Household Basic Needs Support and Insufficient Sleep Among United States High School Students: Evidence From the 2023 National Youth Risk Behavior Survey

Abstract

Background

Insufficient school-night sleep is common among U.S. adolescents. The 2023 Youth Risk Behavior Survey (YRBS) includes a basic-needs support item about adult effort to ensure safety, clean clothes, and food.

Methods

We conducted a cross-sectional secondary analysis of the 2023 national YRBS. Insufficient sleep was defined as fewer than 8 hours on an average school night. Support was coded as present versus lacking. Survey-weighted models adjusted for demographic, behavioral, mental-health, and BMI covariates.

Results

Among students with nonmissing sleep data (n = 17,441), 76.8% reported insufficient sleep. In the sleep/support frame (n = 15,607), prevalence was 76.0% with support present and 82.0% with support lacking. In the multiply-imputed primary model (m = 20), lacking support was associated with a small, statistically detectable increase in insufficient sleep (aPR = 1.052, 95% CI 1.007 to 1.098; ARD = +4.3 percentage points, 95% CI + 0.5 to +8.1). A complete-case sensitivity model gave a comparable but less precise estimate (aPR = 1.036, 95% CI 0.990 to 1.085).

Conclusions

Lacking perceived basic-needs support marked higher unadjusted insufficient-sleep prevalence, but adjusted estimates were modest. Sleep screening and basic-needs assessment may be clinically useful together; longitudinal work is needed to clarify directionality.

Plain Language Summary

Many high-school students sleep less than the recommended amount on school nights. This study used 2023 national Youth Risk Behavior Survey data to examine whether sleep differed by students’ reports that an adult in their household tried hard to make sure their basic needs were met, such as safety, clean clothes, and enough to eat. Students who reported lacking this support had higher insufficient-sleep prevalence than students who reported support. After adjustment, the difference was small; the primary model was statistically detectable, while the complete-case sensitivity estimate was less precise. These findings do not prove that household support causes better sleep, but they suggest that sleep screening and basic-needs assessment may be useful together in adolescent care.

Keywords

adolescent sleep basic-needs support health-related social needs social determinants of health youth risk behavior survey

Introduction

Most U.S. high school students do not get the recommended amount of sleep on school nights, and this shortfall has widened over the past decade (Centers for Disease Control and Prevention, 2024b). The Youth Risk Behavior Survey asks students how many hours they sleep on an average school night, and CDC classifies fewer than 8 hours as insufficient sleep for this age group. The threshold is clinically recognizable and useful for surveillance, but the ordinal distribution still matters: very short sleep may carry different risks than sleep that falls just below the recommended range. Short or disturbed sleep is associated with poorer mental health, suicidal behaviors, and neurocognitive development concerns (Marino et al., 2021; Wang et al., 2024; Yang et al., 2022). Sleep is therefore a clinical and prevention concern, not only a school-policy issue.

Family context may shape whether adolescents can obtain adequate school-night sleep. The 2023 national YRBS added a protective-experiences item asking whether an adult in the household tried hard to ensure basic needs such as safety, clean clothes, and enough to eat (Centers for Disease Control and Prevention, 2024a; Verlenden et al., 2024). The item captures adolescents’ perceived reliability of adult effort, and nothing more. It is not a measure of household income, caregiver warmth, or bedtime structure. A household that reliably meets these needs may also have more stable routines, lower material strain, or adult monitoring, but those mechanisms are not measured by this item and should be treated as explanatory context.

Bedtime routine and evening structure are not the same construct: a household may reliably ensure food, clothing, and safety and still lack the calmer evenings associated with longer sleep. We therefore frame basic-needs support as a clinically interpretable marker of household context, not as proof that routine quality explains sleep differences. Related evidence links food insecurity, parent-adolescent bedtime or waketime interactions, and school-start-time policies with sleep outcomes, but the present analysis tests only one cross-sectional YRBS exposure (de Camargo et al., 2024; Ewing et al., 2024; Yip et al., 2022).

We tested whether lacking household basic-needs support is associated with insufficient sleep in the 2023 national YRBS. We emphasize prevalence ratios, adjusted risk differences, and confidence intervals, because the outcome is common and odds ratios can overstate effect size. We also report the ordinal sleep distribution descriptively, so the binary under-8-hour outcome can be interpreted against the broader sleep pattern.

Methods

Study design and data source. We analyzed public-use, de-identified 2023 national YRBS high-school data. The national YRBS uses a three-stage cluster sample of students in grades 9–12 in U.S. public and private schools (Brener et al., 2024; Centers for Disease Control and Prevention, 2024a). In 2023, 155 of 311 sampled schools participated; 20,103 usable questionnaires were available (school response 49.8%, student 71.0%, overall 35.4%). The school-based frame supports inference to students enrolled in participating public and private schools, not to adolescents outside school or in exclusively online or asynchronous programs unless sampled through the YRBS school frame. Analyses used CDC design variables for weight, stratum, and primary sampling unit to mitigate selection and nonresponse bias (Lumley, 2010). Sample size was fixed by the 2023 national YRBS frame; we did not perform an a priori power calculation.

Measures. Insufficient sleep was coded from Q85/QN85 as fewer than 8 hours on an average school night, consistent with CDC surveillance definitions and pediatric sleep guidelines (Paruthi et al., 2016). The ordinal sleep item was retained for descriptive context and ranged from 4 or fewer hours to 10 or more hours. Household basic-needs support was coded from Q99/QN99 as support present for most of the time/always, and support lacking for never/rarely/sometimes. The wording asks about an adult in the household trying hard to ensure safety, clean clothes, and enough food; it does not measure household income, food insecurity severity, or caregiver relationship quality. Covariates were sex, grade, CDC bridged race/ethnicity, physical activity, current alcohol use, depressive symptoms, and BMI percentile.

Statistical analysis. Weighted descriptive estimates used records with nonmissing sleep and support. Because per-variable missingness was non-trivial (insufficient sleep 11.0%, basic-needs support 16.9%, BMI percentile 11.8%), we used multiple imputation by chained equations (m = 20; mice package, van Buuren & Groothuis-Oudshoorn, 2011) under a missing-at-random assumption conditional on the imputation model as the primary analysis, and report a complete-case model as a sensitivity check. The imputation model included the outcome, the exposure, all covariates, and the YRBS survey-design variables; estimates were pooled by Rubin’s rules. Reported p-values use Wald z-tests on the log scale for aPR and on the linear scale for ARD; multiply-imputed estimates apply Rubin’s-rules pooling. Survey-design weights, stratum, and primary sampling unit were applied within each imputed dataset (Lumley, 2010). Adjusted prevalence ratios (aPRs) were estimated with modified Poisson regression (Zou, 2004), and adjusted risk differences (ARDs, percentage points) by marginal standardization. The focal contrast was support lacking versus support present.

Ethics. The analysis used de-identified public-use data and was determined exempt from human-subjects review by the authors’ institutional review board. Full ethics details are provided on the title page. Reporting follows the STROBE statement for cross-sectional studies (von Elm et al., 2007). This study was not pre-registered; the focal contrast and analysis plan were prespecified in the archived analytic script (yrbs2023_focal_final.R) prior to model fitting.

Results

Among 17,441 students with nonmissing sleep data, 13,435 reported fewer than 8 hours of sleep; the weighted prevalence was 76.8% (95% CI 75.0 to 78.6). The ordinal sleep distribution showed that insufficient sleep was not concentrated only near the 8-h threshold: 8.8% reported 4 or fewer hours, 14.4% reported 5 hours, 25.0% reported 6 hours, 28.6% reported 7 hours, 17.6% reported 8 hours, 4.1% reported 9 hours, and 1.5% reported 10 or more hours. The binary outcome is therefore CDC-aligned while still reflecting wide variation in sleep duration. Very short sleep (5 hours or fewer) was reported by 22.4% of students with household basic-needs support present and 35.6% of those with support lacking, indicating that the elevation among students lacking support was concentrated in the very-short-sleep range as well as the conventional under-8-hour threshold.

The sleep/support analytic frame included 15,607 students: 13,462 with support present and 2,145 with support lacking. Insufficient sleep was more common among students lacking support (82.0%) than among those with support present (76.0%). Table 1 summarizes selected sample characteristics by support group. Grade rows describe how the support-present and support-lacking groups are composed by grade, rather than grade-specific sleep effects. Table 2 reports the adjusted focal estimates, and Figure 1 visualizes their direction, magnitude, and uncertainty.

Table 1.

Selected Characteristics by Household Basic-Needs Support

Characteristic	Category	Support present n	Support present %	Support lacking n	Support lacking %
Total	All	13,462	86.3	2,145	13.7
Sex	Female	6,630	48.0	1,054	46.9
Sex	Male	6,775	51.7	1,070	52.3
Grade	9th	3,752	26.6	594	25.7
Grade	10th	3,684	25.8	558	24.3
Grade	11th	3,238	23.6	522	23.6
Grade	12th	2,743	23.7	448	25.2
Race/ethnicity	Black or African American	1,357	13.8	245	17.3
Race/ethnicity	Hispanic/Latino	2,746	25.8	594	34.4
Race/ethnicity	White	6,534	49.0	815	37.4
Race/ethnicity	Other/multiple groups	2,663	10.2	458	10.0

Note. Total row reports weighted support distribution; other percentages are weighted within support category. Grade rows are descriptive, not grade-specific sleep effects. Per-covariate missingness counts are provided in Supplemental Table S2A. Other/multiple groups combines American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and multiple races (non-Hispanic). Percentages may not sum to 100% because of weighting and missingness.

Table 2.

Sleep Prevalence and Adjusted Focal Association

Quantity	Analysis n	Estimate
Sleep nonmissing overall	n = 17,441	76.8% insufficient sleep (95% CI 75.0 to 78.6)
Support present	n = 13,462	76.0% insufficient sleep
Support lacking	n = 2,145	82.0% insufficient sleep
Adjusted prevalence ratio (MI primary, m = 20)	n = 15,607	1.052 (95% CI 1.007 to 1.098); p = .022
Adjusted risk difference (MI primary, pp)	n = 15,607	+4.3 (95% CI + 0.5 to +8.1); p = .028
Adjusted prevalence ratio (complete-case sensitivity)	n = 13,465	1.036 (95% CI 0.990 to 1.085); p = .126

Note. Models adjusted for sex, grade, race/ethnicity, physical activity, current alcohol use, depressive symptoms, BMI percentile, and YRBS design. The primary insufficient-sleep prevalence (76.8%) has a Taylor-linearization standard error of approximately 0.92 percentage points, corresponding to a design effect of about 8 for this three-stage clustered sample.

Figure 1.

Primary adjusted association of lacking household basic-needs support with insufficient sleep. Note. Points show estimates; bars show 95% confidence intervals. MI = multiple imputation; aPR = adjusted prevalence ratio; ARD = adjusted risk difference; pp = percentage points

In the multiply-imputed primary model (n = 15,607), support lacking was associated with a small, statistically detectable increase in insufficient sleep (aPR = 1.052, 95% CI 1.007 to 1.098; p = .022; ARD = +4.3 percentage points, 95% CI + 0.5 to +8.1; p = .028). A complete-case sensitivity model (n = 13,465) gave a comparable point estimate with a wider, null-spanning interval (aPR = 1.036, 95% CI 0.990 to 1.085; p = .126; ARD = +3.0 percentage points, 95% CI -0.9 to +6.9; p = .130). These estimates are consistent with a modest adverse association of small magnitude.

Discussion

In this national cross-sectional sample, students who perceived less reliable adult effort to meet basic needs were also more likely to sleep fewer than 8 hours on school nights. The association remained after multiply imputed adjustment but was small (aPR = 1.052, 95% CI 1.007 to 1.098); the complete-case sensitivity estimate pointed in the same direction but was less precise. Students who perceived less reliable adult effort to meet basic needs also carried a slightly higher burden of insufficient sleep, but the estimate is not evidence of a large independent effect.

The exposure item requires a narrow reading. It reflects an adolescent’s report that an adult in the household made strong efforts to meet basic needs; it does not directly measure household income, food security, caregiving skill, bedtime routines, or sleep opportunity. That distinction matters because short sleep may arise through several pathways, not through a single socioeconomic, caregiving, or sleep-opportunity mechanism. A caregiver may provide food, clothing, safety, and emotional effort, and still be unable to protect sleep when shift work, transportation, crowded housing, neighborhood safety, or school timing run in the other direction. CDC work similarly treats sleep as socially patterned across family, school, community, and structural levels, rather than solely as an individual behavior (Wheaton & Claussen, 2021). Pairing youth appraisal with caregiver report and more specific social-needs measures would help separate perceived effort from material adequacy, household routine, and environmental constraint.

The ordinal sleep distribution places this finding in a wider public-health frame. AASM, endorsed by the AAP, recommends 8 to 10 hours per 24 hours for adolescents aged 13 to 18 and links adequate sleep with attention, learning, emotional regulation, physical and mental health, and safety (Paruthi et al., 2016). CDC YRBS trend data show that in 2023 only about one in four high school students reported at least 8 hours on an average school night, with declines from 2013 to 2023 (Centers for Disease Control and Prevention, 2024b). The 8-h threshold is therefore clinically recognizable and aligned with surveillance practice; this cut point compresses meaningful variation in adolescent sleep. Very short sleep, weekday-weekend discrepancies, sleep timing, regularity, sleep quality, and daytime sleepiness may each carry distinct clinical and social implications.

The result is useful as a case-finding signal, not a predictive one. Asking adolescents about both school-night sleep and household basic-needs support during routine visits could surface students who may benefit from care navigation, family support, behavioral sleep counseling, or school-based services. This implication is consistent with pediatric social-needs screening literature, which emphasizes linking screening to feasible referrals rather than treating screening as an intervention by itself (Sokol et al., 2019). International evidence from Taiwanese adolescents supports the plausibility of hardship-sleep clustering (Lee et al., 2021), but this study did not test food insecurity, material hardship trajectories, or intervention effects.

Limitations. The cross-sectional design rules out directional inference. Insufficient sleep could shape how adolescents rate household support, and unmeasured stressors could push both in the same direction. Both focal variables were single-item self-reports collected through an anonymous school-based survey. Generalizability is bounded by the YRBS sampling frame and the 35.4% overall response rate, although CDC weights account for selection, oversampling, and nonresponse to the extent possible (Brener et al., 2024). Broader strategies such as later school start times are relevant to adolescent sleep promotion (American Academy of Pediatrics, 2014; Yip et al., 2022), but they remain contextual here; the analysis did not test school schedules, transportation, employment, or asynchronous schooling. Future longitudinal and mixed-methods studies should measure family routines, material hardship, caregiving reliability, school timing, sleep quality, and sleep timing together.

The likely direction and magnitude of bias warrant explicit discussion. Reverse causation is plausible: adolescents with insufficient sleep may evaluate household effort less favorably, which would tend to overstate the cross-sectional aPR as an estimate of any prospective effect of household support on sleep. Residual confounding by parental work hours, household structure, screen environment, and neighborhood safety could move the estimate in either direction. Given the modest association, however, the observed aPR of 1.052 could plausibly attenuate toward the null under typical confounding scenarios. CDC weighting partially addresses nonresponse in the setting of the 35.4% overall response rate, but residual nonresponse bias may remain. If students with both low household support and short sleep were less likely to be present on survey administration days, the remaining bias would most likely attenuate the association.

Conclusions. Lacking perceived household basic-needs support marked a modestly higher prevalence of insufficient school-night sleep in a national sample of adolescents. The adjusted association was small but detectable, and sensitivity results were directionally consistent. These findings should not be read as evidence that improving perceived support alone would lengthen sleep. They do, however, support a practical clinical stance: adolescents who report insufficient sleep may also warrant brief, respectful assessment of basic-needs support and referral options. The clearest next step is longitudinal work that can separate family effort from material hardship, household routines, and structural sleep opportunity.

Supplemental Material

Supplemental material - Household Basic Needs Support and Insufficient Sleep Among United States High School Students: Evidence from the 2023 National Youth Risk Behavior Survey

Supplemental material for Household Basic Needs Support and Insufficient Sleep Among United States High School Students: Evidence from the 2023 National Youth Risk Behavior Survey by Sasha R. Sioni, Nishka Jakkidi, Claudia Morales, Rachel D. Clarke, Onelia G. Lage in Clinical Child Psychology and Psychiatry.

Footnotes

ORCID iD

Sasha R. Sioni

Ethical Considerations

This study involved secondary analysis of de-identified 2023 national Youth Risk Behavior Survey microdata and met criteria for exemption under 45 CFR 46.104(d) (4). The project was reviewed and exempted by the Florida International University Institutional Review Board on May 21, 2025 (reference #115946).

Consent to Participate

This study is a secondary analysis of de-identified public-use survey data with no direct contact with participants.

Consent for Publication

No identifiable individual person’s data, images, videos, or case-level descriptions are included.

Author Contributions

Sasha R. Sioni, DBH, MPH, LMHC: Conceptualization; Methodology; Software; Formal analysis; Visualization; Writing - original draft; Writing - review and editing; Supervision.

Rachel D. Clarke, PhD: Conceptualization; Methodology; Writing - review and editing.

Nishka Jakkidi: Data curation; Investigation; Writing - review and editing.

Claudia Morales: Data curation; Validation; Writing - review and editing.

Onelia G. Lage, MD: Supervision; Resources; Writing - review and editing.

All authors approved the final manuscript and agree to be accountable for its content.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Public-use, de-identified 2023 national YRBS microdata and documentation are available from the Centers for Disease Control and Prevention Youth Risk Behavior Surveillance System Data and Documentation portal. Project materials will be deposited in the Open Science Framework repository (OSF project identifier x5w8b) upon acceptance for publication.*

Preprint

The authors have not posted this manuscript to a preprint server.

Artificial Intelligence Disclosure

AI tools were not used to generate analysis code, statistical results, scientific writing in the manuscript body, or citations. The authors reviewed, revised, and verified the final content, analyses, citations, and interpretations and retain full responsibility for the submitted work.

Supplemental Material

Supplemental material for this article is available online.

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