Abstract
Sleep is critical to teen physical and mental health, daily function, and school performance. Yet, sleep deficiency is prevalent among ethnoracially diverse teens. The purpose of this community-engaged focus group study was to explore multilevel influences on teen sleep from teen and community stakeholder perspectives and to use this information to develop a tailored sleep health intervention. We conducted seven focus groups (N = 46) and analyzed data via content analysis. Five themes, each with subthemes, described sleep knowledge/attitudes, sleep habits, the multilevel causes and consequences of decreased nighttime sleep and suggestions for improving teen sleep. Teen health, mood, and school engagement were all impacted by inadequate nighttime sleep. Exhaustion emerged as an overarching theme and coincided with the transition to high school. The data from this study provide insight into important areas of focus for a sleep intervention tailored to the needs of ethnoracially diverse teens living in an urban community.
Sufficient sleep is critical to teen health, daily function, and well-being (Segura-Jimenez et al., 2015), yet 70% of American high school students do not get the recommended 8–10 h of nighttime sleep (Paruthi et al., 2016; Wheaton et al., 2018). Short sleep duration, inconsistent bedtimes/wake times, and poor sleep quality are common and are associated with negative physical (Schneider et al., 2020; Turel et al., 2016) and mental health (Ly et al., 2015; McMakin & Alfano, 2015), risky, antisocial, and internalizing/externalizing behaviors (Chang et al., 2017; Fuligni et al., 2018; Owens et al., 2017; Uy & Galvan, 2017), and the risk of injury (e.g., motor vehicle crashes) (Garner et al., 2017). Sleep deficiency increases daytime sleepiness and visits to the school nurse and decreases classroom time (Wernette & Emory, 2017), academic performance (Dubuc et al., 2020; Fuligni et al., 2018), school attendance, and school engagement (Dunbar et al., 2017; Hysing et al., 2016).
Recent research suggests that Black teens have shorter nighttime sleep duration, averaging over 30 min less compared to teens from other racial or ethnic backgrounds (Guglielmo et al., 2018; James et al., 2020; Yip et al., 2020). Latino youth reported more daily sleep disturbance relative to Black and Asian teens, and Asian teens reported the greatest level of daytime dysfunction (Yip et al., 2020) 1 . A systematic review found that socioeconomic status did not account for sleep disparities among adolescents from diverse racial or ethnic backgrounds (Guglielmo et al., 2018). Currently, inadequate research exists regarding the sleep habits, knowledge, and beliefs about sleep, as well as the potential causes and perceived consequences of inadequate sleep among ethnoracially diverse teens attending urban high schools (Marczyk Organek et al., 2015; Patte et al., 2017).
Few teen sleep promotion studies have been conducted in the United States; one school-based program achieved short-term increases in time-in-bed and earlier bedtimes in preteens (Wolfson et al., 2015). A second study revealed that sleep education messages delivered to teens via text message increased sleep duration in non-Hispanic white teens (Tavernier et al., 2017). Despite these promising results, it is unclear whether existing programs would be effective for ethnoracially diverse groups of teens. It is also unclear whether efforts to increase sleep duration by delaying school start times are feasible and acceptable for diverse communities. Although the sleep-related benefits of delaying school start times are clear (Alfonsi et al., 2020), little is known about potential adverse effects (Marx et al., 2017), especially in ethnoracially diverse communities.
The purpose of this focus group study was to explore multilevel influences on teen sleep and obtain foundational data to guide the development of a tailored community-based sleep health intervention for ethnoracially diverse teens living in an urban community. We examined the perceptions of key stakeholders about teen sleep health.
Method
We used a community-engaged research (CEnR) method. The term “community-engaged” refers to research that involves various levels of collaboration among community members and academic researchers with a common goal (Pasick et al., 2010; Sadler et al., 2012). CEnR approaches may consist of different levels of engagement from low (i.e., participants are recruited from the community, but are not involved in planning or conducting the research) to high engagement, with equal partnership and participation in all phases of research that addresses community needs and priorities (London et al., 2020). The underlying premise of CEnR is that community partners bring essential expertise, equal in value to the researchers (Pasick et al., 2010).
The research team members have expertise in adult and pediatric nursing, sleep health, teen health in school-based health centers (SBHC), public health, and qualitative research methods. The team collaborated with the University's NIH-funded Center for Clinical Investigation's Cultural Ambassadors and formed a community advisory board (CAB) to guide the study. The CAB includes key stakeholders assembled to advise the research team on how to conduct the study in the context of a diverse urban community and elicit the perspectives of teens, parents, and school personnel. Members included a school nurse, a high school teacher, a pediatric nurse practitioner, a pediatric sleep medicine physician, a recent high school graduate, a local church member serving a Black congregation, and a representative from a local nonprofit organization supporting the social and economic advancement of Latino communities. The CAB recommended focus group topics, potential research questions, and suggestions for community recruitment. The study was approved by the Yale University Human Investigations Committee.
Sample
We used convenience sampling to recruit the focus group participants through personal contacts, recruitment flyers, word-of-mouth, and by text or email. We included participants who lived, worked, or attended school in the community and had contact with teens at home, through school or a community agency, and were English speaking. Participants were encouraged to invite a friend to attend the focus group with them (Daley, 2013; Krueger & Casey, 2015).
Procedure
Separate focus groups were arranged to include similar individuals (e.g., parents or teens) and held in convenient locations (Krueger & Casey, 2015) that included a community church (N = 2), university (N = 1), local restaurant (N = 2), and community agency (N = 2). Groups included 3–10 individuals each and lasted 30–76 min in length. A member of the research team reviewed the study details, answered questions, and obtained consent from all adults, and for those under the age of 18, parental consent and teen assent. We obtained demographic information from participants via a short questionnaire. Refreshments were provided, and each participant received a $25 stipend. The questioning route (Table 1) was developed from the study questions and input from the CAB (Butcher, 2022; Krueger & Casey, 2015). A member of the research team led the focus groups and audio-recorded them. Recordings were de-identified and transcribed verbatim. We took field notes during the discussion to aid in the transcription and analysis of data. Members in two of the groups were bilingual. When necessary, a group member provided translation. These transcripts were transcribed in both languages and back-translated to ensure the accuracy of the data (Al-Amer et al., 2015). The research team reviewed and validated each transcript.
Focus Group Questioning Route.
Population/Setting
Seven focus groups were conducted with 46 participants over a seven-month period in an urban Northeastern community. Three focus groups were conducted with teens, two with parents, and one each with school staff (teachers/social worker [Teachers/SW] and school nurses/nurse practitioner [SNs/NP]). Demographic data of participants are provided in Table 2 and the composition of each focus group is included in Table 3.
Demographic Characteristics of Focus Group Participants.
*n = 4 missing data for 1 participant.
Focus Group Composition.
Data Analysis
Data analysis was conducted to identify patterns and themes in the transcripts using qualitative content analysis (Krippendorff, 2019). This technique assists the researcher in “making replicable and valid inferences for texts” (p. 382). All focus group transcripts were entered into ATLAS ti8 for data management and analysis. Two researchers independently read the transcripts to gain an understanding of the data. They made a preliminary list of recording units or codes to be used during the analysis that emerged from the data. Two researchers coded the first transcript independently and met and discussed the recording units until an agreement was reached on the coded data. Additional recording units were added to the list as needed throughout the analysis (Krippendorff, 2019). This process was repeated for all seven transcripts. The researchers then discussed and recoded the transcripts until an agreement was reached on all recording units. Each recording unit was reviewed individually for cohesion of the data included in each code and adjustments were made as needed. The coded data were then unitized into themes and subthemes for each research question (Krippendorff, 2019). The themes and subthemes that emerged from the data were presented to the CAB for input on the interpretation of the findings and discussion of the next steps toward building an intervention for the adolescents in our community.
Results
The data that emerged from the focus groups were included in the following themes: Knowledge and Attitudes about Sleep, Sleep Habits, Causes and Consequences of Decreased Sleep, and Suggestions for Improving Sleep, via a tailored sleep intervention. Exhaustion was an overarching theme.
Knowledge and Attitudes About Sleep
Knowledge
All focus group participants were aware of the recommendations for 8+ hours of nighttime sleep for teens and the health benefits associated with obtaining sufficient sleep (e.g., overall health, more energy). Teen participants described the tie between sleep and “diet, eating and digestion” (Focus Group [FG]1), but they felt they did not have adequate knowledge to make appropriate choices about sleep. Their school health curriculum did not include information about sleep health. Teens relied on family members and their health care providers for this information. Teens held many misperceptions about sleep. For example, “studying before sleep makes material stick in your mind more” (FG1) and they thought that going to bed later improved their energy and that they could catch up on their sleep. “Some people are like you can’t catch up on sleep. I’ve heard people say that. I was like, actually you can.” (FG1).
Parents believed sleep habits are inherited and felt that they had insufficient knowledge to help improve their teen's sleep. The SNs/NP Group identified the importance of sleep for peak performance in both school and sports. They were aware that teens have a “natural ability to be awake later at night” (FG6) and identified a tie between sleep and weight. The Teacher/SW Group shared that teens believed they functioned better on less nighttime sleep and napping improved school performance.
Attitudes About Sleep
Teens viewed sleep as a means of self-care. However, they shared “I don’t think anybody gets eight hours of sleep…unless you are like old” (FG2). Teens also discussed that they prioritized time with friends, homework, and playing video games over their sleep and some felt “sleep is boring” (FG3). In contrast, the SNs/NP Group believed teens enjoyed sleeping and the Teachers/SW Group believed “parents, teens, and society do not value sleep.”
Sleep Habits
Sleep Routine
Parents and teens recognized the importance of a sleep routine and a consistent bedtime. Parents shared “everyone has their own habits and routine around sleep” (FG5). A teen who had military experience related, “you would be out all day from 5 in the morning…so you realize how important sleep really is” (FG1). A teen parent explained that her sleep routine had changed because of her baby, “I sleep when she sleeps” (FG3). Teens in high school reported that they had difficulty getting up in the morning, slept through their alarms, and delayed getting up as long as possible, leaving no time for breakfast. “Literally during the school year I set three [alarms] because I just be like ‘STOP, STOP’ [and turn my alarm off]” (FG1). Teens reported less difficulty waking up in middle school because of a later school start time, and their parents helped them to get up on time. The Teachers/SW Group thought that the average bedtime for teens was between 2 and 3 a.m. because teens nap after school. Parents and SNs/NP Groups also believed teens went to bed late, often after midnight.
Weekend Sleep
Some teens slept more on weekends: “Weekends it be the best because you don’t got to wake up” (FG2). Conversely, many had weekend activities and responsibilities, “it's worse because I just feel like I have more to do. It's my activity time” (FG2). Parents shared that weekend sleep schedules were different. “Sometimes [goes to bed] 4 a.m. and wakes at 2 in the afternoon” (FG5). The SNs/NP Group believed that teens “get to sleep longer on the weekends, but still go to bed at the same time or later” than on school nights.
Naps
Middle school students reported naps only if they were ill. Napping was more universal for high school students and was attributed to earlier school start times. “I used to not be able to take a nap like in middle school, like 8th grade… but since I started high school, yes!” (FG3). Napping was prioritized and occurred for several hours, on most days, after school. “You go home, nap for like 4 h, wake up, do your homework, and go back to bed” (FG1). Teens described their naps as “a mini nighttime” (FG1). Teens who had jobs nap on their afternoons off, to catch up on their sleep. Parents recognized a shift in napping that began in high school. “In middle school she didn’t sleep during the day, only at night. Now that she started high school, she takes naps” (FG5). Parents recognized that naps pushed teen bedtimes later.
The SNs/NP Group viewed naps as teens “collapsing [from exhaustion], I don’t think they could stay awake even if they wanted to…they go home, sleep for 3 h, wake up at 8 p.m. and then they are like ‘Oh, I have my homework’ and are up until 2 a.m.” (FG6). They also shared that teens may nap after school because they are not participating in afterschool activities or if they are depressed. This group also believed that napping allowed teens to stay up socializing “almost preparing to be up…so that they can be on their phones and talking” (FG6).
Causes of Decreased Nighttime Sleep
Packed Schedule
Participation in after-school activities caused teens to get home late and push dinner, bathing, and studying later into the evening. “I have work and then dance, and I won’t be able to sleep until all of their homework and responsibilities were completed for the day” (FG1). High school students described the added pressures of college applications. “You try to like put everything in your schedule, so you have something to show for college” (FG2). Employment was important for many of the teens; “work is more important to me than sleep” (FG2). Teens who would be the first in their families to attend college emphasized that they spent a lot of time preparing applications and applying for financial aid without their parent's assistance, “Nobody in my family like knew what to do…I was literally on my own…I spent so much time” (FG1). Parents acknowledged that younger teens were also preparing for college, and this interfered with their sleep. “My daughter (13 years old) spends most of her time thinking a lot about colleges already” (FG5). The Nurses/NP and Teachers/SW Groups imparted students often worked as many as 40 h a week and until 10 or 11 p.m. on school nights.
Homework
Studying and homework were major contributors to decreased nighttime sleep. Teens were often tired but needed to complete assignments and expressed that they “wouldn’t be able to sleep knowing that I didn’t do my homework” (FG1). As a result, “you be falling asleep doing your homework” (FG2). Teens believed that “the smart kids pull all-nighters just to stay up and study” (FG1) and a teen explained that “I took a lot of APs [Advanced Placement classes], so I had a very heavy workload. It was like going to sleep early was not happening” (FG1). Parents were aware that homework and studying interfered with nighttime sleep.
Teachers/SW and SNs/NP Groups felt teens are “up really late trying to keep up with their AP classes” (FG6), “they have straight A's and it's because they’re up all night trying to keep those grades up” (FG6). A teacher described a student who had stayed up all night completing her capstone project, “she said ‘I started at 10 last night and I finished at 5 this morning.’ She wanted to show her parents what she could do” (FG7).
I…drop my brother off to work…make my mom's lunch, drop her off…drop my little brother at summer school. Sometimes I would sleep a little bit, but sometimes not. I wouldn’t sleep and then just from there, function the whole day until night. (FG1)
At night, teens often delayed homework and bedtime because they were responsible for caring for their siblings or own child until they went to sleep. Teachers were aware of their students’ responsibilities and agreed that this decreased their nighttime sleep.
Nighttime Socializing
Teens described nighttime as a time to socialize with friends “everybody is up at night and on their phones” and a reward for completing their daily responsibilities. “Like when you’re finished everything, you go to bed and then like you finally are free to go on your phone for however long you want to” (FG1). The teens did not feel that their phones interfered with their sleep and shared that they often fell asleep while on their phone. “I don’t have to put my phone down to go to sleep” (FG2). Some teens felt their phones made it harder to get work done and interfered with sleep. “All my friends be asking, ‘you want to play Fortnite or Call of Duty’” (FG3). Another shared, “My girlfriend will wake me up like with messages, she’ll blow up my phone” (FG3).
Parents reported that they accidentally found their teen on the phone, late at night, and now monitor them. “I always have to walk in. I have to watch her that she's not with her friend on the phone” (FG5). Parents also described their teens being “wide awake…having a whole group chat” (FG4), socializing or watching videos, rather than sleeping. Parents confirmed teens often slept with their phone and they found that if took it away the teen would then go to sleep earlier. However, they were reluctant to limit nighttime phone use or set a formal bedtime for their teen if their teen was performing well in school. “He's an honor student, so I mean, I really don't really push the issue because he does what he's supposed to do. If he didn't then it would be a real issue” (FG4).
The Teachers/SW Group shared “they’d [teens] rather hang out with friends [ than sleep].” The SNs/NP Group agreed that teens were often up late on their phones socializing and felt this was a result of being afraid they would miss something while sleeping. The SNs/NP Group also expressed concern about teens and their lack of a bedtime sleep routine. “They’re studying in bed; they’re socializing in bed. They’re doing everything in bed” (FG6).
Environment
All the groups identified environmental factors that interfered with nighttime sleep. Family members often had different schedules, shared rooms, and were up late. For others, siblings with special needs or dog barking would prevent them from sleeping. Neighborhood noise from “music, motorcycles, you know fights, a lot you know…it's difficult” (FG5) also caused sleep interruptions and resulted in parental frustration.
Mental Health
The data concerning mental health and mood were connected and often described as both causes and consequences of inadequate nighttime sleep. Teens and parents felt that stress and sleep were interconnected. Parents recommended that their teens seek help at school to relieve some of their academic stress and worries that kept them up at night. The SNs/NP and Teachers/SW Groups discussed how anxiety and depression affected teens’ sleep. “I can’t believe the stressful lives and traumatic things (e.g., parents divorcing, fighting) that are going on in some of their lives” (FG6). SNs/NP Group believed social media use contributed to teens’ anxiety and impacted their sleep. The Teachers/SW and SNs/NP Groups identified a link between the lack of sleep and the exacerbation of anxiety or depression. “If they are anxious, they will be more anxious. If they are depressed, they will be more depressed…So many [teens] do not realize that depression and sleep go hand-in-hand” (FG7); “They are looking for that escapism—by watching Netflix all night, like 8 h (FG7).
Consequences of Decreased Nighttime Sleep
Mood
All focus groups identified mood-related changes resulting from sleep deprivation. Teens felt that tiredness affected their relationships, “It can affect how you treat other people. If you are not good with it [sleep], you’re not going to be good with other people” (FG1) and shared teens often opted to not engage with others or were viewed by parents as lazy when they were tired. Parents noted that when their teens do not sleep “their character changes” (FG5). They reported that teen became aggressive, irritable, moody, and easily bothered by others due to a lack of sleep. The SNs/NP and Teachers/SW Groups discussed the impact of sleep on the teen's interactions with peers. “They are a little…quick to take offense with their peers” (FG7). “They come to school, a lot of them, really revved up…and then they start fighting” (FG6). This group also felt teens “don’t know how to help themselves” (FG7).
Health
Teens described themselves as tired “every day” (FG1) and their “bod[ies] being worn out” (FG2) from a lack of sleep. Parents believed inadequate nighttime sleep is “bad on your heart,” (FG4) “takes a toll on your body,” (FG4) and can lead to illness, “she’ll be sick, and she starts shutting down her body” (FG4). The SNs/NP Group explained that without sleep teens’ “brains don’t ever shut off” and “their thought processes are all screwed up.” At school, the SNs/NP Group reported that teens often “come in for a headache…but it is really because they didn’t sleep” and expressed those teens were more likely to believe, “that they had an exotic disease” rather than that they were affected by inadequate sleep. The Teachers/SW Group added that hunger contributes to fatigue among students. “How tired they get and how much they eat, there's definitely an association there.” They explained tiredness and the lack of energy among students is “like a sugar coma…they bottom out, they kind of lose it” (FG7). This group agreed with the parents that lack of sleep could have consequences on their heart health later in life.
School
Lack of nighttime sleep impacted school attendance, classroom engagement, and performance. Additionally, teachers needed to accommodate tired or late students in the classroom.
Tardiness and Attendance
Teens described that oversleeping caused them to be late for school and miss the first class of the day. Arriving late added procedural challenges. The teachers explained that when students were tardy, they are required to “go to the main office and stand in line for a long time…first they have to buzz in the building…go to security and get wanded 2 , but if they were on time, they just go through the metal detectors like everyone else” (FG7). After this, late students “are kept in a pack in one area and not allowed to leave” (FG7) the area and issued detentions. The teachers called the process for late students “the shame machine” (FG7) and felt that it deterred kids from coming to school, if they were late. Several teens explained that if they missed school or classes because of being tired, “you’re going to lose credits…you could fail [your classes]” (FG2). Teachers elaborated that there are students who are “failing for the entire year…they sleep so late, they come to school late every day that they miss most or all of first period” and as a result “they are going to be repeating the grade” (FG6).
Classroom Engagement
All focus groups identified the effect of inadequate sleep on teens’ focus, motivation, memory, attention, and completion of their schoolwork. Teens explained the consequences of falling asleep in class “[you] get kicked out of class,” (FG2) sent to the office for the remainder of the period, or “sometimes if a student gets tired, they’ll go to the nurse's office and say they’ve got a headache, and the nurse will make them lay down” (FG2). The SNs/NP Group added, “We see kids everyday who have fallen asleep in school” (FG6).
Performance
Teens recognized that if “you only got two hours of sleep, you’re going to be sleeping on the test” (FG2). Parents and SNs/NP Groups felt that teens were unable to think clearly and did not retain information. This led to poor grades. Sleep “helps with memorizing things… [teens are] not able retain anything if [they are] not sleeping" (FG4).
Accommodating Tired Students
Teachers described situations in which they needed to accommodate students who were late by “try[ing] to clear up information they missed in the next class” (FG7), permitting students to take a nap because teens were unable to sleep at home, or allowing time in class to study prior to taking a test. They shared that administrators who observed teens sleeping in their classes viewed teachers negatively. The stream of late arrivals, particularly during the first period of the day, caused disruption, repetition of content, or a delayed start to classes.
Suggestions for Improving Sleep
Phone Use
Adult participants believed that phone use was a major contributor to decreased sleep, exhaustion, and decreased school performance. They recognized “to give it up [the phone] is a big deal” (FG6). They discussed the potential beneficial effects of reducing phone use on sleep quantity and quality through earlier bedtimes and avoiding engaging with movies or shows, social media, incoming texts, calls, or posts. To some extent, teens agreed and added that if they needed to, they could use the “do not disturb” feature on their phones and achieve the same outcome. However, some thought “phones are part of everyday life and don’t impact sleep.” (FG2). The teens added that their phones were essential for completing school assignments and communicating with teachers because many did not have access to the internet in their homes.
Sleep Education
All focus groups identified the need for sleep education. Teens expressed “education [about sleep] is a big thing because a lot of us don’t know. We literally don’t know. I’ve only learned this year that if you are not sleeping enough, it's literally going to impact your whole day” (FG1). They further explained that they did not receive information about proper sleep habits and the impact of inadequate sleep from school, home, or their health care providers. The teens lamented that they could not change their sleep habits if they were not given the information to inform their choices. They suggested small group conversations at school, like focus groups, to learn about sleep within a comprehensive self-care curriculum. The parents thought “outside resources” may have more impact on teens because when information about sleep came from parents, teens viewed it “as nagging” (FG4). Some teachers incorporated sleep-related content into psychology and health classes. “It's not part of my everyday curriculum, but I add it in” (FG7). The SNs/NP Group shared ideas, including teen-themed posters, public service announcements, and afterschool programs that address inadequate sleep, and a comprehensive approach to wellness including “eating, exercise, water intake, and sleep” (FG6). Participants felt that parents also need sleep education to guide children and teens. Sleep education was identified as an important, yet missing component of well-patient visits. The SNs/NP Group explained that they incorporated sleep education into their school-related services.
The Teachers/SW Group felt that teens would respond to an intervention that included the use of an electronic sleep tracker, sleep app, or diary to evaluate sleep habits to identify specific areas of focus to improve their sleep. They thought that monetary incentives might help teens to participate in an intervention. “We all want to get paid for our work. There is no motivation other than ‘I may feel better…that's not enough for them” (FG6).
School Schedule
All groups felt that starting school later may assist teens to get more nighttime sleep. One parent commented “it would be better for me, because they’d [teen] have 10 or 11 h of sleep” (FG5). “I think it is great because it shows that they're actually taking an interest on how the kids perform in school. They don't want your kids to go to school tired” (FG4). Others thought the mornings would be less hectic, saying, “They’d have more chance in the morning to prepare and not to go with stress” (FG5). Some parents were concerned that later school start would allow less family time and could interfere with getting teens to appointments after school: “If they get out earlier, we can bring them to a doctor's appointment or programs in the evening” (FG5). Other perceived drawbacks for parents had to do with their teen being at home after they leave for work: “they take their time and go to school late” (FG5). Parents and Teachers/SW Groups commented that later start times would impact after school activities, and this would require changes in the scheduling of sports practices and games. However, changing the school start time may reduce tardiness among students who oversleep. Teens suggested decreasing their homework load, eliminating excess credits beyond graduation requirements, and allowing senior students to have study halls or leave school early, which may facilitate earlier bedtimes and increased nighttime sleep.
Exhaustion
Exhaustion is defined as “drained of strength or energy, worn out” (Dictionary.com, 2023) results from feeling “strain and chronic fatigue” (Walburg, 2014, p. 28) and was an overarching theme in this study. Participants identified symptoms of exhaustion that included chronic tiredness or sleepiness, headaches, impaired decision-making/judgment, and moodiness. Misperceptions about sleep and individual/family attitudes about sleep and sleep habits contributed to a lack of nighttime sleep and exhaustion. Multiple factors influenced inadequate nighttime sleep and in turn, teen health, mood, and school engagement (Figure 1). Exhaustion started with the transition to high school and other aspects of this transition, including earlier school start times, longer commuting distance to school, newfound independence and responsibilities, academic and college preparation pressures, and nighttime socializing with peers. These factors contributed to shorter nighttime sleep duration, daytime sleepiness, and napping after school. Participant suggestions, for a tailored sleep intervention, focused on the perceived contributors to exhaustion and included phone use, lack of sleep-related education in school and by pediatric clinicians, and the current school schedule.
Influences on teen sleep and exhaustion model.
Discussion
Participants identified a significant shift related to nighttime sleep that coincided with the transition from middle to high school. Many factors influenced bedtimes and the amount of teens’ nighttime sleep. These changes coincide with the biological shift in circadian rhythms (Owens & Weiss, 2017) and developmental changes, such as the need for increased independence and the desire for social interaction with peers (Sanders, 2013). These factors contributed to the daily “busyness” and missed nighttime sleep. This study highlights the impact of packed schedules on nighttime sleep for teens and it is clear something needs to give to allow teens the opportunity to develop healthier sleep habits and achieve optimal nighttime sleep.
School-related burnout is common among diverse populations of high school students (Salmela-Aro et al., 2021). Burnout has important implications related to teen depression (Salmela-Aro et al., 2021), risk of suicidal ideation (Ang & Huan, 2006), somatic symptoms (Murberg & Bru, 2007), and high school dropout (Salmela-Aro & Upadyaya, 2014). Notably, exhaustion is one of three factors that contribute to school burnout. We did not specifically ask participants about the other factors, cynicism, or inefficiency (Maslach, 2001), however, the third element, exhaustion was an overarching theme in this study. Teens described symptoms of exhaustion that was validated by parents and school personnel, and this warrants significant attention given the potential implications related to mental health and academic success.
Participants identified structural factors that affected their sleep. Most teens had working parents, who expect them to assume responsibility for their sleep routines with little, if any, knowledge about healthy sleep behavior and the added demands of high school. Transportation presented challenges for teens. Oversleeping meant missing the school bus or arriving late to school. Many teens worked after school and on weekends to cover their personal expenses and/or contributed to the household. Younger students contributed to their families by caring for their siblings and doing household chores. All of these responsibilities pushed bedtime later and contributed to less nighttime sleep. Later school days may impact these responsibilities and make it harder for families. Many teens were the first in their families to attend college and devoted a significant amount of time preparing. Greater college planning support for students and parents that includes the application process, course selection, and advisement on a feasible number of extracurricular activities to support their applications is an additional area of need that may have a significant impact on the demands of high school students and nighttime sleep duration.
Phone use is a key consideration in planning a sleep intervention for teens to improve their nighttime sleep. Adults consistently emphasized the influence of phones, electronics, and videogames on sleep. It was not surprising that teens and adults had disparate views on teen phone use. Teens described phone use as an essential part of everyday life, including school, and felt that they were able to manage phone so that it did not interfere with their homework or sleep. They viewed access to the phone as a reward for completing their daily responsibilities. Previous research that restricted pre-bedtime phone use during school nights had a positive impact on nighttime sleep duration. However, more research is needed (Bartel et al., 2019). Parents are an important resource to leverage in assisting teens to establish a balance between the need for sufficient sleep with the competing demands of school, extracurricular activities, family responsibilities, and socializing.
Clinical, Intervention, and Policy Implications
The deficit in knowledge about sleep and its importance for health, mental health, school engagement, and performance among teens and parents provides an important area of focus for future sleep interventions. Although sleep education has been found to increase sleep-related knowledge among adolescents, it is less successful in changing sleep-related behavior long term (Blunden & Rigney, 2015; Gruber, 2017; Gruber et al., 2018; Illingworth, 2020; Illingworth et al., 2020). Pediatric health care providers can be a significant source of information for adolescents and parents regarding the importance of sleep, how to establish healthy sleep-related habits, and reinforcing healthy sleep behavior. Current pediatric preventative guidelines do not include guidance on sleep after the age of 15 months, apart from the number of recommended hours and factors related to identifying sleep disorders (Hagan et al., 2017; Honaker & Meltzer, 2016), and fail to address other essential factors. This is a missed opportunity for all pediatric health and mental health providers to assist in providing evidence-based sleep education and assisting families to help children and adolescents establish and maintain healthy sleep routines and address unhealthy sleep-related behaviors.
Napping was nearly universal among high school students and interfered with nighttime sleep (Inazumi et al., 2020; Ye et al., 2015). Naps may improve neurocognitive function (Ji et al., 2019; Lo et al., 2019) and help to offset the effects of sleep loss when adequate nighttime sleep cannot be obtained (Lau et al., 2018; Lo et al., 2020). Current sleep science does not support daily napping as a substitute for nighttime sleep in adolescents (Lo et al., 2019). The teens in this study did not identify boredom, depression, or anxiety-related symptoms as reasons for napping or sleep disruption. Parents described symptoms that are commonly associated with depression and anxiety in teens. Given the prevalence of mental health disorders among teens, screening is universally recommended for teens annually and as needed (Hagan et al., 2017).
School personnel provided an important view of what it is like to teach exhausted teens. Similar to prior research, participants described the negative impacts on school attendance and engagement (Dunbar et al., 2017; Hysing et al., 2016), academic performance (Dubuc et al., 2020; Fuligni et al., 2018), daytime sleepiness (Wolfson & Carskadon, 1998), and increased visits to school nurses (Wernette & Emory, 2017). A finding unique to this study pertains to broader consequences of inadequate sleep. Teachers described a chaotic scenario, at the start of each school day, where tardy and exhausted students interfered with teaching and learning, impacting other students and the school environment. Teens that fell asleep in class reflected negatively on the teacher's ability to engage students, caused missed instructional time, and students were sent from the classroom to the school nurse, SBHC, or office. Teens described the burden of homework and “busywork” (Gaarde et al., 2020). Information is needed to determine whether homework is the result of district policy or may be a strategy of teachers to cover material missed due to decreased student engagement and disruptions.
There is increased interest in delaying school start times to increase sleep duration among teens (Meltzer et al. 2021; Walker, 2022). Delaying school start times increases sleep duration (Minges & Redeker, 2016; Nahmod et al., 2019) and improves attendance and graduation rates among students (McKeever & Clark, 2017). Later start times may also lower rates of car accidents among students (Foss et al., 2019; Vorona et al., 2014; Vorona et al., 2011). Yet, a Cochrane review concluded that outcomes, other than sleep duration, were mixed; the quality of current evidence is inconsistent, and little is known about adverse effects (Marx et al., 2017). Parents’ perceptions that delayed school start times may negatively affect family time, childcare, transportation, and after school activities may be barriers to this change (Dunietz et al., 2017). Although the potential sleep-related benefits of delayed school start times are clear, the logistical issues, such as timing of athletics and bus schedules need to be considered (Alfonsi et al., 2020). Perhaps a middle ground, as suggested by the teens in this study, is to unpack the school day by carefully evaluating what is essential to accomplish at and after school, within the context of local educational policy. Shorter school days combined with more school days may be a solution.
Future Research
Research is needed regarding sleep habits, knowledge, and beliefs about sleep, as well as the potential causes and perceived consequences of inadequate sleep among ethnoracially diverse teens attending urban high schools. Exhaustion, as a component of school-related burnout, needs further exploration as it pertains to teens in the United States. Additionally, research is needed to determine the best way to help fill the sleep education needs of teens and parents and the impact of comprehensive wellness interventions that include sleep hygiene, time management, and how to leverage phones to augment sleep-related interventions for adolescents.
Implications for School Nurses and School-Based NPs
Sleep deprivation can have a significant impact on health, mental health, and school performance (Segura-Jimenez et al., 2015). School nurses and NPs providing care to teens in SBHCs provide an essential connection between health and education. School nurses are often most aware of factors that may be influencing student's ability to participate fully in school. These factors may include medical or mental health diagnoses, medications, family stressors, food or financial insecurity. Nurses can be instrumental in assisting to shape and implementing a comprehensive sleep intervention for teens in school, provide individualized sleep-related advice to teens and their parents, and monitor school engagement. Teens with suspected sleep disturbances can also be referred to the SBHC for more involved assessment, intervention, and referral. Many of the participants in this study discussed the school-related demands that impacted their sleep. School nurses and SBHC NPs are in a unique position to help their school or district determine what can be adjusted to allow teens to get enough nighttime sleep and ultimately help to improve overall health/mental health, school performance, school engagement, and social interactions.
Strengths and Limitations
A significant strength of this study was the multiple perspectives of key stakeholders captured via the focus groups, which provide insight into multilevel influences on adolescent sleep patterns and needs. The rigor of the data collection and analysis conducted by a research team, as well as the input of the CAB in all aspects of this study, were additional strengths. Potential limitations of this study were the use of a convenience sample, which may have been a source of bias since only those most interested in teen sleep likely participated and all participants were from one community. The sample included teens who ranged from middle school to college and included a diverse population of teens and parents. Two of the groups included school personnel, but others, such as administrators and guidance counselors, may have added additional perspective.
Conclusion
Improving sleep and sleep health for ethnoracially diverse teens living and attending school in an urban community will require a multifaceted approach that carefully addresses each contributing factor, assists teens to prioritize sleep with the guidance of parents and school personnel, and provides opportunity for behavioral change. A school-based intervention has the added benefit of broadly providing sleep-related education, ideally within a comprehensive health education curriculum. School personnel can help teens and parents by reinforcing this education through student interactions.
Footnotes
Acknowledgments
The authors gratefully acknowledge the research funding provided by Yale School of Nursing Pilot Funding Program. The authors are grateful to the Community Advisory Board for their role in this study, as well as the teens, parents, teachers, social worker, and nurses who participated.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Yale School of Nursing Pilot Funding Program.
