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Sleep Sci. 2019 Jul-Sep; 12(3): 138–146.
This article has been cited by other articles in PMC.
Keywords: sleep deprivation, sleep quality, adolescent, gender and health, health behaviour
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Sleep is of upmost importance for everybody and especially for adolescents who face life and leisure challenges that may impair their sleep. This study aimed to verify if girls are at a higher risk to present sleep problems and if associations of a sleep perception are different between sexes even when accounting for biological maturation.
Data is from the HBSC Portuguese survey 2014, all variables were self-reported. Participants were 3869 adolescents (2057 girls), mean age 14.8 years. Participants' socio-demographic characteristics included sex, age, school grade, father and mother education; besides participants were inquired about sleep duration and characteristics of their sleep quality.
Sleep deprivation was reported by 13.1% of the adolescents (girls 14.3%, boys 11.7%, p <0.05). The most prevalent characteristics of poor sleep quality were waking up tired (50.8%) and difficulties falling asleep (19.5%), for both girls presented higher prevalence than boys. Overall, girls presented a poorer sleep health with low quality and quantity of sleep. Furthermore, associations of an enough and good sleep were different between boys and girls, even when controlling for the impact of delayed pubertal maturity.
Together with screen time, substance use, poorer nutrition, sedentary behaviours and abuse of screen time, sleep is an issue that must be addressed by professionals, families and public policies with impact in family life and family routines. Modelling a health education in schools should include the sleep topic. In addition, yes, sex matters and must be included on board.
Sleep is fundamental for health and quality of life 1 , 2 . In spite of recent recommendations 3 it may be difficult to determine the adequate sleep need for adolescents 4 , but it is possible to describe specific features of disturbed sleep that can compromise optimal daytime functioning, including mainly poor sleep quality, difficulty falling asleep and waking up frequently during the night 5 . These aspects may result in daytime sleepiness and further sleep disorders, bringing more difficulties when dealing with academic, social and emotional demands and putting at risk a healthy development 6 .
The biological and social changes that occur during adolescence can disrupt health and behaviour, including sleep 7 . For instance, screen time is pointed out as having a harmful effect on young people's sleep 8 , 9 . Furthermore, during adolescence the central circadian clock starts to shift later, i.e., there is a phase delay 10 . Additionally, one important factor influencing the sleep of adolescents are the school schedules, namely the school starting time, that together with other factors such as circadian phase delay, bedtime autonomy, academic pressure, screen time and social networking, nudges adolescents to late bedding and early rising 11 . Also, higher sedentary time, higher adiposity markers and increased and inadequate food intake are associated with short sleep duration 12 . Adolescents with less-healthy sleeping patterns have lower scores on emotional, social, school, psychosocial functioning, and global quality of life 6 , 13 , and adolescents who are sleep deprived experience less positive and more negative effects 14 , 15 . Sleeping less than recommended for adolescents is also linked to symptoms of depression and lower self-esteem 16 . Most investigations about adolescents' sleep show a pattern of later sleep timing and reduced sleep duration as they grow older with a tendency to increase sleep debt along pubertal stages 4 , 17 . In spite of contradictory results in the past, this epidemic of sleep deprivation during adolescence appears to be present both in younger and older teenagers, and in boys and girls 18 .
Since early adolescence, studies have shown that there are sex differences in sleep quality and quantity 19 - 21 , with girls reporting more complains about poor sleep than boys. It is suggested that girls' poor sleep may be related with psychological issues, such as depression and anxiety symptoms, and emotion-focused coping strategies, regardless of age 19 . Furthermore, differences can also be associated with consumption of caffeine or other substances, since more girls than boys drink caffeine drinks after dinner 21 . When looking at sex differences in adolescents' sleep, researchers have found that girls have more irregular sleep patterns, with longer time in bed, more sleep time and later wake up times than boys during weekends 22 . These differences appear to be related with female higher pubertal stages when compared to boys of the same chronological age, evidencing the already described association between puberty and sleep mechanisms. Lee et al. 23 have demonstrated that girls had significant earlier wake times during weekdays than boys and that they were more likely to report daytime sleepiness or even falling asleep more easily during the afternoon. However, there were no sex differences in self-reported difficulty falling asleep and daytime sleepiness.
Regarding sex differences in the circadian phase preference, there are contradictory results that may be related with changes in sexual hormones production 24 . The tendency for eveningness is probably linked with the release of sexual hormones, which can explain the rapid progression of this chronotype in adolescents. Roenneberg et al. 25 have already stated that women have their peak of eveningness earlier than men, supporting the notion that sexual hormones may play an important role in circadian regulation of sleep. Both boys and girls have later bedtimes across higher pubertal stages and there are some evidence sustaining the hypothesis of a greater influence of puberty in the adolescent sleep phase delay, more than psychosocial factors which appear to be less influential regarding phase preference 26 . However, some psychosocial factors like light exposure, such as screen time, at night are also suggested to have an essential role on phase delay of adolescents 8 , 9 . This pattern appears to be more significant in girls, although it could be related to methodological issues since some female samples present higher percentage of advanced stages of maturation than boys 26 . Notwithstanding, some studies have not found any sex differences in sleep complaints and patterns, suggesting a sociocultural influence that can minimize biological sleep regulatory processes 27 . Looking at sleep structure 28 it appears that girls spend less time in rapid eye movement (REM) sleep, have lower REMs activity and lower REMs density. There is still much to learn about a sex related framework of adolescent sleep patterns, since studies have reported conflicting results when comparing boys and girls 28 . Furthermore, it is important to recognize that the need for sleep appears to be relatively stable across adolescents' development in spite of all the developmental changes and sex differences 18 .
The underlying mechanisms that can explain the differences between sexes are not clear 29 , 30 . However, biological maturation, levels of physical activity, excessive use to electronic equipment, eating habits and substance consumption may explain the differences 31 , 32 . Therefore, this study aimed to verify if girls are at a higher risk to present sleep problems both in quantity and quality of sleep, and if associations of a good or a poor sleep perception are different between boys and girls either considering the comparison of same age boys and girls either introducing an age gap to balance delayed puberty in boys (2 years).
The present study uses data from the Health Behaviour in School-Aged Children (HBSC) Portuguese survey 2014 33 . HBSC is a nationally representative school-based survey on health behaviours and lifestyles and their context in young people conducted every four years 34 . The HBSC Portuguese database comprises a representative sample of 6026 adolescents. However, for this study only students from grades 8 and 10 were selected, because the questions about sleep were only addressed to them, according to the national survey design, meaning students from grade 6 were therefore excluded (n=2157). The final sample consisted of 3869 adolescents (2057 girls 53.2%, 1812 boys 46.8%), aged 13-19 years old (mean age=14.8±1.2).
Public schools were randomly selected from a nationwide list, stratified geographically by administrative and educational regional divisions, and a self-administered questionnaire was applied to the students. The administration of the survey was conducted by trained teachers during class time, according to standard guidelines from the HBSC survey protocol 34 . Written consent from school administrators, legal guardians, and adolescents was previously obtained. Participation was voluntary, anonymous, and there were no incentives to participation. Research was conducted in accordance with both the Ethical Committee of Oporto Medical School and the National Data Protection System.
All variables were self-reported. Participants' socio-demographic characteristics included sex, age, school grade, father education and mother education (response options: no education, primary school, middle school, secondary school and superior education). Adolescents were asked to report sleep deprivation and frequency of some characteristics of their sleep quality, such as sleeping less than wanted, having difficulties falling asleep, waking up tired and waking up in the middle of the night. It was inquired how many hours of sleep they have the nights before school days and the nights before non-school days (weekends). Sleep deprivation was defined as the difference between the reported hours of sleep before non-school days (weekend), minus the reported hours of sleep before school days: Sleep deprivation was considered when that difference was 3 hours or more 6 , 35 - 37 .
As for characteristics of
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6932838/
https://www.cdc.gov/healthyschools/features/students-sleep.htm
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