J Sleep Res.

(2013) 22, 549–556 Adolescents and insomnia

Sleep patterns and insomnia among adolescents:

a population-based study
MARI HYSING1,2, STÅLE PALLESEN3,4, KJELL M. STORMARK1,6,
A S T R I J . L U N D E R V O L D 1 , 2 , 7 and B Ø R G E S I V E R T S E N 5 , 6
1
The Regional Centre for Child and Youth Mental Health and Child Welfare, Uni Health, Uni Research, Bergen, Norway, 2Department of
Biological and Medical Psychology, University of Bergen, Bergen, Norway, 3Department of Psychosocial Science, University of Bergen, Bergen,
Norway, 4Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway, 5Division of Mental Health,
Norwegian Institute of Public Health, Bergen, Norway, 6Department of Clinical Psychology, University of Bergen, Bergen, Norway and 7K. G.
Jebsen Centre for Research on Neuropsychiatric Disorders, University of Bergen, Bergen, Norway

Keywords SUMMARY
adolescents, epidemiology, insomnia, The aim of the current study was to examine sleep patterns and rates of
prevalence, sleep
insomnia in a population-based study of adolescents aged 16–19 years.
Correspondence Gender differences in sleep patterns and insomnia, as well as a
Dr Mari Hysing, Centre for Child and Adolescent comparison of insomnia rates according to DSM-IV, DSM-V and
Mental Health and Welfare, Postbox 7810, 5020 quantitative criteria for insomnia, were explored. We used a large
Bergen, Norway.
population-based study in Hordaland county in Norway, conducted in
Tel.: +55-58-86-98;
fax: +47-55-58-98-78; 2012. The sample included 10 220 adolescents aged 16–18 years (54%
e-mail: mari.hysing@uni.no girls). Self-reported sleep measurements included bedtime, rise time,
time in bed, sleep duration, sleep efficiency, sleep onset latency, wake
Accepted in revised form 8 March 2013;
after sleep onset, rate and frequency and duration of difficulties initiating
received 18 January 2013
and maintaining sleep and rate and frequency of tiredness and
DOI: 10.1111/jsr.12055 sleepiness. The adolescents reported short sleep duration on weekdays
(mean 6:25 hours), resulting in a sleep deficiency of about 2 h. A
majority of the adolescents (65%) reported sleep onset latency exceed-
ing 30 min. Girls reported longer sleep onset latency and a higher rate of
insomnia than boys, while boys reported later bedtimes and a larger
weekday–weekend discrepancy on several sleep parameters. Insomnia
prevalence rates ranged from a total prevalence of 23.8 (DSM-IV
criteria), 18.5 (DSM-V criteria) and 13.6% (quantitative criteria for
insomnia). We conclude that short sleep duration, long sleep onset
latency and insomnia were prevalent in adolescents. This warrants
attention as a public health concern in this age group.

of mental health problems (Cousins et al., 2011) as well as

INTRODUCTION
During adolescence a range of biological, psychological and
social factors interact, resulting in shortened sleep duration,
in what has been characterized as ‘the perfect storm’
(Carskadon, 2011). Secular trends suggest that sleep defi-
ciency and sleep problems are increasing among adoles-
cents (Matricciani et al., 2012; Pallesen et al., 2008). As this
shortened sleep duration is not accompanied by a reduction
in sleep need during adolescence, a large proportion of
adolescents experience sleep deficiency or insufficient sleep
(Fallone et al., 2002), with possible negative consequences
in terms of reduced daytime functioning and school perfor-
mance (for a review, see Dewald et al., 2010), increased risk
increased risk of traffic accidents (Danner and Phillips, 2008).
Insufficient sleep has been defined as the duration of sleep
below which waking deficits begin to accumulate (van
Dongen et al., 2003), whereas sleep need has been defined
as habitual sleep duration in the absence of pre-existing
sleep debt (Dement and Grenber, 1966). Most studies rely
solely upon sleep duration as an indicator of insufficient
sleep, which may be inaccurate due to large variations in
individual sleep need (Mercer et al., 1998). Others have
defined insufficient sleep as sleep duration far below age-
expected norms (Pallesen et al., 2011) or ask explicitly
whether and to what degree the respondent has not obtained
enough sleep (Altman et al., 2012). Perhaps a better

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550 M. Hysing et al.
approach to making it possible to express the magnitude of
insufficient sleep is to calculate the discrepancy between
self-reported sleep and perceived sleep need. This approach
has also been used in previous studies (Hublin et al.,
2001).
Adolescent sleep is characterized by a large discrepancy
between weekdays and weekend sleep patterns, including a
sleep phase shift to later bedtimes as well as an average of 1
and 2 h longer sleep durations during weekends (Crowley
et al., 2007; Gradisar et al., 2011a). While adolescent sleep
phase delay is well documented (Taylor et al., 2005), less is
known about the time it takes adolescents to fall asleep, as
assessment of sleep onset latency (SOL) is seldom included
in general population-based studies. In a recent review of
studies on sleep patterns among adolescents, only three
single studies assessed SOL. These showed that between
20 and 26% of the samples took more than 30 min to fall
asleep (Gradisar et al., 2011b). An Icelandic study reported
an average SOL of 16.8 min among adolescents (Thorleifs-
dottir et al., 2002). The authors proposed that the definition of
an acceptable/normal SOL may differ between adults and
adolescents. This issue has not been resolved, and inclusion
of SOL as a central sleep parameter in future studies of sleep
among adolescents is therefore recommended (Gradisar
et al., 2011b).
Prolonged SOL is also a defining characteristic of insomnia.
The exact rate of insomnia among adolescents is uncertain
(Roane and Taylor, 2008) due to large variations in opera-
tionalization across studies, thus complicating comparisons.
In a European general population study of adolescents aged
between 15 and 18 years, a 4% prevalence rate of insomnia
according to the DSM-IV criteria was found (Ohayon et al.,
2000). An American population-based study reported a
10.7% lifetime prevalence of insomnia according to the
DSM-IV criteria, including a frequency criterion of 4 days a
week (Johnson et al., 2006). The proposed revision in the
DSM-V concerning insomnia disorder will probably affect the
estimated prevalence, as it adds a minimum frequency
criterion of 3 days to the diagnosis and increases the minimal
duration threshold from 1 to 3 months. Similarly, estimated
prevalence rates are different when using the suggested
quantitative criteria for insomnia, recommending an opera-
tionalization of insomnia based on a thorough review of the
literature in order to identify the most valid criteria (Lichstein
et al., 2003). These criteria specify a SOL of more than
30 min, and insomnia occurring on three or more nights a
week for at least 6 months. The prevalence of insomnia using
the new proposed DSM-V definition or the quantitative criteria
has, to our knowledge, not been assessed previously in
population samples of adolescents.
While no gender differences in prepubertal children in
insomnia rates were found, a more than twofold risk for
insomnia was found in postmenes girls compared to boys in
an American population-based study using the DSM-IV
diagnostic criteria (Johnson et al., 2006). However, there
are few studies regarding gender differences in insomnia in
adolescence, and potential gender differences based on
DSM-V and research criteria for insomnia in adolescence
have, to the best of our knowledge, not been investigated.
Based on the above considerations, the aim of the present
study was to characterize sleep patterns in adolescence,
including gender differences, in a large population-based
study. The second aim was to assess the rate of insomnia
according to the definitions of DSM-IV, DSM-V and quanti-
tative criteria for insomnia, analysed separately for girls and
boys.
METHODS
In this population-based study, we employed information
from the ung@hordaland survey of adolescents in the county
of Hordaland in western Norway. All adolescents born
between 1993 and 1995 and all students attending second-
ary education during spring 2012 were invited to participate in
the ung@hordaland survey, the main aim of which was to
assess mental health problems and service use in adoles-
cents, with a special emphasis on the prevalence of mental
health problems. The data were collected during spring 2012.
Adolescents in upper secondary education received informa-
tion via e-mail, and one school hour was allocated for them to
complete the questionnaire at school. Those not at school
received information by postal mail to their home addresses.
The questionnaire was web-based, and covered a broad
range of mental health issues, daily life functioning, use of
health care and social services, demographic background
variables and a request for permission to obtain school data,
and to link the information with national health registries and
parental questionnaires. Uni Health collaborated with Horda-
land County Council in conducting of the study. The study
was approved by the Regional Committee for Medical and
Health Research Ethics in western Norway. The current
study is based on the first version of data files released in
May 2012.
Sample
All adolescents born between 1993 and 1995 (n = 19 430)
were invited to participate in the current study, which took
place during the first months of 2012, 10 220 of whom
agreed, yielding a participation rate of 53%. Sleep variables
were checked for validity of answers based on preliminary
data analysis, resulting in 374 subjects being omitted due to
obvious invalid responses (e.g. negative sleep duration and
sleep efficiency). Thus, the total sample size in the current
study was 9875.
Instruments
Demographic information
All participants indicated their vocational status, with
response options being ‘high school student’, ‘vocational
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training’ or ‘not in school’. Maternal and paternal education
were reported separately, with four response options:
‘primary school’, ‘secondary school’, ‘college or university:
less than 4 years’ and ‘college or university: 4 years or
more’.
Sleep variables
Self-reported bedtime and rise time were reported sepa-
rately for weekends and weekdays. Time in bed (TIB) was
calculated by subtracting bedtime from rise time. SOL and
WASO were reported in hours and minutes, and sleep
duration was defined as TIB minus SOL and WASO.
For the purpose of the present study, sleep duration was
also split into ten categories (<4, 4–5, 5–6, 6–7, 7–8, 8–9,
9–10, 10–11, 11–12 and >12 h). Sleep efficiency was
calculated as sleep duration divided by TIB multiplied by
100 (reported as a percentage). Subjective sleep need
was reported in hours and minutes, and sleep defi-
ciency was calculated separately for weekends and week-
days, subtracting total sleep duration from subjective sleep
need.
Difficulties initiating and maintaining sleep (DIMS) were
rated on a three-point Likert scale, with response options of
‘not true’, ‘somewhat true’ and ‘certainly true’. Given a
positive response (‘somewhat true’ or ‘certainly true’), the
participants were then asked how many days per week they
experienced problems either initiating or maintaining sleep.
The participants also provided information on the duration of
DIMS.
A joint question on tiredness/sleepiness was rated on a
three-point Likert-scale with response options of ‘not true’,
‘somewhat true’ and ‘certainly true’. If confirmed (‘somewhat
true’ or ‘certainly true’), participants reported the number of
days per week on which they experienced sleepiness and
tiredness, respectively.
Three operationalizations of insomnia were investigated
(see Table 1). All three definitions included a positive
response (‘somewhat true’ or ‘certainly true’) to (i) DIMS
and (ii) sleepiness and/or tiredness (see above). In addition,
to fulfil the criteria for DSM-IV insomnia, duration of DIMS for
at least 1 month was also required. For DSM-V insomnia, the
following additional criteria were required: a DIMS frequency
of at least 3 days per week and duration of insomnia of at
least 3 months. The quantitative criteria for insomnia (Lich-
stein et al., 2003) were operationalized as follows: reporting
DIMS at least three times a week, with a duration of 6 months
or more, in addition to reporting SOL and/or WASO of more
than 30 min.
Statistics
IBM SPSS version 20 (SPSS Inc., Chicago, IL USA) for
Windows was used for all analyses. Multivariate analysis of
variance (MANOVA) was used to examine gender and age
differences on the sleep variables, as well as interaction
effects between age and gender. Chi-square tests were
used to examine differences in sleep duration (10 different
duration categories) between weekdays and weekends.
Gender differences in insomnia prevalence were estimated
using logistic regression analyses using gender as the
exposure variables and the three insomnia definitions (DSM-
IV insomnia, DSM-V insomnia and quantitative criteria for
insomnia) as outcome variables. To investigate whether
gender differences were significantly different across the
three operationalizations, we also calculated the relative risk
ratio (RRR), as recommended by Altman and Bland (2003),
in order to test for significant differences between the odds
ratios. This is a well-established test of interaction to
compare estimates on a log scale.
Table 2 Demographical variables in the ung@hordaland study
(n = 9846)
Mean SD
Age (years) 17.0 0.87

% n

Girls 53.5 5215

Table 1 Overview of the insomnia diagnosis in DSM-IV, the
Vocational situation
proposed revision in DSM-V and the quantitative criteria for
High school student 97.9 9219
insomnia
Vocational training 1.4 132
Duration Frequency Not in school 0.7 67
of of SOL and Daytime Maternal education
insomnia insomnia WASO functioning Primary school 7.7 742
Secondary school 31.4 3042
Diagnostic criteria for insomnia College/university (<4 years) 15.2 1469
DSM-IV 1 month None Not Not College/university (4+ years) 21.8 2112
specified specified Paternal education
DSM-V 3 months 3 nights/ Not X Primary school 7.9 763
week specified Secondary school 34.7 3343
Quantitative >6 months 3 nights/  31 min X College/university (<4 years) 9.5 920
criteria week College/university (4+ years) 22.7 2186

SOL, sleep onset latency; WASO, wake after sleep onset. SD, standard deviation.

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552 M. Hysing et al.

RESULTS
Of the adolescents born between 1993 and 1995 (with a
mean age of 17 years), 53.5% of the participants were girls;
the majority comprised high school students (98%). For
details and information on socioeconomic status and demo-
graphic information, see Table 2.
Fig. 2 for details). SOL was significantly longer for girls than
boys (P < 0.001). Mean WASO was 15 min, and 79% of the
adolescents reported less than 15 min WASO. Mean sleep
efficiency during weekdays was 85%, with girls (84%) having
lower sleep efficiency than boys (87%). Higher sleep
efficiency was observed at the weekend, but with similar
gender differences (88% versus 90% for girls and boys,
respectively (P < 0.001).

Sleep patterns
Bedtime, rise time, TIB and sleep duration for the total
sample, stratified by gender, are presented in Table 3. The
mean bedtime on weekdays was 23:18 hours, significantly
later for boys (23:56) than girls (23:10). Mean TIB for
weekdays was 7:29 hours (boys: 7:26 and girls: 7:32),
whereas mean sleep duration was 6:25 hours (boys: 6:28
and girls: 6:22).
Bedtime during weekends was, on average, 2 h and
25 min later than on weekdays (01:13), while the corre-
sponding rise time discrepancy was 4 h and 28 min, reflect-
ing that the adolescents slept on average 2 h and 12 min
more during weekends than on weekdays. Both rise- and
bedtime discrepancies between weekdays and weekends
were significantly larger for boys than girls (P < 0.001).
Distribution of sleep duration on weekdays and at weekends
are presented in Fig. 1.
The adolescents’ subjective sleep need was 8 h and
35 min, yielding a sleep deficiency on weekdays of 2 h and
9 min. No sleep deficiency was found for weekends.
Insomnia
The prevalence of insomnia was calculated for the total
sample and separately for the two gender groups using three
different definitions. All insomnia definitions included an algo-
rithm of difficulties initiating and/or maintaining sleep and
tiredness and/or sleepiness during daytime. The prevalence
estimates ranged from a total prevalence of 23.8%, using the
DSM-IV criteria, to 18.5% according to the proposed DSM-V
criteria, expanding the duration from 1 to 3 months and
including frequency criteria of 3 days per week (See Fig. 3).
According to the quantitative criteria for insomnia, the
prevalence was 13.6%. Girls had a significantly higher
prevalence of insomnia across all three insomnia definitions,
but there were no significant differences in the magnitude of
gender differences between the three diagnostic criteria, as
calculated by the RRR (all 95% confidence intervals included
the value 1.0).
Age, gender and interaction effects

Significant gender differences were found for most sleep

SOL, WASO and sleep efficiency
variables, as detailed in Table 3. There was a significant age
Mean SOL was 47 min, with 24.2% reporting SOL less than effect on some sleep variables, with the youngest age
15 min and 59% reporting SOL longer than 30 min (see cohorts reporting earlier bedtimes and rise times both on

Table 3 Sleep characteristics in the ung@hordaland study (n = 9846)

Girls Boys Total

Mean SD Mean SD P-value Mean SD

Weekdays
Bedtime 23:10 0:57 23:26 1:01 <0.001 23:18 0:59
Rise time 6:42 0:40 6:53 0:41 <0.001 6:47 0:41
Time in bed 7:32 1:01 7:26 1:02 <0.001 7:29 1:01
Sleep duration 6:22 1:40 6:28 1:37 0.006 6:25 1:39
Sleep efficiency (%) 84.2 18.0 86.6 17.2 <0.001 85.3% 17.7
Weekends
Bedtime 1:17 1:22 1:52 1:34 <0.001 1:33 1:29
Rise time 11:06 1:24 11:26 1:38 <0.001 11:15 1:31
Time in bed 9:48 1:19 9:34 1:26 <0.001 9:41 1:23
Sleep duration 8:39 1:50 8:35 1:52 0.018 8:37 1:51
Sleep efficiency (%) 88.0 13.8 89.6 13.5 <0.001 88.7% 13.7
Weekdays/weekends
Sleep onset latency 0:51 0:58 0:43 0:56 <0.001 0:47 0:57
Wake after sleep onset 0:17 0:38 0:12 0:40 <0.001 0:15 0:39
Subjective sleep need 8:43 1:43 8:26 2:03 <0.001 8:35 1:54

P-level indicates significant differences between girls and boys. SD, standard deviation.

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Figure 1. Sleep duration on weekdays and at weekends. Error bars represent 95% confidence intervals.
Figure 2. Sleep onset latency (SOL) and wake after sleep onset (WASO) among adolescents in the ung@hordaland study (n = 9846).
weekdays and at weekends, and also sleeping longer at
weekends. The youngest cohort also spent more TIB, had
larger subjective sleep need, had more sleep deficiency
during weekdays and reported less insomnia than older
adolescents (all Ps < 0.001). There were no significant age
differences in SOL, WASO and sleep efficiency.
Few significant interaction effects between age and gender
were observed, except for bedtime, rise time and TIB during
weekdays (all Ps < 0.001). For example, while TIB increased
with age for girls, a corresponding decrease with age was
observed for boys (P < 0.001).
DISCUSSION
To sum up the main findings: sleep patterns of adolescents
between 16 and 19 years were characterized by late
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Sleep in adolescence 553
bedtimes, long SOL and a short sleep duration, contributing
to a daily sleep deficiency of about 2 h on weekdays. A high
rate of insomnia was evident across the diagnostic defini-
tions, with total prevalence ranging from 23.8% using the
DSM-IV criteria to 18.5% according to the proposed DSM-V
criteria and to 13.6% using the quantitative criteria for
insomnia. Girls had a significantly higher prevalence of
insomnia than boys across all three insomnia definitions.
Information about sleep patterns during weekdays revealed
late bedtimes. Rise time on school days showed limited
variations, due probably to the fact that most of the
adolescents were high school students with fixed and early
school starting times. To obtain the recommended sleep
duration of 8–9 h, which was also in accordance with their
self-perceived sleep need, they should have gone to bed at
around 22:00 hours. At weekends, their sleep duration was in
554 M. Hysing et al.
Figure 3. Prevalence of insomnia according to different operationalizations, stratified by gender. Error bars represent 95% confidence intervals.
accordance with their subjective sleep need, with a shift
towards later bedtime of more than 2 h and an even later rise
time. The adolescent’s sleep pattern in the present study
confirmed sleep phase delays and the late bedtimes reported
in previous studies of adolescents (Crowley et al., 2007;
Gradisar et al., 2011b).
The mean sleep duration of approximately 6½ h on
weekdays shown in the present study is, however, shorter
than that reported in most previous studies. One reason
could be differences in definitions, methods and samples
between our and other studies of adolescent sleep duration.
For example, in the Ohayon study the mean sleep duration
in a European sample of 15–18-year-olds was approxi-
mately 8 h (Ohayon et al., 2000). This was methodologically
comparable to the present study, as both calculated sleep
duration by subtracting sleep latency from bedtime. Other
studies have used more dissimilar definitions. We have, for
example, defined sleep duration by subtracting reported
wake time (SOL and WASO), whereas results from many
previous studies are based on TIB only. In their review of
international sleep studies, Gardiner et al. suggested that
the reported sleep duration was probably overestimated by
about a quarter of an hour. The review of international sleep
studies (Gradisar et al., 2011b) suggested that the sleep
duration reported in their overview was probably over-
estimated, as it was calculated based on the SOL in an
icelandic study that reported SOL of about 15 minutes
(Thorleifsdottir, et al., 2002). Mean SOL was 47 min in the
present study, which is more than twice as much as
reported previously in studies of SOL in adolescents
(Gradisar et al., 2011b), and a considerably longer mean
SOL than reported in the aforementioned Icelandic study
(Thorleifsdottir et al., 2002). The fact that the SOL was
longer in the present study than in most previous studies
may reflect cohort effects. This interpretation is in line with
studies showing a secular increase in the proportion of
adolescents reporting sleep onset difficulties (Pallesen
et al., 2008).
Another possible reason for the observed discrepancies
between the findings in the current and previous studies may
be seasonal variations in terms of daylight illumination during
the time of data collection. The data in the current study were
collected from February to May 2012, and while we cannot
rule out a possible seasonal influence on our data, a recent
study from Norway investigating seasonal variation in insom-
nia and sleep duration found no evidence of such a seasonal
effect (Sivertsen et al., 2011).
The adolescents reported a mean sleep need of between 8
and 9 h. While there are individual differences, the mean
reported sleep need in the present study is in accordance
with the empirically derived suggested sleep need in
adolescents of about 8–9 h (Carskadon et al., 1980). In the
present study, their sleep duration is in accord with their
subjective sleep need during weekends, as they probably do
not have such specific demands or obligations in the
morning. This underscores that the sleep duration during
weekdays are too short. As short sleep duration is known to
be related to a range of impairments in terms of academic
functioning (Dewald et al., 2010), overweight (Danielsen
et al., 2010), depressive symptoms and mental health
problems in general (Cousins et al., 2011), there are reasons
to be concerned about the sleep habits of the majority of
adolescents included in the present study.
There was a high rate of insomnia in the present study,
ranging from 13.6% to 23.6%, depending on diagnostic
criteria. The paucity of studies assessing insomnia in
adolescents and the different definitions used hinders com-
parisons across studies, but the prevalence is higher than the
estimated rates of between 4 and 10% reported in previous
studies using DSM-IV insomnia criteria (Johnson et al., 2006;
Ohayon et al., 2000). Another potential limitation in the DSM-IV
definitions concerns the independence of co-occurring psychi-
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atric disorders. While the DSM-IV differentiates between
primary insomnia and insomnia related to another disorder,
we have not differentiated between these subtypes in order to
ease comparison with the other diagnostic systems. Another
limitation of the present study relates to the exclusive use of
questionnaire-based information. Thus, diagnostic interview
data, the gold standard for diagnosing insomnia, was not
collected, but we relied instead upon a broad range of
questionnaire-based sleep parameters that were used in
accordance with specific diagnostic definitions. The criteria
for daytime functional impairment in the present study were
tiredness and sleepiness assessed by a joint variable.
Although sleepiness is used more commonly as a symptom
of obstructive sleep apnea, we chose to include both tiredness
and sleepiness in the operationalization of insomnia due to a
large overlap of these terms in the Norwegian language and
due to limited ability in lay-people to discriminate between the
two constructs.
A final limitation relates to how sleep duration was
calculated. No data on time awake in bed prior to putting
the light out and lying awake prior to rising were collected,
and thus TIB – (SOL + WASO) might also include such
periods. This may, potentially, lead to sleep duration being
even shorter than reported in the current study.
The present study has shown that prevalence rates are
influenced strongly by the quantitative operationalization and
definitions of insomnia. While including a cutoff for SOL and a
longer duration of the symptoms based on the quantitative
criteria for insomnia, nevertheless a high percentage (13.6%)
was diagnosed with insomnia. While this could mirror the high
rate of true insomnia in adolescents, it could also reflect the
need for adjustment of some of the criteria related to the
respondents’ age/maturation, for instance. The cutoff
(>30 min) for SOL used in the research criteria is based on
epidemiological studies of adults. In adolescence, a long
SOL seems to be the norm and may reflect pubertal-related
delayed circadian rhythms (Taylor et al., 2005) as well as
pubertal slowing of the homeostatic sleep drive build-up
(Jenni et al., 2005). Thus, the appropriate cutoff for SOL in
determining insomnia in adolescents has still not been
settled. Nocturnal awakenings seems to be less frequent in
adolescents, thus the present criterion (>30 min) might be
acceptable. As the present study indicates, the duration
criteria will have only minor effects on the prevalence rates as
most of the adolescents report insomnia for more than
1 year. Based on the present study, we cannot decide what
is the most accurate or optimal operationalization. How these
definitions are related to outcome measures in terms of
functioning/impairment, other co-occurring disorders and the
associated level of distress should, in future, be used as
guidelines for choosing the most useful definitions.
Gender differences emerged regarding sleep patterns and
insomnia prevalences irrespective of insomnia definition,
showing a considerable female preponderance. This is in
accord with findings in some previous studies, especially the
gender-typical pattern of higher insomnia rates after puberty
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Sleep in adolescence 555
in girls (Johnson et al., 2006). While the results support the
importance of gender-specific analysis in this age group, the
mechanisms leading to these differences are, by and large,
unknown. While the shorter TIB and shorter sleep duration
found in boys could be due to the lower perceived sleep
need that they reported in the present study, the differences
could also be related to later pubertal development in boys,
as there was an interaction effect of gender and age on
some sleep patterns; e.g. bedtime and rise time during
weekdays. However, there was no interaction effect
between age and gender on insomnia and sleep efficiency,
and thus pubertal developmental levels are less likely to
account for these differences. As insomnia and lying awake
in bed has been found to be related to worrying and
depressive symptoms, some of the gender differences in
sleep efficacy, SOL and WASO may be related to the
parallel increased rate of depression in girls after puberty
(Danielsson et al., 2012).
The strengths of the present study include the combination
of large sample size and inclusion of a broad range of sleep
parameters. The attrition from the study could affect gener-
alizability, with a response rate of approximately 53% and
with adolescents in schools over-represented. Based on
previous research from the former waves of the Bergen Child
Study, non-participants often have more psychological prob-
lems than participants (Stormark et al., 2008).
How can we help adolescents to achieve a sleep duration
in agreement with their self-perceived need, and also their
need according to recommended guidelines? The magni-
tude of the problem demonstrated in the present study
indicates that short sleep duration is a public health issue.
The results from previous school-based sleep education
intervention studies for adolescents show positive effects on
knowledge, but not on basic sleep habits (Cain et al., 2011;
Moseley and Gradisar, 2009). In addition, the adolescents in
the present study seem to be aware of the discrepancy
between their obtained sleep during weekdays and their
sleep need. In an Australian study, parent-set betimes were
found to be related to longer sleep duration and improved
daytime functioning, suggesting that parents may be key in
improving adolescents sleep (Short et al., 2011). However,
as this was an observational study, further intervention
studies are needed. Few older adolescents will probably
regard such an approach as acceptable, as fewer than 10%
of high school students seem to have their bedtimes set by
parents (Carskadon and Acebo, 2002). On a societal level,
later school starting times have been suggested as a means
of improving adolescents sleep (Carrell et al., 2011; Danner
and Phillips, 2008; Kirby et al., 2011; Vedaa et al., 2012).
More research is needed to both pinpoint the mechanisms
leading to short sleep, including the effect of electronic media
(Cain and Gradisar, 2010). The current findings emphasize
that sleep problems among adolescents are a significant
public health concern, and that low-threshold interventions
and prevention programmes should be targeted for this age
group.
556 M. Hysing et al.

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Johnson, E. O., Roth, T., Schultz, L. and Breslau, N. Epidemiology of
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