J. Sleep Res.

(2006) 15, 266–275

Epidemiological aspects of self-reported sleep onset latency in

Japanese junior high school children
GAINA ALEXANDRU1, SEKINE MICHIKAZU1, HAMANISHI SHIMAKO2,
CHEN XIAOLI3, KANAYAMA HITOMI1, YAMAGAMI TAKASHI4,
W I L L I A M S W . R O B E R T 5 and K A G A M I M O R I S A D A N O B U 1
1
Faculty of Medicine, Welfare Promotion and Epidemiology, University of Toyama, 2Department of Education, Training, Technology and
Development, National Institute of Public Health, Saitama, Japan, 3Department of International Health, Bloomberg School of Public Health,
John Hopkins University, Baltimore, USA, 4Hokuriku Health Service Association, Japan and 5School of Care Sciences, Glamorgan University, UK

Accepted in revised form 11 April 2006; received 11 January 2006

SUMMARY The purpose of this study was to investigate the relationships between sleep onset
latency (SOL) and other sleep–wake patterns and media use habits in Japanese
schoolchildren. A total of 9718 junior high school children responded (12.8 years) and
9199 questionnaires were used in the present analyses. The questionnaire assessed
sleep–wake patterns, TV viewing and videogame habits. Overall, 72.1% of the subjects
reported short SOL (£20 min). Long SOL subjects (>20 min) were strongly associated
with disturbed sleep manifested especially by increased risk of night awakenings,
decreased sleep depth, and bad sleep in general (overall sleep quality). Prolonged SOL
was also associated with daytime sleepiness, difficulties in falling asleep, bad morning
feeling and sleep insufficiency. We found a U-shaped relationship between sleep period
and SOL. Increase in bedtime was accompanied by increased risk of prolonged SOL.
The impact of ultra-short and ultra-long SOL (£5 and ‡40 min) was also analysed.
Long durations of watching television and playing videogame were significantly
associated with prolonged SOL. After adjustment for sex, girls presented significantly
higher risk of prolonged SOL. Body mass index adjustment did not reveal any
significant results. SOL presents a significant component of sleep–wake habits; poor
sleep hygiene and insufficient sleep time significantly increase SOL. Parents, healthcare
practitioners and children themselves should be aware of the potentially negative
influence of prolonged SOL. Additionally, the optimal coherent sleep–wake schedule
must be promoted in parallel with the limitation on the viewing TV and game practices.
keywords media use, schoolchildren, sleep, sleep onset latency, sleep–wake
patterns, Toyama study

in creating a comfortable atmosphere that promote sleep

INTRODUCTION
In contrast to the plentiful research on lifestyle habits and their
influence on sleep patterns, little information characterizes the
factors which influence the sleep onset latency (SOL) during
schooldays. The restorative function of sleep is essential for
optimal physical and mental function, especially during
transition period (Carskadon, 2002). Many cues are critical
Correspondence: Alexandru Gaina, Department of Welfare Promotion
and Epidemiology, Graduate School of Medicine, University of
Toyama, 2630 Sugitani, Toyama, 930-0194, Japan. Tel.: +81 76 434
7270; fax: +81 76 434 5022; e-mail: alga@med.u-toyama.ac.jp
onset. The most important are related to behavioural and
cognitive aspects, circasemidian regulation and phasic event.
On the other side, SOL regulation also includes chronobio-
logical, homeostatic (sleep pressure), constitutional, social,
environmental, metabolic, symptomatic and neuropathologi-
cal aspects (Ogilvie and Harsh, 1994).
Sleep onset latency definitely is not a static point, but a
discrete and a gradual process of complex behavioural,
psychological, physiological and cognitive-mentational process
interactions (Ogilvie and Harsh, 1994). Moreover, according
to Ogilvie (1985) SOL can be defined as the transition between

266  2006 European Sleep Research Society


relaxed, drowsy wakefulness and unresponsive sleep. Till now,
three major phases have been remarked: (i) quiescence and
immobility; (ii) decrease in muscle tone, detected by dropping
hand-held objects; and (iii) increase in auditory threshold
(Tryon, 2004). In addition, many studies reported decrease in
respiratory and thoracic amplitude (Oglivie and Wilkinson,
1984), decrease in heart rate (Pivik and Busby, 1996), cognitive
event-related potentials (Salisbury, 1994), arousal (Segalowitz
et al., 1994) and evidently, significant changes in electroen-
cephalogram (EEG) (Ogilvie, 2001).
The schooldays are manifested by various biological, social
and psychological changes, which have an eminent repercus-
sion on sleep–wake patterns (Yang et al., 2005). Even children
during puberty require more sleep than during prepuberty;
they frequently get less sleep than they need (Carskadon,
1990). Additionally, starting early to school (Carskadon et al.,
1998), sleep phase delay (Carskadon et al., 2001), increasing
social and academic pressures significantly modify children’s
sleep patterns with direct repercussion on daytime behaviour
and SOL (Roberts et al., 2002; Stein et al., 2001; Wolfson and
Carskadon, 1998).
However, there is insufficient knowledge regarding SOL and
related sleep–wake patterns in schoolchildren population. Not
much research has been done into SOL. For example, Ishihara
(2002) found a strong correlation between sleep amount and
SOL. In the same way, Gaina et al. (2005d) found a higher sleep
quality score and morning-type preference among short SOL
children without any gender effect. Camhi et al. (2000) reported
a significantly higher prevalence of disorders of initiating and
maintaining sleep in adolescent girls. Yang et al. (1987) and
Vigneau et al. (1997) reported significantly higher sleep-initi-
ating problems among girls (17.4% and 26.1% respectively).
Even sleep patterns are often investigated by researchers;
however, big cross-sectional studies with specific focus on SOL
are still rare. The present topic was investigated seldom,
especially in children in schooldays. This cross-sectional study
described SOL and its relation to sleep–wake patterns, as well
as the effects of several independent factors on SOL. Further-
more, we analysed the association between media use (TV and
PC, TV video games) and SOL. We hypothesized that SOL
variation will be also reflected in sleep–wake patterns and
media use variables with preference for short latency children
to show better indicators.
METHODS
Study site
The study was conducted in 93 public junior high schools,
located in Toyama prefecture, central part of Honshu main
island, north-western Japan. Toyama prefecture has no
significant economical, social or cultural differences between
cities (9), towns (18) and villages (8) that participated in the
present study. The prefecture has a high number of households
in which both husbands and wives work. Around 80.4% have
own houses.
 2006 European Sleep Research Society, J. Sleep Res., 15, 266–275
SOL in school children 267
Participants
Toyama study is a population-based open cohort study
focusing on children’s development and lifestyle habits. Data
was collected from June to July 2002. A total of 10 453
questionnaires were sent to all schools with a response rate of
93% (9718). Overall, there were no more than 4% missing
answers for sleep–wake habits. Children (9199) responded well
regarding SOL and gender. All participants were junior high
school children in the first grade with 4715 girls (mean age
12.7±0.3 years) and 4484 boys (mean age 12.8±0.3 years).
The mean body mass index (BMI, kg m)2) was 19.2 (3.2) for
boys and 19.1 (3.0) for girls.
Procedure
A set consisting of a covering letter, a questionnaire and an
envelope for returning the questionnaire was sent to the
schools. The students were asked to respond to the question-
naire either during class time or at home. Results of the study
were later provided to each school.
SOL threshold
In our analyses, we set SOL threshold at 20 min. Different
criteria have been used to define SOL. For example, Web (1986)
according to PSG criteria recommended 5 min of continuous
sleep, beginning at stage 2, whereas Carskadon and Rechts-
chaffen (2000) suggested that the first 10 min of continuous
sleep is much suitable. Interestingly, average multiple SOL test
(MSLT) of 10 min or less have been found to be statistically
significant (at least 2 SD below the mean for children who are
well-slept and >10 min but <20 min in children following
suboptimal conditions and for clinical sample) (Fallone et al.,
2002). We selected 20 min as the criterion for defining short and
long SOLs, because such criteria are used consistently in the
sleep studies among schoolchildren (Carskadon and Rechts-
chaffen, 2000; Fallone et al., 2002).
Questionnaire
The questionnaire consisted of seven sections, but in the
present study, we used only few of them: demographic data,
media use and sleep habits parameters (see Appendix). The
sleep questionnaire (Gaina et al., 2005c) covered the following
aspects: (i) sleep/wake cycle parameters (with answers ex-
pressed as categorical variables): bedtime, wake-up time, sleep
time (every 1/2 h interval), sleepiness, SOL, difficulty in falling
asleep, awakenings at night, sleep depth, morning feeling, sleep
duration, sleep in general (sleep quality); (ii) time spent on
media such as TV, PC and videogames. The phrasing of the
question was as follows: ÔDuring schooldays, the average time
of watching TV is …Õ. Response categories for questions
related to falling asleep, sleep depth, bad morning feeling, sleep
duration and sleep in general were to be answered on a five-
and four-point scales from very well, well, fair, bad, very bad,
268 G. Alexandru et al.

and very short, short, long, very long respectively. Responses 35 32.7
31.4 Boys
30.2
for night awakenings started from zero to four times or more. 30 Girls
Response categories for SOL question comprised the following Total
25

Percentage (%)
answers: 5, 10, 20, 30, 40, 50, 60 or over 60 min. The present 21.4
22.7
21.3
19.4 19.9
article analysed only SOL associations, the rest of sleep–wake 20 17.6
16.5
patterns, e.g. bedtime, wake time, sleep time, sleepiness, etc. 15 13.6
14.9

are the subjects for future research.

10

5 4.1 4.8 4.4 3.1 3.1

2.3 2.4 2.4 2.9
Statistical analysis 1.4 1.8 1.6
0
<5 10 20 30 40 50 60 >60
Descriptive statistics for SOL and falling asleep were calcula- Minutes (min)
ted. To assess the relationship between SOL and correlated
factors, t-test, chi-squared test (or Fisher’s exact test when Figure 1. Sleep onset latency distribution. Number of subjects ¼
appropriate with Cramer’s V) were performed. Binominal 9199. The numbers above the columns represent exact percentage
values.
logistic regression analyses were used to obtain odds ratios
(OR) and their 95% confidence intervals (95% CI) of sleep–
10000
wake parameters, media use and SOL. Goodness-of-fit was ≤20 min
9000
assessed by the Hosmer–Lemeshow test. SOL <20 min was >20 min
8000 Total

Number of subjects
used as a reference. The cut-off value for ultra-short SOL was 7000
£5 min and for ultra-long SOL ‡40 min. A value of P ¼ 0.05 6000
was considered statistical significant. Statistical analyses were 5000
performed by SPSS (10.0 J) (SPSS Inc, Chicago, IL, USA). 4000
3000
2000

RESULTS 1000
0
Socio-demographic characteristics Total Easy Fair Difficult

The majority of children lived with both parents, only 4.3%
reported absence of mother and 8.7% absence of father.
Moreover, 51.6% and 37.0% reported presence of grand-
mother and grandfather respectively. Also, 89.4% of partic-
ipants reported presence of brothers and sisters. Presence or
absence of parents, grandparents or brothers and sisters did
not influence SOL and falling asleep distribution.
Body mass index for boys showed significantly higher
values: 19.3 (3.2) in comparison with girls 19.1 (2.9);
P ¼ 0.024. Additionally, schoolchildren with long SOL pre-
sented significantly higher BMI values in comparison with
short SOL respondents: 19.4 (3.1) versus 19.1 (3.0); P < 0.001.
Regarding home conditions, 88.6% reported that they sleep
in their own room. 85.0% of the children considered their
bedrooms silent and 80.6% considered it sunny. The question of
having their own room had no association with SOL and falling
asleep variables, instead room quietness presented significant
differences, with preference for children living in quiet room to
have shorter SOL (52.3% versus 47.7%; P ¼ 0.001). Also,
room quietness facilitated falling asleep process: from children
who reported quiet room environment, 50.3% easy fall asleep;
37.8% normal and 11.8% with difficulties in comparison with
43.2%; 38.3% and 18.5% respectively for children from noisy
rooms (P < 0.001). Interestingly, home insolation had no
relationship with SOL, but respondents living in a sunny room
were falling easier asleep (87.4% versus 83.8%; P ¼ 0.019).
Home environment presented significant differences: quiet
environment significantly (P ¼ 0.001) decrease SOL and faci-
litate falling asleep (P < 0.001).
Figure 2. Sleep onset latency and falling asleep distribution. Number
of subjects ¼ 9199.
SOL, gender differences and falling asleep distribution
Almost one-fifth of the sample (19.4%) reported SOL <5 min
and 3.1% >1 h (Fig. 1). A total of 12.4% of all sample
reported difficulties with falling asleep. As expected, significant
differences were found between quantitative aspects of SOL
and qualitative variables of falling asleep process (Fig. 2).
Thus, short SOL respondents (£20 min), 59.7% reported easy
of falling asleep in comparison with only 20.6% among long
SOL counterparts (P < 0.001). On the contrary, difficulties in
falling asleep were associated with increased SOL. Thus 6.4%
with short SOL reported difficulties in falling asleep in
comparison with 30.7% among long SOL subjects. Regarding
gender differences (Table 1), significantly more boys presented
SOL <20 min in comparison with girls (P < 0.001). Among
girls, difficulties with falling asleep were much more common
(12.9% versus 12.7% respectively; P < 0.001).
Ultra-short and ultra-long SOL in relationship to sleep–wake
habits
We also analysed the effect of SOL extremities (ultra-short
£5 min and ultra-long ‡40 min) on sleep–wake habits
(Table 2). Overall, 1835 children represented ultra-short SOL
group and 1075 ultra-long SOL. Significant gender differences
were found between ultra-short and ultra-long SOL; in boys,

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 SOL in school children 269

Table 1 Sleep onset latency, falling asleep and gender differences awakenings and poor morning feeling; sleep depth was very
Total Boys Girls P-value
poor; sleep duration was too short and sleep in general was not
restorative.
SOL
£20 min 6809 (73.2) 3486 (51.2) 3323 (48.8) <0.001*
>20 min 2490 (26.8) 1145 (46.0) 1345 (54.0) SOL and sleep–wake patterns
Falling asleep
easy 4521 (49.3) 2358 (51.7) 2163 (47.0) <0.001 Table 3 summarizes the ORs and 95% CI for association
fair 3474 (37.9) 1625 (35.6) 1849 (40.2) between short-long SOL (less and more than 20 min) and
difficult 1174 (12.8) 581 (12.7) 593 (12.9) sleep–wake patterns. To explore factors associated with
Data are given as number and percentages. increased risk of long SOL, the following variables were
*Chi-squared with Fisher’s correction. included in logistic regression model: sleepiness, easy fall
Pearson’s chi-squared. asleep, night awakenings, sleep depth, bad morning feeling,
sleep duration and sleep in general. As expected, all sleep–
Table 2 Ultra-short and ultra-long sleep onset latency in relationship wake factors deteriorated with increase in SOL time. Increas-
to gender and sleep variable ing SOL time was associated with a higher risk of sleepiness,
Ultra-short Ultra-long difficulties in falling asleep, night awakenings, bad sleep depth,
SOL, SOL, poor morning feeling and bad sleep in general. Difficulties in
N (%) N (%) Cramer’s V P-value falling asleep, night awakenings, sleep depth and sleep in
Gender general were the strongest associated factors of prolonged
Boys 1007 (54.9) 506 (47.1) 0.075 <0.001 SOL. After adjusting for sex, girls presented higher risk of all
Girls 828 (45.1) 569 (52.9) sleep–wake parameters in comparison with boys. Interestingly,
Sleepiness multiple logistic regression analyses revealed no significant
Almost always 448 (24.3) 392 (35.9) 0.131 <0.001
difference for the above parameters after adjustment for BMI.
Often 858 (46.5) 466 (42.7)
Seldom 282 (15.3) 128 (11.7) Binominal logistic model showed significant relationship
Never 256 (13.9) 106 (9.7) between SOL and three basic sleep–wake variables: bedtime,
Fall asleep wake-up time and sleep time. In our analyses, sleep time and
Easy 1538 (84.0) 179 (16.6) 0.684 <0.001 bedtime remained to be the strongest predictor of SOL. The
Fair 232 (12.7) 412 (38.1)
ORs of sleep time (and subsequently bedtime and wake-up
Difficult 60 (3.3) 489 (45.3)
Night awakenings time) demonstrated that decreased sleep duration, delay in
0 1406 (75.8) 560 (51.2) 0.298 <0.001 bedtime and wake-up time were all significantly associated
1 383 (20.7) 332 (30.4) with an elevated risk of increase in SOL time. For example, the
‡2 65 (3.5) 201 (18.4) maximum delay in bedtime (>01:00 hours) presented an OR
Sleep depth
3.76 (P < 0.001). We obtained a U-shaped relationship
Well 1725 (93.3) 682 (62.7) 0.387 <0.001
Fair 98 (5.3) 286 (26.3) between sleep time and SOL. Minimum sleep duration
Bad 25 (1.4) 120 (11.0) (<6 h) was associated with twofold increase in SOL
Morning feeling (P < 0.001) and maximum sleep duration (>10 h) were also
Good 781 (42.2) 233 (21.3) 0.234 <0.001 associated with an increased risk of long SOL (OR 2.66;
Fair 574 (31.1) 362 (33.2)
P < 0.001). After adjustment, girls with higher BMI values
Poor 493 (26.7) 497 (45.5)
Sleep duration were significantly associated with increase in SOL.
Fair 869 (47.2) 368 (33.9) 0.135 <0.001
Short 900 (48.9) 680 (62.8)
Long 71 (3.9) 36 (3.3) SOL and media factors
Sleep in general
Television, PC and TV video-related games were significantly
Well 833 (45.3) 200 (18.5) 0.310 <0.001
Fair 798 (43.4) 557 (51.4) associated with children’s sleep. As shown in Table 4, it is easy
Bad 208 (11.3) 326 (30.1) to observe that increase in the duration of watching TV was
associated with an elevated risk of SOL increase as in the case
Ultra-short SOL £5 min and ultra-long SOL ‡40 min. All Cramer’s
of PC and TV video games. After adjustment, female sex and
V-valuses are statistically significant (P < 0.001).
high BMI values presented higher risk of prolonged SOL.
1007 (54.9%) presented ultra-short SOL versus 828 (45.1%) in Interestingly, 56.1% (2613) of girls reported no PC and TV
girls, whereas in ultra-long SOL group, boys presented lesser in video game affiliation.
number (47.1% versus 52.9%; P < 0.001). As expected, the
measure of associations presented higher values for fall asleep
DISCUSSION
variable (Cramer’s V ¼ 0.684). Regarding the rest of variables,
we found weak positive association. Children from ultra-long The link between sleep habits and SOL has great practical
SOL group presented significantly higher level of sleepiness; relevance to sleep patterns and sleep complaints. SOL has
they had difficulties in falling asleep; and complaints of night polyvalent dimension in terms of physiological, psychosocial

 2006 European Sleep Research Society, J. Sleep Res., 15, 266–275

270 G. Alexandru et al.

Table 3 Binominal logistic regression for sleep onset lantency and sleep–wake patterns among junior high school children

Crude Adjusted

CI CI

P-value OR Lower Upper P-value OR Lower Upper

Sleepiness
No 1 Reference 1 Reference
Seldom <0.001 1.61 1.35 1.91 <0.001 1.63 1.34 1.97
Sometimes 0.034 1.19 1.01 1.40 0.048 1.20 1.00 1.44
Very often 0.667 0.96 0.79 1.16 0.908 1.01 0.82 1.25
Easy of fall asleep
Very easy 1 Reference 1 Reference
Fair <0.001 4.16 3.71 4.67 <0.001 4.14 3.65 4.69
Difficult <0.001 13.97 12.03 16.23 <0.001 14.01 11.90 16.50
Night awakenings
0 1 Reference 1 Reference
1 <0.001 1.42 1.28 1.56 <0.001 1.43 1.28 1.60
‡2 <0.001 2.78 2.40 3.26 <0.001 2.70 2.28 3.20
Sleep depth
Excellent 1 Reference 1 Reference
Fair <0.001 2.57 2.28 2.90 <0.001 2.57 2.25 2.93
Bad <0.001 3.63 2.93 4.49 <0.001 3.61 2.84 4.57
Morning feeling
Excellent 1 Reference 1 Reference
Fair <0.001 1.48 1.32 1.66 <0.001 1.49 1.31 1.69
Bad <0.001 2.19 1.95 2.46 <0.001 2.15 1.89 2.45
Sleep sufficiency
Sufficient 1 Reference 1 Reference
Insufficient <0.001 1.40 1.27 1.53 <0.001 1.34 1.20 1.47
Excessive 0.084 1.28 0.97 1.71 0.099 1.30 0.95 1.76
Sleep in general
Excellent 1 Reference 1 Reference
Fair <0.001 1.88 1.68 2.11 <0.001 1.86 1.64 2.11
Bad <0.001 3.16 2.75 3.64 <0.001 3.20 2.74 3.74
Bedtime (hours)
<21:00 0.959 0.99 0.63 1.56 0.723 1.10 0.66 1.84
21:00–21:30 0.564 0.93 0.74 1.18 0.454 0.91 0.71 1.17
21:30–22:00 0.092 1.16 0.98 1.37 0.131 1.15 0.96 1.39
22:00–22:30 1 Reference 1 Reference
22:30–23:00 0.002 1.24 1.08 1.42 0.021 1.20 1.03 1.39
23:00–23:30 0.001 1.32 1.13 1.54 0.018 1.23 1.04 1.46
23:30–24:00 <0.001 1.58 1.33 1.88 <0.001 1.46 1.21 1.77
24:00–24:30 <0.001 2.20 1.69 2.86 <0.001 2.08 1.55 2.79
24:30–1:00 <0.001 2.67 1.90 3.75 <0.001 2.79 1.94 4.02
>1:00 <0.001 3.76 2.55 5.54 <0.001 3.63 2.36 5.59
Wake up (hours)
<6:00 0.002 0.73 0.60 0.89 0.004 0.73 0.59 0.91
6:00–6:30 <0.001 0.83 0.74 0.92 <0.001 0.80 0.71 0.90
6:30–7:00 1 Reference 1 Reference
7:00–7:30 0.009 1.19 1.05 1.36 0.007 1.22 1.06 1.40
7:30–8:00 0.011 1.73 1.14 2.64 0.007 1.89 1.94 2.99
>8:00 0.132 1.87 0.83 4.22 0.715 1.22 0.42 3.52
Sleep time (h)
<6 <0.001 2.00 1.51 2.66 <0.001 2.06 1.51 2.80
6–6.5 <0.001 1.64 1.33 2.01 <0.001 1.52 1.21 1.91
6.5–7 <0.001 1.49 1.26 1.78 0.001 1.39 1.15 1.69
7–7.5 0.009 1.23 1.05 1.44 0.012 1.24 1.05 1.47
7.5–8.0 0.637 1.04 0.90 1.20 0.435 1.06 0.91 1.25
8.0–8.5 1 Reference 1 Reference
8.5–9 0.039 1.21 1.01 1.44 0.057 1.21 0.99 1.46
9–9.5 0.849 1.02 0.81 1.30 0.876 1.02 0.784 1.33
9.5–10 0.132 1.32 0.92 1.88 0.101 1.37 0.94 2.01
>10 0.002 2.66 1.41 5.00 0.006 2.89 1.36 6.15

OR, odds ratio; CI, 95% confidence interval, reference SOL £20 min; adjusted for sex and BMI.

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 SOL in school children 271

Table 4 Binominal logistic regression for

Crude Adjusted
sleep onset latency and media use among
junior high school children CI CI

P-value OR lower upper P-value OR lower upper

TV time (h)
<1 1 Reference 1 Reference
1–2 0.690 1.03 0.89 1.20 0.636 1.04 0.88 1.23
2–3 0.005 1.25 1.07 1.46 0.006 1.27 1.07 1.50
3–4 <0.001 1.39 1.16 1.66 0.019 1.27 1.04 1.55
>4 <0.001 1.95 1.62 2.36 <0.001 1.83 1.48 2.25
PC and TV video games (h)
<1 1 Reference 1 Reference
1–2 0.905 1.01 0.90 1.12 0.103 1.11 0.98 1.25
2–3 0.001 1.23 1.09 1.40 <0.001 1.39 1.20 1.62
3–4 0.001 1.44 1.17 1.76 <0.001 1.57 1.24 1.98
>4 h 0.006 1.43 1.11 1.86 0.002 1.59 1.19 2.13

OR; odds ratio; CI, 95% confidence interval, reference SOL £20 min; adjusted for sex and BMI.

and behavioural aspects. Even falling asleep and SOL in
particular are widely recognized as an essential starting points
for entire sleep (Ogilvie and Harsh, 1994); the mechanisms
through which SOL influences overall sleep patterns and vice
versa are not well understood. Some concerns exist that
schoolchildren could be particularly vulnerable to the effects
resulting from insufficient sleep that may contribute to
subsequent dysfunctions in sleep–wake patterns in general
and subsequently increase SOL (Carskadon, 2002). Our large,
cross-sectional study demonstrated strong relationship be-
tween sleep–wake patterns dysfunctions and SOL increase. In
this study, the prevalence of difficulty in falling asleep reached
12.4%, which is consistent with results reported by Ohayon
et al. (2000) and Ohayon (2002), 12.4% and Liu and Zhou
(2002), 10.8%. Our findings are partially in accordance with a
study on Chinese junior high school children, 27% of whom
reported increased SOL (Gau and Soong, 1995) and with
another on American adolescents among whom 16.8% repor-
ted disorders of initiating sleep (Camhi et al., 2000). However,
it is somewhat difficult to compare the previous results because
of differences in parameter definition, sample population,
cohort effect, assessment techniques, as well as methodological
approach, sample age and size, socio-cultural background and
statistical analyses. Different criteria between studies may
explain discrepancies.
The aim of our study was to characterize and find the
relation between short–long SOL and sleep–wake. The most
interesting finding is related with SOL–sleep time association.
Our results showed that there were significant relationships
between amount of sleep and sleep latency. Interestingly, this
relationship presented a U-shaped form. Too long and too
short amounts of sleep presented a higher risk of increased
SOL. We found that for an optimal SOL one requires 7.5–
8.5 h of sleep. Our results are partially in accordance with
other findings (Carskadon, 1990; Carskadon et al., 1998,
2001), where the optimal sleep time ranged between 8 and
9 h. However, some cultural differences, along with curriculum
schedule, and various activities, which can explain the
discrepancies, should be acknowledged (Gaina et al., 2005d;
Gau and Soong, 1995; Owens, 2004). Relationship between
sleep time and SOL is not investigated often by researchers.
However, Gaina et al. (2005d) found significant relationship
between short–long SOL (less and more than 10 min) and
sleep time during weekends but not schooldays. Similarly,
Ishihara (2002) reported significant positive correlations
between amount of sleep and SOL. Indeed, the overlying
impression is one supporting highly similar findings across
Asian and North American studies.
As regards the bedtime–SOL relationship, delay in bedtime
was expected to significantly increase the risk of long SOL.
Thus, delay in bedtime is accompanied by an increase in SOL.
The same relationship has been reported in junior high school
children only for weekends, but not on schooldays (Gaina
et al., 2005d).
Regarding the rest of sleep–wake pattern variables, it should
be mentioned that because of chronic sleep deprivation,
especially manifested during junior high school period, the
amount of sleep time remains to be the causa potissimus of all
sleep–wake patterns variables. However, long SOL could be a
serious complaint. The results are evident: long SOL children
(>20 min) were two times more at risk of having sleep
disturbances in comparison with short SOL children. Some
researchers reported the association between insomnia and
behavioural problems (Liu and Zhou, 2002), others mentioned
the increased SOL (Lazaratou et al., 2004), but all mentioned
the same association of increased SOL with insufficient total
sleep duration (Ohayon, 2002; Liu and Zhou, 2002; Gau and
Soong, 1995).
Excepting SOL and sleep duration relationship, we found
that sleep onset length is significantly associated with perceived
impression about own sleep (sleep in general). Thus children
with bad impression about their own sleep were 3.2 times more
likely to report SOL longer than 20 min. In the same way, the
morning feeling was significantly associated with sleep onset

 2006 European Sleep Research Society, J. Sleep Res., 15, 266–275

272 G. Alexandru et al.
length, with evident (OR 2.2) predisposition to long SOL
respondents for bad morning feeling. In reference to the
number of night awakenings, the same tendency persisted, with
higher risk of long SOL sleepers to wake up during sleep (OR
2.8). According to Akerstedt et al. (1997) falling asleep
parameter is a basic component of sleep quality, along with
maintaining sleep and subjective feeling of good or poor sleep.
Our present findings perfectly fit into the sleep quality
components and demonstrate that short SOL children present
significantly higher sleep quality in comparison with long SOL
sleepers. It has been reported in Japanese junior high school
children that short SOL (10 min) subjects presented signifi-
cantly higher sleep quality index versus their long SOL
counterparts (Gaina et al., 2005d). Few studies have shown
the relation between uneasiness and tension at bedtime and
subjective sleep quality (Akerstedt et al., 1997; Kecklund
et al., 2003; Desager et al., 2005). Similarly, Bruni et al.
(2002) presented the relationship between sleep quality and
sleep cycling alternating pattern in normal schoolchildren.
In respect of ultra-short and ultra-long (£5 min and
‡40 min) SOLs, we demonstrated that both SOL extremities
are associated with sleep disturbances, with worst indices for
ultra-long SOL. Both, ultra-short and ultra-long SOLs, are
strong markers for sleep disturbances, as a result of chronic
sleep insufficiency. Nevertheless, in our sample significantly
more ultra-long SOL subjects reported short sleep duration in
comparison with their ultra-short counterparts.
An interesting finding is related to gender differences in
falling asleep. The author demonstrated that by means of
actigraphy, higher sleep quality was found in junior high
school girls versus boys, without significant gender effects on
SOL (Gaina et al., 2005a). However, in the present study, boys
presented shorter SOL (both cut-off values) and higher ability
to fall asleep in comparison with the girls. It could be related to
lower actual sleep values among boys, as demonstrated by
objective measurements (Gaina et al., 2005a). In accordance
with our findings, Yang et al. (2005) in a sample of Korean
teenagers reported longer SOL in girls. Similarly, Ohida et al.
(2004) in a representative sample of Japanese schoolchildren
found that 15.3% of boys versus 16.0% of girls reported
difficulties in initiating sleep. Additionally, the gender differ-
ences could be explained by the circadian preference affiliation.
For example, Takeuchi et al. (2002) recently reported that
Japanese junior high school girls were more evening-type
oriented. Moreover, evening-type children presented signifi-
cantly lower sleep quality parameters detected by actigraphy
(Gaina et al., 2005b). A new factor (characteristic for Japan)
which may influence sleep quality in girls is the usage of mobile
phones. We already reported (Gaina et al., 2006) that Japanese
girls presented significantly higher preference towards e-mails
(SMS), mobile phone internet surfing and listening to music in
comparison with boys. Especially for girls, mobile phones
could serve as a potentially significant influential factor for
prolonged SOL.
A special attention should be addressed to the influence of
audio-visual media on sleep patterns and especially SOL.
According to national survey (KTC, 2004), on average, TV
viewing time for Japanese junior high school children boys was
2.0 h and 1.6 h for girls (it corresponds with recommendations
of AAP (American Academy of Pediatrics Committee on
Communications, 1995) – no more than 2 h daily. But, 66.2%
responded that TV is essential in daily life, comparing with
25.5% for books and 22% for PC and games. However, it has
been found that extensive TV viewing may be associated with
diverse sleep disturbances during adolescence (Van den Bulck,
2004). Furthermore, the presence of a TV or computer in
children’s room results in a significant modification of the
sleep–wake parameters, especially related to bedtime and time
in bed (Van den Bulck, 2004). Owens et al. (1999) reported
that a TV in the child’s bedroom was the most powerful
predictor of overall sleep disturbance and bedtime resistance.
In our study, we found that TV watching presents significant
correlation with SOL too. Thus, more than 4 h spent on TV,
results in almost twofold risk of SOL increase. Computer and
games presented smaller risk (OR 1.4). Our results are
consistent with the results obtained by Johnson et al. (2004)
in a sample of 14-year-old American children. Thus, TV
viewing was associated with an elevated risk of midnight
awakenings (OR 3.8) and difficulties in falling asleep (OR 2.2).
In a sample of young adults, Higuchi et al. (2005) reported
significant increase in SOL recorded by EEG after playing
games than after control conditions.
It has been reported, that with long-lasting consequences,
adolescents who watched TV more than 3 h daily, were at
significantly elevated risk of frequent sleep problems by early
adulthood (Johnson et al., 2004). From the sleep hygiene
approach, TV daily watch time reduced until 1 h by middle
adolescence significantly reduces the risk of subsequent sleep
problems during late adolescence or early adulthood (Johnson
et al., 2004). Tracing the results, we can conclude that the
habit of viewing TV is a marker for sleep problems, which
should be taken in account during sleep pattern assessment. In
respect to children’s game time, we found that moderate game
attachment presents no association with sleep–wake habits.
Instead, if game time exceeds 2 h, the risk of sleep disturbances
become significant. The same finding has been noted by Van
den Bulck (2004) who reported negative influence of computer
games on sleep behaviour.
Interestingly, the sleep atmosphere (especially room and
home environment) presents association with SOL. We dem-
onstrated that quiet room and home environment, including
insolation presents a positive effect on SOL process.
According to Ogilvie and Harsh (1994) in young adult
humans, there are three efficient causes of sleep onset: sleep
demands (defined by prior wakefulness); circadian tendencies
(defined by sidereal time) and behavioural responding (defined
by sleep-antagonistic responding). In our results exactly one-
half (50.8%) of the sample reported SOL <10 min and 12.4%
reported difficulties with falling asleep. However, short SOL
indicates a higher level of physiological sleepiness. Almost
two-thirds (72.3%) of the sample reported sleepiness episodes
during schooldays. The above result corresponds with previous
 2006 European Sleep Research Society, J. Sleep Res., 15, 266–275

reports regarding sleepiness in schoolchildren (Fallone et al.,
2002).
It has been reported, that sleep hygiene optimization
presented significant effects on the treatment of migraine
(Bruni et al., 1999). Generally speaking, sleep educational
programmes (with SOL explanations) should be promoted
among schoolchildren (Cortesi et al., 2004). By implication,
from sleep hygiene point of view, it would be desirable to
elaborate measures to shorten sleep onset to <20 min in
children who take longer than 20 min to fall asleep. However,
little is known about how to do this and additional research
will be very useful.
We suppose, that one of the reasons for prolonged SOL
during junior high schooldays could be related to a physiolo-
gical tendency toward delayed circadian phase, insufficient
sleep period time, increasing ability in setting own bedtime,
selection of social desirable bedtime routine and media use
(especially TV, games for boys and mobile phones for girls). If
we consider that many behavioural changes are not entirely
synchronized (Akerstedt and Folkard, 1994), e.g. decline in
response to auditory stimulation appears to lag behind the
decline in response to visual stimuli, the negative pressure of
mass media on sleep onset process becomes obvious. More-
over, sleep structure and propensity are regulated by the
interactions of the circadian pacemakers and of a sleep–wake
dependent process. In the same way, sleep onset may be
predicted on the basis of circadian and homeostatic regulation
of sleep. Both are determined by circadian phase, prior time
awake and length of prior sleep (Rechtschaffen, 1994).
According to Rechtschaffen (1994), active sleep mechanisms
may modulate relatively independent sleep behaviour systems,
and the asynchronies of sleep may result from differential
activation of the modulatory mechanisms. Additionally, the
neurophysiological onset of sleep is frequently not the same as
behavioural or subjective sleep onset. In children, this gradual
transition from drowsiness to stage 1 is significantly shorter in
comparison to adults (Cooper, 1994); however, it should be
considered as a continuous process rather than a discrete event
(Tryon, 1996).
In respect of limitations of this study, we were not able to
analyse symptoms suggestive of some sleep pathologies (e.g.
sleep related breathing disorders, restless legs), because our
survey, based on non-clinical population, contained only a
limited number of sleep-related questions. Sleep disorders can
affect SOL; further studies are required to elucidate reciprocal
relationship in both clinical and non-clinical population.
Some additional limitations on our analyses and results
should be considered. Even a mixed-model approach could be
applied for data analyses; in the present paper, we used
binominal logistic regression, because no significant social,
economical, cultural, educational or environmental differ-
ences, along with no cluster effect within the same school or
district was found (Goldstein, 2003; Chen et al., 2005). In
respect of SOL threshold, a clear cut-off criterion for SOL
during schoolchildren period is not established yet. However,
from the existing literature (Ogilvie and Harsh, 1994; Carsk-
 2006 European Sleep Research Society, J. Sleep Res., 15, 266–275
SOL in school children 273
adon, 2002; Fallone et al., 2002) the threshold of 20 min seems
to be an optimal solution. In addition, extreme SOL thresholds
(<5 min and >40 min) provided additional information
which could be used in characterizing sleep and sleep problems
among schoolchildren. Our sample represented typical Japa-
nese junior high school children population. As suggested by
Owens (2004) some cultural practice could influence sleep–
wake patterns. All components of postindustrial lifestyle
(technical progress, increasing social and academic demands,
high urbanization level, etc.) definitely affect sleep onset. In
addition, we could not detect the relationship between BMI
and SOL, even we used BMI growth charts (cut-offs)
separately for age and sex (Cole et al., 2000). It could be
related with lower BMI values and lower incidence of obesity
among Japanese schoolchildren (Tokumura et al., 2004).
Because our sample was restricted to seventh graders exclu-
sively, we could not examine the age effect and SOL relation-
ship. Another obvious limitation is that we did not have
objective data on SOL among junior high school pupils.
Schoolchildren often prefer to report socially desirable
responses, especially those related to sleep–wake patterns
and media use (Wolfson et al., 2003). On the contrary, it has
been reported that correlation coefficients between objective
and subjective results represented acceptable values (Gaina
et al., 2005c; Wolfson et al., 2003). One more limitation should
be acknowledged: self-reported studies are subject to error
especially among poor sleepers. However, in our study most
participants (84.0%) were good sleepers. Even observational
studies using objective methods, especially actigraphy, are very
useful; self-reports and questionnaires remain to be the
measure of choice in such huge community surveys.
To our knowledge, the present study is the first reflection of
the sleep–wake patterns and media use in relationship to SOL.
SOL has never been reported separately in such big propor-
tions. Moreover, sleep surveys performed in Japanese popu-
lation are highly competitive, because the effects of the modern
society development and their influence on human health are
primary visible here, because of rapid technical and informa-
tional progress. In addition, winter/summer time is not
applicable in Japan, in contrast to Europe or the USA. Thus,
sleep/wake patterns in schoolchildren pursue their natural,
unchangeable rhythm.
The nature of our study does not permit us to conclude the
pathways and cause–effect association complexity between
SOL versus sleep parameters and media use. The possible
mechanism remains to be found in the future studies.
CONCLUSIONS
In sum, a proper identification of sleep onset plays an
important role in the general characteristics of sleep–wake
patterns and sleep disorders. Sleep onset is the last point of
wakefulness, but the influence is not the least. The present
study demonstrates in premiere the strong relationship
between short–long SOL, sleep patterns and TV, video game
habits. Sleep hygiene and optimal SOL should be promoted
274 G. Alexandru et al.
among schoolchildren. Sleep onset is an important indicator of
sleep–wake habits in general and some lifestyle habits in
special. Large prospective studies and intervention trials,
investigating the association and causality between SOL and
different factors, especially sleep–wake patterns and lifestyle
habits are necessary.
ACKNOWLEDGEMENTS
This present study is the last one, from a series of nine articles,
published in different journals during my PhD course (2002–
2006). Special thanks to my professor (Kagamimori S.) and my
mentor (Sekine M.) for their academic contribution. I owe my
greatest thanks to Takano Hiroshi (Toyama, Japan) for his
support and advice. I owe my gratitude to Robert Ogilvie
(Brock University, Canada) for his suggestions and academic
support.
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APPENDIX: TRANSLATION FROM JAPANESE
1. During schooldays how often do you have sleepiness?
(almost always; often; seldom; never)
2. How long does it take to fall asleep from the time you
entered the bed? (£5; 10; 20; 30; 40; 50 60; >60 min)
3. Do you feel easy to fall asleep? (very easy, easy, fair,
difficult, very difficult)
4. How many times do you wake up during your sleep? (0; 1;
2; 3; 4 times or more)
5. How is your sleep depth in general? (very well; well; normal;
bad; very bad)
6. How do you feel when you wake up in the morning? (very
good; good; fair; poor; very poor)
7. Do you feel your sleep duration is sufficient? (very short;
short; fair; long; very long)
8. Generally speaking how is your sleep? (very well; well; fair;
bad; very bad)