Adolescents who were homeschooled during a COVID-19 lockdown slept longer on school days and drank less alcohol and caffeine than before the pandemic, according to a cross-sectional online survey of nearly 9,000 students in Switzerland.
Researchers found that longer sleep durations were associated with better health-related quality of life among the participants. However, these gains were offset by an increase in depressive symptoms during the COVID-19 lockdown period.
“Although negative associations of COVID-19 pandemic high school closures with adolescents’ health have been demonstrated repeatedly, some research has reported a beneficial association of these closures with adolescents’ sleep,” Joëlle N. Albrecht, MSc, of the Child Development Center at the University Children’s Hospital Zurich in Switzerland, and colleagues wrote in JAMA Network Open. “The present study was, to our knowledge, the first to combine both perspectives.”
The researchers analyzed survey responses from 5,308 students (65.1% girls) that were collected in 2017 as well as survey responses from 3,664 students (66.3% girls) that were collected during a partial COVID-19 lockdown in 2020. The median age of both cohorts was 16 years. Since depression symptoms were not assessed in the pre-pandemic group, the researchers conducted a subsample analysis to ascertain if there was a link between sleep duration and health-related characteristics.
Albrecht and colleagues reported that students who were surveyed during the lockdown slept a median of 75 minutes longer than students who were surveyed before the pandemic (semipartial R2 statistic [R2*] = 0.238; 95% CI, 0.222-0.254) and experienced better health-related quality of life (R2* = 0.007; 95% CI, 0.004-0.012), drank less caffeine (R2* = 0.01; 95% CI, 0.006-0.015) and drank less alcohol (R2* = 0.014; 95% CI, 0.008-0.022). Further analyses revealed significant associations between longer sleep times and better health-related quality of life (R2* =0.027; 95% CI, 0.02-0.034) and lower caffeine consumption (R2* =0.013; 95% CI, 0.009-0.019).
In the lockdown cohort, the prevalence of depressive symptoms was 4.5 times higher than “the expected level of 2%,” with 9.1% of students having clinically relevant levels of depressive symptoms, the researchers wrote. An inverse association was found between depressive symptoms and health-related quality of life (R2* = 0.285; 95% CI, 0.26-.0311) and a positive link was found with caffeine consumption (R2* = 0.003; 95% CI, 0-0.008).
The researchers said that the most important limitation to their study was its pseudo-longitudinal approach.
“The two samples consisted of students from mostly the same schools, and it is likely that some students participated in both samples,” they wrote. “However, because the surveys were answered anonymously, quantification or even paired analysis was not possible. Therefore, the data only allowed investigation of associations between measures, not the investigation of associations among changes or causality.”
According to the researchers, other study limitations included differences between the two cohorts, the passage of 3 years (and the potential increase in digital media use) between surveys and the lack of information on survey participants’ specific school start and stop times during the partial lockdown.
Even so, “the findings suggest that school closures allowed students to better align their sleep schedules with adolescents’ late sleep phase,” Albrecht and colleagues wrote. “Of most importance, to our knowledge, this study provides the first scientific evidence for the beneficial sleep-related associations of school closures with adolescents’ health … [and] provides further support for delaying [school start times] in countries with early [school start times].”
PERSPECTIVE
Cora Collette Breuner, MD, MPH
Better, longer sleep is protective against a number of health issues. This study by Albrecht and colleagues, in which a mostly homogeneous, teenaged Swiss population got more sleep during the pandemic than before it, shows the importance of a good night’s sleep in preventing some negative health consequences in the short term (eg, lower alcohol consumption, decreased caffeine consumption) and trending towards lower depression scores.
I was on the AAP’s Adolescent Sleep Working Group when the AAP published recommendations on the issues of inadequate sleep. These recommendations included pushing for later school start times. Many schools now have later school start times but not all have pivoted in this direction. Over the 7 years since that AAP publication, sleep in teenagers has continued to suffer. We also know that behavioral and mental health issues have been on the rise in adolescents before the COVID pandemic began.
In this study by Albrecht and colleagues, teens who received about 1 hour more of sleep nightly were less likely to drink alcohol or caffeine or be depressed. Layer the Albrecht and colleagues’ findings on top of the existing data that support later school times and there is a sounder, more valid argument for later school start times. We should continue to push for later school start times to improve sleep quality and quality of life for school-aged children and teenagers.
Reference:
Owens J. Pediatrics. 2014; doi:10.1542/peds.2014-1696.Cora Collette Breuner, MD, MPHSpokesperson, AAP
Physician, division of adolescent medicine and orthopedics and sports medicine, Seattle Children’s Hospital
Professor of pediatrics and adjunct professor of orthopedics and sports medicine, University of Washington School of MedicineDisclosures: Breuner reports no relevant financial disclosures.
PERSPECTIVE
Carol L. Rosen, MD
Albrecht and colleagues’ study about sleep duration and health in Swiss teenagers with homeschooling during COVID-19 high school closures is a “good news/bad news” story.
The good news is that during pandemic lockdown, teens got more sleep on school nights. With those 75 minutes of extra sleep time, they got up to 9 hours! These sleep gains translated into better health-related quality of life with less caffeine and alcohol use. The bad news is that these pandemic-related sleep gains were offset by the appearance of depressive symptoms with worsening health-related quality of life. The prevalence of depressive symptoms in teens increased more than fourfold during the lockdown period.
These findings may be of no surprise to some physicians. Studies of later school start times consistently show that increasing sleep improves adolescent health. At the same time, pandemic-related school lockdowns show a negative impact on teen mental health and well-being. However, this study adds a unique perspective by modeling several factors at the same time. The findings confirm longer sleep duration as a key driver of improved health-related quality of life in teens. However, these sleep gains can be canceled out by other life-disrupting changes related to the pandemic like school closures.
Most physicians understand that sleep is essential for optimal health in adolescents. However, some providers may not be aware that more than two-thirds of U.S. teens are short on sleep, getting less than 7 hours on school nights. The American Academy of Sleep Medicine recommends that teens 13 to 18 years of age should sleep 8 to 10 hours per 24 hours on a regular basis to promote optimal health and daytime alertness. Regularly sleeping fewer than the recommended number of hours is associated with injury-related risk behaviors, school and learning problems, hypertension, obesity, diabetes, depression and risk for self-harm.Carol L. Rosen, MDSpokesperson, American Academy of Sleep Medicine
Board member, American Academy of Sleep Medicine and American Academy of Sleep Medicine Foundation
Pediatric sleep medicine specialist and professor of pediatrics (emerita),
Case Western Reserve University School of Medicine, Cleveland
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