Elsevier

Sleep Medicine

Volume 53, January 2019, Pages 1-8
Sleep Medicine

Original Article
Excessive daytime sleepiness among children and adolescents: prevalence, correlates, and pubertal effects

https://doi.org/10.1016/j.sleep.2018.08.028Get rights and content

Highlights

  • Excessive daytime sleepiness is prevalent among children and adolescents.

  • The prevalence of sleepiness dramatically increases with age and pubertal maturation.

  • Female-predominance of sleepiness emerges after mid-puberty.

  • Puberty and sex moderate sleepiness through interaction with time in bed and chronotype.

  • Sleepiness is independently associated with an array of mental and behavioral problems.

Abstract

Objectives

To examine the prevalence and correlates of excessive daytime sleepiness (EDS) among Hong Kong children and adolescents. We investigated the potential roles of sex and puberty in modulating the occurrence of EDS.

Methods

A total of 10,086 students (male, 48.1%) aged 6–18 (mean ± SD: 12.3 ± 3.2) years old participated in this cross-sectional survey. EDS was defined by a total score >18 on the Pediatric Daytime Sleepiness Scale. Sociodemographic characteristics, time in bed, chronotypes, sleep problems, emotional and behavioral difficulties, mental health, and pubertal stages were assessed.

Results

The overall prevalence of EDS was 29.2%, and increased from 19.8% at Tanner stage 1 (pre-puberty) to 47.2% at Tanner stage 5 (post-puberty). Female predominance emerged at Tanner stage 3 (mid-puberty). EDS was significantly associated with short weekday time in bed, both long and short weekend time in bed, eveningness chronotype, insomnia symptoms, and sleep-disordered breathing symptoms. Females were more likely to have short weekday time in bed and eveningness chronotype than males. Children and young adolescents at pre and mid-puberty were protected against EDS by morningness chronotype. EDS was independently associated with daytime napping, alcohol and energy beverage consumption, emotional and behavioral difficulties, as well as poor mental health even after adjusting for potential confounding factors.

Conclusions

EDS is prevalent among children and adolescents with the emergence of female preponderance at mid-puberty and independent association with pervasive adverse emotional and behavioral problems. The mechanisms underlying the modulation effects of sex and puberty on EDS merit further investigation.

Introduction

Excessive daytime sleepiness (EDS) is a global major health concern affecting up to 40% of children and adolescents [1], [2]. As EDS significantly increases with age during adolescence [1], it suggests that puberty may play a critical role in the development of EDS. Puberty is a critical period for a transition from childhood to adulthood, associated with changes in sleep structure [3], delayed circadian phase [4], and increased sleep disturbances including insomnia [5]. Conversely, the etiology of EDS is likely to be complex and interrelated [6], [7], as it may be associated with insufficient sleep [8], [9], [10], eveningness chronotype [4], sleep disturbances [11], and lifestyle factors (eg, electronics use) [12]. Nonetheless, the detailed interactions of puberty with these multiple factors, especially on the occurrence of EDS during adolescence remain unclear.

There has been a consistent female predominance of sleep problems and EDS among adolescent and adult population, but not in children [13], [14], [15], [16]. In this regard, it was reasonable to hypothesize the emergence of female predominance of EDS at some time point during pubertal maturation, albeit there was no current supporting data. However, EDS in the young population is tightly associated with mood dysregulation, behavioral problems, and substance misuse [9], [17], [18], [19]. As insomnia and eveningness chronotype are also found to be associated with mood and behavioral problems [5], [18], [20], it remains unclear whether the association of EDS with these adverse health consequences is independent of those of sleep and chronotype effects.

Thus, we hypothesized that the prevalence of EDS might increase along with pubertal development during which sex difference in EDS emerges. We aimed (1) to explore the prevalence of EDS across pubertal stages and determine the time point at which sex differences emerge; (2) to investigate the correlates of EDS in terms of demography, time in bed, sleep problems, chronotype, daytime activities, lifestyle factors, and mental health consequences; and (3) to investigate the potential interactive effects of sex and puberty with time in bed and chronotype on the occurrence of EDS.

Section snippets

Study design, procedure, and sample recruitment

The present study was part of a large-scale sleep education program (Healthy Sleep, Healthy School Life) which involved students from 31 primary and secondary schools in Hong Kong [21], [22]. Ethical approval was obtained from the Joint CUHK-NTEC clinical research ethics committee (reference no: CRE-2011.249-T). The data collected in this study were from a cross-sectional survey [5], [21]. Baseline questionnaires, a consent form for both parent(s)/caregiver(s), and individual assent were packed

The prevalence of EDS across pubertal stages and its demographic and biological correlates

A total of 19,341 students were eligible to participate in this study, of which 10,671 (55.2%) returned the questionnaires between December 2011 and March 2012. Among the respondents, a total of 10,086 (94.5%) children and adolescents (male, 48.1%) aged from 6 to 18 years old (mean age: 12.3 ± 3.2 years) had a valid PDSS score, and 7373 (69.1%) had both a valid PDSS and Tanner pubertal stage assessment.

EDS was found in 29.2% of the total sample, with a significant gender difference (24.4% in

Discussions

The present large-scale community-based study revealed that EDS was prevalent among children and adolescents in Hong Kong. The prevalence of EDS progressively increased with pubertal maturation, with the emergence of the female preponderance of EDS at mid-puberty. EDS was significantly associated with short weekday time in bed, short and long weekend time in bed, eveningness chronotype, insomnia symptoms, and SDB related symptoms. Furthermore, there was an interaction between puberty and

Conclusion

EDS is prevalent among children and adolescents, with a progressive increase across pubertal maturation. Given that a constellation of complex and interrelated factors may contribute to the high prevalence of EDS, there is a need for families, educational authorities, and health professionals to foster a healthy environment for enhancing sleep health literacy, promoting adequate sleep habits and practices among growing children and adolescents.

Disclosure statement

This was not an industry supported study.

Funding/support

This project was supported by Public Policy Research of the University Grants Committee (Reference number: CUHK4012-PPR-11), Hong Kong SAR, China. Dr. YP Liu was partially supported by the Faculty Postdoctoral Fellowship Scheme of the Chinese University of Hong Kong. The funding body had no role in the conception, design, conduct, interpretation, or analysis of the study nor in the approval of the publication.

Author contributions

Dr. YP Liu conceptualized and conducted the data analyses, drafted the initial manuscript, reviewed and revised the manuscript. Dr. YK Wing conceptualized and designed the study, supervised all the aspects of the research project and critically reviewed the manuscript. Drs. JH Zhang and SX Li managed the data, conducted the data analyses and critically reviewed the manuscript. Ms. NY Chan, Ms. MWM Yu, and Dr. SP Lam designed the data collection instruments, and coordinated and supervised data

Acknowledgment

The authors wish to thank all the principals and teachers of participating schools for approving and accommodating the implementation of the program. We also would like to thank all the parents, teachers and students who participated in the study.

References (62)

  • N. Cain et al.

    Electronic media use and sleep in school-aged children and adolescents: a review

    Sleep Med

    (2010)
  • Y. Liu et al.

    Help-seeking behaviors for insomnia in Hong Kong Chinese: a community-based study

    Sleep Med

    (2016)
  • M.H. Hagenauer et al.

    The neuroendocrine control of the circadian system: adolescent chronotype

    Front Neuroendocrinol

    (2012)
  • N.Y. Chan et al.

    Impact of a modest delay in school start time in Hong Kong school adolescents

    Sleep Med

    (2017)
  • K.F. Chung et al.

    Sleep-wake patterns and sleep disturbance among Hong Kong Chinese adolescents

    Sleep

    (2008)
  • E.S. Gibson et al.

    "Sleepiness" is serious in adolescence: two surveys of 3235 Canadian students

    BMC Public Health

    (2006)
  • I.M. Colrain et al.

    Changes in sleep as a function of adolescent development

    Neuropsychol Rev

    (2011)
  • S.F. Gau et al.

    The transition of sleep-wake patterns in early adolescence

    Sleep

    (2003)
  • J. Zhang et al.

    Emergence of sex differences in insomnia symptoms in adolescents: a large-scale school-based study

    Sleep

    (2016)
  • School start times for adolescents

    Pediatrics

    (2014)
  • J. Zhang et al.

    Roles of parental sleep/wake patterns, socioeconomic status, and daytime activities in the sleep/wake patterns of children

    J Pediatr

    (2010)
  • J. Owens

    Insufficient sleep in adolescents and young adults: an update on causes and consequences

    Pediatrics

    (2014)
  • L. Fricke-Oerkermann et al.

    Prevalence and course of sleep problems in childhood

    Sleep

    (2007)
  • C.J. Calamaro et al.

    Adolescents living the 24/7 lifestyle: effects of caffeine and technology on sleep duration and daytime functioning

    Pediatrics

    (2009)
  • B. John

    Sleep duration and daytime sleepiness in indian adolescents: is there a gender difference?

    Indian J Pediatr

    (2014)
  • C.K. Yang et al.

    Age-related changes in sleep/wake patterns among Korean teenagers

    Pediatrics

    (2005)
  • E. Lindberg et al.

    Sleep disturbances in a young adult population: can gender differences be explained by differences in psychological status?

    Sleep

    (1997)
  • S.L. Calhoun et al.

    Prevalence and risk factors of excessive daytime sleepiness in a community sample of young children: the role of obesity, asthma, anxiety/depression, and sleep

    Sleep

    (2011)
  • J.A. Owens et al.

    Impact of delaying school start time on adolescent sleep, mood, and behavior

    Arch Pediatr Adolesc Med

    (2010)
  • F. Giannotti et al.

    Circadian preference, sleep and daytime behavior in adolescence

    J Sleep Res

    (2002)
  • Y.K. Wing et al.

    A school-based sleep education program for adolescents: a cluster randomized trial

    Pediatrics

    (2015)
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