By

Monique Thompson, Ph.D.

Partner, San Francisco Bay Area Center for Cognitive Therapy

A growing body of research shows that we are raising a generation of teens who are over-stressed and under-slept (see SFBACCT partner Daniela Owen’s blog post on the recent Atlantic article on teen suicide HERE). A 2014 report published by the American Academy of Pediatrics called the issue of tired teens a “national epidemic.” The most recent poll on teens from the National Sleep Foundation found that more than 87% of high school students in the US are getting less than the recommended minimum of 8 hours of sleep. Fewer than 10% of high school students are actually meeting the recommended 8-10 hours of sleep time. Furthermore, more than half of the students reported exhaustion and sleeplessness due to school stress. More recent studies find that the amount of sleep teens are getting is decreasing rapidly as social media and technology are invading teen’s bedrooms.

Sleep deprivation predicts a wide range of negative outcomes for teens, including impaired attention and concentration, poor grades, car accidents, anxiety, depression, greater suicide risk, obesity, and diabetes. In other words, lack of sleep makes our teenagers not only drowsy, grumpy, and inattentive but also risks their well-being, health, and lives. A study of 28,000 high school students in Virginia found that each hour of sleep deprivation predicted a 38% increase in depression symptoms, a 23% increase in substance abuse, and a 58% increase in suicide attempts.

Problem 1: Circadian Clocks versus School Clock

Sleep deprivation is a growing problem for all ages. But the problem has a particularly acute effect on teens whose lives are driven by a school system that requires them to wake up hours before their biological clock is inclined to be wakeful. During the teen years, the natural circadian clock shifts and teens develop a natural “owl tendency”: teens do not feel sleepy until later in the evening, and would naturally sleep later in the morning. Yet, our school systems require them to wake up for an early high school start time. This inevitably compresses the number of hours of sleep teens are actually getting; most high schools begin before 8:30 and their natural circadian clocks make it difficult for them to feel sleepy before 11:00pm.

Schools and families are beginning to address these systemic factors in impactful ways. I encourage parents to advocate for their teens:  Bring up your concerns about sleep to the schools and support later start times and other sleep friendly policies (i.e., reasonable homework assignments).

 

Problem 2: The Invasion of Electronics and Social Media into Teen’s Lives and Bedrooms

Beyond these systemic factors, the rise of electronic devices and social media has changed how much time teens spend with electronics and how much access they have to entertainment content and social media.  A recent Norwegian study of 10,000 teens found that the use of electronic devices during the day, and especially one hour prior to bedtime, significantly inhibits teens’ ability to fall asleep. The researchers propose that the increase in electronics use explains the significant changes in teen sleep over the past decade. More than 4 hours of screen use per day predicted getting less than 5 hours of sleep per night. These finding are relevant to the 97% of American teens who have at least one electronic device in their room at bedtime.  A new study at JFK Medical Center found that in a large sample of high school students, 80% were not getting enough sleep because of late night phone use, and 25% reported being awakened at night to respond to text messages. This research is helping us understand how electronics are disrupting sleep not just by reducing the number of time available to sleep, but also because the social content is of great interest to teens and thus activates the nervous system. In addition, the intense light emitted by these devices disrupts the body’s wake/sleep cycle. Nevertheless, parents who would never allow a TV in the bedroom of their children now routinely allow their teens to have their laptops, iPads, and iPhones in their bedrooms. The rapid influx of electronics into every aspect of our lives is new territory that individuals and families are just beginning to grapple with.

 

In my experience working with teens in sleep treatment and with their families, curtailing electronics use is the hardest pill to swallow and often the biggest obstacle to change. Teens have a very strong belief that their phones are not an external device but an extension of themselves. This is how they communicate with their friends, keep their music and photos, watch TV, connect to social media, track their schedules, and do their homework. Parents are hard-pressed to enforce technology guidelines and rules when teens feel so strongly about their “inherent right” to have with them at all times the device that indeed serves so many critical functions. When I suggest a technology curfew that involves removing all technology from the bedroom an hour prior to sleep, a teen will claim the need for the laptop because that is how she does her homework. The most common reason that I hear from teens who do not want to see the phone disappear from their bedroom is that they need to use the phone as an alarm clock. I keep a basket full of inexpensive manual alarm clocks in my office, so I am ready when this “reason” invariably comes up.

 

It is very difficult to loosen a teen’s resistance to removing technology from the bedroom, but it is the single most impactful thing that parents can do to improve teen sleep. Every family will find their own standards and guidelines. Parents may often need to honestly consider their own dependence and preoccupation with their own devices.

 

What can you do to help your teen get the sleep she or he needs? I have compiled a list of suggestions based on what we know from the growing body of research on teens and sleep, and what I have learned in my years of working with teens in sleep treatment, both in my my practice at the San Francisco Bay Area Center for Cognitive Therapy and as a staff psychologist at the Golden Bear Sleep and Mood Research Center at UC Berkeley.

 

Suggestion #1: The Entire Family Needs to Prioritize Sleep

After working with many teens in individual treatment for sleep disorders, I have learned that it is nearly impossible to improve the sleep of a teen without working with the entire family on a sleep plan.  I sometimes call this a “whole family sleep initiative” and try to get the entire family on-board a program that prioritizes sleep.  It is interesting to note that many teens who present for sleep treatment have parents who struggle with sleep issues.  Integrating the family into the treatment plan allows the family members to support each other to make changes to their routines and to increase the amount and quality of sleep for everyone.

 

The problem of teen sleep is NOT a teen problem but it is a systemic problem. Any intervention that is going to be effective needs to address the systems that scaffold the teen’s schedule and routines.

 

Suggestion #2: Set Realistic Goals and Implement Them

Given the constraints of high school schedules and the realities of a teen’s circadian clock, the most optimal sleep window for teens is 11:00pm – 8:00am. Most teens won’t be tired before 11:00pm and most schools begin before 8:30. If we want teens to get close to the 8-10 hours we know that they need for optimal brain and body development, we need to shoot for a regular bedtime close to 11:00pm and a wake-up time close to 8:00 am.  Optimally, the teen will refrain from electronics use at least 30 minutes prior to bedtime (60 minutes would be better).  This means that homework, entertainment/relaxation time, socializing, etc. should be finished by 10:00pm. This goal requires some fairly significant changes to the average family’s life. Every family needs to examine their evening routines to determine what changes they can realistically make to accommodate the sleep needs of their teens. Rules and guidelines will need to be set and then followed and monitored by all family members.

 

Our current society conspires to make it nearly impossible for teens to get close to the recommended 8-10 hours, but teens can get more and better sleep if the family is committed to making sleep a priority. When I work with teens in sleep treatment, I often do a set of timelines with the teen to compare the teen’s actual sleep/wake routines to the ideal time line prescribed by sleep science. Once we see the inevitable disparity between the amount of sleep they are actually getting and what is recommended, we can begin to negotiate how the teen might be able to “buy themselves more sleep,” for example by doing homework earlier so that they aren’t faced with a mountain of homework before bedtime, skipping the after-school nap that makes it more difficult to fall asleep at night, or setting the alarm a little later in the morning to skip hitting the snooze button multiple times. Often, family habits interfere with sleep (late dinner times, chaotic schedules), so I will meet with the entire family to explore if family routines can be changed to support the goals of the treatment.

 

Suggestion #3: Parents: You Really are the “Decider” on Bedtime

Although teens are beginning to want to express their independence and make their own decisions, the research shows clearly that bedtime is not one of the decisions teens can make for themselves with good result. A 2010 study in the journal Sleep found that families wherein parents set healthy bedtimes had teens who reported feeling happier and better rested. On the other hand, families wherein parents set bedtimes after midnight had teens who were more likely to be depressed and to have suicidal thoughts.

 

I encourage parents to take a firm stand on bedtime and technology, and to expect some resistance from most teens. In my experience, after a week or two of improved sleep, the teen’s resistance decreases significantly.  I often talk to teens about the research findings about the benefits of improving teen sleep. Teens are fascinated to learn that better sleep will improve their grades, increase their attractiveness to the opposite sex, make them less moody, etc.  It is very gratifying when a teen comes in after a few weeks of improved sleep and tells me that they notice that they are having less conflict with their families and friends or are finding school work more engaging.  But despite all of the evidence for why they should make changes to their sleep/wake routines, I have rarely seen a teen make those changes for themselves. Parental involvement and enforcement of bedtime and electronics rules are a must for lasting change and consistent sleep routines.

 

Suggestion #4: Don’t Overlook the Basics

Nearly everyone has heard the term “sleep hygiene.” Good sleep hygiene refers to some basic principles that seem so obvious that people overlook them when aiming to improve their teen’s sleep.  I have found that some of the Sleep Basics are indeed obvious but important and often overlooked. My Top 10 favorites follow below:

 

Sleep Basics: The Top 10

1–Exercise during the day, not at night – Exercise helps to increase the amount of deep, restorative sleep that you get. It will also help you feel more energetic during the day, but do not exercise too close to bedtime.

2–Limit caffeine in the afternoon – After six hours, only half of the caffeine from a cup of coffee or tea has left your body.

3–Reduce or eliminate napping – From the moment we wake up in the morning, we are building pressure to sleep again. Taking a nap will reduce your “appetite” for sleep, making it much harder to fall asleep and stay asleep at night.

4–Wind-down before bed – Create a wind-down routine in the 30-60 minutes before bedtime to help you relax and prepare your mind and body for sleep.  Engaging in relaxing activities, such as reading, listening to a guided meditation or writing in a journal ,will cue your body to begin to reduce your body temperature and cortisol levels and prepare your body for sleep.

5—Schedule a time before bed time to review your dayMany people find that the first time they have time to mull over their day is when their head finally hits the pillow at bedtime. If you find yourself worrying over the day when you go to sleep, consider dedicating time in the afternoon or evening to process the day and plan for tomorrow.

6–Keep your bed for sleep only – It is very important that your bed is associated with sleep and rest. Try not to use your bed for wakeful activities such as doing homework or watching TV. This gives our brain mixed signals about what to do in bed. Reserve your bed for sleep only to increase the conditioned association between being in bed and falling asleep.

7–The bedroom needs to be dark – Reduce light at bedtime with light-blocking curtains and removing electronics from the bedroom. Darkness sends a signal to your brain to release melatonin. Melatonin is the hormone that makes us feel sleepy.

8—In the morning, resist the snooze button – Many of us set our alarms early to ensure that we wake up in time for our day. Unfortunately, snoozing is not sleeping and does not have the same health benefits as restful sleep. If you can, set your alarm for the time when you want to get up and refrain from the snooze button – you’ll buy yourself some extra sleep.

9–Expose yourself to sunlight or bright light the moment you wake up – This sends a signal to the pineal gland in your brain to refrain from secreting Melatonin, the sleep hormone that helps you to fall and stay asleep.

10–Expect sleep inertia every morning – We sometimes perceive sleep to be like a light switch that flips off at night and on in the morning. But science shows us that it is more like a dimmer switch that slowly shifts into sleep and wakefulness. We all feel a bit groggy and a foggy as we shift into the day. This feeling does not mean that you have had a bad night’s sleep, but is simply a normal transition in the sleep cycle.

 

Additional resources and references:

https://med.stanford.edu/news/all-news/2015/10/among-teens-sleep-deprivation-an-epidemic.html_

http://healthysleep.med.harvard.edu/need-sleep

http://www.njtvonline.org/news/video/sleep-study-finds-texting-source-of-sleep-deprivation-in-teens/

http://www.reuters.com/article/us-later-teen-bedtimes-idUSBRE9AR0JU20131128

http://www.techtimes.com/articles/30658/20150203/teens-overusing-electronics-arent-getting-enough-sleep.htm

http://www.huffingtonpost.com/entry/7-scary-ways-sleep-deprivation-affects-teen-physical-and-mental-health_us_55a7bd07e4b04740a3df0fb3

https://www.youtube.com/watch?v=P6zcSFA7ymo – Why not to push the snooze button

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