The sleep-deprived human brain.

How does a lack of sleep affect our brains? In contrast to the benefits of sleep, frameworks exploring the impact of sleep loss are relatively lacking. Importantly, the effects of sleep deprivation (SD) do not simply reflect the absence of sleep and the benefits attributed to it; rather, they reflect the consequences of several additional factors, including extended wakefulness. With a focus on neuroimaging studies, we review the consequences of SD on attention and working memory, positive and negative emotion, and hippocampal learning. We explore how this evidence informs our mechanistic understanding of the known changes in cognition and emotion associated with SD, and the insights it provides regarding clinical conditions associated with sleep disruption.

Sleep Problems and Autism Impairments in a Large Community Sample of Children and Adolescents.

Sleep problems are common in individuals with autism spectrum disorder (ASD). How sleep problems reflect specific ASD phenotypes is unclear. We studied whether sleep problems indexed functional impairment in a heterogeneous community sample of individuals with ASD. We analyzed 977 probands (233 females; age = 11.27 ± 4.13 years) from the Rhode Island Consortium for Autism Research and Treatment dataset, a unique public-private-academic collaboration involving all major points of service for families in Rhode Island. We found that individuals with a confirmed diagnosis of ASD were more likely to have sleep problems. However, across the whole sample and above and beyond a formal diagnosis, sleep problems were dimensionally associated with worse social impairment and poorer adaptive functioning. By using a large dataset reflective of the diversity of presentations in the community, this study underscores the importance of considering sleep problems in clinical practice to improve adaptive functioning in individuals with ASD.

Genome-wide DNA methylation patterns associated with sleep and mental health in children: a population-based study.

BACKGROUND: DNA methylation (DNAm) has been implicated in the biology of sleep. Yet, how DNAm patterns across the genome relate to different sleep outcomes, and whether these associations overlap with mental health is currently unknown. Here, we investigated associations of DNAm with sleep and mental health in a pediatric population. METHODS: This cross-sectional study included 465 10-year-old children (51.3% female) from the Generation R Study. Genome-wide DNAm levels were measured using the Illumina 450K array (peripheral blood). Sleep problems were assessed from self-report and mental health outcomes from maternal questionnaires. Wrist actigraphy was used in 188 11-year-old children to calculate sleep duration and midpoint sleep. Weighted gene co-expression network analysis was used to identify highly comethylated DNAm 'modules', which were tested for associations with sleep and mental health outcomes. RESULTS: We identified 64 DNAm modules, one of which associated with sleep duration after covariate and multiple testing adjustment. This module included CpG sites spanning 9 genes on chromosome 17, including MAPT - a key regulator of Tau proteins in the brain involved in neuronal function - as well as genes previously implicated in sleep duration. Follow-up analyses suggested that DNAm variation in this region is under considerable genetic control and shows strong blood-brain concordance. DNAm modules associated with sleep did not overlap with those associated with mental health. CONCLUSIONS: We identified one DNAm region associated with sleep duration, including genes previously reported by recent GWAS studies. Further research is warranted to examine the functional role of this region and its longitudinal association with sleep.

Naturalistic, multimethod exploratory study of sleep duration and quality as predictors of dysregulated eating in youth with overweight and obesity.

Although poor sleep has been found to adversely impact eating and weight regulation in youth, past research is limited by retrospective reporting and/or non-naturalistic designs. We investigated the feasibility of combining three momentary, ecologically valid approaches to assessing sleep and eating behavior, and associations between these constructs, among youth (aged 8-14y) with overweight/obesity (n = 40). Participants completed 14 overlapping days of actigraphy assessment and smartphone-based ecological momentary assessment (EMA) of eating behavior, of which 3 days also included computerized, self-guided 24-h dietary recall. Feasibility of completing measures concurrently was evaluated by generating frequencies of compliance. Associations between sleep indices and next-day eating behavior were examined via generalized estimating equations. Of 29 participants who provided EMA and 24-h recall data that aligned with previous night actigraphy data, both EMA and sleep data were available on an average of 8.6 out of 14 possible days, and both 24-h recall and sleep data on an average of 2.7 out of 3 possible days. Each additional hour of sleep was associated with consuming fewer calories from solid fats, alcohol, and added sugars (b = 0.70; p = .04). Combining naturalistic, momentary assessments of sleep and eating behavior appears to be acceptable in youth. Larger experimental studies are needed to further understand associations between sleep parameters and eating behavior.

White Matter Structure in Older Adults Moderates the Benefit of Sleep Spindles on Motor Memory Consolidation.

Sleep spindles promote the consolidation of motor skill memory in young adults. Older adults, however, exhibit impoverished sleep-dependent motor memory consolidation. The underlying pathophysiological mechanism(s) explaining why motor memory consolidation in older adults fails to benefit from sleep remains unclear. Here, we demonstrate that male and female older adults show impoverished overnight motor skill memory consolidation relative to young adults, with the extent of impairment being associated with the degree of reduced frontal fast sleep spindle density. The magnitude of the loss of frontal fast sleep spindles in older adults was predicted by the degree of reduced white matter integrity throughout multiple white matter tracts known to connect subcortical and cortical brain regions. We further demonstrate that the structural integrity of selective white matter fiber tracts, specifically within right posterior corona radiata, right tapetum, and bilateral corpus callosum, statistically moderates whether sleep spindles promoted overnight consolidation of motor skill memory. Therefore, white matter integrity within tracts known to connect cortical sensorimotor control regions dictates the functional influence of sleep spindles on motor skill memory consolidation in the elderly. The deterioration of white matter fiber tracts associated with human brain aging thus appears to be one pathophysiological mechanism influencing subcortical-cortical propagation of sleep spindles and their related memory benefits.SIGNIFICANCE STATEMENT Numerous studies have shown that sleep spindle expression is reduced and sleep-dependent motor memory is impaired in older adults. However, the mechanisms underlying these alterations have remained unknown. The present study reveals that age-related degeneration of white matter within select fiber tracts is associated with reduced sleep spindles in older adults. We further demonstrate that, within these same fiber tracts, the degree of degeneration determines whether sleep spindles can promote motor memory consolidation. Therefore, white matter integrity in the human brain, more than age per se, determines the magnitude of decline in sleep spindles in later life and, with it, the success (or lack thereof) of sleep-dependent motor memory consolidation in older adults.

Sex, Sleep Deprivation, and the Anxious Brain.

Insufficient sleep is a known trigger of anxiety. Nevertheless, not everyone experiences these effects to the same extent. One determining factor is sex, wherein women experience a greater anxiogenic impact in response to sleep loss than men. However, the underlying brain mechanism(s) governing this sleep-loss-induced anxiety increase, including the markedly different reaction in women and men, is unclear. Here, we tested the hypothesis that structural brain morphology in a discrete network of emotion-relevant regions represents one such explanatory factor. Healthy participants were assessed across sleep-rested and sleep-deprived conditions, with brain structure quantified using gray matter volume measures. Sleep loss triggered greater levels of anxiety in women compared with men. Reduced gray matter volume in the anterior insula and lateral orbitofrontal cortex predicted the anxiogenic impact of sleep loss in women, yet predicted resilience in men, and did so with high discrimination accuracy. In contrast, gray matter volume in ventromedial prefrontal cortex predicted the anxiogenic impact of sleep loss in both men and women. Structural human brain morphology therefore appears to represent one mechanistic pathway (and possible biomarker) determining anxiety vulnerability to sleep loss-a discovery that may help explain the higher prevalence of sleep disruption and anxiety in women.

Human Hippocampal Structure: A Novel Biomarker Predicting Mnemonic Vulnerability to, and Recovery from, Sleep Deprivation.

Sleep deprivation impairs the formation of new memories. However, marked interindividual variability exists in the degree to which sleep loss compromises learning, the mechanistic reasons for which are unclear. Furthermore, which physiological sleep processes restore learning ability following sleep deprivation are similarly unknown. Here, we demonstrate that the structural morphology of human hippocampal subfields represents one factor determining vulnerability (and conversely, resilience) to the impact of sleep deprivation on memory formation. Moreover, this same measure of brain morphology was further associated with the quality of nonrapid eye movement slow wave oscillations during recovery sleep, and by way of such activity, determined the success of memory restoration. Such findings provide a novel human biomarker of cognitive susceptibility to, and recovery from, sleep deprivation. Moreover, this metric may be of special predictive utility for professions in which memory function is paramount yet insufficient sleep is pervasive (e.g., aviation, military, and medicine).

Stage 2 Sleep EEG Sigma Activity and Motor Learning in Childhood ADHD: A Pilot Study.

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in motor learning and sleep. In healthy adults, overnight improvements in motor skills are associated with sleep spindle activity in the sleep electroencephalogram (EEG). This association is poorly characterized in children, particularly in pediatric ADHD. Polysomnographic sleep was monitored in 7 children with ADHD and 14 typically developing controls. All children were trained on a validated motor sequence task (MST) in the evening with retesting the following morning. Analyses focused on MST precision (speed-accuracy trade-off). NREM Stage 2 sleep EEG power spectral analyses focused on spindle-frequency EEG activity in the sigma (12-15 Hz) band. The ADHD group demonstrated a selective decrease in power within the sigma band. Evening MST precision was lower in ADHD, yet no difference in performance was observed following sleep. Moreover, ADHD status moderated the association between slow sleep spindle activity (12-13.5 Hz) and overnight improvement; spindle-frequency EEG activity was positively associated with performance improvements in children with ADHD but not in controls. These data highlight the importance of sleep in supporting next-day behavior in ADHD while indicating that differences in sleep neurophysiology may contribute to deficits in this population.

Sleep Deprivation Impairs the Human Central and Peripheral Nervous System Discrimination of Social Threat.

Facial expressions represent one of the most salient cues in our environment. They communicate the affective state and intent of an individual and, if interpreted correctly, adaptively influence the behavior of others in return. Processing of such affective stimuli is known to require reciprocal signaling between central viscerosensory brain regions and peripheral-autonomic body systems, culminating in accurate emotion discrimination. Despite emerging links between sleep and affective regulation, the impact of sleep loss on the discrimination of complex social emotions within and between the CNS and PNS remains unknown. Here, we demonstrate in humans that sleep deprivation impairs both viscerosensory brain (anterior insula, anterior cingulate cortex, amygdala) and autonomic-cardiac discrimination of threatening from affiliative facial cues. Moreover, sleep deprivation significantly degrades the normally reciprocal associations between these central and peripheral emotion-signaling systems, most prominent at the level of cardiac-amygdala coupling. In addition, REM sleep physiology across the sleep-rested night significantly predicts the next-day success of emotional discrimination within this viscerosensory network across individuals, suggesting a role for REM sleep in affective brain recalibration. Together, these findings establish that sleep deprivation compromises the faithful signaling of, and the "embodied" reciprocity between, viscerosensory brain and peripheral autonomic body processing of complex social signals. Such impairments hold ecological relevance in professional contexts in which the need for accurate interpretation of social cues is paramount yet insufficient sleep is pervasive.

Impaired prefrontal sleep spindle regulation of hippocampal-dependent learning in older adults.

A hallmark feature of cognitive aging is a decline in the ability to form new memories. Parallel to these cognitive impairments are marked disruptions in sleep physiology. Despite recent evidence in young adults establishing a role for sleep spindles in restoring hippocampal-dependent memory formation, the possibility that disrupted sleep physiology contributes to age-related decline in hippocampal-dependent learning remains unknown. Here, we demonstrate that reduced prefrontal sleep spindles by over 40% in older adults statistically mediates the effects of old age on next day episodic learning, such that the degree of impaired episodic learning is explained by the extent of impoverished prefrontal sleep spindles. In addition, prefrontal spindles significantly predicted the magnitude of impaired next day hippocampal activation, thereby determining the influence of spindles on post-sleep learning capacity. These data support the hypothesis that disrupted sleep physiology contributes to age-related cognitive decline in later life, the consequence of which has significant treatment intervention potential.

Tired and apprehensive: anxiety amplifies the impact of sleep loss on aversive brain anticipation.

Anticipation is an adaptive process, aiding preparatory responses to potentially threatening events. However, excessive anticipatory responding and associated hyper-reactivity in the amygdala and insula are integral to anxiety disorders. Despite the co-occurrence of sleep disruption and anxiety disorders, the impact of sleep loss on affective anticipatory brain mechanisms, and the interaction with anxiety, remains unknown. Here, we demonstrate that sleep loss amplifies preemptive responding in the amygdala and anterior insula during affective anticipation in humans, especially for cues with high predictive certainty. Furthermore, trait anxiety significantly determined the degree of such neural vulnerability to sleep loss: individuals with highest trait anxiety showed the greatest increase in anticipatory insula activity when sleep deprived. Together, these data support a neuropathological model in which sleep disruption may contribute to the maintenance and/or exacerbation of anxiety through its impact on anticipatory brain function. They further raise the therapeutic possibility that targeted sleep restoration in anxiety may ameliorate excessive anticipatory responding and associated clinical symptomatology.

Altered sleep architecture following consecutive nights of presleep alcohol.

STUDY OBJECTIVES: Alcohol consumption before sleep decreases sleep latency, explaining the common use of alcohol as a sleep aid. The full impact of alcohol on sleep architecture is not well understood, particularly the potential cumulative effects of presleep alcohol consumption across consecutive nights. Here, we describe the effects of presleep alcohol on sleep architecture across three consecutive nights. METHODS: Thirty adult participants took part in a crossover, within-participants study consisting of two sets of three consecutive nights of in-lab polysomnography. For each series of nights, participants drank one of the two beverages: a mixer only or a mixer plus alcohol (targeting a BrAC of 0.08 mg/L), ending 1 hour before lights out. Polysomnography (PSG) was used to stage sleep, and standard sleep variables were extracted. Linear mixed-effect analysis and generalized additive modeling were used to examine the effect of alcohol on sleep architecture. RESULTS: Alcohol before sleep increased the rate of slow wave sleep (SWS) accumulation across all three nights and decreased the rate of rapid eye movement (REM) sleep accumulation at the start of each night. Alcohol also decreased the total amount of REM sleep but did not affect the total amount of SWS each night. CONCLUSIONS: These data indicate that drinking alcohol before sleep substantially affects sleep architecture, including changes to the rate of accumulation of SWS and REM sleep. We show that alcohol disrupts normal sleep architecture, leading to a significant decrease in REM sleep; thus, the use of alcohol as a sleep aid remains a public health concern.

The associations between instructional approach, sleep characteristics and adolescent mental health: Lessons from the COVID-19 pandemic.

OBJECTIVES: To test whether adolescents' mental health during the COVID-19 pandemic is associated with the combination of their instructional approach(es) and their sleep patterns. DESIGN: Cross-sectional. SETTING: Adolescents were recruited through social media outlets in October and November 2020 to complete an online survey. PARTICIPANTS: Participants were 4442 geographically and racially diverse, community-dwelling students (grades 6-12, 51% female, 36% non-White, 87% high schoolers). MEASUREMENTS: Participants completed items from the PROMIS Pediatric Depressive Symptoms and Anxiety scales. Participants reported their instructional approach(es), bedtimes, and wake times for each day in the past week. Participants were categorized into five combined instructional approach groups. Average sleep opportunity was calculated as the average time between bedtime and waketime. Social jetlag was calculated as the difference between the average sleep midpoint preceding non-scheduled and scheduled days. RESULTS: Emotional distress was elevated in this sample, with a large proportion of adolescents reporting moderate-severe (T-score ≥ 65) levels of depressive symptoms (49%) and anxiety (28%). There were significant differences between instructional approach groups, such that adolescents attending all schooldays in-person reported the lowest depressive symptom and anxiety T-scores (P < .001, ηp2 = .012), but also the shortest sleep opportunity (P < .001, ηp2 = .077) and greatest social jetlag (P < .001, ηp2 = .037) of all groups. Adolescents attending school in person, with sufficient sleep opportunity (≥8-9 hours/night) and limited social jetlag (<2 hours) had significantly lower depressive (ηp2 = .014) and anxiety (ηp2 = .008) T-scores than other adolescents. CONCLUSIONS: Prioritizing in-person education and promoting healthy sleep patterns (more sleep opportunity, more consistent sleep schedules) may help bolster adolescent mental health.

Instructional approach, sleep, and perceived academic well-being in adolescents during COVID-19: Evidence from the NESTED study.

OBJECTIVES: At the peak of COVID-19, adolescent life was disrupted as schools adapted their instructional approaches such as online, in-person, or hybrid instruction. We and others have previously commented on how these shifts facilitated longer, later and (more developmentally appropriate) sleep. Here, we report how sleep contributed to associations between remote instruction and broader academic well-being (e.g., cognitive function, school connectedness, and stress). METHODS: Adolescents from all 50 U.S. states (n = 4068) completed online self-report surveys in fall 2020. Instructional approach was operationalized from fully in-person instruction to fully asynchronous online education. Sleep parameters included sleep timing and duration, sleep disturbances, and sleep-related impairments. Perceived academic well-being was defined as cognitive function, school connectedness, and school-related stress. Sleep and perceived academic well-being are examined across instructional approaches, in their association, and in structural models. RESULTS: Sleep and perceived academic well-being differed between hybrid and online instruction groups. Less variable or disturbed sleep was associated both with in-person instruction, and with positive outcomes in cognitive function, school connectedness, and stress domains. Sleep mediated a substantial portion of variance in perceived academic well-being attributable to instructional approach. CONCLUSION: These data highlight the need to protect both healthy sleep and in-person instruction. Appropriate sleep timing and duration, fewer sleep disturbances and sleep-related impairments accounted for a substantial degree of variance in the association between remote instruction on academic outcomes. While many students experienced "lost learning" because of COVID-19, this study joins a broader discussion of ensuring developmentally appropriate school-start times to support both sleep and achievement.

Structural brain correlates of human sleep oscillations.

Sleep is strongly conserved within species, yet marked and perplexing inter-individual differences in sleep physiology are observed. Combining EEG sleep recordings and high-resolution structural brain imaging, here we demonstrate that the morphology of the human brain offers one explanatory factor of such inter-individual variability. Gray matter volume in interoceptive and exteroceptive cortices correlated with the expression of slower NREM sleep spindle frequencies, supporting their proposed role in sleep protection against conscious perception. Conversely, and consistent with an involvement in declarative memory processing, gray matter volume in bilateral hippocampus was associated with faster NREM sleep spindle frequencies. In contrast to spindles, gray matter volume in the homeostatic sleep-regulating center of the basal forebrain/hypothalamus, together with the medial prefrontal cortex, accounted for individual differences in NREM slow wave oscillations. Together, such findings indicate that the qualitative and quantitative expression of human sleep physiology is significantly related to anatomically specific differences in macroscopic brain structure.

The role of sleep in directed forgetting and remembering of human memories.

Ample evidence supports a role for sleep in the offline consolidation of memory. However, circumstances exist where forgetting can be as critical as remembering, both in daily life and clinically. Using a directed forgetting paradigm, here, we investigate the impact of explicit cue instruction during learning, prior to sleep, on subsequent remembering and forgetting of memory, after sleep. We demonstrate that sleep, relative to time awake, can selectively ignore the facilitation of items previously cued to be forgotten, yet preferentially enhance recall for items cued to be remembered; indicative of specificity based on prior waking instruction. Moreover, the success of this differential remember/forget effect is strongly correlated with fast sleep spindles over the left superior parietal cortex. Furthermore, electroencephalography source analysis of these spindles revealed a repeating loop of current density between selective memory-related regions of the superior parietal, medial temporal, and right prefrontal cortices. These findings move beyond the classical notion of sleep universally strengthening information. Instead, they suggest a model in which sleep may be more ecologically attuned to instructions present during learning while awake, supporting both remembering and targeted forgetting of human memories.

Sleep and mental health in childhood: a multi-method study in the general pediatric population.

BACKGROUND: Sleep problems, altered sleep patterns and mental health difficulties often co-occur in the pediatric population. Different assessment methods for sleep exist, however, many studies only use one measure of sleep or focus on one specific mental health problem. In this population-based study, we assessed different aspects of sleep and mother-reported mental health to provide a broad overview of the associations between reported and actigraphic sleep characteristics and mental health. METHODS: This cross-sectional study included 788 children 10-11-year-old children (52.5% girls) and 344 13-14-year-old children (55.2% girls). Mothers and children reported on the sleep of the child and wrist actigraphy was used to assess the child's sleep patterns and 24 h activity rhythm. Mental health was assessed via mother-report and covered internalizing, externalizing and a combined phenotype of internalizing and externalizing symptoms, the dysregulation profile. RESULTS: Higher reported sleep problems were related to more symptoms of mental health problems in 10-11- and 13-14-year-old adolescents, with standardized ß-estimates ranging between 0.11 and 0.35. There was no association between actigraphy-estimated sleep and most mental health problems, but earlier sleep onset was associated with more internalizing problems (ß = - 0.09, SE = 0.03, p-value = 0.002), and higher intra-daily variability of the 24 h activity rhythm was associated with more dysregulation profile symptoms at age 10-11 (ß = 0.11, SE = 0.04, p-value = 0.002). DISCUSSION: Reported sleep problems across informants were related to all domains of mental health problems, providing evidence that sleep can be an important topic to discuss for clinicians seeing children with mental health problems. Actigraphy-estimated sleep characteristics were not associated with most mental health problems. The discrepancy between reported and actigraphic sleep measures strengthens the idea that these two measures tap into distinct constructs of sleep.

Adolescent sleep health and school start times: Setting the research agenda for California and beyond. A research summit summary.

In fall 2019, California passed and signed into law SB328, the first US statewide legislation explicitly designed to protect adolescent sleep health by requiring most California public school districts to start no earlier than 8:00 AM for middle schools and 8:30 AM for high schools. Recognizing the unique opportunity presented by the bill's 3-year implementation period, a group of experts in adolescent sleep and school start times held a virtual summit on January 22-23, 2021 to (1) summarize the research on adolescent sleep and school start time change; (2) develop recommendations for relevant, refined, and innovative research areas and research questions; (3) provide input regarding research design, methodology, and implementation; and (4) offer a forum for networking, exchanging ideas, and establishing interdisciplinary research collaborations. Participants represented a multidisciplinary range of academic backgrounds including sleep and circadian biology, neuroscience, education, medicine, public health, mental health, safety, public policy, economics, implementation science, criminology, diversity studies, and science communication. This paper summarizes summit presentations regarding current knowledge on adolescent sleep health and school start times and key research recommendations from small group workshops on topics including research design and tools, methodological issues, sleep health disparities, logistical challenges in conducting school-based research, public-health impact, and novel and expanded approaches to research.

Racial disparities in sleep-related cardiac function in young, healthy adults: implications for cardiovascular-related health.

STUDY OBJECTIVES: Considerable evidence shows that individuals from marginalized racial/ethnic groups in the United States experience greater rates of sleep disturbance and cardiovascular complications. Because sleep is a modifiable factor that is critically involved in cardiovascular health, improved understanding of the association between sleep and cardiovascular health during early adulthood can prevent cardiovascular disparities. This study examined racial/ethnic differences in cardiovascular function during sleep using heart rate and heart-rate-variability analyses. METHODS: Participants in this laboratory-based sleep study included healthy, "good sleepers" who were in early adulthood and resided in the United States at the time of participation (14 non-Hispanic Black [NHB; age = 30.9 (6.6), 57% female], 12 Asian [Asian, age = 26.0 (5.2), 42% female], and 24 non-Hispanic white [NHW; age = 24.6 (5.8), 79% female]). RESULTS: After adjusting for demographic factors and an apnea-hypopnea index, we found significantly higher heart rate within NREM Stage 2 (N2) (b = -22.6, p = .04) and REM sleep (b = -25.8, p =.048) and lower heart rate variability during N2 sleep (b = -22.6, p = .04) among NHB individuals compared with NHW individuals. Furthermore, NHB and Asian participants demonstrated significantly lower percent of time in slow wave sleep (SWS) compared with NHW participants (NHB: b = -22.6, p =.04; Asian: b = -22.6, p = .04). Individuals' percent of time in SWS significantly mediated differences in heart rate during N2 (indirect = 0.94, 95% CI [0.03, 2.68]) and REM sleep (indirect = 1.02, 95% CI [0.04, 3.04]). CONCLUSIONS: Our results showed disparities in sleep-related cardiovascular function in early adulthood that are mediated by SWS. These data suggest targeting sleep health in early adulthood might help reduce cardiovascular disease burden on individuals from marginalized groups.

COVID-19 instructional approaches (in-person, online, hybrid), school start times, and sleep in over 5,000 U.S. adolescents.

STUDY OBJECTIVES: To examine associations among instructional approaches, school start times, and sleep during the COVID-19 pandemic in a large, nationwide sample of U.S. adolescents. METHODS: Cross-sectional, anonymous self-report survey study of a community-dwelling sample of adolescents (grades 6-12), recruited through social media outlets in October/November 2020. Participants reported on instructional approach (in-person, online/synchronous, online/asynchronous) for each weekday (past week), school start times (in-person or online/synchronous days), and bedtimes (BT) and wake times (WT) for each identified school type and weekends/no school days. Sleep opportunity was calculated as BT-to-WT interval. Night-to-night sleep variability was calculated with mean square successive differences. RESULTS: Respondents included 5,245 racially and geographically diverse students (~50% female). BT and WT were earliest for in-person instruction; followed by online/synchronous days. Sleep opportunity was longer on individual nights students did not have scheduled instruction (>1.5 h longer for online/asynchronous than in-person). More students obtained sufficient sleep with later school start times. However, even with the same start times, more students with online/synchronous instruction obtained sufficient sleep than in-person instruction. Significantly greater night-to-night variability in sleep-wake patterns was observed for students with in-person hybrid schedules versus students with online/synchronous + asynchronous schedules. CONCLUSIONS: These findings provide important insights regarding the association between instructional approach and school start times on the timing, amount, and variability of sleep in U.S. adolescents. Given the public health consequences of short and variable sleep in adolescents, results may be useful for education and health policy decision-making for post-pandemic secondary schools.