Sleep Medicine 12 (2011) 110–118

Contents lists available at ScienceDirect

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

Review Article

Recent worldwide sleep patterns and problems during adolescence: A review

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

a r t i c l e i n f o a b s t r a c t

Article history: Adolescent sleep health is becoming increasingly recognized internationally as a significant concern, with
Received 22 July 2010 many countries reporting high incidences of sleep disturbance in our youth. Notwithstanding the value of
Received in revised form 29 October 2010 findings obtained from each large-scale survey of adolescent sleep performed within individual countries,
Accepted 7 November 2010
the field lacks synthesis and analysis of adolescent sleep studies into a single review. This review presents
Available online 22 January 2011
findings from a meta-analysis of 41 surveys of worldwide adolescent sleep patterns and problems pub-
lished in the last decade (1999–2010). Sleep patterns tended to delay with increasing age, restricting
Keywords:
school-night sleep. Notably, Asian adolescents’ bedtimes were later than peers from North America
Adolescent sleep patterns
Daytime sleepiness
and Europe, resulting in less total sleep time on school nights and a tendency for higher rates of daytime
Insomnia sleepiness. Weekend sleep data were generally consistent worldwide, with bedtimes 2+ hours later and
Bedtimes more total sleep time obtained. We note a worldwide delayed sleep–wake behavior pattern exists con-
Sleep measurement sistent with symptoms of Delayed Sleep Phase Disorder, which may be exacerbated by cultural factors.
Delayed Sleep Phase Disorder Recommendations for future surveys of adolescent sleep patterns are discussed and provided in light
of current methodological limitations and gaps in the literature.
Ó 2010 Elsevier B.V. All rights reserved.

1. Introduction 2. Literature search and inclusion criteria

Sleep problems during adolescence are common. Recently,
Crowley et al. [1] reviewed literature over the past 30 years on
the sleep parameters of adolescents in the USA in light of how
parameters change through this period. However, no review has
covered adolescent sleep surveys worldwide. Consequently the
aim of this paper is to review and contrast the recent literature
on surveys of adolescent sleep patterns (bedtimes, sleep duration)
and problems across the globe, thus possibly providing insights
into cultural differences and similarities between countries. This
review concludes by demonstrating that many studies have as-
sessed symptoms of Delayed Sleep Phase Disorder (DSPD) [2,3]
and provides recommendations for future surveys so that preva-
lence estimates of this sleep disorder during adolescence may be
determined worldwide.
Abbreviations: DSPD, Delayed Sleep Phase Disorder; SOT, sleep onset time; WUT,
wake-up time; TST, total sleep time; BT, bedtime; SSHS, School Sleep Habits Survey;
DS, daytime sleepiness; ESS, Epworth Sleepiness Scale; PDSS, Pediatric Daytime
Sleepiness Scale; SOI, sleep-onset insomnia; DIS, difficulty initiating sleep; DSM,
Diagnostic and Statistical Manual of Mental Disorders; ICSD, International Classi-
fication of Sleep Disorders.
⇑ Corresponding author. Tel.: +61 8 8201 2324; fax: +61 8 8201 3877.
E-mail addresses: michael.gradisar@flinders.edu.au, grad0011@flinders.edu.au
(M. Gradisar).
Surveys of adolescent sleep problems were searched using the
search term ‘‘adolescent sleep’’ in the following electronic dat-
abases and on-line journal home pages: OVID Psyc Articles, Pub-
Med, Behavioral Sleep Medicine, Journal of Clinical Sleep Medicine,
Journal of Pediatrics, Journal of Sleep Research, Pediatrics, Sleep, and
Sleep Medicine. Additionally, reference lists of reviews of adolescent
sleep problems were used to find further surveys. Inclusion criteria
included: the studies contain information on adolescent sleep
parameters, sampled more than 300 participants aged 11–
18 years, and published from 1999 to 2010. This last criterion is
justified given that the changes in technology (e.g., mobile phones,
internet) in the last decade may contribute to differences in sleep
parameters between the 1990s and 2000s. As this review presents
sleep parameters as a function of age (see figures to follow), studies
providing mean sleep estimates for samples extending beyond the
age limits (e.g., 8–15 years) were excluded. Using these criteria, 41
surveys were found (see Table 1). Each survey was analyzed in the
present review in terms of typical sleep parameters measured on
school and weekend nights. Although adolescents may experience
a range of sleep problems (e.g., Restless Legs Syndrome; Obstruc-
tive Sleep Apnea), it was clear during the review process that
two major types of sleep problems were commonly reported in
studies: insomnia (predominantly difficulty initiating sleep) and

1389-9457/$ - see front matter Ó 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2010.11.008
Table 1
Surveys of adolescent sleep.

Demographics School Weekend Unspecified Measures DS Insomn. Impaired funct.

Studies Country N Age BT TST WUT BT TST WUT BT TST WUT SD Act. SSHS
Acebo and Wolfson (2002) [44] USA 3119 13–19 x x x x
Danner and Phillips (2008) [30] USA 10,656 14–17 x x
Johnson et al. (2006) [43] USA 1014 13–16 x x
Knutson and Lauderdale (2009) [45] USA 2978 15–17 x x x x x
NSF (2006) [8] USA 1602 11–17 x x x x x x x x x x
Patten et al. (2000) [46] USA 7960 12–18 x x
Roberts et al. (2004) [47] USA 5118 13–18 x x x
Roberts et al. (2006) [48] USA 4175 11–17 x x
Spilsbury et al. (2007) [18] USA 411 11–17 x x x x
Wolfson et al. (2003) [10] USA 302 13–19 x x x x x x x x x x

M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118

Gibson et al. (2006) [29] Can. 3235 14–18 x xa x
Laberge et al. (2001) [49] Can. 1146 10–13 x x x x x x x x x
Iglowstein et al. (2003) [50] Switz. 493 0–16 x
Loessl et al. (2006) [51] Germ. 818 12–19 x x x x
Meijer et al. (2000) [42] Netherl. 449 9–14 x x x x x
Ohayon et al. (2000) [20] Europe 1125 15–18 x x x x x x
Ohayon and Roberts (2001) [34] Europe 2242 15–18 x x
Palessen et al. (2008) [52] Norway 26,288 11–15 x
Giannotti et al. (2002) [41] Italy 6631 14–18 x x x x x x x x x x
Russo et al. (2007) [12] Italy 1073 8–14 x x x x x x x x x
Thorleifsdottir et al. (2002) [6] Iceland 688 1–29 x x x x x x x x x x x
Spruyt et al. (2005) [53] Belgium 3045 6–13 x x x x x x x x
Van den Bulck (2004) [54] Belgium 2546 12–17 x x x x x x x
Voit-Blanc et al. (2006) [35] France 502 15–19 x xa x
Gau and Soong (2003) [21] Taiwan 1572 9–16 x
Gau (2006) [33] Taiwan 2463 6–16 x x x x x x x x
Yen et al. (2010) [55] Taiwan 8319 12–19 x x
Liu et al. (2000) [39] China 1365 12–18 x x
Liu et al. (2008) [19] China 1056 13–17 x x x x x x x x x
Chung and Cheung (2008) [13] Hong Kong 1629 12–19 x x x x x x xa x x
Mak et al. (2010) [22] Hong Kong 29,397 12–18 x x
Ouyang et al. (2009) [56] China 621 11–17 x x x x x
Gaina et al. (2006) [36] Japan 9718 12–13 x
Kaneita et al. (2006) [38] Japan 102,451 13–18 x x
Kaneita et al. (2009) [57] Japan 516 13 x x x
Ohida et al. (2004) [32] Japan 106,297 12–18 x x x
Tagaya et al. (2004) [58] Japan 3478 15–18 x x x
Chol Shin et al. (2002) [28] Korea 3871 16–17 x x x xa
Yang et al. (2005) [9] Korea 1457 12–18 x x x x x x x x x
Abdel-Kahlek (2004) [24] Kuwait 5044 14–19 x x
Warner et al. (2007) [17] Aust. 308 15–18 x x x x x x x x x

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

111
112 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118
daytime sleepiness. A third and important theme emerged: the im-
pact of sleep problems on adolescents’ general functioning. As the
assessment of sleep parameters and these three sleep problems
map closely onto a sleep disorder common during adolescence
(i.e., DSPD), this review thus highlights future researchers’ oppor-
tunities to assess the prevalence of this disorder. Meta-analysis in-
volved correlations between age (in years) with sleep parameters
(in time units); where comparisons were to be made between re-
gions, analysis of covariance (controlling for age) with Bonferroni
corrections applied. Means for regional sleep parameters are ad-
justed for age. Effect sizes are also reported.
3. Typical sleep parameters and their measurement
Unlike the sleep patterns of children and adults, adolescent
sleep is typically more variable across our 7-day week, with
school-night sleep shorter than sleep on weekends. What appears
to be associated with this variability in sleep duration is a develop-
mental delay of not only bedtimes, but specifically sleep times.
That is, sleep onset time (SOT) and wake-up time (WUT) become
increasingly later during adolescence. When this delayed SOT cou-
ples with the need to attend school the following morning (early
WUT), this invariantly results in a short school-night total sleep
time (TST; e.g., 5–8 h). Consecutive nights of short school-night
TST lead to the creation of ‘‘sleep debt’’ [4], with adolescents recov-
ering this debt on weekends with longer TSTs (e.g., 9–12 h).
Sleep–wake parameters can be measured in several ways. Ide-
ally, a 7-day sleep diary or wrist actigraphy monitoring are used
[2]. However, the impracticality and expense of surveying many
adolescents with actigraphy means that sleep diaries are the mea-
sure of choice. Self-report questionnaires can also be used. The
School Sleep Habits Survey (SSHS) [5] was found to be the most
widely adopted sleep survey in this review. Wolfson et al. [5] found
no significant difference between school-night TST and WUT when
comparing the SSHS to 8-day sleep diary and actigraphy monitor-
ing. School-night bedtime (BT) was slightly earlier when using the
SSHS, and weekend TST and WUT were longer and later when
using the SSHS. Consequently, survey studies using the SSHS or
similar self-report questionnaires are likely to provide accurate
school-night TST, WUT, and weekend BT, but caution is needed
for school-night BT, weekend TST and WUTs.
Fig. 1. Average school night bed time. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle; Ouyang et al. [56] reported school night bed times for males and females separately, and therefore this study is not included in the above graph.
3.1. School-night and weekend SOT (Bed time)
Of the 41 surveys analyzed, none provided information on
school-night or weekend SOT (see Table 1). But 13 surveys pro-
vided information on school-night and weekend bed time (BT).
By definition, SOT is always later than BT, and SOT has been re-
ported to occur on average 16.8 min later than BT for adolescents
aged 15–18 [6]. This average will be used to provide an estimate
of SOT for the adolescent surveys reviewed.
Fig. 1 shows that adolescent school-night BTs ranged from
8:46 pm to 12:54 am and were clearly related to age,
r(49) = 0.63, p < .0001. A longitudinal study found that adolescents
optimally need on average 9 h sleep per night regardless of their
pubertal stage [7]. Other reports state less than 8 h sleep as being
insufficient [8]. As school start times range from 7:30 to 8:30 am in
most countries, adolescents may typically wake for school between
6:30 and 7:30 am (see Fig. 5). This means that an adolescent who
intends to wake up at 7:30 am and desires the optimal 9 h of sleep
[7,8] must go to bed before 10:30 pm (i.e., in the ‘‘optimal’’ range
displayed in Figs. 1 and 2). At worst, to avoid getting insufficient
sleep (i.e., <8 h), the adolescent needs to sleep before 11:30 pm
(i.e., within the ‘‘borderline’’ range, and below the ‘‘problematic’’
cut-off). Fig. 1 illustrates half of samples’ BTs (i.e., 50%) fell within
the optimal range required for adolescents to obtain 9 h sleep.
These samples derive from North American, mainland European,
Chinese, and Australian studies, and tend to be younger adoles-
cents (i.e., most <15 years). Nearly one-third of samples lie in the
borderline range and tend to be slightly older (i.e., 15–16 years).
Icelandic adolescents of all ages tended to go to bed later than
other samples, ranging from borderline BTs (younger adolescents)
to insufficient BTs (older adolescents) [6]. Korean adolescents’
mean BTs were mainly in the insufficient range [9], thus prevent-
ing the majority of them obtaining sufficient school-night TST.
Worth noting is that Figs. 1 and 2 represent mean bed times.
Wolfson and colleagues’ [10] data show school-night BT for adoles-
cents aged 13–19 years fits a normal distribution. In a normal dis-
tribution approximately 34% of adolescents’ BTs will fall within
1 SD above the mean, 13.5% fall between 1 and 2 SDs above the
mean, and 2% fall between 2 and 3 SDs above the mean [11]. Table 2
shows the distribution of mean school-night BT across studies. The
mean BT for all these studies is later than 10:30 pm for all age
groups. BTs are clearly worse for adolescents outside 1 SD. For
 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118 113

Fig. 2. Average weekend bed time. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle.

Table 2
Bedtime distribution for adolescent samples where school-night BT limits opportunity for sufficient school-night TST.

Studies Age Mean (SD) 0–1 SD above mean (i.e., 34% of sample) 1–2 SD above mean (i.e., 13.5% of sample)
Russo et al. (2007) [12] 12 10:31 (41) 10:31–11:12 11:12–11:53
Russo et al. (2007) [12] 13 10:33 (39) 10:39–11:12 11:12–11:51
Thorleifsdottir et al. (2002) [6] 13 11:10 – –
Chung and Cheung (2008) [13] 13 11:00 (56) 11:00–11:56 11:56–12:52a
Kaneita et al. (2009) [57] 13 11:15 – –
Yang et al. (2005) [9] 13 11:12 (66) 11:12–12:18 12:18–01:24a
Russo et al. (2007) [12] 14 10:43 (38) 10:43–11:21 11:21–11:59
Chung and Cheung (2008) [13] 14 11:23 (63) 11:23–12:26 12:26–01:29a
NSF (2006) [8] 15 10:32 – –
Thorleifsdottir et al. (2002) [6] 15 11:55 – –
Chung and Cheung (2008) [13] 15 11:26 (67) 11:26–12:33 12:33–01:40a
Yang et al. (2005) [9] 15 12:00 (66) 12:00–01:06a 01:06–02:12a
Wolfson et al. (2003) [10] 15 10:59 (53) 10:59–11:52 11:52–12:45a
NSF (2006) [8] 16 10:51 – –
Ohayon et al. (2000) [20] 16 10:36 (62) 10:36–11:38 11:38–12:40a
Van den Bulck (2004) [54] 16 10:54 (42) 10:54–11:36 11:36–12:08a
Chung and Cheung (2008) [13] 16 11:35 (66) 11:35–12:41a 12:41–01:47a
NSF (2006) [8] 17 11:02 – –
Warner et al. (2008) [17] 17 10:47 (51) 10:47–11:38 11:38–12:29a
Thorleifsdottir et al. (2002) [6] 17 12:05 – –
Yang et al. (2005) [9] 17 12:54 (84) 12:54–02:18a 02:18–03:42a
Chung and Cheung (2008) [13] 18 11:47 (76) 11:47–01:03a 01:03–02:19a
Thorleifsdottir et al. (2002) [6] 18 12:15 – –
a
Notes: Bed times within the insufficient range; SOT is likely to be 17 min later for all averages displayed.

these adolescents, bedtimes range from (at best) 15 min near the
11:30 pm insufficient BT cut-off for younger Italian adolescents
[12], through to older adolescents from Korea going to bed over
4 h later than the 11:30 pm cut-off [9]. Indeed, there is a tendency
for a large proportion of adolescents from Asian samples to lie
within the insufficient range [9,13]. Overall, although the mean
school-night BT for Asian samples (11:23 pm) was not significantly
greater than that for European samples (10:46 pm, p = 0.12), a very
large effect nonetheless exists (i.e., d = 1.97). Statistically, the mean
Asian BT was later than that for North American samples
(10:06 pm, p = 0.02), representing a very large effect (i.e.,
d = 3.90). This difference in BT may suggest the influence of cul-
tural factors, as there is little difference in the latitude where sur-
veys were conducted between North America and Asia, suggesting
environmental factors (e.g., daylight duration) play a lesser role.
For instance, one Asian study reported adolescents finished school
at 8:30 pm [19] which is likely later than the school-end time in
North America. The situation for BTs becomes worse when consid-
ering school-night BT measured using surveys is earlier than if
measured using actigraphy monitoring [10], and SOT is approxi-
mately 17 min later than BT [6]. Consequently, a higher proportion
of adolescents are likely to fall in the ‘‘insufficient’’ range when this
underestimation is taken into consideration.
Interestingly, the Icelandic study [6] demonstrated consistently
later BTs (and WUTs; see Fig. 5) when compared to other Western
samples. One explanation for such a delayed BT may be a lack of
morning sunlight to reset their circadian rhythms [23]. However,
data were collected in the springtime, when there is a substantial
amount of sunlight (e.g., approx. 18 h). Alternatively, societal
schedules could be delayed with so much daylight. But school
reportedly starts at 8 am [15]; thus these adolescents experience
ample morning light exposure. Thorleifsdottir et al. [6] argue that
114 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118

the discrepancy between the sleep habits in Iceland and other
Western countries is a ‘‘well-known phenomenon’’ (p. 536), having
been found in other Icelandic studies [16]. They speculate that the
delay in BTs and WUTs may be an example of a weak dominance of
the external clock in the regulation of the biological clock, given
that Icelandic local time has adopted Greenwich Mean Time
(GMT) all year round, rather than the 1½ h geographical distance
between Iceland and the UK, who use GMT solely in winter.
Fig. 2 shows results from the 13 surveys that reported average
weekend BT. These surveys show that weekend BT is related to
age, r(40) = 0.68, p < .0001, is consistently later than average
school-night BT (mean diff. = 122.3 min, t(39) = 11.17, p < .0001),
and yet is not affected by the region the adolescent resides,
F(2,12) = 2.62, p = 0.10. An adolescent is more likely to go to bed
at their preferred BT on the weekend, possibly making this more
illustrative of their circadian sleep phase preference or a behavioral
choice due to the removal of a fixed wake-up time. The higher pro-
portion (i.e., from 18% to 59%) of BTs in the insufficient range on
weekends suggests that an even higher percentage of adolescents
might have a significantly delayed sleep circadian rhythm than
predicted by the school-night statistics.
3.2. School-night and weekend TST
Of the 41 surveys analyzed, 14 reported school-night and/or
weekend TST (see Table 1). A negative relationship exists between
age and school-night TST, r(33) = 0.66, p < .0001, but not for
weekend TST, r(34) = 0.28, p = .10. Fig. 3 shows that in 53% of
samples, average school-night TST was insufficient (i.e., <8 h)
[8,10,13,17–19]. Despite the fact that some studies reviewed here
are not the same as those reviewed for BTs, there is nonetheless
a mismatch between the percentage reporting insufficient
school-night sleep, yet not an insufficient school-night BT (e.g.,
[10,17,19,20]). This anomaly may be primarily explained due to
‘‘sleep opportunity’’ (i.e., time in bed) being compared to ‘‘sleep
duration’’ (i.e., TST). That is, even though BTs and WUTs are re-
ported, this does not include the time spent awake in bed attempt-
ing sleep (sleep onset latency), during the night (wake after sleep
onset), or dozing on and off at the end of the sleep period. Unlike
the differences in BTs, however, the mean school-night TST for
Asian samples (7.64 h) was significantly less than that of European
samples (8.44 h, p = .04), but not North American samples (7.46 h,
p = .64). Fig. 4 illustrates that weekend TST is on average 91.6 min

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

Fig. 4. Average total sleep time on weekends. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle; Australasian
sample = white circle.
 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118 115

longer than school-night TST, t(12) = 9.80, p < .0001, indicating that
short school-night TSTs result in the creation of a sleep debt re-
lieved by longer weekend TSTs. No studies reported insufficient
weekend TST, with many (71%) reporting optimal TST regardless
of age or country. The few studies reporting sufficient weekend
TST were from the USA, Korea and Australia. Somewhat similar
to the results of school-night TST, North American adolescents ob-
tained less weekend TST than European adolescents (8.80 vs.
10.03 h, p < .0001), but not Asian adolescents (9.23 h, p = 0.11;
see Fig. 5).
3.3. School morning and weekend WUT
Thirteen of the 41 surveys reported school-night and/or week-
end WUTs (see Table 1). Fig. 6 shows that school morning WUT
is relatively consistent across samples (range = 5:50–8:10 am,
F(2,10) = 2.48, p = 0.13) and across age, r(34) = 0.12, p = 0.50; and
likewise for weekend WUT (region: F(2,10) = 0.29, p = 0.76; age:
r(34) = 0.19, p = 0.28). However, two notable exceptions are the
Icelandic sample [6] who consistently wake later than all other
samples, and at the other extreme a Chinese sample who on school
mornings participate in exercise at 6:15 am, prior to starting
school [56]. Weekend WUT is significantly later than average
school morning WUT (mean diff. = 2 h 31 min, p < .0001; see
Fig. 7). This is most likely a result of later weekend BTs (see
Fig. 2), longer weekend TSTs (see Fig. 4) and reduced weekend
morning commitments.
4. Clinical markers of adolescent sleep problems
4.1. Daytime sleepiness
Adolescent daytime sleepiness (DS) has been measured in a
variety of ways including the number of daytime or classroom naps
[8,21,22], the desire to have more sleep [23], morning sleepiness
[24–26], and oversleeping [8]. The Epworth Sleepiness Scale (ESS)
[27], designed to measure adult DS, has measured DS in adoles-
cents [28–30], and scores of 10 or greater indicate DS in adults
and adolescents [27,28,30]. Nevertheless, some argue the ESS is
considered an insensitive measure of DS in adolescents because
situations used to assess DS in adults are often not applicable to
adolescents [29]. One validated measure tailored to adolescents
is the Pediatric Daytime Sleepiness Scale (PDSS) which was based
on the ESS but modified to suit school-aged children and adoles-
cents [31].
The majority of surveys examined (i.e., 61%) reported at least
one behavioral parameter relating to DS (see Table 1). But most
only measured one aspect of DS using a variety of unstandardised
self-report or parent-report questions. For example, in surveys of
Asian adolescents, 52.7% reported feeling ‘‘very’’ or ‘‘rather’’ sleepy

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

Fig. 6. Average wake-up time on school mornings. Note: North American samples = black diamond; European samples = white diamond; Asian samples = grey circle;
Australasian sample = white circle.
116 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118

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

in the morning [13], while another found 33.3% of boys and 39.2%
of girls reported ‘‘always’’ or ‘‘often’’ feeling excessively sleepy dur-
ing the daytime [32]. Some other findings were more moderate. For
example, using parental reports, Gau [33] found that 10.9% of
Taiwanese adolescents napped inadvertently, and Ohayon and
Roberts [34] found that 5.9% of 15- to 18-year-old European
adolescents reported a tendency to fall asleep easily and anywhere
in the daytime. These assessments of only one aspect of DS may
either produce wildly differing rates due to measurement error,
or the variability may reflect a natural response to variable TSTs
across cultures.
Several surveys measured a combination of DS parameters. A
large national survey of 1602 USA adolescents found that 20% of
adolescents reported at least one problem with daytime sleepiness
every day, or almost every day (e.g., fell asleep in school, while
doing homework, too sleepy in general, too sleepy for sports, over-
slept) [8]. The ESS was used in five of the surveys, and scores of
greater than 10 varied from 15.9% [28] and 30% [35], to 37% [30],
40.9% [36] and 41.9% [13] in adolescents. These results support
the high rates (i.e., 20–40%) of behavioral parameters of DS found
in surveys that measured one parameter of DS. The use of stan-
dardized measures was minimal, with only one study comparing
standardized DS measures against each other (i.e., the PDSS, the
sleepiness scale in the SSHS, and the authors’ Cleveland Adolescent
Sleepiness Questionnaire) [18]. Unfortunately, no data were pre-
sented on the prevalence of excessive sleepiness in their sample
of 411 adolescents. Nonetheless, their study provides researchers
with further options for assessing DS in adolescents using psycho-
metrically sound instruments, and from this review it seems likely
that DS is a reasonably significant and prevalent problem in ado-
lescents from many countries across the world.
4.2. Insomnia
Insomnia, along with DS, is another clinical sleep parameter
that is frequently investigated, with more than half of studies re-
viewed (i.e., 54%) assessing at least one aspect (see Table 1). Insom-
nia may include difficulty maintaining sleep, early morning
awakening, and unrefreshing sleep [2,3]. Most studies reviewed
in this paper, though, chose to assess difficulties with sleep initia-
tion or sleep-onset insomnia (SOI). The presence of SOI is most
commonly established through the length of sleep onset latency
(SOL; time taken to fall asleep) [2,37]. SOL is most accurately mea-
sured using a 7-day sleep diary [37], but can also be measured to
some degree of accuracy using the SSHS [5,10]. The threshold for
delineating short SOL from long SOL has been considered by some
authors to be 20 min [36] and others to be 30 min [8,12]. Another
method of evaluating SOI is through a measure of difficulty initiat-
ing sleep (DIS). This commonly involves a single item that requires
adolescents to answer the question ‘‘Do you have difficulty falling
asleep at night?’’ on a 5-point Likert scale, ranging from ‘‘always’’
to ‘‘never.’’ An answer of ‘‘often’’ or ‘‘always’’ is considered by most
surveys as evidence of DIS [38,39].

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

Studies DIS (%) Studies SOL >30 min (%)

Abdel-Kahlek (2004) [24] 14.6 (boys) 20.3 (girls) Chung and Cheung (2008) [13] 20.1
Johnson et al. (2006) [43] 11.6 NSF (2006) [8] 26.0
Kaneita et al. (2006) [38] 14.8 Russo et al. (2007) [12] 20.0
Laberge et al. (2001) [49] 26.5 (boys) 36.2 (girls)
Liu et al. (2000) [39] 10.8
Mak et al. (2010) [22] 19.0
NSF (2006) [8] 11.0
Ohayon et al. (2000) [20] 12.4
Ohayon & Roberts (2001) [34] 14.1
Ohida et al. (2004) [32] 15.3 (boys) 16.0 (girls)
Pallesen et al. (2008) [52] 16.8
Roberts et al. (2004) [47] 16.7
Roberts et al. (2006) [48] 7.1
 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118
Of the 41 surveys, 21 reported information about SOI (see Ta-
ble 1). Table 3 shows that 7–36% of adolescents report DIS, and
20–26% of adolescents report SOL greater than 30 min. What is
interesting is the most reported percentage for DIS is in the ‘‘teens’’
(mean = 16%) despite a consistently low 20s percentage (mean
22%) for an SOL >30 min. The slight discrepancy between these
two sets of statistics might illustrate that while a sleep latency
greater than 30 min is problematic by adult standards [40], this
cut-off may be higher by adolescent standards; but this is yet to
be investigated.
4.3. Impact of sleep problems on general functioning
Of the 41 surveys analyzed, 16 surveys reported at least one
parameter indicative of distress or impairment in functioning (see
Table 1). This is a relatively understudied yet significant component
of these surveys, as it highlights the importance of healthy sleep
needed by adolescents and its possible impact on aspects of their
lives. For example, a survey of 5044 adolescents from Kuwait found
that 9.2% of girls and 7.7% of boys reported their sleep affects social
relations, while a higher percentage said their sleep affects their
work performance (14.9% of girls, 14.2% of boys) [24]. The NSF Sleep
in America Poll found that of those adolescents who had driven in the
past year, 27% reported having had an accident or near accident due
to drowsiness, and 5% had fallen asleep while driving [8].
Several studies reported correlations between lack of sleep or
sleepiness and impaired functioning. Giannotti et al. [41] found
that adolescents with later BT and WUTs had more attention prob-
lems, poor school achievement, more injuries, and more emotional
problems. Another survey found that adolescents with an ESS score
>10 had more school absenteeism [35]. Meijer et al. [42] found that
sleep quality had a direct positive relationship with four aspects of
school functioning: receptivity with regard to the teacher’s influ-
ence, self-image as a pupil, achievement motivation and control
over their own aggression. These 16 studies illustrate that im-
paired functioning due to sleep problems should be incorporated
into surveys of adolescent sleep.
5. Delayed Sleep Phase Disorder
From the review of these 41 studies, it is clear that adolescent
sleep is typified by late BTs and WUTs, resulting in restricted and
insufficient TST on school nights, with weekend TST being extended
and ‘‘normal.’’ Consequences of insufficient sleep include daytime
sleepiness, plus a host of broader problems in various areas of func-
tioning. Insomnia, and particularly SOI, appears common. It is worth
noting here that these aforementioned sleep problems highly
resemble symptoms of Delayed Sleep Phase Disorder (DSPD) [2].
DSPD is a circadian rhythm disorder where the individual’s sleep
pattern is timed significantly later so that it conflicts with their
weekly obligations (e.g., school, weekend morning extra-curricular
activities). The prevalence of DSPD is said to be 7–16% and more
common in young adults and adolescents [2,3]. We would posit that
due to cultural influences the prevalence of adolescent DSPD may
be higher in specific regions (i.e., Asia, Iceland).
Many studies reviewed in this paper represented an opportu-
nity to observe the percentage of adolescents who possessed a col-
lection of DSPD symptoms to warrant the diagnosis, at least when
using diagnostic criteria from DSM-IV [3]. That is, survey questions
could target a chronic pattern of delayed sleep onset and wake-up
times with associated daytime sleepiness or insomnia (Criterion A)
as well as an associated impact on functioning (Criterion B). But
DSPD diagnostic criteria from the International Classification of
Sleep Disorders second edition (ICSD-II) require sleep monitoring
via sleep diaries or actigraphy (Criterion C) [2], which few studies
have used (e.g., [10]). Finally, if surveys coupled with sleep
117
monitoring are able to ask questions differentiating DSPD from
other sleep disorders common during adolescence (e.g., Inadequate
Sleep Hygiene, Behaviorally Induced Insufficient Sleep Syndrome,
Primary Insomnia) [2,3,43] then the remaining criteria will be
addressed, and the research and clinic fields will have a better
idea of the present prevalence of this apparently common sleep
disorder in adolescents.
6. Conclusions and recommendations
A systematic review and analysis of adolescent sleep patterns
and problems across the world is currently needed, and this review
of 41 studies published in the past decade demonstrates a number
of insights into age- and culturally-related influences on adoles-
cent sleep. First, there is a moderate-to-strong age influence on
adolescent school-night bedtimes and total sleep time worldwide,
with older adolescents going to bed later and obtaining less sleep.
Second, this effect is amplified for Asian adolescents who go to bed
later (than North American adolescents), obtain less sleep (than
European samples), and tended to report higher rates of daytime
sleepiness than adolescents from other regions. Third, cultural
influences are virtually ameliorated on the weekends with adoles-
cents across the world demonstrating delayed bedtimes and wake-
up times of greater than 2 h. Combining this common delayed
sleep–wake behavior with the often reported sleep-onset insomnia
and impacts on adolescents’ general functioning, the findings from
this review suggest the prevalence and impact of Delayed Sleep
Phase Disorder during adolescence may be currently under-rated.
Very few studies measured or reported the broad spectrum of
sleep–wake behaviors and problems described in this review. Thus,
we recommend that studies planning to survey adolescent sleep
patterns attempt to assess multiple sleep parameters simulta-
neously. For large-scale surveys, the SSHS could be used, and some
translations may already exist (e.g., Italian [41], German [51],
Mandarin [19]). Ideally, sleep diaries could be used in conjunction
with surveys. During our review, we found it was unfortunately
common for large-scale studies to assess only bedtimes and thus
calculate ‘‘time in bed.’’ With the growing wealth of knowledge
about the importance of ‘‘sleep,’’ it is clear from the present review
that future studies should ask additional questions about total
sleep time, difficulties initiating sleep, daytime sleepiness, and
the impact of sleep on general functioning.
Despite the large number of studies that are now investigating
adolescent sleep with large samples, we know very little about re-
cent sleep patterns of adolescents in many regions of the world.
For instance, two continents were not featured in this review.
Despite the excellent work being performed in South America, not
one study was large enough and reported sleep characteristics con-
sistent with this review’s inclusion criteria. Further, to our knowl-
edge, the field knows too little about the sleep of teens in Africa.
Although Australasia was featured in this review, only one large-
scale study was found that reported sleep, thus preventing this
region from being included in statistical comparisons with other
regions. Perhaps in the next decade, with more surveys of adolescent
sleep patterns and problems conducted worldwide, the field will
have more data to better investigate ‘‘similarities and differences
in sleep and sleep-related practices within and across countries
(that) may facilitate an understanding of factors that underlie
sleep–wake regulation during adolescence’’ (LeBourgeois et al., p.
264) [59].
Conflict of Interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on
the following link: doi:10.1016/j.sleep.2010.11.008.
118 M. Gradisar et al. / Sleep Medicine 12 (2011) 110–118

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