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PEDIATRIC PERSPECTIVE

Teenagers need help to form better sleep habits

Teenagers need as much sleep as the rest of us: Adolescents who get a good night's sleep do better in school and on standardized tests than those who don't get enough, they have less anxiety, and they're less likely to get into car accidents.

But many factors conspire against a good night's sleep, including early-morning school start times, heavy homework loads, afterschool jobs -- and even doctors' lack of training. In response to more and more research about the risks of sleep deprivation, doctors, policy makers, and parents have proposed solutions that include simply educating doctors better and seeking new kinds of drugs to maximize people's productivity.

Left to their own devices, teenagers sleep about nine hours a night, studies show. Generally, they go to bed later and wake up later than younger children and adults, perhaps due to hormonal-induced changes in circadian rhythm.

But in reality, most American teenagers get far less sleep, regardless of their biological clocks. Hormones don't explain why Swiss children go to bed almost an hour earlier than American kids. Some researchers point to the excessive homework here.

Plus, 30 percent of teenagers are employed for more than 20 hours weekly, and they have more symptoms of daytime sleepiness than those who don't work jobs. Finally, only one in 20 high school students have a bedtime set by parents -- and most just fall asleep after watching television, socializing, or completing homework, rather than following a set routine.

In the latest study of teenage sleep, published in this month's Pediatrics, researchers from Northwestern University teamed up with high school teachers to track sleep patterns of advanced-placement biology students. After the school year began, students slept two hours less per weeknight. The students accumulated ''sleep debt," and required extra sleep on weekends. During the school year, the students also performed worse on tests of alertness in the early morning.

This shouldn't be surprising, since a 2001 study showed that college students sleeping more than nine hours nightly have higher grade-point averages than those sleeping less than six hours (3.2 GPA vs. 2.7). Sleep-deprived students often have ''microsleeps" during class, disrupting task performance.

Sleep deprivation may even weaken immunity (laboratory rats deprived of sleep die of overwhelming infection after a few days) and can increase risks of traffic accidents fivefold. Youths with sleep problems also are more likely to have attention problems and anxiety. Yet during annual physicals, fewer than 40 percent of doctors ask teenagers about sleep habits. Of the major human drives -- food, sex, and sleep -- the latter is most neglected by doctors during teenage checkups.

A 2004 survey found more than 500 websites devoted to sleep habits in children, more than 20,000 parenting books mentioning the subject, and 40 mass-market books entirely about pediatric sleep. Most parenting magazines regularly run columns about sleep.

Contrast this with the pediatrician's bookshelf: Number of pages about childhood sleep in the Harriet Lane Handbook, the reference guide for pediatric residents: 0. Number of chapters about sleep in the best-selling pediatrics textbook: 0. Pages of lecture notes about sleep problems in children from my seven years of medical school and residency: 1.

The first step is for doctors to ask about teenage sleep at checkups. To help teenagers who are sleepy all day long, the American Academy of Pediatrics recently published a flow-chart to help diagnose and treat teen sleepiness. (See http://pediatrics.aappublications.org/cgi/content/full/115/6/1774/F1). Based on a child's total sleep time, ability to fall asleep, snoring, and other factors, the chart helps define a child's sleep problem.

A parent and doctor can then help by changing the child's sleep schedule, setting routines, or testing for medical conditions such as sleep apnea or restless leg syndrome.

Another way to cope is to change the teenager's environment.

For example, in their Pediatrics paper, the Northwestern researchers call for standardized tests to begin after 10 a.m. rather than 8 a.m., since students generally perform better on tests later in the day.

In the late 1990s, fed up with poor school attendance and performance, Minnesota officials pushed back public high school start times from 7:15 to 8:40 a.m. Later studies showed that attendance jumped and academic scores improved as students averaged an additional hour more sleep per night. In Fayette County in Kentucky, teenage car crashes declined by 16 percent after high schools shifted to a later start.

In Minnesota, some who opposed later start times said teenagers shouldn't be coddled -- as adults they'll have to live on too little sleep as well, so why not train them early, those opponents argued.

Of course, most people from adolescence through adulthood cope with lack of sleep by self-medicating with coffee, Red Bull, or other stimulants. Better chemical solutions to sleep deprivation are probably inevitable.

And the research needed to find those solutions is already well underway, particularly in the military. Typically, long-haul military pilots take caffeine or amphetamines (like Dexedrine) to stay awake during missions; however, these are habit forming and cause jitteriness. Pentagon research shows the drug modafinil, or Provigil -- which has not been tested in children -- is a better option for these critical situations because it induces wakefulness without the jitters, is nonaddictive and free of major side effects. Pilots given the drug can stay awake for several days straight with no loss of performance.

But until and unless those stimulants are proven safe for adolescents, I recommend a lower-tech solution. The best thing parents can do is teach their children healthy sleep habits from infancy and childhood, and continue those through the school years; habits like a consistent bed- and wake-up time, and an age-appropriate amount of shut-eye in between.

I'll be putting my 3-year-old to bed at 7:30 tonight.

Dr. Darshak Sanghavi, a clinical fellow at Children's Hospital and Harvard Medical School, can be reached at www.darshaksanghavi.com.  

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