly tool was designed in the late 1970s.

The most widely used measurement tool for morningness-eveningness in an individual is

the self-report measure from Horne and Ostberg (1976) that identifies each individual into one of

three categories which are morning type (MT), neutral or neither type (NT), and evening type

(ET) (Adan, et al., 2012). It is translated into many different languages and tests for reliability

and validity show that all versions are quite highly rated. (Hines, 2004; Adan, et al., 2012) Even

though a diagnosis of definitely morning type or definitely evening type is relatively rare there is

still enough evidence to show that teens shift toward a definite evening type during puberty

(Hines, 2004).


Sleep Disorders

Probably the most common of the sleep disorders is insomnia. However, most people do

not understand that there are many different symptoms of insomnia (Mayo Foundation for

Medical Education and Research, 2007). Professionals have agreed that the general amount of

sleep needed is 7 ½ to 8 hours of sleep. Some people may even require nine to ten hours of sleep

per night. Some of the symptoms of insomnia are waking up too early, daytime sleepiness,

irritability throughout the day, and the most common symptom is not being able to fall asleep

when desired. So, what causes insomnia? It can be caused by stress, depression, medications,

change in environment, change in activity levels, and can even be caused by eating too much too

late at night. It almost seems that avoiding insomnia is like walking on a tight rope. Insomnia

may be the most common form of sleep disorder, but by far is not the only type. Medicines have

been developed to battle insomnia and help people fall asleep and stay asleep throughout the

night; though, even over-the-counter antihistamines (diphenhydramine), taken in appropriate

quantities, can have the same effect for some people (Mayo Foundation for Medical Education

and Research, 2007).

Sleep apnea is also a common sleep disorder. Of the three sleep apnea disorders (central,

mixed and obstructive), OSA, or Obstructive Sleep Apnea is the most common. Obstructive

sleep apnea is a period of sleep where the person actually stops breathing for a time. The airway

collapses and air is cut off from the lungs. The brain interrupts the sleep cycle to wake up just

enough to breathe. Loss of breathing can occur hundreds of times each night. The cessation of

breathing can last for fifteen seconds to one minute before the brain interrupts sleep (Sleep

Research Society, 1997).


The final type of sleep disorder covered is circadian rhythm disorder. As discussed later,

a person’s circadian rhythm slows down the metabolism and lower’s the body temperature at

certain times of the day. These times vary for each individual, which accounts for the terms

night owl and morning person. Because of the high variability of circadian rhythms, societal

constraints may put some people (night owls) at a disadvantage. Some individuals stay up late at

night because of a little known circadian disorder called Delayed Sleep Phase Syndrome (DSPS).

This disorder’s main symptom is the inability to fall asleep within two hours of the desired sleep

time (Sharma & Feinsilver, 2009). Because a person is unable to fall asleep at the desired hour,

they are forced to get up at a time that their body is not set for (Sharma & Feinsilver, 2009). The

general idea here is that a person’s circadian clock is pushed back by two or more hours. They

usually need the same amount of sleep that others need, but the problem arises when they are

forced to cut their sleep time short by waking up according to the schedule society has laid out

(Sharma & Feinsilver, 2009).

An increasing amount of literature is showing adolescents are at a higher risk of

developing DSPS because of their biology. Hagenauer, Perryman, Lee, and Carskadon (2009)

identified several different reasons that are contributing to DSPS in adolescents including light

exposure and hormone fluctuations. They also theorize that this problem is not limited to only

the human species but that when different animals are put under the same conditions they also

exhibit similar symptoms (Hagenauer, Perryman, Lee, & Carskadon, 2009).

Sleep Debt

Each night that that an individual is deprived of a portion of this sleep accrues over time

until the person is able to catch up. Another way to think of this is with the homeostatic sleep

pressure. If a person is unable to get sufficient sleep to take sleep pressure down to its lowest


level, they will build the pressure back to its highest point much quicker than before. To explain

this concept an example can be used. If an adult requires, on average, eight and a half hours of

sleep each night to feel fully rested that would be their required sleep amount. If over a one-

week period this person were to go to bed one hour later each night but wake up at the normal

time each day, they would only receive seven and a half hours each night. By the end of the

seven days, they would accrue a seven-hour sleep debt that must be accounted for. Some

researchers have used a bank account as a metaphor to help explain this concept. If you accrue a

sleep debt, you will owe your body that much sleep and somehow it will make you pay up. The

question then becomes, where do we end up making up for this sleep debt? For many

individuals the sleep debt is reconciled each weekend when they finally get to sleep in. Sleeping

in two to three hours each day on the weekends will normally fulfill a person’s sleep debt and

leave them feeling better rested and functioning better.

Dr. William C. Dement has become one of the leading researchers on sleep, and has

strong interests in the area of the sleep debt. Sleep debt is based on research that says individuals

have a certain number of hours they need of sleep each night. According to the idea of sleep

debt, a person must reach the appropriate number of hours they are supposed to sleep or else

missed hours add up throughout the week. An example of this would be a normal adult who

requires eight hours of sleep each night. If this adult has a stressful week and only attains an

average of about six hours of sleep per evening, he will acquire a sleep debt of 14 hours.

According to Dement, a person will sleep off the debt over the weekend. However, because

Friday night is the most prominent time for social activities, driving around with a sleep debt of

14 hours can cause driving hazards. In addition, after a prolonged time of sleep debt and sleep


deprivation, a person can start to have serious detrimental health issues (National Sleep

Foundation, 2007).

Other hazards of sleep deprivation have been noted in other recent studies. A study in

2004 done by a researcher at Harvard University suggested that “hospitals could reduce the

number of medical errors by as much as 36 percent by limiting an individual doctor’s work shifts

to 16 hours and reducing the total work schedule to no more than 80 hours per week” (Harvard

Medical School, 2008). In addition, basic human functioning suffers. Sleep deprivation

negatively influences our mood, our ability to focus, and our ability to access higher-level

cognitive functions (2008). These are just a few of the negative impacts that sleep has on an

individual. With these included, many problems have been further studied throughout current

research.

With these and all other identified problems as side effects of sleep deprivation, the

mystery of how to regain control of sleep is still being studied. Many people have their own

ideas of how to increase productivity and cut down on sleep so they can get further ahead in our

society. However, they are putting themselves in dangerous territory for problems in many areas

of their lives because of the sleep deficit.

Sleep Requirements and Development

Sleep also changes throughout the developmental stages ranging from babies needing 18

hours of sleep each day to the elderly who seemingly need approximately 6 to 7 hours each

night. Figure 7 shows a chart of the average number of hours of sleep required each night as

opposed to the average amount of REM sleep per night throughout the developmental lifespan.

Though when asked how many hours of sleep humans need most of the population might

say eight hours, as stated earlier, each person needs a different amount of sleep to function at an


optimal level. This number is also based on developmental stages. Newborn babies through two

months will sleep between 10 and 18.5 hours on average. Between three months and eleven

months infants will typically sleep nine to twelve hours during the night and take 30 minute to

two-hour naps, one to four times a day. At ages one through three, toddlers usually need

between 12 and 14 hours of sleep in a 24-hour period. When they reach about 18 months of age

their naptimes will decrease to once a day lasting about one to three hours. Preschoolers

between ages three and five will need approximately 11 to 13 hours of sleep and they might take

naps in midday but not usually after the age of five. School aged children, ages five to twelve,

average a need of 10 to 11 hours of sleep each night. That means that if school starts at 7:30 in

the morning, a child will probably need to be up and getting ready one hour prior and bedtime

would be 8:00 each evening.

Adolescence is a “period marked by dramatic biological and social changes that can

affect health and behavior, including sleep” (Colrain & Baker, 2011). Several different studies

support different sleep patterns within the adolescent stage of life. These changes not only take

place within behavioral differences but in the basic structure of adolescence. Sleep changes

affect sleep quality, quantity and the increased demands in social and academic workloads of an

adolescent (Colrain & Baker, 2011; Wolfson & Carskadon, 1998).

Many different things are attributable to getting a good night’s sleep during adolescence.

A study written by Chen, Wang, Jeng (2006) found three different major findings. The first of

these is “adequate sleep is positively correlated with the frequency of health-promoting

behaviors.” (p. 6) This is based on the idea that when an adolescent gets the sleep they need they

are more frequently found to have better “stress management, healthy diet, life appreciation,

health responsibility and exercise” (p. 6) These habits can be attributed to adequate sleep.


Another finding is adolescents getting adequate sleep have a higher probability of not becoming

overweight and having fewer appointments with doctors. Lastly, they found “middle school

students had a higher frequency of adequate sleep than high school students.” (p. 6)

Sleep based beliefs are another facet of sleep education that are understood less than

optimally. Diaz-Morales, Prieto, Barreno, Mateo and Randler (2012) looked into the sleep

beliefs of adolescents and their correlation with eveningness and morningness. They showed

that evening type students had a higher likelihood to have improper sleep beliefs. They also

posited that this could be because evening types generally have different beliefs because of their

eveningness. (Diaz-Morales, Prieto, Barreno, Mateo, & Randler, 2012) However, for

adolescents that have to abide in a morning type schedule to go to school, evening type beliefs

may not be appropriate.

Teens and Sleep Deprivation

The National Sleep Foundation published a report in 2000 that identifies teens need at

least 8.5 hours of sleep each night and once puberty hits there is a phase delay in teen sleep

habits. According to this report, teens have a hard time falling asleep earlier than 11:00pm.

They also listed an increase in daytime sleepiness as an attribute of teen sleep (National Sleep

Foundation Sleep and Teens Task Force, 2000). In research done by Gibson et al. (2006) over

1000 Canadian adolescent students were surveyed to identify how prevalent their subjective level

of sleepiness was and whether it has an impact on curricular or extracurricular activities. They

found that over 70% of students were sleep deprived according to the necessary 8.5 hours of

sleep requirement. The researchers also suggested that “parents and educators need to know that

adolescents’ tendency to go to bed late and wake late is normal, and this must be considered in


addressing sleep habits and in academic scheduling and transportation” (p. 6). Gibson et al.

continues to say:

There is a need for educators to be more aware of the impact of school start times and

academic scheduling, and to consider sleep problems as potential factors in students who

fail to achieve or who exhibit behavioral problems. … Perhaps the most significant

impact of sleep deprivation may be on the secondary development of the brain that

commences during puberty. The lag between attainment of sexual maturity and

emotional development of high intensity feelings, such as risk taking, and the

development of a set of neurobehavioral systems for self-control and affect regulation

may be accentuated by sleep deprivation.

As mentioned earlier, teens have a difficult time getting the sleep they need on a regular

basis. This brings to question, why is it so much more of a problem for them than adults? At

first glance, it seems simple to determine that the reason why teenagers are so much more sleep

deprived than their younger peers is increases in homework, social demands and the

opportunities for getting a job. However, another factor is contributing to the problem that in the

past may have been thought of as part of the rebellious stage. Teenagers have a biological

tendency to stay up later in the evening, which leads to them getting decreased amounts of sleep

as they get older (Wiggins & Freeman, 2014). That is to say, teens are more likely to display

evening type traits that may contribute to more problems with waking early in the morning and

life demands.

According to the two-process model, sleep pressure builds throughout the day and only

dissipates upon sleep. Jenni, Achermann, and Carskadon (2005) further established this concept


when using a controlled experimental design to measure sleep deprivation on adolescents

between the ages of 10 and 19. Through the process, they deprived the adolescents of sleep for

36 hours and measured their brain activity using an EEG. Results echoed previous research

showing a correlation between the age of the child and a steady decrease in sleep pressure

depending on the child’s age (Jenni, Achermann, & Carskadon, 2005).

Fischer et al. (2008) summarized the findings of over 11,000 European student surveys

by saying, “we can conclude that adolescents around the world shorten sleep according to age

mainly by delaying timing of sleep due to biological and psychosocial reasons and that they are

subjected to premature forced awakenings in connection to school days” (p. 19). Other studies

have found similar results in studies with adolescents in other countries around the world

suggesting the adolescent population affected by sleep deprivation might be worldwide (Fischer,

et al., 2008; Gradisar, Gardner, & Dohnt, 2011; Loessl, Valerius, Hornyak, Riemann, &

Voderholzer, 2008).

A study written by Hansen, Janssen, Schiff, Zee and Dubocovich (2005) used sleep

diaries and bright light therapy to determine if early school start times were making a difference

on students sleep habits. In addition to finding that bright light therapy had no effect on school

performance in mornings for students, they concluded that school start times do contribute to

sleep deprivation for students. The high school students involved were asked to keep a sleep

diary starting two weeks before the beginning of school and then for another six weeks during

the school year intermittently. The average sleep time before school started was 8.7 hours and

dropped to 7 hours once school started. This number was significantly different from weekdays

during the summer. However, weekend sleep times were not significantly different from the


summer averages. This contributed to the conclusion that school start times directly contribute

to sleep deprivation in adolescents (Hansen, Janssen, Schiff, Zee, & Dubocovich, 2005).

Another factor often overlooked in adolescent sleep research is the difference in

appropriate sleep times among different socioeconomic classes. Marco, Wolfson, Sparling and

Azparje (2012) used data from questionnaires, actigraphs and sleep diaries to determine the

levels of sleep deprivation among urban adolescents. They used the results to determine that

adolescents with a low socioeconomic status (SES) obtain significantly less sleep on a regular

basis. While this study does not discuss specific factors within environments, the researchers

mention that even different parenting styles could be contributing factors among the sleep

problems within low SES adolescent sleep problems (Marco, Wolfson, Sparling, & Azuaje,

2012).

Negative Impacts of Sleep Deprivation

One research article combines several studies ranging from correlational to quasi-

experimental and draws conclusions regarding how sleep or a lack thereof affects mental health,

academic performance and behavior. In the article, Beebe (2011) states that “findings from

studies that used complementary research methods have converged to strongly suggest that

inadequate sleep quality and quantity are causally linked to sleepiness, inattention, and probably

other cognitive and behavioral deficits that impact daytime functioning, with potential

implications for long-term development.” (p. 7) When adding a developmental context to all of

the studies he looked at in the study, he found that even “short-term sleep deprivation can alter

neural plasticity,” which is one of the brain’s major building blocks for memory and pathway

maintenance. (Beebe, 2011, p. 6)


Another article used frequently in adolescent sleep research and covers many different

facets of the problems facing teens is Excessive Sleepiness by Millman (2005). In the article

Millman discusses many of the concepts including biological, emotional, and behavioral

problems that may occur due to sleep. Daytime sleepiness is a leading contributor to many of the

problems that face teens with within their daily lives such as school performance, cognitive

function, and mood. (Millman, 2005)

Mood. Many studies have found problems with mood and affect when mixed with sleep

problems. Mood disorders, sleep disorders and other problems have a higher prevalence among

those who experience sleep deprivation due to school schedules (Giannotti, Cortesi, Sebastiani,

& Ottaviano, 2002; Wiggins & Freeman, 2014). Mood is also affected more by partial sleep

deprivation, such as one or two hours per day over a period of time, than a full day of sleep

deprivation is on a human being by an entire standard deviation (Durmer & Dinges, 2005).

Talbot, McGlinchy, Kaplan, Dahl, and Harvey (2010) completed a study in which they

identified characteristics in the moods of sleep-deprived individuals and non-sleep-deprived

individuals. They found participants reported less positive affect characteristics such as

“interested, excited, happy, strong, energetic, cheerful, active, proud, and delighted” when sleep

deprived (Talbot, McGlinchey, Kaplan, Dahl, & Harvey, 2010). They also found that there were

increased levels of anxiety in the sleep deprived participants as opposed to those who were rested

(Talbot, McGlinchey, Kaplan, Dahl, & Harvey, 2010).

Depression. Those who are sleep deprived are at a higher risk for depressive symptoms

and have an increased amount of irritability that can change their outlook on life. This outlook

on life can then become irrational and influence their overall mood. Most research within

adolescent sleep deprivation has used correlations among grades and school performance when


supporting hypotheses. Correlational design makes it impossible to define direct causal

relationships between two different variables. However, Dagys, McGlinchey, Talbot, Kaplan,

Dahl and Harvey (2011) used an experimental design to determine the effects of sleep

deprivation and chronotype on adolescent affect. Through their research they were able to

support their hypothesis stating that “participants reported less PA (positive affect) when sleep

deprived than when well rested.” This meant that when an adolescent is sleep deprived they are

less likely to have a positive affect though they also found contrary results to their hypotheses

saying that negative affect did not increase because of sleep deprivation. When looking at

chronotype in adolescents, the research showed that evening type adolescents were indeed more

likely to have decreased positive affect and a higher level of negative affect. This could be due

to sleep deprivation but also due to the evening chronotype being forced to function outside of

its’ optimal performance time (Dagys, et al., 2012).

There is also a genetic link between mood and sleep problems. Mendlewicz (2009)

discusses the genes within the human bodies that influence depressive symptoms such as sleep

phase problems. While the research does not draw conclusion as to whether one causes the

other, circadian genes are linked to mood genes through behavior and the brain. (Mendlewicz,

2009)

Suicide risk. One element of sleep deprivation, and the most lethal, is its effect on

mental health. Mental health professionals many times know to check if an individual has had

enough sleep when suicidal ideation and attempts take place. However, there are times when

sleep is overlooked as a possible reason for symptoms. Research indicates, “Fatigue resulting

from sleep difficulties may lead to hopelessness and decreased impulse control.” (Goldstein,

Bridge, & Brent, 2008)


People who complete suicide are more likely to have higher rates of difficulty with sleep

than controls even during their most recent depressive episode according to research. This same

study found that suicide completers were 10 times more likely to experience sleep problems

during the episode, and 4 to 5 times more likely to experience sleep problems or insomnia in the

week before death. “Sleep deprivation may impair problem-solving ability which when paired

with a decreased capacity to regulate emotional states when tired, vulnerable adolescents may

utilize limited alternatives for tolerating emotional distress.” (Goldstein, Bridge, & Brent, 2008)

Within the adolescent population, “adolescents sleeping less than 8 hours at night were

approximately 3 times more likely to make a suicide attempt than those who slept 9 hours or

more” (Liu, 2004). While there is no one sure way to determine whether or not an individual or

adolescent is thinking of suicide without self-reports, suicidal behavior may be due to poorer

judgement, concentration and impulse control and the increased risk of fatigue, hopelessness and

mental disorders.

Health. Other serious health problems are linked to sleep deprivation in past studies

including obesity, which can lead to high blood pressure, stroke, heart attack, and diabetes

(Wells & Vaughn, 2012).

Obesity. There is a large amount of research emerging on the link between sleep

deprivation in adolescents and obesity (Owens, 2014; Schmid, Hallschmid, Jauch-Chara, Born,

& Schultes, 2008; Spruijt-Metz, 2011; Taheri, Lin, Austin, Young, & Mignot, 2004). One

avenue of research has identified late sleepers as eating a higher amount of calories on average

and eating more after the 8:00pm mark than regular sleepers. Its’ findings also suggested that

those with a higher level of sleep deprivation had a higher BMI (Body Mass Index) and ate less

fruits and vegetables than others (Baron, Reid, Kern, & Zee, 2011). A population that is possibly


of even more concern is children that are struggling with their weight. When trying to

understand the reasons why children are struggling about their weight more and more as the

years go by there have been a few possible theories as to how sleep habits or the lack thereof

could be part of the problem.

One of the suggested reasons for this might be because of a similar hormonal fluctuation

as is seen with melatonin and cortisol. However, the hormones that are seen in weight gain are

leptin and ghrelin. When one goes to sleep at night the hormone leptin is secreted. This prevents

hunger from occurring while sleeping (Schmid, Hallschmid, Jauch-Chara, Born, & Schultes,

2008). When sleep duration is cut short or depleted this hormone does not flow and ghrelin, its’

counterpart is then released more throughout the waking hours. Ghrelin is a hormone that

triggers hunger. With more ghrelin running through the system, the body will feel hunger more

often (Taheri, Lin, Austin, Young, & Mignot, 2004; Schmid, Hallschmid, Jauch-Chara, Born, &

Schultes, 2008). An individual becomes sleep deprived, ghrelin in their system increases, and

they end up eating more because of the increase in food cravings throughout the day (Schmid,

Hallschmid, Jauch-Chara, Born, & Schultes, 2008). This shows that there is increasing evidence

that when children are getting less sleep at night they have increased ghrelin in their system and

this can be a cause for overweight and obese children (Buckhalt, Wolfson, & El-Sheikh, 2009;

Taheri, Lin, Austin, Young, & Mignot, 2004).

In their research, Knutson, Spiefel, Penev, and Van Cauter (2007) wanted to review

literature that added to the evidence of an imbalance of leptin and ghrelin in sleep-deprived

individuals and how this imbalance can affect metabolic systems within the body. They

identified at least three pathways that are at risk due to sleep deprivation which are the way the

body metabolizes glucose, an increase in appetite due to the hormonal imbalance, and a decrease


in energy expenditure (Knutson, Spiegel, Penev, & Van Cauter, 2007). These three things put

together make a combination that adds to the problems facing adolescents who are already at a

loss because of sleep deprivation.

A smaller and yet possibly more important avenue of research is between childhood

sleep, adolescent sleep, and obesity. Chen, Beydoun and Wang completed a meta-analysis of

over 42 different studies on children’s sleep habits and obesity. What they found was “strong

evidence to quantify the relationship between sleep duration and overweight/obesity in children

and adolescents.” They also found that “children with shorter sleep duration had a 58% higher

risk for overweight or obesity, and children with shortest sleep duration had an even higher risk

(92%) when compared with children having longer sleep duration. For each hour increase in

sleep, the risk of overweight/obesity was reduced on average by 9%.” (p. 271) They were able to

show an association with short sleep duration and an increased likelihood of obesity in the future.

The study suggests, “A combination of strategies targeting both earlier bedtime and later wake

time to increase sleep duration may help prevent childhood obesity.” (p. 272)

Cognitive function and academic performance. Academic performance has been a

difficult way to measure negative impacts of sleep deprivation. A reason for this might be no

way to control for academic performance across an entire population. Even though most

research agrees adolescent students need around nine hours of sleep each night, many surveys

suggest that students only get an average of seven hours (Louzada, da Silva, Peixoto, & Menna-

Barreto, 2008). Other school and life commitments make it difficult for teens to get that much

sleep on a nightly basis such as social demands, jobs, additional homework loads and

extracurricular activities (Dahl, 1999; Eliasson, Eliasson, King, Gould, & Eliasson, 2002).

Researchers have identified that academic performance is linked to sleep deprivation and


adjustments must be made to increase adolescent performance (Randler & Frech, 2009).

However, instead of using one measurement for academic performance, most researchers rely on

many different factors.

The first factor that sleep researchers look to is daytime sleepiness. Students sleep

through classes, have a decreased amount of attention on classroom activities and struggle to

follow basic instructions (Louzada, da Silva, Peixoto, & Menna-Barreto, 2008; Buckhalt,

Wolfson, & El-Sheikh, 2009; Hahn, et al., 2012). Sleep deprivation of one to two hours each

day for a week can cause symptoms of sleepiness (Louzada, da Silva, Peixoto, & Menna-Barreto,

2008).

Daytime sleepiness is most often measured using the Multiple Sleep Latency Test

(MSLT). During the MSLT a participant is monitored by a trained sleep technologist. It consists

of four 20-minute naps separated in two-hour intervals (Littner, et al., 2005). The amount of

time that it takes a participant to fall asleep is then given a score between 1 and 20; 20 being

falling asleep within the first 30 seconds and a score of 1 taking longer than 20 minutes to fall

asleep. The scores of the four naps are averaged which is then used as a score for daytime

sleepiness. The faster the individual falls asleep the higher the score for daytime sleepiness

(Littner, et al., 2005). Another study, done on over 6600 students found that evening type

students subjectively reported more problems with academic performance (Giannotti, Cortesi,

Sebastiani, & Ottaviano, 2002)

Wolfson and Carskadon (1998) published an article on adolescents sleep schedules and

academic performance. The researchers state that students who reported getting poor grades or

who were failing school were getting at least a half hour less sleep each night than those who


were doing well. They also found that those same students slept more on weekends than those

who get more sleep during the week (Wolfson & Carskadon, 1998).

According to a meta-analysis written by Curcio, Ferrara and De Gennaro (2006) of sleep

research, the first study to show that a sleep restriction of 5 hours one night is enough to affect

abstract learning in children negatively was by Randazzo et al. A follow-up study had similar

results and supported the findings that executive functioning in children is impaired even after a

small sleep impairment of 7h of sleep. The sleep restriction affected their verbal fluency and

creative thinking in both studies. Curcio, Ferrara and De Gennaro concluded based on the 9

major sleep research studies they included in their analysis, that “The effects of sleep loss are

mainly evident on higher cognitive functions (attention, memory, problem-solving, etc); as a

result, learning capacity and academic performance may seriously be affected.” (Curcio, Ferrara,

& De Gennaro, 2006)

Lim and Dinges (2010) completed a meta-analysis of 147 articles about the effects of

total sleep deprivation on cognitive variables. In their analysis, they found that “although total

sleep deprivation does produce statistically significant differences in most cognitive domains, the

largest effects are seen in tests of simple, sustained attention.” (p. 386) Because many activities

including driving a car are included in the sustained attention activity domain, adolescents are at

an increased risk because long-term partial sleep deprivation may be even worse.

Buckhalt, Wolfson and El-Sheikh (2009) found that “total sleep time, erratic sleep/wake

schedules, late bedtimes and rise times, and poor sleep quality are associated with poorer school

performance when rated by teacher ratings, grades, individual and group achievement tests,

specialized tests of neurocognitive functioning, and comprehensive norm-referenced intelligence

batteries.” (p. 61) They went on to say that “self-reported eveningness, delayed sleep schedules,


and early school start times are associated with daytime sleepiness, dozing in class, attention

difficulties, and lower grades.” (p. 61) Also, “there is strong evidence based on research that

lower academic performance of children under stress is related to sleep.” (p. 62)

Durmer and Dinges (2005) wrote an article evaluating and identifying current research on

the neurocognitive consequences of sleep deprivation. They identified many of the problems

that are associated with not only full sleep deprivation but also partial sleep deprivation over

time. They reported that when comparing 2 weeks of partial sleep deprivation to 4 hours sleep

restriction each night, they showed equivalent deficits as those with two full days of sleep

deprivation in attention, working memory, and cognitive functions (Durmer & Dinges, 2005).

One article suggests mental performance deteriorates the longer a person is awake and

activities using mental performance are probably better done earlier in the day while artistic and

physical activities should be in the afternoon because of this. (Valdez, Reilly, & Waterhouse,

2008) Similarly, Durmer and Dinges (2005) suggest that sleep propensity increases the more a

person is sleep deprived and as a result cognitive performance is more variable due to the sleep

deprivation. (p. 118)

Gillen-O’Neel, Huynh, and Fuligni (2013) is another study demonstrating the effects of

sleep deprivation on academic performance. In their study, the researchers followed a sample of

students over their high school career. They had the students fill out diaries for two weeks each

year to assess daily study and sleep time and daily academic problems. They found that even

though study time remained the same across the years of high school, the amount of sleep the

students obtained decreased each year. Another finding was that when students stay up to study

late one night, they will have decreased performance the following day. They found that no

matter how much a student studies each day, if they sacrifice sleep to study more, they “will


have more trouble understanding material taught in class and be more likely to struggle on an

assignment the following day” (p. 139).

Behavioral. Most parents can attest to times that their children have been lacking

enough sleep and how that can negatively affect their child’s behavior. Research on this topic is

narrow for adolescents because many have accepted the teen years as a time of rebellion and in

so much toss aside possibilities of an improved demeanor with a little added sleep. Clinkenbeard

et. al (2011) found support for a hypothesis that “adolescents who sleep fewer hours than are

recommended are engaged in more delinquency” and that “even mild sleep deprivation has

immediate effects on cognitive functioning, which may increase an adolescent’s risk of

involvement in delinquent behavior.” (Clinkinbeard, Simi, Evans, & Anderson, 2011) They went

even further and said “individuals with diminished cognitive functioning are prone to a broad

range of poor decisions that include delinquent and criminal conduct. (Clinkinbeard, Simi,

Evans, & Anderson, 2011) “Sleep deprivation increases irritability which can then make teens

more prone to violence and higher levels of aggression throughout adolescence.” (Clinkinbeard,

Simi, Evans, & Anderson, 2011)

One link to behavioral issues in adolescence due to sleep deprivation might be

chronotype. As mentioned earlier, chronotype refers to an individual’s preference towards

morningness or eveningness or neither one. Adolescents are predominantly evening types

because of their later wake times, later optimal performance times, and later bed times.

Problems linked to this are behavioral problems. According to a study by Lange and Randler

(2011) students who have a higher level of eveningness on the Composite Scale of Morningness

(CSM), are more likely to have more behavioral and emotional problems than those with higher

morningness levels (Lange & Randler, 2011; World Health Organization: Europe, 2004).


Risk-taking and impulsivity. Teens lacking the appropriate amount of sleep and

operating on a sleep debt are more likely to take part in risky behavior that they otherwise might

not have. “Inadequate sleep has been shown to adversely affect a person’s decision-making by

elevating the expectation of gains and diminishing the perceived likelihood of loss following

risky decisions”. (Clinkinbeard, Simi, Evans, & Anderson, 2011) Some research that lends

support to the theory of teens being more likely to have a higher level of eveningness is “highly

impulsive individuals perform better in the evening than in the morning due to differences in

their arousal rhythms when compared to others” (Hines, 2004).

Hildebrand, Daly, Nicholls, Brooks-Holliday and Kloss (2013) found that students who

had insufficient sleep had an increased risk in taking part in “school violence-related behaviors”

such as interpersonal violence and resulting injuries, including those that occur within the school

setting”. (p. 1) The data set they used for analysis was from the 2009 Youth Risk Behavior

Survey that was developed by the Centers for Disease Control and Prevention to assess different

areas of adolescent behavior. Combining the results of the data set on the amount of sleep with

the National Sleep Foundation’s recommendation for sufficient sleep, researchers found

correlations between many of the violence-related behavior characteristics and insufficient sleep

(Hildebrand, Daly, Nicholls, Brooks-Holliday, & Kloss, 2013).

Contributing to these studies, in a study on over 6600 students in 2002, Gianotti, Cortesi,

Sebastiani and Ottaviano reported that their evening type participants “to counteract the effect of

daytime sleepiness…used more frequently psychoactive substances such as caffeine, caffeine-

containing beverages and tobacco.” (p. 197) Substance abuse can be a heavy impact on sleep

deprived adolescents (Wong, Rowland, & Dyson, 2014; Giannotti, Cortesi, Sebastiani, &

Ottaviano, 2002; O'Brien & Mindell, 2005).


Safety. The National Sleep Foundation’s 2011 Sleep in America poll found that among

those polled who drove, about one-half (52%) indicated that they had driven drowsy, with more

than one-third (37%) doing so in the previous month (Young People More Likely to Drive

Drowsy, 2012).

In an article on DrowsyDriving.org, which is an affiliate of the National Sleep

Foundation, the article Young People More Likely to Drive Drowsy gives a few of the signs that

you might be too tired to be driving. These signals include a difficulty focusing, frequent

blinking and/or heavy eyelids, difficulty in keeping daydreaming and thought navigation on

driving, trouble keeping your head up, drifting from your lane, swerving, tailgating and/or hitting

rumble strips, inability to clearly remember the last few miles driven, missing exits or traffic

signs, yawning repeatedly, and feeling restless, irritable, or aggressive (Young People More

Likely to Drive Drowsy, 2012; Inoue & Komada, 2014).

In an article written in 1995, David Dinges states there is no “agreed upon reliable

estimate of the extent to which sleepiness contributes to the incidence and costs of accidents

resulting from human error.” However, at that time he stated, “Recent estimates for the

percentage of accidental injuries and deaths attributable to sleepiness vary from as low as 1-2%

to as high as 41%.” (Dinges, 1995) Estimates have gotten much better in the last 19 years with

better indicators for law enforcement and tools for identifying accident causes.

Most recently, the American Automobile Association (AAA) did a study that estimates

that “one out of every six (16.5%) deadly traffic accidents, and one out of eight (12.5%) crashes

requiring hospitalization of car drivers or passengers is due to drowsy driving.” (Tefft, 2010)


Forty one percent of drivers admitted to having fallen asleep at the wheel at some point with one

in ten of those reporting they did so within the past year (Tefft, 2010).

Pertaining specifically to teenagers, one in seven licensed drivers ages 16 to 24 admitted

to nodding off at least once while driving in the past year as compared to one in ten of all

licensed drivers who confessed to falling asleep during the same period (Young People More

Likely to Drive Drowsy, 2012). The same article reports that being awake for more than 20

hours results in impairment equal to a blood alcohol concentration of 0.08%, the legal limit in all

states and a 3-4 second microsleep can occur without realizing it (Young People More Likely to

Drive Drowsy, 2012). A report done by the Department of Transportation on distracted driving

indicated that five seconds is the average time a person’s eyes are off the road while texting.

When traveling at 55 miles per hour, in five seconds, one can cover the length of a football field

(U.S. Department of Transportation, 2009). Most highway and freeway speed limits are now

reaching between 65 and 80 miles per hour.

Possible Solutions

Later school time. One possible solution that many states, districts and at times

individual schools have either adopted or considered is later school times.

In an article written by Edwards (2012) over 150,000 middle school students’

standardized test scores were observed as they transitioned through a full one-hour delay of

school start time. Edwards reported that math scores improved an average of two full percentile

points and one full point in reading when school start time changed from 7:30am to 8:30am. He

also found that students with a delay of one hour in school start time will have approximately

twenty-five percent less absences.


Many research studies recommend more research into later school times and how that

may improve the current problems with lack of sleep in adolescents in not only North America

but also many other countries (Colrain & Baker, 2011; Wolfson, Spaulding, Dandrow, & Baroni,

2007). A study published in Sleep and Biological Rhythms by Borlase, Gander and Gibson

(2013) utilized a questionnaire handed out in 1999 at a high school in New Zealand. School start

times were unchanged for the entire school except for high school seniors. Researchers then

returned to the same school nine years later with the same questionnaire to determine what may

have changed due to technology and other factors. Based on their research, “students with the

later start time were less likely to report sleep loss on school nights and were less sleepy than

their counterparts nine years earlier, despite perceived sleep need and an increase in the number

of technologies in their bedroom.” Later school times would give teens a chance to add

approximately forty-five minutes to an hour to their sleep time each night depending on when

they start to begin with.

Another study completed by Carskadon (1999) shows that because of biological

differences in melatonin secretion during adolescence, even when an older teen has the same

amount of time to sleep as a younger teen, they are unable to go to sleep any earlier in the

evening to make up for the discrepancy in sleep necessity. This would also suggest that later

school time would be beneficial for older teens. However, Carskadon also notes that teens may

use the later school start time as permission to stay up later at night. She suggests, “if students

learned about sleep, they have a basis to use changed school starting time to best advantage.

Adding information about sleep to the school curriculum can certainly help.” (1999)

Carskadon, Wolfson, Acebo, Tzischinsky and Seifer (1998) completed a study of the

effects of school time transition on a group of ninth graders throughout their shift to the tenth


grade. During the shift, the students experienced an advance in time of sixty-five minutes

(8:25am to 7:20am). Researchers included surveys of sleep and wake times, actigraphy

measuring, and self-report monitoring at different times throughout the transition. They were

able to conclude that the “imposition of an early school start time may require unrealistic -- if not

unattainable -- bedtimes to provide adequate time for sleeping.” They went on to say:

Our study clearly showed that early school start times for adolescents were

associated with significant sleep deprivation. The consequences of insufficient sleep in

adolescents are substantial. Excessive sleepiness of the degree documented here can be

associated with performance decrements, memory lapses, and mood changes, as well as

behavior problems. In susceptible young people, this pattern may lead to academic,

behavioral, and psychological problems, as well as increased risk for accidents and

injuries, particularly for teenaged automobile drivers. (Carskadon, Wolfson, Acebo,

Tzischinsky, & Seifer, 1998, p. 880)

Researchers in Brazil studied adolescent students and their teachers using sleep diaries,

surveys and actigraphs to determine daytime sleepiness, activity, and sleep wake cycles. Their

conclusion in the study was also that early wake times are difficult on both groups and schools

should consider the possibility of changing school start times to improve not only student

performance but also the work performance of the teachers (de Souza, de Souza, Maia, & de

Azevedo, 2012). With the many benefits of pushing back school starting times for teenagers,

problems also arise.

One of the first reasons why later school times might be a problem is busing schedules.

At this point, most elementary school students bus to school after a bus drops off middle and


high school students. This means that the elementary students are able to leave their homes after

their older sibling or at least the older children to catch the bus. For later school times, the last

option would be all schools having the same times and all kids going home at the same time.

Having all children go to school and come home at the same time would solve the issues for both

populations of students. The older children would be able to accompany their younger siblings

when parents are not with them. The problem with this option is the most obvious to most.

School district budgets do not allow enough money to purchase more buses, pay for more bus

parking, maintain more buses and pay enough drivers to maintain all routes for that many

children all at one time

However, Edwards (2012) suggested a one tier busing system that would increase test

scores by delaying school times for all students and sending them all at the same time. This

system would increase cost overall for a district. However, many districts look to decreasing

class sizes to increase test scores. According to Edwards, comparable improvements to test

scores are possible while spending $150 per child to change to a one-tier bus schedule versus

over $2000 per child to decrease a class size per child (p. 57).

Opponents also use the athletic department scheduling conflicts to shut down

conversation of later school times (Wolfson & Carskadon, 2005). Many sports use after school

schedules to practice or to schedule games during the season. An example of this would be

football. Football teams in the fall might spend an extra hour after school each day to practice

with their teams before Thursday night, Friday night or other weekend-scheduled games. If later

school times are introduced the students on sports teams will be home even an hour later than

they are now.


One possible alternative to later school times that there is very little research at this time

is adjusting student class schedule to their chronotype. It has been shown that evening-type

students are at a disadvantage because they perform optimally at later times of day. If school

officials were to implement a screening each year to identify a student’s eveningness or

morningness preferences, they could schedule the classes needing higher cognitive functioning to

later in the day and easier classes to later in the day (Preckel, et al., 2013; Valdez, Reilly, &

Waterhouse, 2008).

While science is in the corner of changing school start times, recommendations from

those who have implemented the time changes should be taken into account. Wahlstrom (1999)

indicated that 17 districts in the state of Minnesota changed their school start times in 1996 and

found that attitudes of stakeholders within the districts were the “same kind of emotional

reaction…as closing a school or changing a school’s attendance area. A school’s starting time

sets the rhythm of the day for teachers, parents, students, and members of the community”

(Wahlstrom, 1999).

Double shift school system. An even less popular, but equally effective, solution to

getting more sleep for our adolescent students is a double shift school system. Double shift (DS)

systems are organized in two shifts of school times. One shift starts early in the morning, for

example between 7:00 and 8:00 in the morning. The second shift would start an hour after the

first shift goes home at approximately 12:00 to 1:00pm. This system has been utilized many

times and has had studies linked to its effects on students.

One article written by Fischer, Radosevic-Vidacek, Koscec, Teixeira, Moreno and

Lowden (2008) gives a summary of studies done on DS systems. They discuss that some DS

systems allow students to either stay on a “fixed shift”, meaning they chose to attend all of their


classes either in the morning or in the evening. Other students in the study changed shifts if

needed and sometimes this would happen on a weekly basis. They discussed the findings stating

that “on weekdays, adolescents who attended school in the afternoon slept on average longer (8

hr 35 min) than adolescents to attended school in the morning (6 hr 40 min)” (p. 19). Similar

results were in another study Fischer et al. looked at with Croatian students between ages 11 and

18. A difference with those students was that they switched each week between morning and

afternoon shifts. A student diary reported that sleep on the weekend after an afternoon school

schedule was not delayed, whereas the weekend after a morning school schedule, students

needed to sleep in to catch up on their sleep.

Most districts utilize a DS system due to budget concerns and function less adequately

due to mismanagement and factors such as overworking teachers, increased wear and tear on the

school, and inability to fit a full school year into the normal school year constraints.

Educational interventions. A lesser-applied solution to the problem of sleep

deprivation in teens that may have the best outcomes and provide the most help is educational

interventions with not only the teens themselves but also with parents and community members.

There are few research studies to show the long-term benefits of sleep education in children and

teens and whether or not it can make a lasting impact on appropriate sleep habits in their future,

it is worth exploring much more with the seriousness of the problem emerging. One study done

in 2012 by Beijamini and Louzada found no changes in the sleep habits of students after an

educational intervention. At the time of their study they did not know of any other studies being

done like theirs. (Beijamini & Louzada, 2012) Other researchers in the field are also reporting

that an increase in research on communities, teachers, parents and students sleep education is


essential to combat problems occurring with adolescents’ sleep habits (Borlase, Gander, &

Gibson, 2013).

In a paper that is the first one to introduce three trials of the same education curriculum

with adolescents in school, the findings from Blunden, Kira, Hull and Maddison (2012) pertain

to introducing a sleep education program. Throughout the three trials that took place in Australia

and New Zealand high schools researchers introduced a curriculum called ACES to students

using teachers within the schools trained identically to introduce the materials. The problems

that they faced were mostly due to added time constraints on teachers, and the idea that

individual teachers have different teaching styles that may have affected student learning. In

spite of the problems, findings suggested, “that this sleep education programme can improve

sleep knowledge and/or sleep duration in adolescents.” (Blunden, Kira, Hull, & Maddison, 2012,

p. 16) One recommendation from the article that should be taken into future considerations is

parents should be included in the education programs are introduced to adolescents. They stated

because sleep is a behavior that is more and more loosely controlled by parents and adolescent

habits “may not improve…without parental guidance…parents should be informed about sleep

hygiene.” (Blunden, Kira, Hull, & Maddison, 2012, p. 16)

Kira, Maddison, Hull, Blunden and Olds (2014) did a recent study on educational

intervention in schools to improve sleep. The researchers wanted to determine whether an

educational program was feasible through a pilot study. In the study, high school students were

given a sleep education program through four classroom sessions. They were then asked to

complete a sleep diary and questionnaire at three different intervals (at the beginning, at 4 weeks,

and at 10 weeks). The results were not what the researchers had expected. They found that

while the Australian Centre for Education in Sleep (ACES) program and the Improving


Adolescent Well-Being (IAWB): Day and Night program have shown positive results in other

studies, and there was an initial positive effect on weekend sleep for adolescents, the overall

effects on weekday sleep were not significant (Kira, Maddison, Hull, Blunden, & Olds, 2014).

In their discussion of the feasibility of the ACES program Kira et al. (2014) discussed

many issues that should be considered in future studies and program utilization. First, they

discussed the fact that students were unenthusiastic to have added homework for the program in

the form of sleep diaries and other work included. This problem has occurred with other studies

in which researchers identify a lack of motivation to change by students (Moseley & Gradisar,

2009) In addition, staff perceptions of the program may have been problematic because of

already increasing time constraints and task loads. Lastly, the time given to the program was

only ten weeks for education. The researchers would have liked the time for the program to be

longer to get a sustained effect of the intervention (Kira, Maddison, Hull, Blunden, & Olds,

2014).

Moran and Everhart (2012) thoroughly reviewed literature on current interventions and

their effectiveness on adolescent populations. They recommend some sort of collaboration

between school officials and researchers to find a school-wide screening to identify students who

would benefit from a small group intervention to educate them on appropriate sleep behaviors.

This would be different from other programs attempted to date and would give researchers an

opportunity to be more interactive with each participant instead of overwhelming educators with

more materials (Moran & Everhart, 2012).

Parent education and involvement. Parental involvement in sleep education and

reinforcement of positive sleep habits can be crucial to adolescents’ futures. Carskadon (2011)

suggests that because of other research, adolescents who have their parents setting bedtimes after


midnight were “more likely to suffer from depression or suicidal ideation.” (p. 5) She continues

by suggesting that pediatricians “support and encourage parents to identify and set an appropriate

bedtime [and] remind families of the utility of a relaxing pre-sleep ritual.” (p. 7) Millman (2005)

also addressed parental involvement in sleep habits of adolescents. The article states during the

transition to adolescence parents change the way they influence the sleep habits of their children.

Parents switch roles from setting bedtimes during childhood and early adolescence to becoming

an alarm clock and waking the children in the morning while not setting bed times in the

evening. This change can have negative impacts on the adolescent’s development (Millman,

2005). Parents have also been found to depend more heavily on daytime indicators of sleep

deprivation than attending to sleep needs at the point of falling asleep each night (Short,

Gradisar, Gill, & Camfferman, 2013). Parents are in need of education of current sleep needs

just as much as adolescents to improve the problem overall (Short, Gradisar, Gill, &

Camfferman, 2013).

An increase in parental involvement in adolescent sleep behavior is appropriate and

necessary at this point, but parents also need to remain educated about the problems their teens

face (Noland, Price, Dake, & Telljohann, 2009). Wong, Rowland, and Dyson (2014) suggest not

only an increase in parent involvement but also in community education to ensure adolescents

understand the mechanisms within sleep and how this affects their behavior.

Conclusion

As demands on adolescents increase, interventions teaching teens about sleep hygiene

should be addressed not only by adjusting environmental schedules but also by introducing

programs to curriculum that will facilitate learning and understanding of the construct of sleep.

This paper aims at identifying past and current literature within the field of adolescent sleep to


gain a better understanding of problems teens in today’s culture face. Students are facing

increasing challenges for attending universities and finding full time employment after high

school. This forces them to start even earlier than past generations when applying

extracurricular activities to their daily lives. However, this application comes with a price.

Teens are sacrificing sleep to supplement their time for additional homework, work, sports and

other activities demands. This sacrifice leads to serious and at times fatal results when sleep

deprivation is at its highest. When given later school times, students perform better academically

and school attendance improves. Research shows decreases in daytime sleepiness which would

indicate safer behaviors by teens overall.

An intervention for sleep deprivation among teens is a new area of research in education.

Many educators and parents believe it is a parent’s responsibility to attend to their child’s sleep

needs. However, biology suggests teens are at a disadvantage from the beginning. Most parents

are unaware of the current biological factors that govern their adolescent’s sleep starting at

puberty. There were no studies found indicating parent knowledge of appropriate sleep hygiene

for adolescents. This area is important for future research to identify whether parents of

adolescents are contributing to the poor sleep habits of their children.

Current research studies on interventions within a school environment are very limited.

More work is needed in the area using different curriculums. Limitations included the lack of

current studies on sleep interventions used within a school environment at any age. This could

be because schools tend to group sleep hygiene in with health classes and thus decide that

parents should give any additional information on sleep. Also, there is a lack of experimental

design studies completed to date that demonstrate how to improve adolescent sleep as opposed to

adult sleep (Taras & Potts-Datema, 2005). This is a possible area for future research. Students


are at an extreme disadvantage due to their biology and increasing sleep deprivation. Increased

awareness of the sleep construct and the overall importance of better sleep can improve not only

adolescent’s lives but also their parents’ and communities’.


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Figure 1

Figure Caption: Placement of electrodes to determine EEG, EOG, and EMG.


Figure 2

Figure Caption: Areas of the brain active during REM sleep dreaming.


Figure 3

Figure Caption: A typical hypnogram from a young, healthy adult. Light-gray areas represent

non–rapid eye movement (NREM) sleep


Figure 7

Figure Caption: Homeostatic regulation of sleep: the pressure to sleep grows stronger across the

day as one stays awake and then dissipates when one sleeps at night (shaded area). Sleep

pressure increases (dashed line) as one stays awake longer into the normal sleeping hours.


Figure 4

Figure Caption: The biological clock is located within the suprachiasmatic nucleus in the brain.


Figure 4

Figure Caption: Body temperature in relation to the sleep cycle.


Figure 5

Figure Caption: Average sleep need (left graph) and percentage of REM sleep (right graph) at

different ages.


Appendix A

Horne-Östberg Morningness-Eveningness Questionnaire

(Horne, J., & Östberg, O. (1976). A self-assessment questionnaire to determine morningness-

eveningness in human circadian rhythms. International Journal of Chronobiology, 4, 97-100.)

For each question, please select the answer that best describes you by circling the point value

that best indicates how you have felt in recent weeks.

1`. Approximately what time would you get up if you were entirely free to plan your day?

5:00 AM – 6:30 AM = 5

6:30 AM – 7:45 AM = 4

7:45 AM – 9:45 AM = 3

9:45 AM – 11:00 AM = 2

11:00 AM – 12:00 noon = 1

2. Approximately what time would you go to bed if you were entirely free to plan your evening?

8:00 PM – 9:00 PM = 5

9:00 PM – 10:15 PM = 4

10:15 PM – 12:30 AM = 3

12:30 AM – 1:45 AM = 2


1:45 AM – 3:00 AM = 1

3. If you usually have to get up at a specific time in the morning, how much do you depend on an

alarm clock?

Not at all = 4

Slightly = 3

Somewhat = 2

Very much = 1

4. How easily do you find it to get up in the morning (when you are not awakened

unexpectedly)?

Very difficult = 1

Somewhat difficult = 2

Fairly easy = 3

Very easy = 4

5. How alert do you feel during the first half hour after you wake up in the morning?


Not at all alert = 1

Slightly alert = 2

Fairly alert = 3

Very alert = 4

6. How hungry do you feel during the first half hour after you wake up?

Not at all hungry = 1

Slightly Hungry = 2

Fairly hungry = 3

Very hungry = 4

7. During the first half hour after you wake up in the morning how do you feel?

Very tired = 1

Fairly tired = 2

Fairly refreshed = 3

Very refreshed = 4

8. If you had no commitments the next day, what time would you go to bed compared to your

usual bedtime?

Seldom or never later = 4


Less than 1 hour later = 3

1 – 2 hours later = 2

More than 2 hours later = 1

9. You have decided to do physical exercise. A friend suggests that you do this for one hour twice

a week, and the best time for him is between 7:00 and 8:00 AM. Bearing in mind nothing but

your own internal “clock,” how do you think you would perform?

Would be in good form = 4

Would be in reasonable form = 3

Would find it difficult = 2

Would find it very difficult = 1

10. At approximately what time in the evening do you feel tired, and, as a result, in need of

sleep?

8:00 PM – 9:00 PM = 5

9:00 PM – 10:15 PM = 4

10:15 PM – 12:45 AM = 3

12:45 AM – 2:00 AM = 2

2:00 AM – 3:00 AM = 1

11. You want to be at your peak performance for a test that you know is going to be mentally

exhausting and will last two hours. You are entirely free to plan your day. Considering only your


“internal clock,” which one of the four testing times would you choose?

8:00 AM – 10:00 AM = 6

11:00 AM – 1:00 PM = 4

3:00 PM – 5:00 PM = 2

7:00 PM – 9:00 PM = 0

12. If you got into bed at 11:00 PM, how tired would you be?

Not at all tired = 0

A little tired = 2

Fairly tired = 3

Very tired = 5

13. For some reason you have gone to bed several hours later than usual, but there is no need to

get up at any particular time the next morning. Which one of the following are you most likely to

do?

Will wake up at usual time, but will not fall back asleep = 4

Will wake up at usual time and doze thereafter = 3

Will wake up at usual time, but will fall asleep again = 2

Will not wake up until later than usual = 1


14. One night you have to remain awake between 4:00 AM and 6:00 AM in order to carry out a

night watch. You have no time commitments the next day. Which one of the alternatives would

suit you best?

Would not go to bed until the watch is over = 1

Would take a nap before and sleep after = 2

Would take a good sleep before and nap after = 3

Would sleep only before the watch = 4

15. You have two hours of hard physical work. You are entirely free to plan your day.

Considering only your internal “clock,” which of the following times would you choose?

8:00 AM – 10:00 AM = 4

11:00 AM – 1:00 PM = 3

3:00 PM – 5:00 PM = 2

7:00 PM – 9:00 PM = 1

16. You have decided to do physical exercise. A friend suggests you do this for one hour twice a

week. The best time for her is between 10:00 PM and 11:00 PM. Bearing in mind only your


internal “clock,” how well do you think you would perform?

Would be in good form = 1

Would be in reasonable form = 2

Would find it difficult = 3

Would find it very difficult = 4

17. Suppose you can choose your own work hours. Assume that you work a five hour day

(including breaks), your job is interesting, and you are paid based on your performance. At

approximately what time would you choose to begin?

5 hours starting between 4:00 AM and 8:00 AM = 5

5 hours starting between 8:00 and 9:00 AM = 4

5 hours starting between 9:00 AM and 2:00 PM = 3

5 hours starting between 2:00 PM and 5:00 PM = 2

5 hours starting between 5:00 PM and 4:00 AM = 1

18. At approximately what time of day do you usually feel your best?

5:00 AM – 8:00 AM = 5

8:00 AM – 10:00 AM = 4

10:00 AM – 5:00 PM = 3

5:00 PM – 10:00 PM = 2


10:00 PM – 5:00 AM = 1

19. On hears about “morning types” and “evening types.” Which one of these types do you

consider yourself to be?

Definitely a morning type = 6

Rather more a morning type than an evening type = 4

Rather more an evening type than a morning type = 2

Definitely an evening type = 1

Total Score =

70 86 = definite morning type

59 - 69 = moderate morning type

42 - 58 = neither type

31 - 41 = moderate evening type

16 - 30 = definite evening type

pamela j. brown - sleep education synthesis (final draft) - nnu master's degree

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