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The Journal of School Nursing: Early To Bed, Early To Rise?: An Exploration of Adolescent Sleep Hygiene Practices
The Journal of School Nursing: Early To Bed, Early To Rise?: An Exploration of Adolescent Sleep Hygiene Practices
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Integrative Review
Cognition, memory, safety, mental health, and weight are all affected by inadequate sleep. Biological studies indicate significant
changes in sleep architecture during adolescence, such as changes in melatonin secretion, and a need for greater total sleep
time. Yet, social contexts and cultural values impinge on these changing biological sleep needs making adolescents vulnerable
to the dangers of insufficient sleep. Sleep hygiene practices are purported as potential mediating factors between biological
sleep needs and the sociocultural context of sleep. The purpose of this literature review is to highlight biological and social
factors contributing to insufficient sleep in adolescents, to explore the evidence of several recommended sleep hygiene
practices, and to stimulate further research about how adolescents negotiate their shifting biological sleep needs amid
increasing social demands.
Keywords
health/wellness, screening/risk identification, high school, integrative reviews
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Malone 349
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350 The Journal of School Nursing 27(5)
their applicability to adolescents, and their appropriateness accepted, the timing of daytime naps is consistently reported
for various cultural groups (Jenni & O’Connor, 2005), raises during early to mid-afternoon. As a result of the evidence sup-
concern. porting a biological tendency for mid-afternoon naps and cul-
tural differences regarding the acceptability of naps,
recommending the avoidance of daytime naps to students is
Sleep Hygiene Practices of questionable value. More research is needed about the
Sleep hygiene has been defined as ‘‘those practices of daily effect of including or excluding daytime naps on adolescent
living that promote good sleep and daytime functioning’’ sleep and overall well-being.
(Spielman & Glovinsky, 1993, p. 550). Thus, the goal of
sleep hygiene practice recommendations is to improve sleep. Establishing regular sleep/wake times. Establishing regular
However, the evidence for many of these recommendations bedtimes (LeBourgeois et al., 2005; Noland et al., 2009;
is scant, in part, because sleep hygiene describes ‘‘a diverse Spielman & Glovinsky, 1993) is another commonly recom-
set of rules, rather than a uniform treatment approach as use mended sleep hygiene practice. However, a hallmark of
of a common term would imply’’ (Stepanski & Wyatt, 2003, adolescent sleep patterns is irregularity—early awakenings
p. 223). As such, the evidence for several commonly recom- on school mornings and sleeping in on weekends. Dahl and
mended practices are considered independently. These Lewin (2002) contend that this irregularity is problematic
include avoiding daytime napping; establishing regular because the adolescent circadian timing system is slow to
sleep/wake times; avoiding bedtime technology use; and change. Several days may be needed to shift the timing
avoiding late afternoon/evening physical, cognitive, and system back to an earlier sleep wake cycle after one week-
social stimulation. School nurses are encouraged to consider end of late nights. Still others report that an irregular sleep
the evidence supporting these recommendations prior to wake pattern is a risk factor for short sleep duration
recommending them to students and their families as well (Li et al., 2010; Manni et al., 1997) and daytime sleepiness
as to consider potential research questions for further inves- (Wolfson & Carskadon, 2003)
tigation of adolescent sleep habits. On the contrary, weekend sleep compensation (defined as
less than 8 hr of sleep during the school week, followed by
Daytime napping. Avoiding daytime naps is a common greater than 8 hr of sleep on the weekend) reduces the like-
sleep hygiene recommendation (LeBourgeois et al., 2005; lihood of overweight/obese in high school students (Wing,
Noland et al., 2009; Stepanski & Wyatt, 2003), however, Li, Li, Zhang, & Kong, 2009). And with melatonin elevation
to date, no studies on the effects of daytime napping on onset beginning at 9:30 or 10 p.m. (Taylor et al., 2005) an
nocturnal sleep in adolescents were found. The return of nap earlier bedtime of 9 p.m. to accommodate early school start
tendencies in the mid-teen years is supported by robust times and 9 hr of sleep may be biologically challenging. In
evidence that human sleep is biphasic as opposed to mono- sum, evidence supporting the practice of establishing regular
phasic (Worthman & Melby, 2002) and by the seminal work sleep patterns for adolescent health is inconsistent and the
of Carskadon et al. (1980) indicating a consistent early potential to establish regularity is challenged by delayed
afternoon/mid-afternoon increase in sleepiness emerging at melatonin secretion.
Tanner stage 2 and persisting throughout Tanner stage 5 and
into adulthood. This mid-afternoon dip in wakefulness Avoiding bedtime technology use. Limiting technology use
reflects the 12-hr biphasic rhythm of slow wave sleep before bedtime is also recommended. Nonetheless, use of
(Dinges & Broughton, 1989; Hayashi, Morikawa & Hori, cell phones, listening to electronic music devices, surfing the
2002). Indeed, daytime naps, lasting greater than 1 hr for internet, watching television and playing video games
young adults with irregular sleep/wake patterns and sleep almost every night before bed are common (National Sleep
debt, does not affect sleep onset or the quality nighttime Foundation, 2011). Distinguishing what types of technology
sleep (Vela-Bueno et al., 2008). Hence, evidence supporting use may help sleep and what types of technology may hinder
the recommendation to avoid daytime naps is lacking. sleep is important.
Furthermore, the presence of daytime napping has varied Evidence supports limiting the use of technology that
across time and between cultures. Extensive data regarding emits light just prior to sleep because of the significant role
the sleep habits (including daytime napping) of 1,700 that light plays in setting the circadian rhythm. This process
cultures from around the world at various historical times begins when the retina detects light and sends a message
exist as part of the Cross Cultural Survey of the Human through the suprachiasmatic nuclei to the pineal gland to
Relations Area File (Webb & Dinges, 1989). A few contem- inhibit melatonin secretion. Brainard, Rollag, and Hanifin
porary studies report that daytime napping is quite prevalent (1997) demonstrated that even low levels of illumination
in older African American children (Crosby, LeBourgeois, & (similar to twilight) are capable of significantly reducing
Harsh, 2005), Chinese adolescents (Liu, Liu, Owens, & melatonin levels. Empirical studies support this association
Kaplan, 2005), and young adults in Spain (Vela-Bueno and television viewing is associated with delayed sleep onset
et al., 2008). Interestingly, in cultures where napping is in school-age children (Li et al., 2007; Smaldone, Honig, &
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Malone 351
Byrne, 2007). Ironically, many adolescents watch television stimulating activities, are of questionable value in promoting
as a way to promote sleep (Noland et al., 2009). adolescent sleep. Distinguishing between the various forms
Cell phone use, particularly texting, and electronic music of technology used prior to bedtime should be considered. The
devices exceed all other forms of technology use by 13- to potential use of music to promote sleep is intriguing. However,
17-year-olds just prior to bedtime (National Sleep Founda- our understanding of these sleep hygiene practice is limited by
tion, 2011). Van den Bulck’s (2007) startling findings on the dearth of research on adolescent sleep habits.
cell phone use after bedtime report that 51% of teens send In summary, while the intuitive appeal of sleep hygiene
or receive calls after bedtime. Of this 51%, 20.3% used their may be strong, evidence for the applicability of these prac-
cell phone for text messages and 17.3% used their cell tices for adolescents is questionable (LeBourgeois et al.,
phones for calls between 12 a.m. and 3 a.m. Adolescents 2005; Moseley & Gradisir, 2009). Strategies that work for
who used their cell phones in this manner once a month or one cultural group may be inappropriate for others. In fact,
more were more likely to be tired during the day than those acculturated Latino adolescents have been found less likely
who did not. to engage in health promoting strategies (including sleeping
On the contrary, listening to 45 min of classical music at 9 hr) than their less acculturated peers (Ebin et al., 2001).
bedtime effectively reduced sleep problems in young adults Similarly, strategies that may work for adults cannot simply
(Harmat, Takacs, & Bodizs, 2008). Studies on the use of be assumed to be strategies that will work for adolescents.
music to enhance sleep in adolescents were not found. Given Indeed, even adolescents desiring more sleep stated that they
that 64% of 13- to 17-year-olds report listening to music 1 hr would be unwilling to incorporate some sleep hygiene prac-
prior to bedtime (National Sleep Foundation, 2011), further tice recommendations (Moseley & Gradisir, 2009). Thus,
investigation on music and sleep in adolescents is warranted. understanding sleep hygiene from the broader sociocultural
In summary, the sleep hygiene practice recommendation to perspective and from the adolescent perspective is critical if
avoid technology use before bedtime is at odds with the life- developmentally and culturally appropriate recommenda-
style of the vast majority of adolescents. Additionally, this rec- tions for enhancing sleep are to be realized.
ommendation needs to distinguish between technologies that This literature review highlighted four common sleep
do interfere with sleep from those that enhance sleep. hygiene recommendations including avoiding daytime
napping; establishing regular sleep/wake times; avoiding
Avoiding late afternoon/evening physical, cognitive, and social bedtime technology use; and avoiding late afternoon/
stimulation. Avoiding late afternoon/evening exercise and evening physical, cognitive, and social stimulation. See
cognitively or emotionally stimulating activities prior to Table 1 for a summary of the findings.
bedtime (LeBourgeois et al., 2005; Li et al., 2010; Stepanski
& Wyatt, 2003) may pose particular challenges for adoles-
cents who may be negotiating athletic practices, athletic Implications for School Nursing Practice
games, academic demands, and social interaction. A meta- The public often seeks the expertise of health care profes-
analysis of the effects of exercise on sleep does not support sionals for advice on many aspects of child rearing, includ-
the proposition that late afternoon or evening exercise ing sleep. Policy makers solicit input on evidence for
impairs sleep (Youngstedt, O’Connor, & Dishman, 1997). delaying high school start times to better meet the needs
Yet, Li et al. (2010) found that excitement before bedtime of adolescents. Conceptually, nursing has long recognized
was one of many risk factors associated with shorter sleep the significance of maintaining a balance between rest
duration. Recent research suggests that extraverts are more and activity for optimal functioning (Orem, 1980). Yet,
vulnerable to sleep insufficiency after socially stimulating adolescents are not typically screened for sleep problems
experiences (Rupp, Killgore, & Balkin, 2010). Therefore, (Mindell & Owens, 2002) and sleep hygiene recommendations
vulnerability for insufficient sleep based on waking soci- are frequently guided by practitioner’s beliefs and values.
alizing opportunities may depend on individual characteris- School nurses are uniquely poised to screen adolescents
tics (i.e., introversion/extraversion). This urges future for sleep disorders and insufficient/restricted sleep. While
researchers to consider introverted and extroverted personal- many screening tools for pediatrics exist, the Sleep Disor-
ities as a potential mediating factor. ders Inventory for Students–Adolescent Form is designed
specifically for adolescents (Luginbuehl, Bradley-Klug,
Ferron, Andreson, & Benbadis, 2008) and has met the cri-
Discussion teria for rigorous tool development (Spruyt & Gozal,
Physiological evidence behind late bedtimes during adoles- 2011). This tool screens adolescents for obstructive sleep
cence continues to build. Increasing awareness of early high apnea, periodic limb movement disorder/restless leg syn-
school start times on adolescent health is spreading. Sleep drome, excessive daytime sleepiness, delayed sleep phase
hygiene practice recommendations thought to promote syndrome, and narcolepsy. It is available from Child Uplift,
sleep, such as avoiding daytime naps, establishing regular Inc. (http://www.sleepdisorderhelp.com) and is recommended
sleep/wake times, and avoiding late afternoon/evening for use by school counselors and school nurses.
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352 The Journal of School Nursing 27(5)
Table 1. Summary of Sleep Hygiene Practices With Supporting Evidence and Nonsupporting Evidence
Sleep Hygiene Practice Evidence Supporting this Practice Evidence not Supporting This Practice
Avoiding daytime naps No evidence exists for adolescence Afternoon naps reflect the biphasic
homeostatic pattern of human sleep that
emerges at Tanner stage 5 and persists
through adulthood (Carskadon et al., 1980;
Hayashi et al., 2002; Worthman &
Melby, 2002)
One hour naps for young adults with irregular
sleep/wake patterns and sleep debt does not
affect sleep onset or the quality nighttime
sleep (Vela-Bueno et al., 2008)
Differences exist between cultures regarding
acceptance of napping behavior (Crosby
et al., 2005; Liu et al., 2005; Vela-Bueno
et al., 2008)
Establishing regular sleep/wake Several days may be needed to shift the Sleeping in on the weekend reduces the
times timing system back to an earlier sleep wake likelihood of overweight/obese in high
cycle after one weekend of late nights (Dahl & school students (Wing et al., 2009)
Lewin, 2002)
An irregular sleep wake pattern is a risk factor
for short sleep duration and daytime sleepiness
(Li et al., 2010; Manni et al., 1997; Wolfson &
Carskadon, 1998)
Limiting technology use at bedtime Low levels of illumination significantly reduce Forty-five minutes of classical music at bedtime
melatonin levels (Brainard et al., 1997) effectively reduced sleep problems in young
Television viewing is associated with delayed adults (Harmat et al., 2008)
sleep onset in school-age children (Li et al.,
2007; Smaldone et al., 2007)
Cell phone use for text messages and calls
between 12 a.m. and 3 a.m. once a month or
more increases daytime sleepiness (Van den
Bulck, 2007)
Avoiding late afternoon/evening Excitement before bedtime is associated with Late afternoon or evening exercise does not
physical, cognitive, and social shorter sleep duration (Li et al., 2010) impair sleep (Youngstedt et al., 1997)
stimulation.
School nurse researchers are well situated to gather rich, that sleeping late on weekends is part of their children’s
descriptive data from adolescents about their sleep hygiene inborn cycle and not lazy or antisocial behavior’’ (p. 1560).
practices and thereby contribute to this body of knowledge. Finally, many local school board policies such as standar-
Descriptive information from adolescents will provide an dized testing times and high school start time fail to base their
understanding of perceptions about adequate sleep and sleep policies on scientific evidence. Standardized testing often
hygiene practices; their willingness to implement various occurs in the early morning hours—a time when adolescents
sleep hygiene practices; or information on other strategies are least likely to perform well (Hansen et al., 2005) and
that may have been tried. Without understanding what sleep delayed high school start times continue to meet resistance
hygiene practices mean to adolescents and what place sleep from numerous parties (Wahlstrom, 2010). School nurses can
has in their lives, interventions and recommendations may play a critical role in informing policy makers on these issues.
yield little results.
School nurses may share recent findings about adolescent
sleep needs and patterns with parent groups. Enhanced Future Research
knowledge of adolescent sleep patterns may contribute to While empirical evidence on how various sleep hygiene
improved parent–adolescent relationships. For example, one practices affect sleep biology is needed, these studies alone
common misunderstanding is delayed wake times on week- will miss the dynamic interplay between biology and culture
ends for adolescents. Hansen, Janssen, Schiff, Zee, and that guides the sleep practices of individuals. Existing
Dubocovich (2005) note, ‘‘Knowledge of the unusual week- quantitative evidence from large mailed and school-based
day/weekend sleep phenomenon among adolescents could surveys have failed to elicit the voice of the adolescent
promote better family relationships if parents understood toward whom many sleep hygiene recommendations may
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Malone 353
be directed. Qualitative descriptive studies are needed to fill Dinges, D., & Broughton, R. (1989). The significance of napping:
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Declaration of Conflicting Interests quality in students. Journal of Advanced Nursing, 62, 327-335.
The author(s) declared no potential conflicts of interest with respect Hayashi, M., Morikawa, T., & Hori, T. (2002). Circasemidian 12 h
to the research, authorship, and/or publication of this article. cycle of slow wave sleep. Clinical Neurophysiology, 113,
1505-1516.
Funding Jenni, O., & O’Connor, B. (2005). Children’s sleep: An interplay
The author(s) received no financial support for the research, between culture and biology. Pediatrics, 115, 204-216. doi:
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